Browsing by Author "Bruijns, Stevan"
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- ItemOpen AccessA cross-sectional study of ECG patterns and outcomes of patients thrombolysed for ST-elevation myocardial infarction at a district, public Cape Town hospital(2018) Kibamba, Crispin Ngoy; Malan, Jacques; Bruijns, StevanIntroduction There is insufficient data to describe ST-elevation myocardial infarction (STEMI) in sub-Saharan African settings using common diagnostic criteria. This study describes the outcomes at discharge (survival, death or transferred) of patients thrombolysed for STEMI at a public hospital without primary percutaneous coronary intervention capability as well as associated ECG changes. Materials and methods A retrospective, cross- sectional study was conducted at an urban, public emergency centre in Cape Town, South Africa that did not have direct access to percutaneous coronary intervention for STEMI. Descriptive statistics for age, length of stay and the various timings surrounding thrombolysis were presented using proportions, mean and standard deviation. Assumptions were tested using the X2 - test or Fishers Exact test. A p-value less than 0.05 was considered significant. Results The study enrolled 104 patients of which 25 were excluded for insufficient data and two for thrombolysis of an incorrect STEMI diagnosis. Of the remaining patients, 56 (64%) survived to discharge, 26 (30%) required transfer and five (6%) died. There was no difference between regions affected and patient outcome (p=0.31). Resolution of ST-segments was seen in 48 (86%) survivors. It was not seen in 21 (81%) who were transferred and in none that died. The difference between resolution of ST-segments between survivors versus those transferred or dead was highly significant (p< 0.001). Conclusion This study described a higher than expected thrombolysis failure rate as well as a higher than expected association of poor outcome with inferior STEMI. It highlights the need for improved health care records to improve health research in low-resourced settings. The creation of a STEMI registry could contribute to research but will need funding. The use of clinical messaging apps to gain senior ECG interpretation may provide an additional layer toward quality care.
- ItemOpen AccessA descriptive study of the use of troponin I testing at a Cape Town district hospital(2018) Gibson, Joshua Glynn; Malan, Jacques; Bruijns, StevanIntroduction: Troponin I tests have been shown to be accurate and are relied upon to assist in making critical decisions regarding patient care in patients presenting with chest pain. The tests are expensive, however, and so their rational use becomes extremely important in a budget-constrained public health sector. The aim of this study was to describe how Troponin I tests are used throughout Victoria Hospital, by a range of requesting clinicians, working in different specialties. Methods A cross-sectional, prospective design was employed, using multiple data sources. We collected a consecutive sample over a three-month period from Victoria hospital’s Emergency Centre using a dedicated data collection tool connected to use of the point-of-care troponin I test. We supplemented this prospective sample with outcome data, using the hospital’s electronic admission record. Results Three hundred and sixteen patient entries were included in the final results. The majority of Troponin tests were negative (70%). Discharge directly from Emergency Centre was 10% in Troponin I positive patients, 37,5% in Equivocal Troponin patients, and 65% in Troponin negative patients. Furthermore, patients were twice as likely to be transferred to a tertiary facility if their Troponin was positive (24%), compared to equivocal (10.4%) or negative (12%). Discussion Chest pain was the most common presenting complaint, with Acute Coronary Syndrome being the most common working diagnosis. The clinical management of patients varied considerably when comparing their Troponin I result. Troponin I appears to be used as an effective rule-out tool in the decision-making pathway.
- ItemOpen AccessAdverse event registry analysis of an EMS system in a low resource setting: a descriptive study(2018) Geraty, Sian; Bruijns, Stevan; Lamprecht, HeinIntroduction Out of hospital emergency medical service patients present unique challenges and ample opportunities for medical error to occur. Identifying medical error is important for mitigating future risk and improving patient safety. Hypothesis/problem Our study describes the adverse event registry of an emergency medical service system in a low resource setting over a six-year period. Methods The Western Cape Emergency Medical Services Adverse Event Registry were reviewed for the period 1 January 2010 to 31 December 2015. From these, all cases classified as an adverse event or near miss were extracted for in depth review. Demographics, type of error, and types of recommendations implemented are reported. Results Altogether 106 (69%) adverse events and 47 (31%) near misses were reported over the six-year period. The mean age of patients was 31 years (standard deviation ±24.8). Of these 65 (42%) cases were adult medical patients, 31 (20%) adult trauma patients, 15 (10%) obstetric patients and 42 (27%) paediatric patients. The caseload was observed to increase over the six-year period, whilst system medical errors decreased and individual medical errors increased over the same period. Conclusion In this low resource emergency medical service system, individual medical errors increased and system medical errors decreased as more recommendations derived from adverse events caused by the system errors were implemented. This created a greater need for individual and group training of EMS clinical providers. We recommend further research in order to adequate describe the reason for the increase individual medical error, as well as to find more effective means of detecting adverse events and near misses in this population.
- ItemOpen AccessDescribing the most common presenting complaints, their priority and corresponding diagnoses at Khayelitsha Emergency Centre(2019) Naidoo, Antoinette Vanessa; Bruijns, StevanIntroduction Emergency centres have to be equipped to provide high-quality care to a number of undifferentiated patients with varying acuity of illness. This study aimed to identify the most common presenting complaints and corresponding linked diagnoses, in total and for each category of the South African Triage Scale (SATS) at Khayelitsha Emergency Centre (EC). Methods A retrospective, cross-sectional, chart review was used. The sample consisted of patients who presented to Khayelitsha EC in January and June 2015. Charts were reviewed via the Electronic Content Management system. Data were collected on demographic profile, triage priority, presenting symptoms at triage, and ICD-10 diagnosis. Results 4006 of 4928 charts that were reviewed were suitable for inclusion. Triage acuity was 28.0% (n=1123) green, 34.2% (n=1372) yellow, 25.7% (n=1030) orange and 3.5% (n=141) red. The most common presenting complaints were trauma (10.3%) and pain (10.1%); the majority of these patients presented in the yellow and green triage categories. The most common diagnosis made in the EC was pneumonia (7.0%) - most frequently presenting as shortness of breath (8.7%) and cough (5.6%). Medical conditions presented with a higher acuity at triage. Presenting complaints documented at triage and those reported by clinicians correlated an acceptable 70.1% of cases (r=0.71). Diarrhoea and vomiting were the predominant symptoms in summer whereas shortness of breath and cough were more frequent in winter. Triage acuity was similar for both months. Conclusion Individual symptoms presented with varying priority and resulted in a variety of eventual diagnoses which showed differences across categories. Presenting complaints provide granularity to otherwise undifferentiated triage priorities. Future research should focus on time-in-motion work to determine the mean clinical care time each of these complaints require. This should allow a calculation of the mean clinical care time for each triage priority. In turn this can be turned into a calculation for optimal staffing.
- ItemOpen AccessDescribing the most common presenting complaints, their priority and corresponding diagnoses at Mitchell’s Plain Emergency Centre(2019) Naidoo, Antoinette Vanessa; Bruijns, StevanIntroduction Triage allows prioritisation of the most severely ill in emergency centres that face a complex and growing burden of disease. The presenting symptom is an independent variable that informs acuity and directs resource allocation. This study describes the most common presenting complaints and linked diagnoses, in total and for each category of the South African Triage Scale (SATS) at Mitchell’s Plain Emergency Centre Methods A retrospective, cross-sectional, chart review was used. The sample consisted of patients who presented to Mitchell’s Plain EC in January and June 2015. Charts were reviewed via the Electronic Content Management system. Data were collected on demographic profile, triage priority, presenting symptoms at triage, and ICD-10 diagnosis on EC disposition. Results 3434 of 4335 charts that were reviewed were suitable for inclusion. Triage acuity was 13.8% (n=475) green, 41.0% (n=1409) yellow, 32.5% (n=1116) orange and 4.3% (n=148) red. Trauma (9.7%) and abdominal pain (8.6%) were the most common presenting complaints- the majority of these were triaged as yellow cases. The most common diagnosis made was pneumonia (3.4%) – most frequently presenting as shortness of breath (14.4%). High acuity complaints were predominantly medical. Triage and clinicians report of the main complaint correlated in 74.3% of cases (r=0.7). The majority of patients and highest proportion of high priority patients presented on Mondays and Saturdays. Conclusion Mitchell’s Plain EC has complex caseload with a significant burden of trauma presentations related to interpersonal violence and penetrating assault. Respiratory and gastrointestinal symptoms due to infections were common across triage acuities, and cardiac or neuropsychiatric complications of chronic diseases presented frequently in high priority categories. Describing these presentations and their linked characteristic diagnoses will allow for further research into clinical flow pathways between arrival and disposition. Staffing requirements may be determined by linking these pathways to reality based time frames.
- ItemOpen AccessEvaluation of self-reported confidence amongst radiology staff in initiating basic life support across hospitals in the Cape Town Metropole West region(2018) Vorster, Isak Dawid; Beningfield, Steve; Bruijns, StevanIntroduction: The immediate response to a cardiac arrest is regarded as one of the most time-critical interventions in clinical medicine. First responders for cardiac arrest in imaging departments are often radiology staff. The study aim was to determine radiology staff-members' confidence in initiating basic life support. Methods: A multi-centre, cross-sectional survey was conducted using peer-validated, anonymous questionnaires. Confidences were recorded using a 10-point Likert scale for recognising cardiac arrest, securing an airway, providing rescue breaths and initiating cardiac compressions. Questionnaires were distributed to and completed by radiology staff working in public sector hospitals within the Cape Town Metropole West. Due to the limited subject pool a convenience sample was collected (with no power calculation). Data were therefore statistically analysed using only summary statistics (mean, standard deviation (SD), proportions, etc.). Detailed between group comparisons were not made, given the sample size and type. Results: We disseminated 200 questionnaires, of which 74 were completed (37%). There were no incomplete questionnaires or exclusions from the final sample. Using the Likert scale, the mean ability to recognise cardiac arrest was 6.45 (SD±2.7), securing an airway 4.86 (SD±2.9), and providing rescue breaths and initiating cardiac compressions 6.14 (SD±2.9). Only 2 (2.7%) of the participants had completed a basic life support course in the past year, while 11 (14.8%) had never completed any basic life support course and 28 (37.8%) had never completed any type of life support or critical care course. Radiologists, radiology trainees and nurses had the greatest confidence in providing rescue breaths and initiating cardiac compressions from all the groups. Conclusion: The study demonstrates substantial lack of confidence in providing basic life support in a large part of the staff in Cape Town’s public hospital imaging departments. The participants indicated that regular training and improved support systems would increase confidence levels and improve skills.