Emergency Medicine

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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.
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.
The burden of diabetic emergencies on the resuscitation area of a district-level public hospital in Cape Town
(Stellenbosch : Stellenbosch University, 2020-12) Lotter, Nuraan; Van Hoving, Daniel J.; Lahri, S.; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine. Emergency Medicine.
ENGLISH SUMMARY : Introduction: Diabetes and its complications continue to cause a daunting and growing concern on resource-limited environments. There is a paucity of data relating to the care of diabetic emergencies in the emergency centres of entry-level hospitals in Africa. The aim of this study was to describe the burden of diabetic emergencies presenting to the emergency centre of an urban district-level hospital in Cape Town, South Africa. Methods: The Khayelitsha Hospital Emergency Centre database was retrospectively analysed for patients presenting with a diabetic emergency within a 24-week randomly selected period. The database was supplemented by a retrospective chart review to include additional variables for participants with diabetic ketoacidosis (DKA), uncomplicated hyperglycemia, severe hypoglycaemia and hyperosmolar hyperglycaemic state (HHS). Summary statistics are presented of all variables. Results: The prevalence of all diabetic emergencies was 8.1% (197/2424) (DKA n=96, 48.7%; uncomplicated hyperglycaemia n=45, 22.8%; severe hypoglycaemia n=44, 22.3%; HHS n=12, 6%). The median age was 48 years, with those presenting with DKA being substantially younger (36 years). A likely precipitant was identified in 175 (88%) patients; infection was the most common precipitant (n=79, 40.1%). Acute kidney injury occurred in 80 (40.6%) cases. The median length of stay in the resuscitation area was 13 hours (IQR 7.2-24) and 101 (51.3%) participants represented with a diabetic- related emergency within six months of the study period. The overall mortality rate was 5% (n=10). Conclusion: This study highlights the high burden of diabetic emergencies on the provision of acute care at a district- level hospital. The high prevalence of diabetic emergency presentations (8%), the high infection rate (40%), and the high percentage of patients returning with a diabetic emergency (51%) could be indicative of the need for improved community-based diabetic programmes.
The characteristics of geriatric patients managed within the resuscitation unit of a district-level emergency centre in Cape Town
(Stellenbosch : Stellenbosch University, 2020-12) Simakoloyi, Natalie; Van Hoving, Daniel J.; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine. Emergency Medicine.
ENGLISH SUMMARY : Introduction: The world’s population is ageing and this trend is also seen in South Africa. This increase will invariably affect acute care services. The geriatric population attending emergency centres have not been described in the South African setting. The objective was to describe the characteristics of geriatric patients presenting to the resuscitation unit of a district-level hospital in Cape Town. Methods: All patients (≥65 years) managed within the resuscitation unit of Khayelitsha Hospital over an 8-month period (01 January - 30 August 2018) were retrospective analysed. Data were collected from the Khayelitsha Hospital Emergency Centre database and by means of a retrospective chart review. Summary statistics are presented of all variables. Results: A total of 225 patients were analysed. The median age was 71.1 years, 148 (65.8%) were female and all were residing in their family home. The majority (n=162, 72%) presented outside office hours, 124 (55.1%) arrived by ambulance, and 94 (41.8%) had presented to the emergency centre within the previous year. Only half the patients (n=114, 50.7%) were triaged as very urgent or higher. Most patients (n=169, 75.1%) were admitted by in-hospital services and the in-hospital mortality was 21.8% (n=49). Diseases related to the circulatory system (n=54, 24.0%) were the most frequent primary diagnosis and acute kidney injury were the most frequent secondary diagnosis (n=101, 44.9%). The most common comorbidities were hypertension (n=176, 78.2%) and diabetes (n=110, 48.9%), and 99 (44%) had three or more comorbidities. Polypharmacy (≥5 medications) occurred in 100 (44.4%) patients with 114 (50.7%) using medications from three or more different classes. The prevalence of hypernatremia was 2.6 % and for hyponatremia 54.4%. Conclusion: Geriatric patients managed within the resuscitation unit of a district-level hospital had a high return rate, multiple co-morbidities and a high prevalence of polypharmacy and hyponatraemia.
Clinical quality and performance measurement in the prehospital emergency medical services in the low-to- middle-income country setting
(Stellenbosch : Stellenbosch University, 2021-03) Howard, Ian Lucas; Wallis, Lee; Lindstrom, Veronica; Cameron, Peter; Castren, Maaret; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine. Emergency Medicine.
ENGLISH SUMMARY : Background: Measuring quality and safety in any healthcare setting however is highly contextual, and depends on the manner in which quality is defined or viewed within that setting. It is this contextual nature that has provoked significant debate and hindered efforts at developing formal standards or criteria for measuring quality and safety in healthcare, regardless of setting. Historically, performance within the Emergency Medical Services (EMS) delivering prehospital emergency care has been assessed primarily based on response times. While easy to measure and valued by the public, overall, response time targets are a poor predictor of quality of care and clinical outcomes. Aim: The overall aim of the research was to develop a framework for clinical quality and performance-based assessment of prehospital emergency care for use in the South African EMS. Method: The research was divided amongst four studies, with each study constituting one of the overall research objectives. Study I was a sequential explanatory mixed methods study with the aim of understanding the knowledge, attitudes and practices of clinical quality and performance assessment amongst South African EMS personnel. Part 1 consisted of a webbased cross-sectional survey, and Part 2 consisted of semi-structured telephonic interviews of select participants from Part 1 to explore the results of the survey. Descriptive statistics were carried out to summarise and present all survey items, and conventional content analysis employed to analyse the interview data. Study II utilised a three round modified Delphi study to identify, refine and review a list of appropriate quality indicators for potential use in the South African EMS setting. For Study III a novel quality indicator appraisal protocol was developed consisting of two categorical-based appraisal methods, combined with the qualitative analysis of their consensus application, and tested against the outcomes of Study II. Descriptive statistics were utilised to describe and summarize the categorical based appraisal data. Inter-rater reliability was calculated using percentage agreement and Gwet’s AC1. Correlation between the individual methods and the protocol was calculated using Spearman’s rank Correlation and z-test. Conventional content analysis was utilised to analyse the group discussions. Study IV utilised a multiple exploratory case study design to evaluate the current state of quality systems in the South African EMS. A formative assessment was conducted on the quality systems of four provincial EMS and one national private EMS, following which semi-structured interviews were conducted to further explore the results obtained from the formative assessment, supported by multiple secondary data sources. Descriptive statistics were utilised to describe and summarize the formative assessment. Conventional content analysis was utilised to analyse the interview data and document analysis utilised to sort and analyse the supporting data. Results: Despite relatively poor knowledge of organisational-specific quality systems, understanding of the core components and importance of quality systems was demonstrated. The role of these systems in the Low to Middle Income Country setting (LMICs) was supported by participants, where the importance of context, system transparency, reliability and validity were essential towards achieving ongoing success and utilisation. The role of leadership and communication towards the effective facilitation of such a system was equally identified. Participating services generally scored higher for structure and planning. Measurement and improvement were found to be more dependent on utilisation and perceived mandate. There was a relatively strong focus on clinical quality assessment within the private service, whereas in the provincial systems, measures were exclusively restricted to call times with little focus on clinical care. Staff engagement and programme evaluation were generally among the lowest scores. A multitude of contextual factors were identified that affected the effectiveness of quality systems, centred around leadership, vision and mission, and quality system infrastructure and capacity, guided by the need for comprehensive yet pragmatic strategic policies and standards. A total, 104 quality indicators reached consensus agreement including, 90 clinical QIs, across 15 subcategories, and 14 non-clinical QIs across two subcategories. Amongst the clinical category, airway management (n=13 QIs; 14%); out-of-hospital cardiac arrest (n=13 QIs; 14%); and acute coronary syndromes (n=11 QIs; 12%) made up the majority. Within the non-clinical category, adverse events made up the significant majority with nine QIs (64%). There was mixed inter-rater reliability of the individual methods. There was similarly poor to moderate correlation of the results obtained between the individual methods (Spearman’s rank correlation=0.42,p<0.001). From a series of 104 QIs, 11 were identified that were shared between the individual methods. A further 19 QIs were identified and not shared by each method, highlighting the benefits of a multimethod approach. Conclusion: For the purposes of this study we focused on the technical competence aspect of quality, in developing our measurement framework. Towards this, we identified a significant number of QIs assessed to be valid and feasible for the South African prehospital emergency care setting. The majority of which are centred around clinically focused processes of care, measures that are lacking in current performance assessment in EMS in South Africa. However, we also discovered the importance and influencing role of the individual practitioners and quality system in which the QIs will be implemented, a point highlighted across all the methodologies and studies. Given the potential magnitude of this influence, it is of the utmost importance that any measurement framework examining technical quality, have equal in-depth understanding of these factors in order to be successful.
Clinical quality and performance measurement in the prehospital emergency medical services in the low-to-middle-income country setting : developing clinical quality and performance indicators as a measure of care in South Africa
(Stellenbosch : Stellenbosch University, 2020-12) Howard, Ian; Wallis, Lee; Lindstrom, Veronica; Cameron, Peter; Castrén, Maaret; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine. Emergency Medicine.
ENGLISH SUMMARY : Background: Measuring quality and safety in any healthcare setting however is highly contextual, and depends on the manner in which quality is defined or viewed within that setting. It is this contextual nature that has provoked significant debate and hindered efforts at developing formal standards or criteria for measuring quality and safety in healthcare, regardless of setting. Historically, performance within the Emergency Medical Services (EMS) delivering prehospital emergency care has been assessed primarily based on response times. While easy to measure and valued by the public, overall, response time targets are a poor predictor of quality of care and clinical outcomes. Aim: The overall aim of the research was to develop a framework for clinical quality and performance-based assessment of prehospital emergency care for use in the South African EMS. Method: The research was divided amongst four studies, with each study constituting one of the overall research objectives. Study I was a sequential explanatory mixed methods study with the aim of understanding the knowledge, attitudes and practices of clinical quality and performance assessment amongst South African EMS personnel. Part 1 consisted of a webbased cross-sectional survey, and Part 2 consisted of semi-structured telephonic interviews of select participants from Part 1 to explore the results of the survey. Descriptive statistics were carried out to summarise and present all survey items, and conventional content analysis employed to analyse the interview data. Study II utilised a three round modified Delphi study to identify, refine and review a list of appropriate quality indicators for potential use in the South African EMS setting. For Study III a novel quality indicator appraisal protocol was developed consisting of two categorical-based appraisal methods, combined with the qualitative analysis of their consensus application, and tested against the outcomes of Study II. Descriptive statistics were utilised to describe and summarize the categorical based appraisal data. Inter-rater reliability was calculated using percentage agreement and Gwet’s AC1. Correlation between the individual methods and the protocol was calculated using Spearman’s rank Correlation and z-test. Conventional content analysis was utilised to analyse the group discussions. Study IV utilised a multiple exploratory case study design to evaluate the current state of quality systems in the South African EMS. A formative assessment was conducted on the quality systems of four provincial EMS and one national private EMS, following which semi-structured interviews were conducted to further explore the results obtained from the formative assessment, supported by multiple secondary data sources. Descriptive statistics were utilised to describe and summarize the formative assessment. Conventional content analysis was utilised to analyse the interview data and document analysis utilised to sort and analyse the supporting data. Results: Despite relatively poor knowledge of organisational-specific quality systems, understanding of the core components and importance of quality systems was demonstrated. The role of these systems in the Low to Middle Income Country setting (LMICs) was supported by participants, where the importance of context, system transparency, reliability and validity were essential towards achieving ongoing success and utilisation. The role of leadership and communication towards the effective facilitation of such a system was equally identified. Participating services generally scored higher for structure and planning. Measurement and improvement were found to be more dependent on utilisation and perceived mandate. There was a relatively strong focus on clinical quality assessment within the private service, whereas in the provincial systems, measures were exclusively restricted to call times with little focus on clinical care. Staff engagement and programme evaluation were generally among the lowest scores. A multitude of contextual factors were identified that affected the effectiveness of quality systems, centred around leadership, vision and mission, and quality system infrastructure and capacity, guided by the need for comprehensive yet pragmatic strategic policies and standards. A total, 104 quality indicators reached consensus agreement including, 90 clinical QIs, across 15 subcategories, and 14 non-clinical QIs across two subcategories. Amongst the clinical category, airway management (n=13 QIs; 14%); out-of-hospital cardiac arrest (n=13 QIs; 14%); and acute coronary syndromes (n=11 QIs; 12%) made up the majority. Within the non-clinical category, adverse events made up the significant majority with nine QIs (64%). There was mixed inter-rater reliability of the individual methods. There was similarly poor to moderate correlation of the results obtained between the individual methods (Spearman’s rank correlation=0.42,p<0.001). From a series of 104 QIs, 11 were identified that were shared between the individual methods. A further 19 QIs were identified and not shared by each method, highlighting the benefits of a multimethod approach. Conclusion: For the purposes of this study we focused on the technical competence aspect of quality, in developing our measurement framework. Towards this, we identified a significant number of QIs assessed to be valid and feasible for the South African prehospital emergency care setting. The majority of which are centred around clinically focused processes of care, measures that are lacking in current performance assessment in EMS in South Africa. However, we also discovered the importance and influencing role of the individual practitioners and quality system in which the QIs will be implemented, a point highlighted across all the methodologies and studies. Given the potential magnitude of this influence, it is of the utmost importance that any measurement framework examining technical quality, have equal in-depth understanding of these factors in order to be successful.
A comparison between differently skilled pre-hospital emergency care providers in major incident triage in South Africa
(Stellenbosch : Stellenbosch University, 2018-12) Ngabirano, Annet Alenyo; Van Hoving, Daniël Jacobus; Smith, Wayne Patrick; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine. Emergency Medicine.
ENGLISH SUMMARY : No abstract available.
Coronary care networks in the resource-limited setting : systems of care in South Africa
(Stellenbosch : Stellenbosch University, 2018-12) Stassen, Willem; Kurland, Lisa; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine. Emergency Medicine.
ENGLISH SUMMARY : BACKGROUND: Owing to an epidemiological transition observed throughout Sub-Saharan Africa, South Africa is experiencing an increase in the incidence of myocardial infarction. ST-elevation myocardial infarction (STEMI) occurs commonly in South Africa and at much younger ages than observed elsewhere in the world. Emergent treatment in the form of coronary reperfusion is required to reduce morbidity and mortality following STEMI. Political and socio-economic factors have led to large disparities in emergency healthcare access for many South Africans. Well organised networks of care (coronary care networks, CCNs) that seamlessly integrate prehospital care, in-hospital assessment and percutaneous coronary intervention is recommended to reduce mortality for these patients. CCNs are underdeveloped and under-studied in South Africa. To this end, the aims of this project was to examine the current state of Coronary Care Networks in South Africa, a low- to middle income country and to provide recommendations for future development of such networks. METHODS: This project was comprised of four studies. Study I was a cross-sectional descriptive study that aimed at determining the current PCI-capable facilities in South Africa and sought correlations between the resources, population, poverty and insurance status using Spearman’s Rho. Study II utilised proximity analysis to determine the average drive times of South African municipal wards (geopolitical subdivisions used for electoral purposes) to the closest PCI-capable facility for each South African province. It further determined the proportion of South Africans living within one and two hours respectively, from such a facility. Study III combined data obtained from Studies I and II with network optimisation modelling to propose an optimised reperfusion strategy for patients with STEMI, based on proximity, using the North West province as a case study. Finally, Study IV employed qualitative methodology to determine the barriers and facilitators to developing CCNs in South Africa by performing interviews with individuals working with the South African contexts of coronary care. RESULTS: South Africa has 62 PCI-capable facilities, with most PCI-facilities (n=48; 77%) owned by the private healthcare sector. A disparity exists between the number of private and state-owned PCI-facilities when compared to the poverty (r=0.01; p=0.17) and insurance status of individuals (r=-0.4; p=0.27) (Study I). This means that reperfusion by PCI is likely inaccessible to many despite approximately, 53.8% and 71.53% of the South African population living within 60 and 120 minutes of a PCI facility (Study II). Yet, we provide an efficient and swift model that provides a recommendation for the best reperfusion strategy even in the instance of a large amount of ward data with these additional constraints. This model can be run in realtime and can guide reperfusion decisions at the bedside or form the basis of regional reperfusion guidelines, and CCN development priorities (Study III). When considering the local CCN, we found an under-resourced CCN that is not prioritised by policymakers and displays considerable variation in performance based on time of day and geographic locale. Specific barriers to the development of CCNs in South Africa included poor recognition and diagnosis of STEMI, inappropriate transport and treatment decisions, and delays. Facilitators to the development of CCNs were regionalised STEMI treatment guidelines, further research and prehospital thrombolysis programmes (Study IV). CONCLUSION: South Africa has a shortage of PCI facilities. Even in areas with high concentrations of PCI facilities. In addition, many patients may not be able to access care due to socio-economic status. When considering proximity alone, most South Africans are able to access PCI within guideline timeframes. Despite this, prehospital thrombolysis should still be considered in some areas – as demonstrated by a novel approach that combines geospatial analysis and network optimisation modelling. This approach is able to efficiently determine the optimum reperfusion strategy for each geographic locale of South Africa. Current CCNs in South Africa are under-resourced, over-burdened and not prioritised. Future efforts should aim at improving STEMI recognition and diagnosis to decrease delays to reperfusion. The findings described should be considered and integrated into a future model of CCNs within South Africa, towards improving reperfusion times and finally morbidity and mortality.
A cross sectional study of the availability of paediatric emergency equipment in 24 hour cape town emergency medicine centres
(Stellenbosch : Stellenbosch University, 2019-12) Lai King, Lauren; Van Hoving, Daniel Jacobus; Cheema, Baljit; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine. Emergency Medicine.
ENGLISH SUMMARY : Background: Healthcare facilities are often not equipped to deliver effective paediatric emergency care despite a significant paediatric emergency patient burden. The availability of paediatric emergency equipment potentially impacts on morbidity and mortality. Objective: To describe the availability of essential, functional paediatric emergency resuscitation equipment on the resuscitation trolley, in 24-hour emergency centres within the Cape Town Metropole. Methods: A cross sectional study was conducted over a 6-month period in government funded hospitals (district-level and higher), within the Cape Town Metropole, providing 24-hour emergency paediatric care. A standardised data collection sheet of essential resuscitation equipment expected to be available on the resuscitation trolley, was used. Items were considered to be available if at least one piece of equipment was present. Functionality of equipment available on the resuscitation trolley was defined as: equipment that hadn’t expired, whose original packaging was not outwardly damaged or compromised and all components were present and intact. Comparisons were done using the χ2-test. Results: Overall, a mean of 43% (30/69) of equipment was available across all hospitals. Mean availability of functional equipment was 42% overall, 41% at district-level hospitals, and 45% at regional/tertiary hospitals (p=0.91). The overall mean availability of equipment in the resuscitation area was 49% across all hospitals. There was no difference between emergency centres run by emergency physicians and those run by non-emergency physicians (43% versus 41%, p=0.95). Conclusion: The suboptimal availability and functionality of equipment at district-level and higher is a modifiable barrier to the provision of high quality paediatric emergency care.
Cross-sectional study of paediatric case mix presenting to an emergency centre in Cape Town, South Africa, during COVID-19
(Stellenbosch : Stellenbosch University, 2021-12) Akuaake, Lembi Magano; Van Hoving, Daniel J.; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine.
ENGLISH SUMMARY : Objective: To describe and compare the effect of level 5 lockdown measures on the workload and case mix of paediatric patients presenting to a district- level emergency centre in Cape Town, South Africa. Methods: Paediatric patients (<13 years) presenting to Mitchells Plain Hospital were included. The level 5 lockdown period (27 March 2020–30 April 2020) was compared with similar 5- week periods immediately before (21 February 2020–26 March 2020) and after the lockdown (1 May 2020–4 June 2020), and to similar time periods during 2018 and 2019. Patient demographics, characteristics, International Statistical Classi"cation of Diseases and Related Health Problems, 10th Revision (ICD-10) diagnosis, disposition and process times were collected from an electronic patient tracking and registration database. The X2 test and the independent samples median test were used for comparisons. Results: Emergency centre visits during the lockdown period (n=592) decreased by 58% compared with 2019 (n=1413) and by 56% compared with the 2020 prelockdown period (n=1342). The proportion of under 1 year olds increased by 10.4% (p<0.001), with a 7.4% increase in self- referrals (p<0.001) and a 6.9% reduction in referrals from clinics (p<0.001). Proportionally more children were referred to inpatient disciplines (5.6%, p=0.001) and to a higher level of care (3.9%, p=0.004). Signi"cant reductions occurred in respiratory diseases (66.9%, p<0.001), injuries (36.1%, p<0.001) and infectious diseases (34.1%, p<0.001). All process times were signi"cantly different between the various study periods. Conclusion: Signi"cantly less children presented to the emergency centre since the implementation of the COVID-19 lockdown, with marked reductions in respiratory and infectious- related diseases and in injuries.
Describing and comparing the availability of acute care resources to treat new onset stroke in different income settings : a self-reported survey of acute care providers at the 2016 international conference on emergency medicine
(Stellenbosch : Stellenbosch University, 2019-12) Chunga, Ramadhan Mohamed; Allgaier, Rachel; Hendrikse, Clint; Bruijns, Stevan R.; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine.
ENGLISH SUMMARY : Introduction: Stroke affects 15 million people annually and is responsible for 5 million deaths per annum globally. In contrast to the trend in low- and middle-income countries (LMICs), stroke mortality is on the decline in high-income countries (HICs). Even though the availability of resources varies considerably by geographic region and across LMICs and HICs, evidence suggests that material resources in LMICs to implement recommendations from international guidelines are largely unmet. This study describes and compares the availability of resources to treat new-onset stroke in countries based on the World Bank’s gross national incomes, using recommendations of the American Heart Association and the American Stroke Association 2013 update. Methods: A self-reported cross-sectional survey was conducted of delegates that attended the April 2016 International Conference on Emergency Medicine using the web-based e-Survey client, Survey Monkey Inc. The survey assessed both pre-hospital and in-hospital settings and was piloted before implementation. Results: The survey was distributed and opened by 955 delegates and 382 (40%) responded. Respondents from LMICs reported significantly less access to a prehospital service (p<0.001) or a national emergency number (p<0.001). Access to specialist neurology services (p<0.001) and radiology services (p<0.001) were also significantly lower in LMICs. Conclusions: The striking finding from this study was that there was essentially very little difference between the responses between LMIC and HIC respondents with a few notable exceptions. The findings also propose a universal lack of adherence to the 2013 AHA/ASA stroke management guideline by both groups, in contrast to the good reported knowledge thereof. Carefully planned qualitative research is needed to identify the barriers to achieving the 2013 AHA/ASA recommendations.
Describing final diagnosis and outcome for patients investigated for suspected acute coronary syndrome at a regional, public South African emergency centre
(Stellenbosch : Stellenbosch University, 2018-12) Kabongo, Diulu; Allgaier, Rachel; Bruijns, S.; Kalla, M.
ENGLISH SUMMARY : No abstract available.
A description of the knowledge and attitudes towards bystander CPR amongst participants in a community outreach initiative in Cape Town
(Stellenbosch : Stellenbosch University, 2020-12) Zaayman, Heinri; Lamprecht, Hein; Saunders, Colleen; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine. Emergency Medicine.
ENGLISH SUMMARY : Introduction: Mortality rates from out-of-hospital cardiac arrest can be reduced by early CPR. A better understanding of the factors that prevent or encourage bystander CPR will assist in tailoring CPR training by community organisations to meet the needs of the communities they serve. The aim of this study was, therefore, to describe the basic CPR knowledge and attitudes towards performing out-of-hospital CPR of laypersons who volunteer for Sisaphila community based CPR courses in Cape Town, South Africa. Methods: Paper-based surveys were distributed at bystander CPR training events, prior to participants receiving free CPR training. Data captured included participant demographics, indications of prior CPR training, basic knowledge of CPR theory and their attitude towards compression-only versus conventional (mouth-to-mouth) CPR. Results: Fifty one surveys were completed and captured. Ninety percent of participants were female, and 31% had previously received CPR training. Participants had a low level of baseline CPR knowledge, with only 20% of the participants able to correctly answer 3 out 5 basic questions about CPR. Participants were hesitant to perform CPR including mouth-to-mouth resuscitation on anybody other than a relative, but over a third (36%) were more willing to perform CPR on a family member, 58% were more willing to perform CPR on a friend or colleague, and 66% were more willing to perform CPR on a stranger if compression-only CPR was an option. Conclusion: We found that South African laypersons have a low level of baseline knowledge of CPR and that they were more willing to perform CPR if hands-only CPR was an option over traditional CPR including mouth-to-mouth breathing, similar to International trends. Our study also indicates that there is a need to regularly retrain those individuals that have had prior CPR training. These findings can assist community based CPR training programmes in their curricular development.
A descriptive analysis of traumatic brain injury (TBI) cases seen at a tertiary hospital's trauma unit in South Africa over a one year period
(Stellenbosch : Stellenbosch University, 2020-03) Habtemariam, Dawit; Allgaier, Rachel L.; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine.
ENGLISH SUMMARY: Introduction: Traumatic brain injury (TBI) is a non-degenerative, non-congenital insult to the brain causing temporary or permanent cognitive, physical or neuropsychiatric impairment. This study looked at the prevalence, demographic and annual distribution of TBI at a South African tertiary academic hospital. Methods: A retrospective, descriptive, cross-sectional study reviewed CT scans and patient folders over a one-year period. Of the 4017 TBI suspected patients, 3829 were eligible for inclusion in the study. From this, a representative sample of 500 patient folders and CT reports were reviewed. Data were analysed with descriptive statistics using Microsoft Excel. Results: During the study period, 12500 patients were treated in the unit for trauma, 3829 (30.6%) had radiological and/or clinical evidence of TBI (case prevalence of 30.6% and 255.3 per 100,000 study population). The overall male to female ratio was 3.5:1. Almost 60% of patients were between the ages of 21 and 40. TBI showed no seasonal spikes and the commonest cause was assault (n=1999, 52.2%). Mild TBI (399/481, 88.2%) was most prevalent, based on GCS, with 71.2% (356/500) being a Marshall type 1 CT scan finding. Of the patients studied, 85.9% (n=413) were managed using a “pharmaco-observational” approach, 6.7% (n=32) underwent surgery and 5.6% (n=27) were managed in an Intensive Care Unit as a primary intervention. Based on Glasgow Outcome Scale, 36.8% (n=177) of patients were not able to work or attend school at the time of discharge, including 22 (4.6%) patients who died during the study period. Conclusion: TBI is prevalent public health problem in the Western Cape of South Africa that particularly affects males who are young and in their productive years. Assault is the primary cause. This study showed an endemic pattern that is a constant burden on medical and paramedical institutions. TBI claimed the lives and/or neurocognitive capacity of over a third of those diagnosed.
Development of an e-learning platform to improve learning delivery in a low-resourced clinical ultrasound training setting
(Stellenbosch : Stellenbosch University, 2017-12) Lamprecht, Heinrich Hilgardt; Kruger, T. F.; Wallis, Lee Allan; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine. Emergency Medicine.
ENGLISH SUMMARY : Background/Objective: Some clinical ultrasound training programmes provide suboptimal training that result in credentialing failure. To address this failing in our low-resourced setting, an e-learning platform was designed and constructed using a participatory action research approach where clinical ultrasound trainees, e-learning developers and researchers collaborated to improve the trainees’ access to learning delivery and enhancement, with the aim to eventually improve their low credentialing success rate. Methodology: The participatory action research approach involved a mixed methodology to collect, manage and analyse data for each of Susman and Evered’s cycle of enquiry steps, namely diagnosis, action planning, intervention, evaluation and reflection. The integration of instrumental and focal theories closed the practice-research gap by adding the necessary rigor to the study. Results: The diagnosis stage revealed that the poor credentialing performance was caused by learning delivery failure that reduced the trainees’ academic engagement. An e-learning platform was designed and constructed as an intervention to consolidate the current training capacity and provide trainees with new alternative access pathways to deliver learning more effectively (action planning). The e-learning platform was designed within a learner-centred, adult learning and motivational pedagogical paradigm. The evaluation of the e-learning platform intervention identified: context-specific resource savings, that all study participant groups accepted the new reality of incorporating e-learning as part of a blended learning approach and the learning access of trainees improved. Future research should focus on validating the usability of the draft e-learning platform and improvements of learning delivery and learning enhancement by initially making use of small peer groups followed by larger user-based groups (reflection). Conclusion: Collaboration led to real practical and social change by creating a custom designed e-learning platform that changed the way clinical ultrasound trainees learn within a low resourced context. Early inclusion of the trainees as study participants led to their early adoption of the ability of a newly designed e-learning platform to firstly improve their learning delivery, then restore their academic engagement and eventually their learning enhancement, which should reflect in improved credentialing success rates.

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