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- ItemA 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 PatrickBackground. 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.
- ItemAbdominal 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.
- ItemAccess 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.
- ItemAdherence 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, LucieENGLISH 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.
- ItemAdmission 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, LucieObjective: 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.
- ItemAdrenaline 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.
- ItemAdult 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, KarenIntroduction: 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.
- ItemAfrican 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.
- ItemAssessment 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.
- ItemAssessment 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, LeeManaging 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.
- ItemThe 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.
- ItemAvailability, 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, AchillesBackground: 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.
- ItemBarriers 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, BobBackground: 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.
- ItemThe burden of HIV and tuberculosis on the resuscitation area of an urban district-level hospital in Cape Town(Elsevier, 2021) Swarts, Lynne; Lahri, Saad; Van Hoving, Daniel J.Introduction: Many patients present to emergency centres with HIV and tuberculosis related emergencies. Little is known about the influence of HIV and tuberculosis on the resuscitation areas of district-level hospitals. The primary objective was to determine the burden of non-trauma patients with HIV and/or tuberculosis presenting to the resuscitation area of Khayelitsha Hospital, Cape Town. Methods: A retrospective analysis was performed on a prospectively collected observational database. A randomly selected 12-week sample of data from the resuscitation area was used. Trauma and paediatric (<13 years) cases were excluded. Patient demographics, HIV and tuberculosis status, disease category, investigations and pro- cedures undertaken, disposition and in-hospital mortality were assessed. HIV and tuberculosis status were determined by laboratory confirmation or from clinical records. Descriptive statistics are presented and com- parisons were done using the χ2-test or independent t-test. Results: A total of 370 patients were included. HIV prevalence was 38.4% (n = 142; unknown n = 78, 21.1%), tuberculosis prevalence 13.5% (n = 50; unknown n = 233, 63%), and HIV/tuberculosis co-infection 10.8% (n = 40). HIV and tuberculosis were more likely in younger patients (both p < 0.01) and more females were HIV- positive (p < 0.01). Patients with tuberculosis spend 93 min longer in the resuscitation area than those without (p = 0.02). The acuity of patients did not differ by HIV or tuberculosis status. Infectious-related diseases and diseases of the digestive system occurred significantly more in the HIV-positive group, and endocrine-related diseases and diseases of the nervous system in HIV-negative patients. HIV-positive patients received more abdominal ultrasound examinations (p < 0.01), blood cultures (p < 0.01) and intravenous antibiotics (p < 0.01). In-hospital mortality was 17% and was not influenced by HIV status (p = 0.36) or tuberculosis status (p = 0.29). tuberculosis on the resuscitation area of a district level nor tuberculosis status were associated with in-hospital mortality.
- ItemThe burden of intentional self-poisoning on a district-level public hospital in Cape Town, South Africa(Elsevier, 2018) Van Hoving, Daniel J.; Hunter, Luke D.; Gerber, Rachel (Elre) J.; Lategan, Hendrick J.; Marks, Carine J.Introduction: Intentional self-poisoning is a significant part of the toxicological burden experienced by emergency centres. The aim of this study was to describe all adults presenting with intentional self-poisoning over a six-month period to the resuscitation unit of Khayelitsha Hospital, Cape Town. Methods: Adult patients with a diagnosis of intentional self-poisoning between 1 November 2014 and 30 April 2015 were retrospectively analysed after eligible patients were obtained from the Khayelitsha Hospital Emergency Centre database. Missing data and variables not initially captured in the database were retrospectively collected by means of a chart review. Summary statistics were used to describe all variables. Results: A total of 192 patients were included in the analysis. The mean age was 27.3 years with the majority being female (n=132, 68.8%). HIV-infection was a comorbidity in 39 (20.3%) patients, while 13 (6.8%) previously attempted suicide. Presentations per day of the week were almost equally distributed while most patients presented after conventional office hours (n=152, 79.2%), were transported from home (n=124, 64.6%) and arrived by ambulance (n=126, 65.6%). Patients spend a median time of 3h37m in the resuscitation unit (interquartile range 1 h 45m–7 h 00 m; maximum 65 h 49 m). Patient acuity on admission was mostly low according to both the Triage Early Warning Score (non-urgent n=100, 52.1%) and the Poison Severity Score (minor severity n=107, 55.7%). Pharmaceuticals were the most common type of toxin ingested (261/343, 76.1%), with paracetamol the most frequently ingested toxin (n=48, 25.0%). Eleven patients (5.7%) were intubated, 27 (14.1%) received N-acetylcysteine, and 18 (9.4%) received benzodiazepines. Fourteen (7.3%) patients were transferred to a higher level of care and four deaths (2%) were reported. Discussion: Intentional self-poisoning patients place a significant burden on emergency centres. The high percentage of low-grade acuity patients managed in a high-acuity area is of concern and should be investigated further.
- ItemThe Cape Triage Score : a triage system for South Africa(Health and Medical Publishing Group (HMPG), 2006-01) Wallis, L. A.; Gottschalk, S. B.; Wood, D.; Bruijns, S.; De Vries, S.; Balfour, C.; Cape Triage GroupThe Cape Triage Score (CTS) has been derived by the Cape Triage Group (CTG) for use in emergency units throughout South Africa. It can also be used in the pre-hospital setting, although it is not designed for mass casualty situations. The CTS comprises a physiologically based scoring system and a list of discriminators, designed to triage patients into one of five priority groups for medical attention. Three versions have been developed, for adults, children and infants. As part of the ongoing assessment process the CTG would value feedback from the readers of this Journal.
- ItemCardiopulmonary resuscitation by emergency medical services in South Africa : barriers to achieving high quality performance(Elsevier, 2018) Veronese, Jean-Paul; Wallis, Lee; Allgaier, Rachel; Botha, RyanIntroduction: Survival rates from out-of-hospital cardiac arrest significantly improve when high-quality cardiopulmonary resuscitation (CPR) is performed. Despite sudden cardiac arrest being a leading cause of death in many parts of the world, no studies have determined the quality of CPR delivery by Emergency Medical Services (EMS) personnel in South Africa. The aim of this study was to determine the quality of CPR provision by EMS staff in a simulated setting. Methods: A descriptive study design was used to determine competency of CPR among intermediatequalified EMS personnel. Theoretical knowledge was determined using a multiple-choice questionnaire, and psychomotor skills were video-recorded then assessed by independent reviewers. Correlational and regression analysis were used to determine the effect of demographic information on knowledge and skills. Results: Overall competency of CPR among participants (n = 114) was poor: median knowledge was 50%; median skill 33%. Only 25% of the items tested showed that participants applied relevant knowledge to the equivalent skill, and the nature and strength of knowledge influencing skills was small. Demographic factors that significantly influenced both knowledge and skill were the sector of employment, the guidelines EMS personnel were trained to, age, experience, and the location of training. Conclusion: Overall knowledge and skill performance was below standard. This study suggests that theoretical knowledge has a small but notable role to play on some components of skill performance. Demographic variables that affected both knowledge and skill may be used to improve training and the overall quality of Basic Life Support CPR delivery by EMS personnel.
- ItemCase mix of patients managed in the resuscitation area of a district-level public hospital in Cape Town(Elsevier, 2017-03) Hunter, L. D.; Lahri, S.; Van Hoving, D. J.Introduction: At the core of the district health system is the emergency centre, for many the entry point into the healthcare system. Limited data is available on the patient population served by district-level emergency centres in South Africa. The objective of this study is to describe the case mix of adult patients managed in the resuscitation unit of a district-level hospital in the Western Cape. Methods: A six-month prospective observational study was conducted in the resuscitation unit of Khayelitsha Hospital. Data were collected by clinicians in the unit by means of a Smartphone application on their own devices. Variables collected included patient demographics, patient acuity, patient comorbidities, diagnosis made in the unit, interventions received, length of stay, and disposition. Summary statistics were used to describe all variables. Results: A total of 2324 patient admissions were analysed. The mean age was 36.9 years with a male predominance (n = 1367, 58.8%). Most patients were triaged into high-acuity categories (n = 1626, 70%). HIV infection was the most common comorbidity (n = 530, 22.8%). Acute medical (n = 1181, 50.8%) and trauma-related patients (n = 928, 39.9%) dominated the cohort. The median length of stay was 195 min and 502 (21.6%) patients were transferred to higher levels of care. There were 74 (3.2%) deaths. Conclusion: This study yields novel epidemiological data of emergency care in a district-level emergency centre. It highlights the burden of trauma and acute medical emergencies at the district level and can be used as a foundation for further research to provide targeted and effective healthcare to all citizens.
- ItemClinical teams' experiences of crowding in public emergency centres in Cape Town, South Africa(Elsevier, 2020) Van De Ruit, Catherine; Lahri, Saad; Wallis, Lee A.Introduction: Crowding is a significant challenge for emergency centres (ECs) globally. While South Africa is not alone in reckoning with high patient demand and insufficient resources to treat these patients; staff-to-patient ratios are generally lower than in the Global North. The study of crowding and its consequences for patient care is a key research priority for strengthening the quality and efficacy of emergency care in South Africa. The study set out to understand frontline staff's perspectives on crowding in Cape Town public ECs to learn how they cope in such high- pressure working conditions, determine what they see as the factors contributing to crowding, and obtain their recommendations for reform. Methods: This research is a qualitative study from interviews and observations at five ECs in Cape Town, con- ducted in June and July 2017. In total 43 staff were interviewed individually or in pairs. The interviews included physicians of varying levels of experience (25), and registered or enrolled nurses (18). Data were analysed with the qualitative text-analysis software NVivo. Results: Both doctors and nurses saw crowding as a consequence of three factors: 1) limited bed space in the EC, 2) insufficient health professionals to care for admitted patients, and 3) the presence of boarders. Systemic or organizational factors as well as human resource scarcity were determined to be the key reasons for crowding. Discussion: With its high patient acuity and volume and its limited human and material resources, South Africa is an important case study for understanding how emergency care providers manage working in crowded conditions. The solutions to crowding recommended the EC workforce and to add discharge lounges and examination tables.
- ItemComparison of mean on-scene times : road versus air transportation of critically ill patients in the Western Cape of South Africa(BMJ Publishing Group, 2007-12) Van Hoving, D. J.; Smith, W. P.; Wallis, L. A.Background: The South African setting lends itself to the extensive use of air transport. There is a perception with healthcare providers that flight crews spend too much time with a patient before departure. The main advantage of aero medical transport is to minimise the delay to definitive care and prolonged on-scene time defies this objective. A study was carried out to examine the mean on-scene times of aero medical and road transport of critically ill patients in the Western Cape of South Africa. Methods: In this retrospective observational study, all critically ill patients transported in the Western Cape between September 2005 and May 2006 were evaluated. The mean on-scene time for each transport mode was calculated. Road transport was compared with air transport (rotor and fixed wing). Every transport mode was further divided into mission types: ‘‘scene’’ missions (scene to a healthcare facility) or ‘‘inter-facility’’ missions (from one healthcare facility to another). Results: A total of 7924 transports were included in the study, 7580 of which (95.7%) were road transports. The air transport group spent 53.2 min (95% CI 51.1 to 55.4) at the scene compared with 27.9 min (95% CI 27.5 to 28.4) for the road transport group. There was a significant difference between scene and inter-facility missions in the air transport group (mean 31.7 min for scene missions vs 58.7 min for inter-facility missions; p,0.001). A significant difference was also found in the road transport (mean 24.6 min for scene missions vs 31.9 min for interfacility missions; p,0.001). Conclusion: The on-scene time for transport missions by road is significantly less than for those done by air. There are significant differences between scene and inter-facility missions in both transport modes. Capacity building programmes with ongoing education and training of staff at referring facilities should be implemented.