Emergency Medicine

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A 5-year analysis of the helicopter air mercy service in Richards Bay, South Africa
(Health & Medical Publishing Group, 2014-02) D'Andrea, Patrick Andrew; Van Hoving, Daniel Jacobus; Wood, Darryl; Smith, Wayne Patrick
Background. A helicopter emergency medical service (HEMS) was established in 2005 in Richards Bay, KwaZulu-Natal, South Africa, to provide primary response and inter-facility transfers to a largely rural area with a population of 3.4 million people. Objective. To describe the first 5 years of operation of the HEMS. Methods. A chart review of all flights from 1 January 2006 to 31 December 2010 was conducted. Results. A total of 1 429 flights were undertaken; 3 were excluded from analysis (missing folders). Most flights (88.4%) were inter-facility transfers (IFTs). Almost 10% were cancelled after takeoff. The breakdown by age was 61.9% adult, 15.1% paediatric and 21.6% neonate. The main indications for IFTs were obstetrics (34.5%), paediatrics (27.9%) and trauma (15.9%). For primary response most cases were trauma (72.9%) and obstetrics (11.3%). The median on-scene time for neonates was significantly longer (48 min, interquartile range (IQR) 35 - 64 min) than that for adults (36 min, IQR 26 - 48; p<0.001) and paediatrics (36 min, IQR 25 - 51; p<0.02). On-scene times for doctor-paramedic crews (45 min, IQR 27 - 50) were significantly longer than for paramedic-only crews (38 min, IQR 27 - 57; p<0.001). Conclusion. The low flight-to-population ratio and primary response rate may indicate under-utilisation of the air medical service in an area with a shortage of advanced life support crews and long transport distances. Further studies on HEMSs in rural Africa are needed, particularly with regard to cost-benefit analyses, optimal activation criteria and triage systems.
Abdominal ultrasound for diagnosing abdominal tuberculosis or disseminated tuberculosis with abdominal involvement in HIV-positive individuals
(John Wiley & Sons, Ltd. on behalf of The Cochrane Collaboration, 2019) Van Hoving, Daniel J.; Griesel, Rulan; Meintjes, Graeme; Takwoingi, Yemisi; Maartens, Gary; Ochodo, Eleanor A.
Background: Accurate diagnosis of tuberculosis in people living with HIV is difficult. HIV‐positive individuals have higher rates of extrapulmonary tuberculosis and the diagnosis of tuberculosis is often limited to imaging results. Ultrasound is such an imaging test that is widely used as a diagnostic tool (including point‐of‐care) in people suspected of having abdominal tuberculosis or disseminated tuberculosis with abdominal involvement. Objectives: To determine the diagnostic accuracy of abdominal ultrasound for detecting abdominal tuberculosis or disseminated tuberculosis with abdominal involvement in HIV‐positive individuals. To investigate potential sources of heterogeneity in test accuracy, including clinical setting, ultrasound training level, and type of reference standard. Search methods: We searched for publications in any language up to 4 April 2019 in the following databases: MEDLINE, Embase, BIOSIS, Science Citation Index Expanded (SCI‐EXPANDED), Social Sciences Citation Index (SSCI), Conference Proceedings Citation Index‐ Science (CPCI‐S), and also ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform to identify ongoing trials. Selection criteria: We included cross‐sectional, cohort, and diagnostic case‐control studies (prospective and retrospective) that compared the result of the index test (abdominal ultrasound) with one of the reference standards. We only included studies that allowed for extraction of numbers of true positives (TPs), true negatives (TNs), false positives (FPs), and false negatives (FNs). Participants were HIV‐positive individuals aged 15 years and older. A higher‐quality reference standard was the bacteriological confirmation of Mycobacterium tuberculosis from any clinical specimen, and a lower‐quality reference standard was a clinical diagnosis of tuberculosis without microbiological confirmation. We excluded genitourinary tuberculosis. Data collection and analysis: For each study, two review authors independently extracted data using a standardized form. We assessed the quality of studies using a tailored Quality Assessment of Diagnostic Accuracy Studies‐2 (QUADAS‐2) tool. We used the bivariate model to estimate pooled sensitivity and specificity. When studies were few we simplified the bivariate model to separate univariate random‐effects logistic regression models for sensitivity and specificity. We explored the influence of the type of reference standard on the accuracy estimates by conducting separate analyses for each type of reference standard. We assessed the certainty of the evidence using the GRADE approach. Main results: We included 11 studies. The risks of bias and concern about applicability were often high or unclear in all domains. We included six studies in the main analyses of any abnormal finding on abdominal ultrasound; five studies reported only individual lesions. The six studies of any abnormal finding were cross‐sectional or cohort studies. Five of these (83%) were conducted in low‐ or middle‐income countries, and one in a high‐income country. The proportion of participants on antiretroviral therapy was none (1 study), fewer then 50% (4 studies), more than 50% (1 study), and not reported (5 studies). The first main analysis, studies using a higher‐quality reference standard (bacteriological confirmation), had a pooled sensitivity of 63% (95% confidence interval (CI) 43% to 79%; 5 studies, 368 participants; very low‐certainty evidence) and a pooled specificity of 68% (95% CI 42% to 87%; 5 studies, 511 participants; very low‐certainty evidence). If the results were to be applied to a hypothetical cohort of 1000 people with HIV where 200 (20%) have tuberculosis then: ‐ About 382 individuals would have an ultrasound result indicating tuberculosis; of these, 256 (67%) would be incorrectly classified as having tuberculosis (false positives). ‐ Of the 618 individuals with a result indicating that tuberculosis is not present, 74 (12%) would be incorrectly classified as not having tuberculosis (false negatives). In the second main analysis involving studies using a lower‐quality reference standard (clinical diagnosis), the pooled sensitivity was 68% (95% CI 45% to 85%; 4 studies, 195 participants; very low‐certainty evidence) and the pooled specificity was 73% (95% CI 41% to 91%; 4 studies, 202 participants; very low‐certainty evidence). Authors' conclusions: In HIV‐positive individuals thought to have abdominal tuberculosis or disseminated tuberculosis with abdominal involvement, abdominal ultrasound appears to have 63% sensitivity and 68% specificity when tuberculosis was bacteriologically confirmed. These estimates are based on data that is limited, varied, and low‐certainty. The low sensitivity of abdominal ultrasound means clinicians should not use a negative test result to rule out the disease, but rather consider the result in combination with other diagnostic strategies (including clinical signs, chest x‐ray, lateral flow urine lipoarabinomannan assay (LF‐LAM), and Xpert MTB/RIF). Research incorporating the test into tuberculosis diagnostic algorithms will help in delineating more precisely its value in diagnosing abdominal tuberculosis or disseminated tuberculosis with abdominal involvement.
Access to top-cited emergency care articles (published between 2012 and 2016) without subscription
(Department of Emergency Medicine, 2019) Hamzy, Murad Al; De Villiers, Dominique; Banner, Megan; Lamprecht, Hein; Bruijns, Stevan R.
Introduction: Unrestricted access to journal publications speeds research progress, productivity, and knowledge translation, which in turn develops and promotes the efficient dissemination of content. We describe access to the 500 most-cited emergency medicine (EM) articles (published between 2012 and 2016) in terms of publisher-based access (open access or subscription), alternate access routes (self-archived or author provided), and relative cost of access.Methods: We used the Scopus database to identify the 500 most-cited EM articles published between 2012 and 2016. Access status was collected from the journal publisher. For studies not available via open access, we searched on Google, Google Scholar, Researchgate, Academia.edu, and the Unpaywall and Open Access Button browser plugins to locate self-archived copies. We contacted corresponding authors of the remaining inaccessible studies for a copy of each of their articles. We collected article processing and access costs from the journal publishers, and then calculated relative cost differences using the World Bank purchasing power parity index for the United States (U.S.), Germany, Turkey, China, Brazil, South Africa, and Australia. This allows costs to be understood relative to the economic context of the countries from which they originated.Results: We identified 500 articles for inclusion in the study. Of these, 167 (33%) were published in an open access format. Of the remaining 333 (67%), 204 (61%) were available elsewhere on the internet, 18 (4%) were provided by the authors, and 111 (22%) were accessible by subscription only. The mean article processing and access charges were $2,518.62 and $44.78, respectively. These costs were 2.24, 1.75, 2.28 and 1.56 times more expensive for South African, Chinese, Turkish, and Brazilian authors, respectively, than for U.S. authors (p<0.001 all).Conclusion: Despite the advantage of open access publication for knowledge translation, social responsibility, and increased citation, one in five of the 500 EM articles were accessible only via subscription. Access for scientists from upper-middle income countries was significantly hampered by cost. It is important to acknowledge the value this has for authors from low- and middle-income countries. Authors should also consider the citation advantage afforded by open access publishing when deciding where to publish.
Adherence to referral criteria at admission and patient management at a specialized burns centre : the case of the red cross War Memorial Children’s Hospital in Cape Town, South Africa
(MDPI, 2017-07-06) Boissin, Constance; Hasselberg, Marie; Kronblad, Emil; Kim, So-Mang; Wallis, Lee; Rode, Heinz; Laflamme, Lucie
ENGLISH ABSTRACT: Referral guidelines for burn care are meant to assist in decision-making as regards patient transfer and admissions to specialized units. Little is known, however, concerning how closely they are followed and whether they are linked to patient care. This is the object of the current study, focused on the paediatric burns centre of the Red Cross War Memorial Children’s Hospital in Cape Town, South Africa. All patients admitted to the centre during the winters of 2011–2015 (n = 1165) were included. The patient files were scrutinized to clarify whether the referral criteria in place were identified (seven in total) and to compile data on patient and injury characteristics. A case was defined as adherent to the criteria when at least one criterion was fulfilled and adherence was expressed as a percentage with 95% confidence intervals, for all years aggregated as well as by year and by patient or injury characteristics. The association between adherence to any individual criterion and hospital care (surgery or longer length of stay) was measured using logistic regressions. The overall adherence was 93.4% (100% among children under 2 years of age and 86% among the others) and it did not vary remarkably over time. The two criteria of “injury sustained at a specific anatomical site” (85.2%) and “young age” (51.9%) were those most often identified. Children aged 2 years or older were more likely to undergo surgery or to stay longer than those of young age (although a referral criterion) and so were those with higher injury severity (a referral criterion). In this specialized paediatric burns centre, children are admitted mainly according to the guidelines. However, given the high prevalence of paediatric burns in the region and the limited resources at the burns centre, adherence to the guidelines need to be further studied at all healthcare levels in the province.
Admission factors associated with the in-hospital mortality of burns patients in resource-constrained settings : a two-year retrospective investigation in a South African adult burns centre
(Elsevier, 2019) Boissin, Constance; Wallis, Lee; Kleintjes, Wayne; Laflamme, Lucie
Objective: Little is known concerning the factors associated with in-hospital mortality of trauma patients in resource-constrained settings, not least in burns centres. We investigated this question in the adult burns centre at Tygerberg Hospital in Cape Town. We further assessed whether the Abbreviated Burn Severity Index (ABSI) is an accurate predictive score of mortality in this setting. Methods: Medical records of all patients admitted with fresh burns over a two-year period (2015 and 2016) were scrutinized to obtain data on patient, injury and admission-related characteristics. Association with in-hospital mortality was investigated for flame burns using logistic regressions and expressed as odds ratios (ORs). The mortality prediction of the ABSI score was assessed using sensitivity and specificity analyses. Results: Overall the in-hospital mortality was 20.4%. For the 263 flame burns, while crude ORs suggested gender, burn depth, burn size, inhalation injury, and referral status were all individually significantly associated with mortality, only the association with female gender, not being referred and burn size remained significant after adjustments (adjusted ORs = 3.79, 2.86 and 1.11 (per percentage increase in size) respectively). For the ABSI score, sensitivity and specificity were 84% and 86% respectively. Conclusion: In this specialised centre, mortality occurs in one in five patients. It is associated with a few clinical parameters, and can be predicted using the ABSI score.
Adrenaline and amiodarone dosages in resuscitation : rectifying misinformation
(Health & Medical Publishing Group, 2013-09-03) Botha, M.; Wells, M.; Dickerson, R.; Wallis, L.; Stander, M.
ENGLISH SUMMARY : Despite the recognition of specialists in emergency medicine and the professionalisation of prehospital emergency care, international guidelines and consensus are often ignored, and the lag between guideline publication and translation into clinical practice is protracted. South African literature should reflect the latest evidence to guide resuscitation and safe patient care. This article addresses erroneous details regarding life-saving interventions in the South African Medicines Formulary, 10th edition.
Adult medical emergency unit presentations due to adverse drug reactions in a setting of high HIV prevalence
(Elsevier, 2021) Mouton, Johannes P.; Jobanputra, Nicole; Njuguna, Christine; Gunter, Hannah; Stewart, Annemie; Mehta, Ushma; Lahri, Saad; Court, Richard; Igumbor, Ehimario; Maartens, Gary; Cohen, Karen
Introduction: South Africa has the world’s largest antiretroviral treatment programme, which may contribute to the adverse drug reaction (ADR) burden. We aimed to determine the proportion of adult non-trauma emergency unit (EU) presentations attributable to ADRs and to characterise ADR-related EU presentations, stratified according to HIV status, to determine the contribution of drugs used in management of HIV and its complications to ADR-related EU presentations, and identify factors associated with ADR-related EU presentation. Methods: We conducted a retrospective folder review on a random 1.7% sample of presentations over a 12-month period in 2014/2015 to the EUs of two hospitals in Cape Town, South Africa. We identified potential ADRs with the help of a trigger tool. A multidisciplinary panel assessed potential ADRs for causality, severity, and preventability. Results: We included 1010 EU presentations and assessed 80/1010 (7.9%) as ADR-related, including 20/239 (8.4%) presentations among HIV-positive attendees. Among HIV-positive EU attendees with ADRs 17/20 (85%) were admitted, versus 22/60 (37%) of HIV-negative/unknown EU attendees. Only 5/21 (24%) ADRs in HIVpositive EU attendees were preventable, versus 24/63 (38%) in HIV-negative/unknown EU attendees. On multivariate analysis, only increasing drug count was associated with ADR-related EU presentation (adjusted odds ratio 1.10 per additional drug, 95% confidence interval 1.03 to 1.18), adjusted for age, sex, HIV status, comorbidity, and hospital. Conclusions: ADRs caused a significant proportion of EU presentations, similar to findings from other resourcelimited settings. The spectrum of ADR manifestations in our EUs reflects South Africa’s colliding epidemics of infectious and non-communicable diseases. ADRs among HIV-positive EU attendees were more severe and less likely to be preventable.
African emergency care providers' attitudes and practices towards research
(Elsevier, 2017-03) Van Hoving, D. J.; Brysiewicz, P.
Introduction: Emergency care research in Africa is not on par with other world regions. The study aimed to assess the perceptions and practices towards research among current emergency care providers in Africa. Methods: A survey was sent to all individual members of the African Federation of Emergency Medicine. The survey was available in English and French. Results: One hundred and sixty-eight responses were analysed (invited n = 540, responded n = 188, 34.8%, excluded n = 20). Responders’ mean age was 36.3 years (SD = 9.1); 122 (72.6%) were male, 104 (61.9%) were doctors, and 127 (75.6%) were African trained. Thirty-seven (22%) have never been involved in research; 33 (19.6%) have been involved in P5 research projects. African related projects were mostly relevant to African audiences (n = 106, 63.1%). Ninety-four (56%) participants have never published. Forty-one (24.4%) were not willing to publish in open access journals requesting a publication fee; 65 (38.7%) will consider open access journals if fees are sponsored. Eighty responders (47.6%) frequently experienced access block to original articles due to subscription charges. Lack of research funding (n = 108, 64.3%), lack of research training (n = 86, 51.2%), and lack of allocated research time (n = 76, 45.2%) were the main barriers to research involvement. Improvement of research skills (n = 118, 70.2%) and having research published (n = 117, 69.6%) were the top motivational factors selected. Responders agreed that research promotes critical thinking (n = 137, 81.5%) and serve as an important educational tool (n = 134, 80.4%). However, 134 (79.8%) feel that emergency care workers need to be shown how to use research to improve clinical practice. Most agreed that insufficient emergency care research is being conducted in Africa (n = 113, 67.3%). Discussion: There is scope to increase research involvement in emergency care in Africa, but solutions need to be find to address lack of research-related funding, training and time.
An analysis of the clinical practice of emergency medicine in public district and regional hospitals in Tanzania
(Stellenbosch : Stellenbosch University, 2013-03) Mbaya, Khalid Rajabu; Wallis, Lee. A.; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine. Emergency Medicine.
ENGLISH SUMMARY : Aim: The aim of the study was to document the burden of disease presenting to Tanzania mainland public district and regional hospitals’ acute intake areas, to describe the range of early diagnostic and procedural interventions performed on acutely ill patients, and to identify the disposition of these patients. Method: We undertook a cross-sectional, prospective study which described the clinical presentation, investigations, procedures and diagnoses of patients presented to public district and regional hospitals in Tanzania. A consecutive convenience sample of patients presenting during the working hours site visit to each hospital were included for those hospitals only open during the day. For hospitals which open for 24 hours, a 12 hour day time visiting period was selected. Results: District hospitals saw 60% of patients, designated district hospitals 16% and regional hospitals 24%. There was no 24 hours functioning acute intake area with a dedicated doctor for such areas in 70% of regional hospitals, 88% of designated district hospitals and 98% of district hospitals. The gender distribution of male to female was 1:1.3. Infants and geriatric patients accounted for 38%, adolescences and adults 50%, children of school age 12%; average work load was 50 patients per day shift. Medical-Surgical cases were 92% of cases, and the rest were trauma. The three most common complaints were fever, cough and abdominal pains. MVA was the leading cause of trauma. Blood test, X-ray, urinalysis, and stool analysis were the most common investigations. Wound care, fracture reduction, Incision and drainage were the commonest procedures performed. Malaria, respiratory infections and genito-urinary diseases were the leading causes of morbidity. 23% of cases ended up admitted for workup, treatment and senior doctor’s consultation, with only 1% of patients referred to higher level hospitals. Conclusion: The study revealed that almost no public hospitals had any form of emergency care system in place; most emergency patients are seen undifferentiated in OPDs. Infectious diseases and trauma are the leading cause of morbidity; investigations and treatments are based specifically on treating the cause, with no consideration on treating the complications of these diseases. Urgent work is required to establish hospital-based emergency care systems in Tanzania.
Analysis of the resources for emergency care in district and regional public hospitals in Tanzania
(Stellenbosch : Stellenbosch University, 2013-03) Kilindimo, Said Salum; Wallis, Lee A.; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine. Emergency Medicine.
ENGLISH SUMMARY : Introduction: As a new speciality in many African countries, Emergency Medicine in Tanzania was recognised in 2011. The aim of the study was to analyse the resources available for emergency care in public hospitals’ acute intake areas by evaluating the equipment, human resource (availability and composition) and supportive (radiological and laboratory) services. Methods: The study was a prospective, cross-sectional design covering 98% of regional and district hospitals, both as first referral point from primary health facilities i.e. dispensaries and health centres. We directly inspected facilities and equipment and employed a structured checklist adopted from the Emergency Medicine Society of South Africa (EMSSA) to capture the data. The investigator also interviewed both the head of the acute intake area/Medical Officer In Charge while the staff working in the area was visited to check the accuracy of the data collection, as well as to provide details on the staffing composition. Results: Among the hospitals surveyed, there was a deficit of human resources, equipment and medications for resuscitating and stabilising acutely ill patients. An oxygen supply was present in 30% of cases while a bag valve mask was found in only 18% of cases. There was no nebuliser or set of equipment for intubation or ventilation. A working pulse oxymeter was observed in 20% of the hospitals, cardiac monitoring was possible in 3% and none had a defibrillator. Amiadorone was available in 4% of the hospitals, potassium chloride in 9% and Verapamil was present in only 7%. An x-ray service was absent in 37% of hospitals; in 25% the reason given was ‘waiting for repair’ and there was not a single CT-scanner among the hospitals. While the main service providers in acute intake areas were the least qualified health personnel (clinical officer in 99% and health attendant in 99%), only 10% of the acute intake areas had access to consultant from any specialty . Conclusion: The study identified deficits in equipment and human resources quality and quantity across regional and district hospitals in Tanzania. A shortage of supplies, misallocation of the resources, a long awaiting repair time and inadequate training in life support skills partly contributed to the deficit observed.
An analysis of the usage patterns of the ‘Cape Town emergency medicine' closed facebook group
(Stellenbosch : Stellenbosch University, 2017-12) Singh, Swasthi; Oosthuizen, Almero; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine.
ENGLISH SUMMARY: Social media is a term that has come into use to describe “software that supports group interaction”. The first incorporation of social media into a Social Network Site existed as early as 1997 in the form of SixDegrees. Since then there has been an exponential growth in social media and Networking sites, with Facebook, Twitter, Flicker etc. becoming household names in many countries. This surge in the incorporation of social media into daily life has transformed large parts of society into an Internet based, interactive global community, transcending geographic and cultural boundaries. The transformation from the original Web 1.0, in which content generation was the repository of the skilled few, to the community based Web technologies where content is generated by many and shared by all, has been dubbed “Web 2.0” Web 2.0 refers to an emerging group of web-based services that allow users to publish, communicate, and engage in social networking anywhere, anytime and, often, on any connected device. This constant digital communication maps a new landscape of easily accessible, ever-expanding knowledge in which learners find themselves today. This new digital reality is being incorporated into medical education at a rapid pace. This creates opportunities for greater educational expansion and innovation, but also raises concerns such as quality assurance. As the Division of Emergency Medicine of the Western Cape continues to expand and evolve, it is important that it remains current and informed of new and potentially useful trends and innovations.
An analysis of Zambia's emergency medicine registrars' experience in South Africa : lessons for the development of emergency medicine care in Zambia
(Stellenbosch : Stellenbosch University, 2019-12) Mwanza, Kephas Elimon; Wallis, Lee; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine.
ENGLISH SUMMARY : Background: There is little data regarding experiences of emergency medicine registrars for the development of emergency care in Zambia. This study describes lessons from the Zambia’s emergency medicine registrars’ training experiences at various stages of their training in South Africa and how these lessons will impact emergency care in Zambia. Methods: In this qualitative, descriptive study, semi-structured, telephonic interviews were conducted with current Zambian emergency medicine trainees. Recorded interviews were transcribed verbatim and subjected to inductive content analysis. A total of five interviews were completed and represent the entire population of interest. Results: Participants perceived the current state of both in-hospital and pre-hospital emergency care as just beginning to develop. Human resource constraints and health professionals working in silos were perceived as hallmarks of the Zambian health care system. Local training was viewed as a strategy for dissemination of emergency medicine knowledge. In addition, basic equipment for emergency centres were listed and standardisation was highlighted as being critical for their practice in Zambia. Trainees also identified that both advocacy and a team approach to practice were imperative for rapid improvement in emergency care. Conclusion: There is an urgent need for the establishment of a structured advocacy program for emergency care, promotion of inter-professional collaborative practice for patient safety, and support for local emergency medicine training which have potential for overall emergency care development in Zambia. In addition, the advancement of prehospital care strategies should incorporate community participation.
An analytical study of the distribution of fatal ocean drowning by tidal phase and state in the Western Cape
(Stellenbosch : Stellenbosch University, 2019-12) Roos, Charlotte; Van Hoving, Daniel Jacobus; Saunders, Colleen; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine. Emergency Medicine.
ENGLISH SUMMARY : Drowning is a serious public health concern that is often overlooked. Understanding risk factors is key to the development of preventative strategies. The aim of this study was therefore to describe the frequency of fatal drowning in the Western Cape during different tidal phases and states. This was a retrospective, analytical study describing all fatal drowning incidents in the ocean, tidal pools and harbours in the Western Cape province of South Africa between 2010 and mid-2017. The most important finding of this study is a 2.4-fold increased incident rate of fatal drownings during spring (29.8 per 100 days) and neap (29.1 per 100 days) tides when compared to Normal tide (12.2 per 100 days). In addition, the odds of drowning during the flooding tide were 2.2-fold higher in spring tides when compared to neap tides. The factors contributing to drowning in the ocean are multifactorial and complex, and these initial findings suggest that future research on the influence of in-shore bathometry and wave character on environmental factors such as current velocity and force would aid understanding our site-specific drowning risk.
Arterial blood gases in emergency medicine: how well do our registrars and consultants currently enrolled in the Western Cape Division of Emergency Medicine interpret them
(Stellenbosch : Stellenbosch University, 2014-12) Xafis, Paul; Cloete, Flip; Louw, Pauline; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine. Emergency Medicine.
ENGLISH SUMMARY : Intro: Arterial blood gas (ABG) analysis is a useful tool in point-of‐care testing for patients presenting to an emergency center (EC). Emergency Medicine (EM) doctors need to be equipped with sufficient skills to interpret ABGs in order to effectively manage patients. This prospective descriptive cross-sectional study assessed ABG theoretical knowledge, interpretation skills and confidence in analysing ABGs amongst EM registrars (trainees) and consultants currently enrolled in the Division of Emergency Medicine in the Western Cape. Methods: Thirty EM registrars and twenty-three EM consultants responded to the ABG interpretation questionnaire. Scores were compared to validated expert scores. Confidence with ABG interpretation and satisfaction with current registrar teaching methods was analysed using a 10-point visual analogue scale. Results: The average ABG questionnaire score for the group was 63%. No candidates achieved expert scores. Senior registrars (3rd and 4th years of training) scored highest, followed by consultants and junior registrars (1st and 2nd years of training). There was no significant difference between registrar and consultants scores (21.1 vs. 22 respectively; p=0.72). There was no significant difference in overall and individual test scores between consultants and registrars at different levels of training (h=10.85; p=0.28). Registrars’ self-rated ABG accuracy improved with increasing level of training, although satisfaction with ABG training did not. Registrars preferred future methods of ABG learning were focused EM teaching sessions, ‘on the floor’ ABG teaching in ECs, and access to online resources and case-based tutorials. Conclusion: Mediocre levels of theoretical knowledge and interpretation skills in ABG analysis were evident. Registrars reported dissatisfaction with current registrar ABG teaching. There is scope to improve the current EM curriculum with regards to ABG training, with the potential to reinforce existing registrar teaching sessions, enhance ‘on the floor’ ABG training in ECs, and to investigate and incorporate social media platforms and computer-assisted learning (CAL) techniques into existing teaching modalities. Consultant continuing education (CME) should focus on reinforcing existing ABG knowledge and interpretation skills.
Assessment of documented adherence to critical actions in paediatric emergency care at a district-level public hospital in South Africa
(Elsevier, 2021) Berends, Esmee A.; Erasmus, Elaine; Van Veenendaal, Nicole R.; Mukonkole, Suzan N.; Lahri, Saad; Van Hoving, Daniel J.
Introduction: The provision of high-quality care is vital to improve child health and survival rates. A simple, practice-based tool was recently developed to evaluate the quality of paediatric emergency care in resource-limited settings in Africa. This study used the practice-based tool to describe the documented adherence to critical actions in paediatric emergency care at an urban district-level hospital in South Africa and assess its relation to clinical outcomes. Methods: This study is a retrospective observational study covering a 19-month period (September 2017 to March 2019). Patients <13 years old, presenting to the emergency centre with one of six sentinel presentations (seizure, altered mental status, diarrhoea, fever, respiratory distress and polytrauma) were eligible for inclusion. In the patients' files, critical actions specific for each presentation were checked for completion. Post-hoc, a seventh group ‘multiple diagnoses’ was created for patients with more than one sentinel disease. The action completion rate was tested for association with clinical outcomes. Results: In total, 388 patients were included (median age 1.1 years, IQR 0.3–3.6). The action completion rate varied from 63% (polytrauma) to 90% (respiratory distress). Participants with ≥75% action completion rate were younger (p < 0.001), presented with high acuity (p < 0.001), were more likely to be admitted (adjusted OR 2.2, 95%CI: 1.2–4.1), and had a hospital stay ≥4 days (adjusted OR 3.4, 95%CI: 1.5–7.9). Conclusion: A high completion rate was associated with young age, a high patient acuity, hospital admission, length of hospital stay ≥4 days, and the specific sentinel presentation. Future research should determine whether or not documented care corresponds with the quality of delivered care and the predictive value regarding clinical outcome.
Assessment of routine laboratory screening of adult psychiatric patients presenting to an emergency centre in Cape Town
(Health and Medical Publishing Group (HMPG), 2011-12) Crede, Andreas; Geduld, Heike; Wallis, Lee
Managing mental health patients forms part of the workload in emergency centres (ECs) throughout the Western Cape (WC), which has an estimated overall lifetime prevalence of mental health disorders of 39.4%. The Mental Health Care Act of 2002 requires that patients presenting with a mental health disorder and requiring involuntary or assisted admission be admitted to a designated hospital for 72 hours for assessment and treatment. Their entry point in most cases is via the EC, which places additional strain on emergency facilities. The high incidence of mental health disorders in adolescence, when many adult mental health conditions begin, is expected to increase because of increasing social stressors such as poverty, displacement and conflict in low-income areas.3 We can therefore expect an increasing human and financial resources burden on health care facilities.
The association between hospital arrival time, transport method, prehospital time intervals, and in-hospital mortality in trauma patients presenting to Khayelitsha Hospital, Cape Town
(Elsevier, 2018) Moller, Anders; Hunter, Luke; Kurland, Lisa; Lahri, Sa'ad; Van Hoving, Daniel J.
Introduction: Trauma is a leading cause of unnatural death and disability in South Africa. The aim of the study was to determine whether method of transport, hospital arrival time or prehospital transport time intervals were associated with in-hospital mortality among trauma patients presenting to Khayelitsha Hospital, a district-level hospital on the outskirts of Cape Town, South Africa. Methods: The Khayelitsha Hospital Emergency Centre database was retrospectively analysed for trauma-related patients presenting to the resuscitation area between 1 November 2014 and 30 April 2015. Missing data and additional variables were collected by means of a chart review. Eligible patients’ folders were scrutinised for hospital arrival time, transport time intervals, transport method and in-hospital mortality. Descriptive statistics were presented for all variables. Categorical data were analysed using the Fisher’s Exact test and Chi-square, continuous data by logistic regression and the Mann Whitney test. A confidence interval of 95% was used to describe variance and a p-value of <0.05 was deemed significant. Results: The majority of patients were 19–44 year old males (n=427, 80.3%) and penetrating trauma the most frequent mechanism of injury (n=343, 64.5%). In total, 258 (48.5%) patients arrived with their own transport, 254 (47.7%) by ambulance and 20 (3.8%) by the police service. The arrival of trauma patients peaked during the weekend, and was especially noticeable between midnight and six a.m. In-hospital mortality (n=18, 3.4%) was not significantly affected by transport method (p=0.26), hospital arrival time (p=0.22) or prehospital transport time intervals (all p-values >0.09). Discussion: Method of transport, hospital arrival time and prehospital transport time intervals did not have a substantially measurable effect on in-hospital mortality. More studies with larger samples are suggested due to the small event rate.
The availability of alternative devices for the management of the difficult airway in public emergency centres in the Western Cape
(Stellenbosch : Stellenbosch University, 2017-12) Jooste, Willem Johannes Lodewyk; Van Hoving, Daniel Jacobus; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine.
ENGLISH SUMMARY: Background: The failed or difficult airway is a rare, but life-threatening situation. Alternative airway devices to direct laryngoscopy are essential aids to manage these scenarios successfully. Objective: To determine which alternative airway devices are currently available in public emergency centres in the Western Cape Province, South Africa. Methods: A cross sectional study was conducted in 15 emergency centres. Data regarding the availability of different classes of alternative airway devices was documented on a standardised data collection sheet by a single investigator via direct observation. Incomplete or non-functional equipment was classified as ‘unavailable’. Summary statistics were used to describe the data. Results: Twenty-six different types of alternative airway devices were documented. Three centres (20%) had no alternative airway device. Five centres (33.3%) stocked only one device, three centres (20%) had two devices and four centres (26.7%) had more than two devices. Most centres (n=12, 80%) stocked supraglottic airways (only one centre (6.7%) had paediatric sizes). Tracheal tube introducers were available in five centres (33.3%). Four centres (26.7%) had video-laryngoscopes, but none had optical laryngoscopes. Retroglottic devices and needle cricothyroidotomy equipment were available in two centres (13.3%). Although surgical cricothyroidotomy equipment was available, the equipment was widely dispersed and only three centres (20%) had pre-packed sets available. None of the specialised paediatric centres had needle cricothyroidotomy equipment readily available. Conclusion: The study demonstrated that Western Cape public emergency centres are currently inadequately stocked with regards to alternative airway devices. A guideline regarding the procurement and implementation of these devices is needed.
Availability, functionality and access of blood pressure machines at the points of care in public primary care facilities in Tororo district, Uganda
(AOSIS, 2021-01) Besigye, Innocent K.; Okuuny, Vicent; Armstrong-Hough, Mari; Katahoire, Anne R.; Sewankambo, Nelson K.; Mash, Bob; Katamba, Achilles
Background: Early diagnosis of hypertension prevents a significant number of complications and premature deaths. In resource-variable settings, diagnosis may be limited by inadequate access to blood pressure (BP) machines. We sought to understand the availability, functionality and access of BP machines at the points of care within primary care facilities in Tororo district, Uganda. Methods: This was an explanatory sequential mixed-methods study combining a structured facility checklist and key informant interviews with primary care providers. The checklist was used to collect data on availability and functionality of BP machines within their organisational arrangements. Key informant interviews explored health providers’ access to BP machines. Results: The majority of health facilities reported at least one working BP machine. However, Health providers described limited access to machines because they are not located at each point of care. Health providers reported borrowing amongst themselves within their respective units or from other units within the facility. Some health providers purchase and bring their own BP machines to the health facilities or attempted to restore the functionality of broken ones. They are motivated to search the clinic for BP machines for some patients but not others based on their perception of the patient’s risk for hypertension. Conclusion: Access to BP machines at the point of care was limited. This makes hypertension screening selective based on health providers’ perception of the patients’ risk for hypertension. Training in proper BP machine use and regular maintenance will minimise frequent breakdowns.
Barriers to accessing cervical cancer screening among HIV positive women in Kgatleng district, Botswana : a qualitative study
(Public Library of Science, 2018) Matenge, Tjedza G.; Mash, Bob
Background: Low and middle-income countries have a greater share of the cervical cancer burden, but lower screening coverage, compared to high-income countries. Moreover, screening uptake and disease outcomes are generally worse in rural areas as well as in the HIV positive population. Efforts directed at increasing the screening rates are important in order to decrease cancer-related morbidity and mortality. This study aimed to explore the barriers to women with HIV accessing cervical cancer screening in Kgatleng district, Botswana. Methods: A phenomenological qualitative study utilising semi-structured interviews with fourteen HIV positive women, selected by purposive sampling. The interviews were transcribed verbatim and the 5-steps of the framework method, assisted by Atlas-ti software, was used for qualitative data analysis. Results:Contextual factors included distance, public transport issues and work commitments. Health system factors highlighted unavailability of results, inconsistent appointment systems, long queues and equipment shortages and poor patient-centred communication skills, particularly skills in explanation and planning. Patient factors identified were lack of knowledge of cervical cancer, benefits of screening, effectiveness of treatment, as well as personal fears and misconceptions. Conclusion: Cervical cancer screening was poorly accessed due to a weak primary care system, insufficient health promotion and information as well as poor communication skills. These issues could be partly addressed by considering alternative technology and one-stop models of testing and treating.

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