Doctoral Degrees (Emergency Medicine)

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Clinical quality and performance measurement in the prehospital emergency medical services in the low-to- middle-income country setting
(Stellenbosch : Stellenbosch University, 2021-03) Howard, Ian Lucas; Wallis, Lee; Lindstrom, Veronica; Cameron, Peter; Castren, Maaret; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine. Emergency Medicine.
ENGLISH SUMMARY : Background: Measuring quality and safety in any healthcare setting however is highly contextual, and depends on the manner in which quality is defined or viewed within that setting. It is this contextual nature that has provoked significant debate and hindered efforts at developing formal standards or criteria for measuring quality and safety in healthcare, regardless of setting. Historically, performance within the Emergency Medical Services (EMS) delivering prehospital emergency care has been assessed primarily based on response times. While easy to measure and valued by the public, overall, response time targets are a poor predictor of quality of care and clinical outcomes. Aim: The overall aim of the research was to develop a framework for clinical quality and performance-based assessment of prehospital emergency care for use in the South African EMS. Method: The research was divided amongst four studies, with each study constituting one of the overall research objectives. Study I was a sequential explanatory mixed methods study with the aim of understanding the knowledge, attitudes and practices of clinical quality and performance assessment amongst South African EMS personnel. Part 1 consisted of a webbased cross-sectional survey, and Part 2 consisted of semi-structured telephonic interviews of select participants from Part 1 to explore the results of the survey. Descriptive statistics were carried out to summarise and present all survey items, and conventional content analysis employed to analyse the interview data. Study II utilised a three round modified Delphi study to identify, refine and review a list of appropriate quality indicators for potential use in the South African EMS setting. For Study III a novel quality indicator appraisal protocol was developed consisting of two categorical-based appraisal methods, combined with the qualitative analysis of their consensus application, and tested against the outcomes of Study II. Descriptive statistics were utilised to describe and summarize the categorical based appraisal data. Inter-rater reliability was calculated using percentage agreement and Gwet’s AC1. Correlation between the individual methods and the protocol was calculated using Spearman’s rank Correlation and z-test. Conventional content analysis was utilised to analyse the group discussions. Study IV utilised a multiple exploratory case study design to evaluate the current state of quality systems in the South African EMS. A formative assessment was conducted on the quality systems of four provincial EMS and one national private EMS, following which semi-structured interviews were conducted to further explore the results obtained from the formative assessment, supported by multiple secondary data sources. Descriptive statistics were utilised to describe and summarize the formative assessment. Conventional content analysis was utilised to analyse the interview data and document analysis utilised to sort and analyse the supporting data. Results: Despite relatively poor knowledge of organisational-specific quality systems, understanding of the core components and importance of quality systems was demonstrated. The role of these systems in the Low to Middle Income Country setting (LMICs) was supported by participants, where the importance of context, system transparency, reliability and validity were essential towards achieving ongoing success and utilisation. The role of leadership and communication towards the effective facilitation of such a system was equally identified. Participating services generally scored higher for structure and planning. Measurement and improvement were found to be more dependent on utilisation and perceived mandate. There was a relatively strong focus on clinical quality assessment within the private service, whereas in the provincial systems, measures were exclusively restricted to call times with little focus on clinical care. Staff engagement and programme evaluation were generally among the lowest scores. A multitude of contextual factors were identified that affected the effectiveness of quality systems, centred around leadership, vision and mission, and quality system infrastructure and capacity, guided by the need for comprehensive yet pragmatic strategic policies and standards. A total, 104 quality indicators reached consensus agreement including, 90 clinical QIs, across 15 subcategories, and 14 non-clinical QIs across two subcategories. Amongst the clinical category, airway management (n=13 QIs; 14%); out-of-hospital cardiac arrest (n=13 QIs; 14%); and acute coronary syndromes (n=11 QIs; 12%) made up the majority. Within the non-clinical category, adverse events made up the significant majority with nine QIs (64%). There was mixed inter-rater reliability of the individual methods. There was similarly poor to moderate correlation of the results obtained between the individual methods (Spearman’s rank correlation=0.42,p<0.001). From a series of 104 QIs, 11 were identified that were shared between the individual methods. A further 19 QIs were identified and not shared by each method, highlighting the benefits of a multimethod approach. Conclusion: For the purposes of this study we focused on the technical competence aspect of quality, in developing our measurement framework. Towards this, we identified a significant number of QIs assessed to be valid and feasible for the South African prehospital emergency care setting. The majority of which are centred around clinically focused processes of care, measures that are lacking in current performance assessment in EMS in South Africa. However, we also discovered the importance and influencing role of the individual practitioners and quality system in which the QIs will be implemented, a point highlighted across all the methodologies and studies. Given the potential magnitude of this influence, it is of the utmost importance that any measurement framework examining technical quality, have equal in-depth understanding of these factors in order to be successful.
Clinical quality and performance measurement in the prehospital emergency medical services in the low-to-middle-income country setting : developing clinical quality and performance indicators as a measure of care in South Africa
(Stellenbosch : Stellenbosch University, 2020-12) Howard, Ian; Wallis, Lee; Lindstrom, Veronica; Cameron, Peter; Castrén, Maaret; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine. Emergency Medicine.
ENGLISH SUMMARY : Background: Measuring quality and safety in any healthcare setting however is highly contextual, and depends on the manner in which quality is defined or viewed within that setting. It is this contextual nature that has provoked significant debate and hindered efforts at developing formal standards or criteria for measuring quality and safety in healthcare, regardless of setting. Historically, performance within the Emergency Medical Services (EMS) delivering prehospital emergency care has been assessed primarily based on response times. While easy to measure and valued by the public, overall, response time targets are a poor predictor of quality of care and clinical outcomes. Aim: The overall aim of the research was to develop a framework for clinical quality and performance-based assessment of prehospital emergency care for use in the South African EMS. Method: The research was divided amongst four studies, with each study constituting one of the overall research objectives. Study I was a sequential explanatory mixed methods study with the aim of understanding the knowledge, attitudes and practices of clinical quality and performance assessment amongst South African EMS personnel. Part 1 consisted of a webbased cross-sectional survey, and Part 2 consisted of semi-structured telephonic interviews of select participants from Part 1 to explore the results of the survey. Descriptive statistics were carried out to summarise and present all survey items, and conventional content analysis employed to analyse the interview data. Study II utilised a three round modified Delphi study to identify, refine and review a list of appropriate quality indicators for potential use in the South African EMS setting. For Study III a novel quality indicator appraisal protocol was developed consisting of two categorical-based appraisal methods, combined with the qualitative analysis of their consensus application, and tested against the outcomes of Study II. Descriptive statistics were utilised to describe and summarize the categorical based appraisal data. Inter-rater reliability was calculated using percentage agreement and Gwet’s AC1. Correlation between the individual methods and the protocol was calculated using Spearman’s rank Correlation and z-test. Conventional content analysis was utilised to analyse the group discussions. Study IV utilised a multiple exploratory case study design to evaluate the current state of quality systems in the South African EMS. A formative assessment was conducted on the quality systems of four provincial EMS and one national private EMS, following which semi-structured interviews were conducted to further explore the results obtained from the formative assessment, supported by multiple secondary data sources. Descriptive statistics were utilised to describe and summarize the formative assessment. Conventional content analysis was utilised to analyse the interview data and document analysis utilised to sort and analyse the supporting data. Results: Despite relatively poor knowledge of organisational-specific quality systems, understanding of the core components and importance of quality systems was demonstrated. The role of these systems in the Low to Middle Income Country setting (LMICs) was supported by participants, where the importance of context, system transparency, reliability and validity were essential towards achieving ongoing success and utilisation. The role of leadership and communication towards the effective facilitation of such a system was equally identified. Participating services generally scored higher for structure and planning. Measurement and improvement were found to be more dependent on utilisation and perceived mandate. There was a relatively strong focus on clinical quality assessment within the private service, whereas in the provincial systems, measures were exclusively restricted to call times with little focus on clinical care. Staff engagement and programme evaluation were generally among the lowest scores. A multitude of contextual factors were identified that affected the effectiveness of quality systems, centred around leadership, vision and mission, and quality system infrastructure and capacity, guided by the need for comprehensive yet pragmatic strategic policies and standards. A total, 104 quality indicators reached consensus agreement including, 90 clinical QIs, across 15 subcategories, and 14 non-clinical QIs across two subcategories. Amongst the clinical category, airway management (n=13 QIs; 14%); out-of-hospital cardiac arrest (n=13 QIs; 14%); and acute coronary syndromes (n=11 QIs; 12%) made up the majority. Within the non-clinical category, adverse events made up the significant majority with nine QIs (64%). There was mixed inter-rater reliability of the individual methods. There was similarly poor to moderate correlation of the results obtained between the individual methods (Spearman’s rank correlation=0.42,p<0.001). From a series of 104 QIs, 11 were identified that were shared between the individual methods. A further 19 QIs were identified and not shared by each method, highlighting the benefits of a multimethod approach. Conclusion: For the purposes of this study we focused on the technical competence aspect of quality, in developing our measurement framework. Towards this, we identified a significant number of QIs assessed to be valid and feasible for the South African prehospital emergency care setting. The majority of which are centred around clinically focused processes of care, measures that are lacking in current performance assessment in EMS in South Africa. However, we also discovered the importance and influencing role of the individual practitioners and quality system in which the QIs will be implemented, a point highlighted across all the methodologies and studies. Given the potential magnitude of this influence, it is of the utmost importance that any measurement framework examining technical quality, have equal in-depth understanding of these factors in order to be successful.
Coronary care networks in the resource-limited setting : systems of care in South Africa
(Stellenbosch : Stellenbosch University, 2018-12) Stassen, Willem; Kurland, Lisa; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine. Emergency Medicine.
ENGLISH SUMMARY : BACKGROUND: Owing to an epidemiological transition observed throughout Sub-Saharan Africa, South Africa is experiencing an increase in the incidence of myocardial infarction. ST-elevation myocardial infarction (STEMI) occurs commonly in South Africa and at much younger ages than observed elsewhere in the world. Emergent treatment in the form of coronary reperfusion is required to reduce morbidity and mortality following STEMI. Political and socio-economic factors have led to large disparities in emergency healthcare access for many South Africans. Well organised networks of care (coronary care networks, CCNs) that seamlessly integrate prehospital care, in-hospital assessment and percutaneous coronary intervention is recommended to reduce mortality for these patients. CCNs are underdeveloped and under-studied in South Africa. To this end, the aims of this project was to examine the current state of Coronary Care Networks in South Africa, a low- to middle income country and to provide recommendations for future development of such networks. METHODS: This project was comprised of four studies. Study I was a cross-sectional descriptive study that aimed at determining the current PCI-capable facilities in South Africa and sought correlations between the resources, population, poverty and insurance status using Spearman’s Rho. Study II utilised proximity analysis to determine the average drive times of South African municipal wards (geopolitical subdivisions used for electoral purposes) to the closest PCI-capable facility for each South African province. It further determined the proportion of South Africans living within one and two hours respectively, from such a facility. Study III combined data obtained from Studies I and II with network optimisation modelling to propose an optimised reperfusion strategy for patients with STEMI, based on proximity, using the North West province as a case study. Finally, Study IV employed qualitative methodology to determine the barriers and facilitators to developing CCNs in South Africa by performing interviews with individuals working with the South African contexts of coronary care. RESULTS: South Africa has 62 PCI-capable facilities, with most PCI-facilities (n=48; 77%) owned by the private healthcare sector. A disparity exists between the number of private and state-owned PCI-facilities when compared to the poverty (r=0.01; p=0.17) and insurance status of individuals (r=-0.4; p=0.27) (Study I). This means that reperfusion by PCI is likely inaccessible to many despite approximately, 53.8% and 71.53% of the South African population living within 60 and 120 minutes of a PCI facility (Study II). Yet, we provide an efficient and swift model that provides a recommendation for the best reperfusion strategy even in the instance of a large amount of ward data with these additional constraints. This model can be run in realtime and can guide reperfusion decisions at the bedside or form the basis of regional reperfusion guidelines, and CCN development priorities (Study III). When considering the local CCN, we found an under-resourced CCN that is not prioritised by policymakers and displays considerable variation in performance based on time of day and geographic locale. Specific barriers to the development of CCNs in South Africa included poor recognition and diagnosis of STEMI, inappropriate transport and treatment decisions, and delays. Facilitators to the development of CCNs were regionalised STEMI treatment guidelines, further research and prehospital thrombolysis programmes (Study IV). CONCLUSION: South Africa has a shortage of PCI facilities. Even in areas with high concentrations of PCI facilities. In addition, many patients may not be able to access care due to socio-economic status. When considering proximity alone, most South Africans are able to access PCI within guideline timeframes. Despite this, prehospital thrombolysis should still be considered in some areas – as demonstrated by a novel approach that combines geospatial analysis and network optimisation modelling. This approach is able to efficiently determine the optimum reperfusion strategy for each geographic locale of South Africa. Current CCNs in South Africa are under-resourced, over-burdened and not prioritised. Future efforts should aim at improving STEMI recognition and diagnosis to decrease delays to reperfusion. The findings described should be considered and integrated into a future model of CCNs within South Africa, towards improving reperfusion times and finally morbidity and mortality.
Development of an e-learning platform to improve learning delivery in a low-resourced clinical ultrasound training setting
(Stellenbosch : Stellenbosch University, 2017-12) Lamprecht, Heinrich Hilgardt; Kruger, T. F.; Wallis, Lee Allan; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine. Emergency Medicine.
ENGLISH SUMMARY : Background/Objective: Some clinical ultrasound training programmes provide suboptimal training that result in credentialing failure. To address this failing in our low-resourced setting, an e-learning platform was designed and constructed using a participatory action research approach where clinical ultrasound trainees, e-learning developers and researchers collaborated to improve the trainees’ access to learning delivery and enhancement, with the aim to eventually improve their low credentialing success rate. Methodology: The participatory action research approach involved a mixed methodology to collect, manage and analyse data for each of Susman and Evered’s cycle of enquiry steps, namely diagnosis, action planning, intervention, evaluation and reflection. The integration of instrumental and focal theories closed the practice-research gap by adding the necessary rigor to the study. Results: The diagnosis stage revealed that the poor credentialing performance was caused by learning delivery failure that reduced the trainees’ academic engagement. An e-learning platform was designed and constructed as an intervention to consolidate the current training capacity and provide trainees with new alternative access pathways to deliver learning more effectively (action planning). The e-learning platform was designed within a learner-centred, adult learning and motivational pedagogical paradigm. The evaluation of the e-learning platform intervention identified: context-specific resource savings, that all study participant groups accepted the new reality of incorporating e-learning as part of a blended learning approach and the learning access of trainees improved. Future research should focus on validating the usability of the draft e-learning platform and improvements of learning delivery and learning enhancement by initially making use of small peer groups followed by larger user-based groups (reflection). Conclusion: Collaboration led to real practical and social change by creating a custom designed e-learning platform that changed the way clinical ultrasound trainees learn within a low resourced context. Early inclusion of the trainees as study participants led to their early adoption of the ability of a newly designed e-learning platform to firstly improve their learning delivery, then restore their academic engagement and eventually their learning enhancement, which should reflect in improved credentialing success rates.
Identifying feasible and effective community health worker supervision strategies : experiences of providing and receiving supervision in a rural South African community health worker programme
(Stellenbosch : Stellenbosch University, 2023-12) Stansert Katzen, Sara Linnea; Tomlinson, Mark; Skeen, Sarah; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine.
ENGLISH SUMMARY: Despite a global focus on reproductive, maternal and child health, maternal and child mortality and morbidity remain real concerns, particularly in low- and middle-income countries (LMICs). The demands on health systems in LMICs continue to escalate due to the high burden of disease and an increased demand for healthcare services, in combination with a shortage of healthcare personnel. Deploying community healthcare workers (CHWs) is an important strategy to bridge the gap in health care and to support the functioning of the healthcare system. While there is substantial evidence of the benefits of CHW programmes, there are concerns regarding the effectiveness of these programmes at scale. Programmatic factors, such as training, access to equipment and sufficient supervision systems, are critical for CHW programme success, yet often lacking or limited in practice – and therefore more focused research is needed. This thesis attempts to address this gap by reporting the results of a qualitative evidence synthesis (QES) and three individual articles presenting findings from qualitative research within the Eastern Cape Supervision Study (ECSS). The ECSS is a cluster randomised controlled trial testing an enhanced supervision and support package for CHWs. In the QES, I report on evidence on how CHWs working in maternal and child health interventions experience supervision. Publications published between 2000 and 2021 were included. In the first qualitative paper I report on qualitative data from interviews with CHWs (who were part of the ECSS study), but which took place during the initial phases of the intervention. This paper reports on their experiences of becoming and remaining CHWs. In the second qualitative paper, I report on qualitative evidence from CHWs in both the intervention and control groups of the ECSS. This paper focuses on how they experience their roles as CHWs, and how they experience supervision, specifically the enhanced supervision intervention. In the third qualitative paper I report on qualitative evidence from interviews with programme stakeholders (in this case supervisors, clinic personnel and programme managers). This paper focuses on their experiences of the CHW programme in general, and the ECSS intervention in particular. The results from these individual substudies highlight substantial shortfalls in the current government-implemented CHW programme in the study area. Limited training, lack of supervision and limited or no access to resources such as equipment and transport were the challenges identified. Four overarching contributions were identified through this work: 1) CHWs’ and stakeholders’ perspectives when developing and improving CHW programmes, 2) Interpersonal skills and relationships to enhance programme delivery, 3) Supportive health system and programmatic environments, and 4: Systems of supportive supervision.
The role of calcium and calcium antagonists in the reperfusion injury of the heart
(Stellenbosch : Stellenbosch University, 2005) Conradie, Suzanne Louise; Coetzee, A. (Andre); Moolman, J. (Johan); Coetzee, J. (Johan); Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Interdisciplinary Health Sciences. Emergency Medicine.
ENGLISH ABSTRACT: The reperfusion injury after myocardial ischemia is relevant in the clinical setting, after cardiopulmonary bypass for cardiac surgery, after PTCA and stenting and after cardiopulmonary resuscitation. The components of the reperfusion injury considered in this study were myocardial stunning and reperfusion arrhythmias. Calcium antagonists have been shown to be beneficial in attenuating the myocardial reperfusion injury in the in vitro and in vivo laboratory setting (Lamping, Gross 1985, Przyklenk and Kloner 1988, Taylor 1990, Ehring 1992, Gross and Piper 1992). However systemic administration of a dose of calcium antagonist, large enough to attenuate the myocardial reperfusion injury in the clinical setting, would inevitably lead to unwanted systemic side effects of the drug. The aim of this study was to investigate the hypothesis that an adequate dose of verapamil administered timeously, directly into the ischemic myocardium, would attenuate the reperfusion injury, either when administered from the onset of ischemia, or from 3 minutes before reperfusion. The anesthetized open chest porcine model of myocardial ischemia (15 min total LAD occlusion) and reperfusion was employed in this study. A low dose of verapamil (0.5 mg/8mt or 0.0625mg/mt), a high dose of verapamil (2mg/8m or O.25mg/ml), or vehicle (saline) (8ml) was infused over 8 minutes, directly into the LAD coronary artery supplying the ischemic segment. The infusion was started either at the onset of ischemia, or from 3 minutes before reperfusion. The time taken for the various parameters to return to pre ischemic values was compared between the different groups. The results showed that the high dose of verapamil (2mg) attenuated the reperfusion injury both when administered from the onset of ischemia, and when administered from 3 minutes before reperfusion, compared to either the low dose of verapamil, or the saline infusions. The high dose of verapamil groups had a faster recovery of both systolic contractile function and diastolic function and a lower incidence of ventricular fibrillation on reperfusion. There were no systemic effects of verapamil infusion in any of the groups. The clinical setting of cardiac surgery expressly lends itself to the clinical application of this finding. There is direct access to the coronary arteries both before ischemia and before reperfusion. A small dose of calcium channel blocking drug, with no systemic effect can be administered into the aortic root at the onset of ischemia, just prior to cardioplegia (when the heart is still warm), and after rewarming a few minutes prior to removal of the aortic cross clamp.

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