Department of Family and Emergency Medicine

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Acceptance of and adherence to full anti-retroviral therapy for prevention of mother to child transmission in HIV infected pregnant women with CD4 count above 350 at Nhlangano Health Centre, Swaziland.
(Stellenbosch : Stellenbosch University, 2018-03) Ndakit, Manighuli Kambasu; Blitz, Julia; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine. Family Medicine and Primary Care.
ENGLISH SUMMARY : Epidemic of HIV infection is hitting Swaziland where the prevalence is among the highest in the world. Nhlangano Health Centre (NHC) in collaboration with Medecins Sans Frontiers Switzerland (MSF Switzerland) opted to hit early by starting Highly Active Anti-retroviral Therapy (HAART) among HIV infected pregnant women with CD4 count cells above 350. This new intervention raised concerns on acceptability and adherence which needed to be assessed. Study design: This was a descriptive study which explored the acceptance of and adherence of pregnant women to full anti-retroviral therapy at Nhlangano Health Centre in the period from 24th June 2014 to 23rd June 2015. The level of adherence was assessed by announced pill counts on subsequent visits. Then, 6 months after initiation, the viral load and a second CD4 count were determined. Results: 98 participants were recruited and initiated; one later died. 80.6% resided in the rural area. 80.6% attended secondary school. Majority were single (79.6%). Mean age was 25.4 years. 64.3% booked at 2nd trimester. Most were multiparous (75.5%). Mean haemoglobin was 11.1g/dl. After 6 months, mean CD4 count was 709.4 up from 554.4 (initial) and 66 (95.6%) had undetectable viral load risen from 14 (20.2%) at initiation. 69 participants (70.4%) were adherent to treatment; 3 (3.1%) of them failed to suppress completely the viral loads. 13 pregnant women refused HAART; of these 12 were interviewed and one declined. The rate of acceptance was 88.3%. Conclusion: Most of the HIV infected pregnant women who visited the clinic accepted the treatment, their CD4 count increased and had undetectable viral loads after 6 months. Anti-retroviral therapy is effective and can be successfully initiated in pregnant women with CD4 count above 350 but should be monitored closely to avoid loss to follow-up.
Adherence of HIV/AIDS patients to antiretroviral therapy in a district hospital in Nankudu, Namibia
(Stellenbosch : Stellenbosch University, 2014-04) Okebie, C. O.; Pather, Michael; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Interdisciplinary Health Sciences. Family Medicine and Primary Care.
ENGLISH SUMMARY : Background: Non-adherence to highly active antiretroviral therapy (HAART) is a strong predictor of progression to AIDS and death. It remains the most important potentially alterable factor that determines treatment outcome. AIM: The main purpose of this study is to determine the current frequency of adherence to HAART in a major HIV/AIDS treatment center in Nankudu District and to identify the local factors contributing to non-adherence. OBJECTIVES: To assess and measure the adherence to antiretroviral therapy. To assess and describe the defaulter rate To assess and describe the interruption rate To describe the local barriers to sub-optimal adherence in the sample patients Methods: The study was a descriptive survey of the below mentioned three methods used to assess adherence to HAART and the determination of local barriers to adherence. The three methods used to measure HAART adherence were: pill counts, pharmacy refill data and self-report. The participants CD4 counts and viral loads were also evaluated. It included a randomly selected sample of 225 adult patients receiving HAART treatment in the Communication for Disease Control (CDC)-HIV clinic of Nankudu district hospital of Namibia. Results: A total of 90% of the patients had an adherence >95% comparable to those reported in most sub-Saharan Africa. The major local barriers to adherence included: distance from clinic (100%), lack of food (100%), lack of money (100%), poverty (100%), occupational factors-migration (100%), travel (81%), ran out of medicine (69%), too busy (69%), medication side effects (56%), felt better ( 56%) and too sick (50%). The major reasons given by the treatment defaulters were similar to those given by the treatment interrupters except for stigma (100%), compared to 19% for the treatment interrupter. Conclusion: The level of HAART adherence in the Communication Diseases Control (CDC)- HIV Clinic, of Nankudu District Hospital in Namibia is comparable to those reported in most sub-Saharan Africa, which is the recommended 95%. The pattern of non-adherence is characterized by treatment defaulters and interrupters. The study revealed that there were more treatment interrupters than defaulters. Financial constraints, travel, running out of ARV medicine, food insecurity, poverty, distance from the clinic, were the major reasons given by the treatment interrupters, while occupational factors, lack of transport, stigma, and long distance of the health facility were the major reasons given by the treatment defaulters.
Adherence to antiretroviral therapy at the Dora Nginza Hospital adult wellness clinic, Port Elizabeth, South Africa
(Stellenbosch : University of Stellenbosch, 2015-04) Ajudua, Febisola Ibilola; Pather, Michael; Ford, Pelisa; University of Stellenbosch. Faculty of Health Sciences. Dept. of Interdisciplinary Health Sciences. Family Medicine and Primary Care.
ENGLISH SUMMARY: Background: Sub Saharan Africa is home to approximately two thirds of the world’s population of HIV positive individuals. In view of the socioeconomic challenges of the region governments have provided antiretroviral therapy free to improve chances of survival among patients. However, adherence to antiretroviral therapy is recognised as more important in predicting patient survival. Aim: The study aimed to describe the prevailing factors that influence adherence to antiretroviral therapy. Methods: The study design was carried out using three methods of data collection. Focus group discussions, semi structured interviews and a questionnaire format. Setting: This study has been conducted among adult patients attending the Dora Nginza Hospital Adult wellness clinic. Results: The methods highlighted factors that influence antiretroviral therapy revealing psychosocial factors – lack of family support, not wanting to take medicines in front of people outside the home; patient factors – co morbidities that disturb patient adherence to therapy, a lack of trust in the patient-care giver relationship, fear of the drug side effects; socioeconomic factors – patients’ inability to afford food or transport costs to clinic appointments. In the semi structured interviews, 25% of patients self reported on poor adherence while in the questionnaire 5% of patients reported poor adherence. In assessing the effect of adherence to therapy on CD4 count and viral load there was a general increase in CD 4 count and a drop in viral load indicating clinical improvement in patients on therapy. Recommendation: There is a need for clinicians developing a health relationship with patients to facilitate adherence. The interventions designed to help patients in adherence to therapy should involve the patients in question in the designing of these interventions. Conclusion: Adherence monitoring is an important aspect of managing patients on antiretroviral therapy. The factors highlighted are similar to findings of other studies in similar contexts i.e. resource poor settings.
Advance directives or living wills- some reflections from general practitioners and frail care coordinators in a small town in KwaZulu Natal
(Stellenbosch : Stellenbosch University, 2012-12) Bull, A. P. A.; Mash, Bob; Stellenbosch University. Faculty of Health Sciences. Dept. of Interdisciplinary Health Sciences.
Background: - Living wills have long been associated with end-of- life care. This study explored the promotion and use of living wills amongst general practitioners and frail care nursing coordinators directly involved in the care of the elderly in Howick, Kwa-Zulu Natal. The study also explored their views regarding the proforma living will disseminated by the Living Will Society. Participants: - Seven general practitioners and three frail care nursing coordinators, making ten in total. Design: - Qualitative in-depth interviews and analysis, using the Framework method. Results:- Both doctors and nursing staff understood the concept of living wills and acknowledged their varied benefits to patient, family and staff. They were concerned about the lack of legal status. They felt that the proforma document from the Living Will Society was simple and clear. Despite identifying the low level of use of living wills, they felt that third party organisations and individuals should promote living wills Conclusion: - GPs and frail care nurse coordinators were knowledgeable of living wills in general and the Living Will Society proforma document in particular. They valued the contribution that living wills can make in the care of the elderly, benefitting patients, their families, health care workers and even the health system. They also valued the proforma living will document from the Living Will Society for its clarity and simplicity. However, both GPs and frail care nursing coordinators viewed the living will process as patient- driven and their main role was as custodians and not advocates of the living will.
After hours case mix at George provincial hospital emergency centre: a descriptive study
(Stellenbosch : Stellenbosch University, 2011-12) Van Wyk, P. S.; Jenkins, Louis; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Interdisciplinary Health Sciences. Family Medicine and Primary Care.
ENGLISH SUMMARY : Introduction: Emergency care of patients in South Africa has become a priority, with the establishment of emergency medicine as a specialty, developing a triage scoring system, and upgrading facilities and services. The Western Cape Comprehensive Service Plan stipulates that ninety percent of health care should be offered at level 1 (primary and district) health care, eight percent at level 2 (general specialist) care, and two percent at level 3 (super specialist) care. It is suspected that a significant proportion of primary health care patients are presenting after hours to level 2 facilities, like George hospital. Little is known about the nature or acuity levels of patients presenting after hours to the George provincial hospital Emergency Centre. A retrospective descriptive study was performed at George hospital in May 2010 to determine the afterhours case mix and workload. Methods: A total of 2560 patients presented afterhours at the emergency centre for the month of May 2010 that was triaged according to the Cape Triage Score (CTS). The case mix was analyzed according to a pre designed Microsoft Excel data sheet. Results: Three quarters of the case mix were adults and 25% were paediatric cases. Sixty five percent of patients were triaged green, followed by twenty seven percent yellow, five percent orange and two percent red (one percent absconded before doctors evaluation). Besides trauma related cases, respiratory and gastrointestinal problems were the most common presentations. The workload included on average fifty four patients per afterhours weekday, one hundred and thirty eight patients per 24-hour weekend days and one hundred and forty seven for the public holiday. Discussion: This study demonstrated that a significant number of the afterhours case mix presenting at George provincial hospital emergency centre consists of green and yellow level 1 cases which could be more appropriately managed at a level 1 health care facility.
Agents of change : the implementation and evaluation of a peer education programme on sexuality in the Anglican church of the Western Cape
(Stellenbosch : Stellenbosch University, 2011-12) Mash, Rachel A.; De Villiers, Pierre J. T.; Mash, Robert J.; Kapp, Chris; Stellenbosch University. Faculty of Health Sciences. Dept. of Interdisciplinary Health Sciences. Family Medicine and Primary Care.
ENGLISH ABSTRACT: INTRODUCTION Religion is important in Africa and many churches are involved in HIV ministry. Prevention programmes, however, are less frequent in the church setting and there is little evaluation of them. If an effective model is found, it can contribute to HIV prevention efforts in Sub-Saharan Africa. This study was conducted in the Cape Town Diocese of the Anglican Church. Fikelela, an HIV/AIDS project of the Diocese, developed a 20-session peer education programme (Agents of Change) aimed at changing the risky sexual behaviour of youth. Workshops were also aimed at parents. A literature review was conducted looking at three areas: 'theories of behaviour change', 'adolescent sexual relationships' and 'religion and HIV'. A conceptual framework for the programme was developed by integrating findings from the literature review. The aim of this research was to evaluate the effectiveness and functioning of the programme, to develop a best practice model and to make recommendations for the use of the programme in the wider church. METHODS Outcome mapping was used to integrate an approach to the design, monitoring and evaluation of the programme. Changes in project partners, key project strategies and organisational practices were all monitored. Project partners were defined as peer educators, facilitators, young people, clergy and parents. Monitoring allowed an in-depth understanding of which aspects of the programme worked. Evaluation was designed as a quasi-experimental study that compared non-randomly chosen intervention and control groups. 1352 participants took part at base-line, 176 returned matched questionnaires in the intervention groups and 92 in the control groups. Reported changes in attitudes, knowledge and sexual behaviour were compared between the two groups. RESULTS The main factors leading to the success of the programme were: a well developed curriculum and programme, effective training camps, the support given by facilitators to peer educators, ongoing mentoring and training, role modelling by peer educators, a participatory style of education and positive peer pressure within a strong church based social network. Challenging the church.s negative attitude to condoms was also important. The weakest areas of the programme were amongst clergy and parents and in challenging media messages and norms on gender. The project impact evaluation showed significant differences at baseline between genders in terms of sexual beliefs and behaviour. There was no significant impact of religiosity on sexual activity. The programme was successful at increasing condom usage (Condom use score 3.5 vs. 2.1; p=0.02) and reduced sexual debut (9.6% vs. 22.6%; p=0.04). There was increased abstinence amongst the intervention group, but it did not reach statistical significance (22.5% vs. 12,5%; p=0.25). There was no effect on the number of partners (Mean 1.7 vs. 1.4; p=0.67). CONCLUSIONS Implementation: The programme should be promoted as a youth development programme rather than an HIV prevention programme. Priority should be given to churches in communities with the highest HIV rates. The target group should include younger teens. Peer educators should be selected by peers not by adults. Strategies: The strategies of training camp and quarterly gatherings are effective, but a new strategy needs to be devised to impact the parents. Content: The programme should build self-efficacy amongst the youth, develop a critical consciousness about sexual health, provide positive messages rather than fear-inducing ones, address sexual coercion and persuasion, explore the linking of condom use with trust, address inter-generational sex and promote community outreach and advocacy activities. The programme is effective and meets the threshold of evidence required to be rolled out. It should be rolled out through the Anglican Church with its estimated membership of two million and could be adapted for other denominations as well.
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.
Antibiotics stewardship in diarrheal cases amongst children under 5 years in primary care settings in Maseru District, Lesotho
(Stellenbosch : Stellenbosch University, 2019-12) Wa Kone, Olga Kone; Malan, Zelra; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine. Family Medicine and Primary Care.
ENGLISH SUMMARY : No abstract available.
Are we ready for an emergency
(Stellenbosch : Stellenbosch University, 2012-12) Adamson, Kaashiefah; Hill, Paul; Stellenbosch University. Faculty of Health Sciences. Dept. of Interdisciplinary Health Sciences.
Introduction Trauma and emergencies contribute to the quadruple burden of disease in South Africa and being prepared for an emergency requires rapid access to emergency equipment, drugs and emergency trolleys to optimally manage an emergency. This is the first descriptive study looking specifically at essential emergency equipment, drugs and the emergency trolley required for the provision of optimal emergency care at Community Health Centres (CHCs) in the Western Cape Metropole. Aims and Objectives The aim of the study was to evaluate whether eight 24 hour emergency units at CHCs in the Western Cape Metropole had the appropriate and essential emergency equipment, drugs and emergency trolleys necessary for the delivery of optimal emergency care, using the Emergency Medicine Society of South Africa (EMSSA) guidelines as the audit tool. Objectives included: 1. To assess availability of essential emergency equipment 2. To assess availability of essential emergency drugs 3. To assess the functionality of existing emergency trolleys Methodology EMSSA guidelines were used as the evaluation audit tool to perform a survey of emergency equipment, drugs and emergency trolleys at eight 24 hour CHCs in the Western Cape Metro pole. Data collection for the study was conducted at the eight 24 hour CHCs over a 3 month period during the months of June 2012 to August 2012. The data was analyzed using the Statistical Package for Health Sciences (Statistica, version 10 of 2012) and Microsoft Excel. Results A total of 81 emergency equipment items, 43 emergency drug items (37 emergency drugs, 6 intravenous fluids) and 78 emergency trolley items were required to be in each emergency unit. An average of 62% of all recommended emergency equipment items, 80% of all emergency drugs and 52.4% of all emergency trolley items were found to be present in this survey. Essential emergency paediatric equipment including bag ventilation devices, Magill’s forceps, masks, intraosseous needles and appropriate blood pressure cuffs were found to be absent at 2 CHCs. All CHCs had access to a defibrillator and ECG machine but these were found to be dysfunctional at 2 CHCs due to expired batteries and no tracing paper being available. Expired first line emergency drugs (adrenaline and atropine) were found at certain CHCs. The recording of emergency trolley checklists and stocking of essential emergency items were found to be incongruent, inconsistent and not up to the recommended standard. Conclusion Essential emergency equipment and drugs and the functionality of emergency trolleys were found to be generally inadequate. Considerable deficiencies of essential emergency items were found, particularly paediatric equipment and drugs and this may negatively impact on resuscitative efforts and outcome in both paediatric and adult emergency care at CHCs in the Western Cape Metropole.
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.
Assessing the validity of random blood glucose testing for monitoring glycemic control and predicting HbA1c values in type 2 diabetics at Karl Bremer Hospital
(Stellenbosch : University of Stellenbosch, 2015-07-23) Oyekemi Funke, Daramola; Bob, Mash; University of Stellenbosch. Faculty of Health Sciences. Dept. of Interdisciplinary Health Sciences
ENGLISH ABSTRACT : The number of adults affected by diabetes mellitus in developing countries, such as South Africa, is projected to grow by 170%, from 84 to 228 million people between 1995 and 2025 .This high and increasing prevalence of diabetes worldwide, and the economic burden of diabetes on developing countries like South Africa emphasizes the importance of ensuring good glycemic control so as to slow down the rate of disease progression and prevent complications. The district health care facilities are the foundation of the health care system of South Africa. The current practice is that diabetics have a point of care random blood glucose (RBG) done on the morning of their clinic appointment and this is used as a form of assessment of glycemic control during the consultation. For further clinical decision making a HbA1c is done once a year as a benchmark of glycemic control. The practical clinical question that arises is whether the assumptions underlying local clinical decision making using the RBG are valid and to what extent RBG can be used to guide clinical management. Aim and Objectives: The aim of this study was to assess the strength of the correlation between RBG and HbA1c and to make recommendations for the interpretation of RBG results in adult patients with Type 2 Diabetes taken at Karl Bremer District Hospital out-patient department. The objectives were: To determine glycaemic control in the study population and compare differences between age, sex and racial groups , and determine the RBG cut-off with the best sensitivity and specificity for predicting poor glycaemic control (HbA1c>7.0% ) as well as the predictive value, likelihood ratio and pre/post-test odds and probability at this cut off. Methods: A retrospective analysis of existing hospital data and the HbA1c tests requested from the NHLS by Karl Bremer Hospital over the 2011 year period. The data was analysed by means of a receiver operating characteristic (ROC) curve analysis to determine the value of RBG with the best combination of sensitivity and specificity to predict poor control of diabetes. A p-value of < 0.05 was assumed to represent statistical significance and 95% confidence intervals were used to describe the estimation of unknown parameters. HbA1c level of < = 7% was taken as representing good control and > 7% poor control. Results: Data was obtained on 349 diabetic patients of whom 203 (58.2%) were female and 146 (41.8%) male. This study population had a mean age of 54.7 years, mean RBG of 13.0mmol/l and mean HBA1c of 9.4%. The total number of black patients was 79 (23%), coloured patients 147 (42%) and white patients 122 (35) % and their mean RBG were 15.4 mmol/l, 12.8 mmol/l and 11.9 mol/l respectively. There was a statistically significant correlation between increasing RBG and increasing HbA1c (p< 0.01). The best value obtained on the ROC curve was an RBG of 9.8 mmol/l, which had a sensitivity of 77% and a specificity of 75%, positive predictive value of 0.88, positive likelihood ratio 3.08 and post-test probability of 88.2% for predicting an HbA1c above 7%. Conclusion: It was concluded that a moderate correlation exists between RBG and HbA1c in this population of diabetic patients. .The best RBG for determining poor control, defined as a HbA1c>7.0%, was found to be 9.8mmol/l and this RBG had a sensitivity of 77% , specificity of 75% and positive predictive value of 88%. Significant differences were found in pre- and post -test probability for different racial groups. Point of care testing using this level of RBG for clinical decision making will inappropriately categorise 23% of patients in this population and therefore introducing point of care testing for HbA1c is recommended.
Assessing the validity of random blood glucose testing for monitoring glycemic control and predicting HbA1c values in type 2 diabetics at Karl Bremer hospital
(Stellenbosch : Stellenbosch University, 2012-12) Daramola, Oyekemi Funke; Mash, R.; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Interdisciplinary Health Sciences. Family Medicine and Primary Care.
ENGLISH ABSTRACT: Background: The number of adults affected by diabetes mellitus in developing countries, such as South Africa, is projected to grow by 170%, from 84 to 228 million people between 1995 and 2025 .This high and increasing prevalence of diabetes worldwide, and the economic burden of diabetes on developing countries like South Africa emphasizes the importance of ensuring good glycemic control so as to slow down the rate of disease progression and prevent complications. The district health care facilities are the foundation of the health care system of South Africa. The current practice is that diabetics have a point of care random blood glucose (RBG) done on the morning of their clinic appointment and this is used as a form of assessment of glycemic control during the consultation. For further clinical decision making a HbA1c is done once a year as a benchmark of glycemic control. The practical clinical question that arises is whether the assumptions underlying local clinical decision making using the RBG are valid and to what extent RBG can be used to guide clinical management. Aim and Objectives: The aim of this study was to assess the strength of the correlation between RBG and HbA1c and to make recommendations for the interpretation of RBG results in adult patients with Type 2 Diabetes taken at Karl Bremer District Hospital out-patient department. The objectives were: To determine glycaemic control in the study population and compare differences between age, sex and racial groups , and determine the RBG cut-off with the best sensitivity and specificity for predicting poor glycaemic control (HbA1c>7.0% ) as well as the predictive value, likelihood ratio and pre/post-test odds and probability at this cut off. Methods: A retrospective analysis of existing hospital data and the HbA1c tests requested from the NHLS by Karl Bremer Hospital over the 2011 year period. The data was analysed by means of a receiver operating characteristic (ROC) curve analysis to determine the value of RBG with the best combination of sensitivity and specificity to predict poor control of diabetes. A p-value of < 0.05 was assumed to represent statistical significance and 95% confidence intervals were used to describe the estimation of unknown parameters. HbA1c level of < = 7% was taken as representing good control and > 7% poor control. Results: Data was obtained on 349 diabetic patients of whom 203 (58.2%) were female and 146 (41.8%) male. This study population had a mean age of 54.7 years, mean RBG of 13.0mmol/l and mean HBA1c of 9.4%. The total number of black patients was 79 (23%), coloured patients 147 (42%) and white patients 122 (35) % and their mean RBG were 15.4 mmol/l, 12.8 mmol/l and 11.9 mol/l respectively. There was a statistically significant correlation between increasing RBG and increasing HbA1c (p< 0.01). The best value obtained on the ROC curve was an RBG of 9.8 mmol/l, which had a sensitivity of 77% and a specificity of 75%, positive predictive value of 0.88, positive likelihood ratio 3.08 and post-test probability of 88.2% for predicting an HbA1c above 7%. Conclusion: It was concluded that a moderate correlation exists between RBG and HbA1c in this population of diabetic patients. .The best RBG for determining poor control, defined as a HbA1c>7.0%, was found to be 9.8mmol/l and this RBG had a sensitivity of 77% , specificity of 75% and positive predictive value of 88%. Significant differences were found in pre- and post -test probability for different racial groups. Point of care testing using this level of RBG for clinical decision making will inappropriately categorise 23% of patients in this population and therefore introducing point of care testing for HbA1c is recommended.
The assessment of acceptance and identification of barriers to use of electronic medical records by doctors in emergency centres in Cape Town, South Africa
(Stellenbosch : Stellenbosch University, 2017-12) Chagani, Mohamedsuhel; Allgaier, Rachel; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine. Family Medicine and Primary Care.
ENGLISH SUMMARY: Introduction: Millions of people in developing countries face serious health risks. It is believed that incorporating technology into healthcare is one way to overcome some of these challenges faced by developing countries. However, acceptance of electronic medical records (EMRs) into daily practice has been poor despite these potential advantages. In order to realise the potential benefits from EMR technologies, they must be adopted broadly and assimilated deeply across healthcare settings. The study aimed to assess acceptance and barriers to use prior to implementation of EMRs. Methods: The Unified Theory of Acceptance and Use of Technology model was used to assess technology acceptance. A self-administered questionnaire-based survey was sent to emergency centre (EC) doctors working in district hospitals in the Cape Town metropolis. Results: With a 73% (n=105) response rate, participants believed that EMRs would be both useful in their practice and improve their productivity. Almost 50% (n=51) of participants felt that they would find EMRs easy to use and approximately 60% (n=61) felt they would receive management support. However, the participants felt that the necessary resources would not be available for success, specifically a lack of financial investment, training and support as well as poor infrastructure and project management skills. Conclusion: The study overall indicates that the majority of doctors are willing to use EMRs in their daily practice. Barriers to successful implementation were similar to those found in similar studies conducted in other environments, and include financial, technical and change process barriers. There is a need to conduct further studies involving other cadres of staff including ECs where EMRs are already in use.
Assessment of the impact of family physicians in the district health system of the Western Cape, South Africa
(Stellenbosch : University of Stellenbosch, 2015-12) Ferreira, Germarie; Mash, Bob; University of Stellenbosch. Faculty of Health Sciences. Dept. of Interdisciplinary Health Sciences.
The main aim was to explore the perceptions of rural district and metropolitan sub-structure managers on the impact of family physicians on the district health services. There were three main objectives: •To explore the perceived effect of Family Physicians on the health system performance (e.g. access to care, continuity of care, comprehensiveness of care, co-ordination of care)(27) •To explore the perceived effect of the Family Physicians on clinical processes (e.g. quality of care for HIV/AIDS, TB, maternal and child healthcare, non-communicable diseases, trauma) •To explore the perceived effect of Family Physicians on health outcomes (e.g. facility level mortality) Conclusion It was perceived that family physicians were fulfilling the role of competent clinician, consultant and leader of clinical governance well. Their role as a champion of community orientated primary care and as a clinical teacher was much less developed. They seemed to have a positive impact on the clinical processes for non-communicable chronic diseases, HIV and TB, mental health, eye care, child health and obstetrics. A few concerns were expressed about their skills in anaesthetics and surgery at rural hospitals. Access, co-ordination, comprehensiveness and efficiency of the health system were positively impacted. It was anticipated that in the long run health outcomes will be positively impacted.
Assessment, diagnosis and management of pulmonary tuberculosis in children under five years of age in the Langeberg sub-district, Western Cape, South Africa
(Stellenbosch : Stellenbosch University, 2020-12) Williams, Andrew; Pather, Michael Karl; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine. Family Medicine and Primary Care.
ENGLISH SUMMARY: Background: TB remains one of the top 10 leading causes of death worldwide as millions of people still contract the disease annually. It is estimated that TB caused between 1.2 and 1.4 million deaths globally in 2017. The incidence of TB in children is a reflection of the underlying factors that fuel the TB epidemic, as these infections reflect ongoing TB-transmission. Aim: To describe how the diagnosis of Pulmonary Tuberculosis (PTB) in children under 5 years is made in the Langeberg sub-district. Setting: The Langeberg sub-district includes Robertson and Montagu District Hospitals as well as their surrounding clinics. A total of nine primary healthcare (PHC) clinics as well as two mobile clinics serving the farm areas in the sub-district were included. Methods: A retrospective descriptive study was conducted. The researcher obtained statistics from the information management department of the Langeberg sub-district and utilised information of all known and notified cases of tuberculosis in the district. All cases of PTB diagnosed from 1st January 2018 to 31st December 2018, in children under 5 years of age were included. Results: A total sample of 166 folders were reviewed. A proven positive adult contact was identified in 39% of cases. A suggestive chest x-ray was found in 93,4% of cases although specific CXR findings were not documented. Gastric washings were done in 52 of the children and had a positive yield of 13%. A total of 4,7% had HIV/TB co-infection and 12% had comorbid malnutrition. 85,5% of children had a positive treatment outcome (treatment completed or cured). Conclusion: The diagnosis of PTB in children primarily remains a radiological diagnosis, but clinical factors like symptoms and their duration, weight trends and the presence of an adult contact have also been considered. Microbiological confirmation was absent in the majority of cases started on TB treatment. Comorbid HIV infection, malnutrition or asthma did not contribute to increased risk for adverse outcomes. Contact tracing needs to be improved within the sub-district.
At what cost? A descriptive study evaluating cost awareness of laboratory investigations in doctors working in district hospitals in the West Coast and Cape Winelands districts
(Stellenbosch : Stellenbosch University, 2019-12) Brownbridge, Joshua; Pather, Michael; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine. Family Medicine and Primary Care.
ENGLISH SUMMARY : Background: Globally the cost of health care is steadily increasing, and in South Africa it is no different. The budget for health care in the 2018 / 2019 financial year is R205 billion and is expected to increase by 7.8%. International research has found cost awareness amongst doctors to be poor and there is limited research in the South Africa. Improving cost awareness amongst clinicians has shown to have a cost saving effect. Aim: To evaluate cost awareness of laboratory investigations among doctors working in district hospitals in the West Coast and Cape Winelands Districts. Setting: Nine district hospitals within the West Coast and Cape Winelands Districts. Methods: A descriptive cross-sectional study in the form of a questionnaire was used. This questionnaire was adapted from previous international research. Results: A response rate of ninety percent was obtained. Doctors accurately estimated cost in 23.53% (95% CI 21.09 – 25.97) of thirty commonly requested investigations. Age, gender, years of experience, position held, and district of practice had no significant impact on cost awareness. On a scale of ten, doctors rated their cost awareness as 5.48, previous training 3.00, access to information on cost as 4.88, cost influencing their decision making as 6.73 and increasing cost awareness would change their ordering as 7.58. Conclusion: Cost awareness was found to be poor amongst doctors working in the West Coast and Cape Winelands and was uninfluenced by their demographic factors. Doctors acknowledged this, however, and reported that they had received minimal cost awareness training and that they had limited access to information about cost.

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