Browsing by Author "Hodkinson, Peter"

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    A 12-month retrospective, descriptive study of Hout Bay Volunteer Emergency Medical Service, Cape Town, South Africa
    (2019) Kahle, Jurgen Werner; Cunningham, Charmaine; Fleming, Julian; Hodkinson, Peter
    Background There is a growing need for Emergency Medical Services (EMS) globally and in Africa, as health services develop. The establishment and continued operation of volunteer ambulance services might assist with this need. This study provides a comprehensive overview of the operational activities of a volunteer ambulance service and forms a first step for further studies of this and other volunteer ambulance services. Objectives This study describes and quantifies the operational activities of Hout Bay Volunteer Emergency Medical Service (Hout Bay EMS) a volunteer ambulance service in Cape Town, South Africa for a one year period from 1 January to 31 December 2016. Methods This retrospective study describes call-outs, shifts and service demographics of Hout Bay EMS for 2016, using Provincial EMS dispatch data and shift records from Hout Bay EMS. Performance comparisons are drawn between Hout Bay EMS and Provincial EMS. Outcomes In the study period, there were 682 call-outs involving Hout Bay EMS, a total mission time of 951 hours worked over 119 shifts by 31 active members in 2016. Assault was the leading call-out type (18.40%); 58.24% of call-outs were Priority 2 (less urgent), and 39.30% of call-outs ended in no patient transport. Response times to Priority 1 call-outs were generally shorter for Hout Bay EMS than those of Provincial EMS within the Hout Bay area. Members largely preferred night shift to day shift by a factor of 4:1; the majority of shifts were worked by Basic Life Support (28.57%) and Intermediate Life Support (57.98%) qualified members compared to the relatively few shifts (13.44%) worked by Advanced Life Support members. This study shows that a small volunteer ambulance service mostly active on weekends can successfully complement the efforts of the larger, full-time provincial ambulance service it is dispatched by. This model could be replicated elsewhere to meet the growing need for emergency medical services.
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    A cross-sectional study of patients presenting to an urban emergency department in Mwanza, Tanzania
    (2024) Kotecha, Shahzmah Suleman; Hodkinson, Peter; Cunningham, Charmaine; Sawe, Hendry Robert
    Introduction: Tanzania suffers from limited healthcare resources, accentuated by the burden of trauma and infectious diseases. There is limited data on the profile of patients attending Emergency Departments (ED). This study describes patients attending the Bugando Medical Centre, Mwanza, Tanzania ED. Methods: A cross-sectional descriptive study was conducted including all patients presenting from 01 – 31 January 2023. Information collected included demographics, referral status, main complaint, ED disposition, hospital length of stay for admitted patients, and hospital outcomes for admitted patients. Results: A total of 3390 patients presented, and 3224 (98%) were included, of which 49.1 % were male, and the median age was 30 years (interquartile range 12-51). Most (72.9%) were self-referrals. The nature of the complaint for the majority of the patients (61.6%) was medical, and the overall median hospital length of stay was 5 days (IQR of 3-12 days) for admitted patients. Higher proportions (17.3% and 18.9%) of patients presented on Mondays and Tuesdays respectively. Among patients aged 14 years and above, hypertensive heart disease with failure, malignant neoplasm of the oesophagus and intracranial injury were the top medical, surgical and trauma diagnoses respectively. In the paediatric population (<14 years), sickle cell anaemia in crisis, hydrocephalus and diffuse traumatic brain injury were the top medical, surgical and trauma diagnoses respectively. The most common complaints among the patients presenting to the ED were gastrointestinal complaints (8.9%), respiratory complaints (3.1%) and congenital abnormalities (3.2%) in the >14 years, 1-14 years and <1 year age groups respectively. Most (63.6%) patients were discharged directly from the ED, and ED and in-hospital mortality were 0.2% and 15.5% respectively. Conclusion: In this study, we observed a high burden of medical complaints, a high rate of ED discharge and high in-hospital mortality. This study can inform future studies in resource mobilization and allocation for the ED, and the health system.
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    A decade of fundamentals of emergency care (FEC) course evaluation: Update from the last two years
    (2024) Kamembela, Ilunga; Hodkinson, Peter
    Introduction: The Fundamental of Emergency Care (FEC) is a short course designed to give key skills and approaches to emergency care for non-specialist healthcare providers. This course has been running since 2012 primarily from the Western Cape of South Africa, open to all medical professionals for a fee. The course is conducted through self-study of a manual, and then two days of intensive skills and simulation based training. We undertook to survey and evaluate past participants of the course to assess the impact and suitability of the course, in order to improve and guide further iterations and expansion of the training. Method: We surveyed and analyzed all participants of FEC courses since inception using a series of email surveys. Descriptive statistics were performed using SPSS. The survey captured information about participants' profiles and opinions of the course. Results: Out of approximately 500 participants in 24 courses over the last decade, 210 (42%) took part in the surveys. The study revealed that a majority of the participants (67.6%) were medical doctors, with only a small percentage (14.76%) working full-time in emergency centres. The participants hailed from diverse backgrounds, including both rural and urban settings, and all facility levels. The overall consensus among respondents was that the course was well-presented, of affordable cost, and contained relevant content that they found useful in their respective practices. Conclusion: The FEC course has been established as a contextually relevant emergency short course for South Africa, providing an alternative to international courses which are often unaffordable, and may lack insights to local burden of disease and resource constraints. We believe that this is a model of training that can be expanded, locally adapted and remains feasible for local healthcare providers.
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    A descriptive study of acutely poisoned patients presenting to the Western Cape Emergency Medical Services
    (2025) Moreira, Fabio; Hodkinson, Peter; Van Koningsbruggen, Candice
    Background: The scale and types of acute poisoning presenting to the prehospital provider in South Africa and other low- or middle-income countries is largely unknown. Emergency medical services (EMS) are often responsible for the on-scene management and transport of these patients and have a range of treatment options depending on scope of practice. The aim of this study was to describe acute poisoning patients presenting to the Western Cape Government Health and Wellness EMS. Methods: A retrospective descriptive study was conducted utilizing electronic patient care data of acute poisoning cases extracted from EMS records for the calendar year 2022. Results: Of the 2254 acute poisoning cases identified, 69.03% were female. The median age was 27 years, and the method of poisoning was most commonly ingestion (97.20%). A single toxin was involved in 46.85% of cases, while 32.03% of cases involved multiple toxins. In 34.38% of all cases, a toxin unknown to EMS was reported. Paracetamol and alcohol were the most common known toxins observed. The top 5 toxins by single toxin involvement were herbicides and pesticides; antiretrovirals; antiseptics and disinfectants; paracetamol; and hydrocarbons. There were a higher number of cases in the second half of the year, with a peak in November and December, as well as more cases. during weekends. Most cases were triaged as moderate to severe acuity. Activated charcoal was administered in 3.46% of cases; oxygen was administered in 3.82% of cases; intravenous access was obtained in 17.7% of patients and 1.97% of cases had a documented airway intervention performed. Conclusion: There is a necessity for better awareness, and improved training for EMS providers to enhance the care of acute poisoning patients. Further research is warranted to investigate the gaps in management and the implications for patient outcomes, ultimately contributing to the development of effective interventions and educational programs aimed at reducing the incidence and severity of acute poisoning.
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    A descriptive study of an adult non- trauma emergency centre at a Cape Town central referral hospital
    (2023) Kubeka, Vuyiswa; Hodkinson, Peter; Evans Derrick
    Objective: The study evaluated the demographics and acuity of patients at a South African central referral hospital. The triage acuity, diagnosis and disposition from the Emergency Centre (EC) were assessed, and the impact of COVID19 initial lockdown on presentations as a secondary outcome. Methods: Data were collected retrospectively from 1 March 2019 to 31 May 2020, including the first 2-month COVID 19 lockdown period. Data was entered electronically by EC staff for routine healthcare management processes, including final ICD 10 code diagnosis on leaving the EC. Results: A total of 38477 patients were included, 20 excluded, with a mean of 2565 seen per month prior to the COVID lockdown when there were 1619 monthly. Lower acuity patients were largely either referred by a general practitioner or self-referred. Of the discharged patients,64% were lower acuity. Some 57% of specialist referrals were high acuity. The top four disease categories were cardiovascular 15%, gastrointestinal and hepatobiliary 14%, neurology 13 % and respiratory 12%. Disposition for referral to an inpatient specialist was 42%. Patients discharged from the EC amounted to 35%. Total time in the EC for patients referred to an inpatient specialist were a median of 561 minutes and 23 minutes for discharged patients. Conclusion: Central referral hospitals offer specialty and subspecialty services for emergency and outpatient presentations. A good deal of the patient load on the EC was relatively low acuity patients that might be more efficiently seen elsewhere such as subspecialty outpatient clinics to alleviate the burden on the EC, and to free it up for high acuity patients. This study can serve as a foundation for reflection on the use of a specialised central referral hospital EC as a resource in the healthcare system. We observed a global trend of decreased EC presentations during COVID19 lockdown period.
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    A descriptive study of call centre complaints and their management in a Western Cape EMS
    (2020) Spicer, Richard Michael Frank; Hodkinson, Peter; Bester, Beatrix
    Introduction Emergency medical services (EMS) play a vital role in addressing the high burden of disease posed by emergency conditions in low-to-medium income countries and it is vital to ensure that EMS care is of a high quality. Complaints and their management are an important mechanism in addressing individual patient concerns and ensuring accountability to the public. Expanding the role of complaints to effectively affect system-wide quality improvement requires knowledge of trends based on aggregated complaint data. This study aims to describe the volume and nature of complaints received by an urban EMS organisation in the Western Cape. Methodology A retrospective analysis was performed of all non-clinical complaints received for the 2018 calendar year by the call centre of a public EMS in Cape Town, South Africa. All complaint documents were collected and collated with the original case dispatch information. Complaints were categorised according to a standardised complaint coding taxonomy published previously. Complaint investigation outcomes and recommendations were analysed by themes identified during the study. Results A total of 156 complaints were received which referred to 172 patients. Complaints originated primarily from healthcare providers (72%) and patients or public (22%). Inter-facility transfers (73%) generated the most complaints. Encoding of complaint narratives revealed 302 individual service issues, which were classified into taxonomy derived domains (Clinical – 36%; Management – 44%; Relationship – 20%). The “Management” domain highlighted delay issues, accounting for 38% (116/302). Conclusion In this urban EMS, the majority of complaints are related to delays. Complaints were primarily lodged by other healthcare providers. Complaint rates lodged by patients and public are low, and would suggest that a unified and well publicised complaint mechanism is necessary, in order to increase public involvement in service quality improvement. Further research is recommended to validate a taxonomy for EMS complaints specifically.
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    A descriptive study of trauma patients transported by the KZN Helicopter Emergency Medical Services to the Durban Inkosi Albert Luthuli Central Hospital level one Trauma centre over a three - year period
    (2021) Pule, Marwala Simon; Hodkinson, Peter; Hardcastle, Timothy
    Background KwaZulu-Natal (KZN), a large province of South Africa has vast distances to referral centres and time to definitive treatment is key in trauma care. Helicopter Emergency Medical Service (HEMS) is an invaluable prehospital asset for the transport of time sensitive trauma. This study reviews the impact of HEMS in the management of trauma at Inkosi Albert Luthuli hospital (IALCH) which is the only public accredited level one trauma centre in the province. Methods A retrospective descriptive study of polytrauma patients transported by HEMS in KZN to IALCH over a three-year period from 01 January 2014 to 01 January 2017. Data was collected around patient demographics, transfer details and patient outcomes. Results Over the three-year period, 117 HEMS transfers were reviewed, with the majority being male (90.6%). Just 26% of HEMS transfers were direct from the scene, with the balance being interhospital transfers largely from distant regional hospitals around the province. Some 60% of injuries were causes by vehicle crashes, and 31% by intentional injury. Mortality was 30% which is reflective of the high severity of injury of the cohort. The injury severity scores (ISS) (median 26 overall) of those who died was higher (median 38) (p-value= 0.0002), and there were more interventions before and during transfer such as thoracostomy, ventilation and immobilization. Some 88% were admitted to ICU at IALH. Conclusions: HEMS in the KwaZulu Natal province was mainly used for long-distance transfer of major trauma patients which is an appropriate use of this essential service, given the single major trauma centre in the province. The majority of patients that were transported by HEMS had severe injury, which was also associated with increased mortality outcomes. Rational use of this essential but expensive resource will require clear policy around the role of HEMS and call out criteria in each setting.
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    A retrospective description of a 12 month caseload at four private emergency centres in South Africa
    (2023) King, Jonathan; Hodkinson, Peter
    Introduction In South Africa, private emergency departments (ED) are often the first port of call for a substantial proportion of the population served by the private healthcare sector. This study aims to describe the number, acuity and chief complaint of patients that presented to a sample of urban private EDs within South Africa. Methods A retrospective review of patient data from January 2018 to December 2018 was performed for four private facilities from a large private healthcare group. Data collected include demographics, time of arrival, disposal, triage score and presenting complaint. Results A total of 71079 patients presented to the four facilities. The South African Triage Scale (SATS) scores were as follows: red (5%), orange (11%), yellow (65%) and green (19%). Patients arrived mostly during the day (08:00-17:00 (54%)), evening (17:00-22:00 (27%)) and night (22:00-08:00 (19%)). Disposal of patients included admission (14%), discharge (77%), transfer to another facility (2%) and those who left without being seen (3%). The most frequent presenting complaints included gastrointestinal complaints, falls, respiratory issues, fever, traffic accidents and chest pain. Conclusion This study is the first description of the caseload and case mix in private EDs in South Africa. The most common presenting complaints were gastrointestinal and respiratory, with chest pain being the commonest red triaged complaint. Such complaints are similar to international data. In contrast, trauma related to assault is ranked 20th in private as opposed to 1st in the public sector. Admission rates are in keeping with US data, but lower than SA public, UK and Australia. Lastly, many green patients are follow ups which likely relates to the fee-for-service nature of the private sector and continuum of care fulfilled by ED doctors.
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    Acute pain assessment and management in the prehospital setting, in the Western Cape, South Africa: a knowledge, attitudes and practices survey
    (2020-04-28) Lourens, Andrit; Hodkinson, Peter; Parker, Romy
    Background Acute pain is frequently encountered in the prehospital setting, and therefore, a fundamental aspect of quality emergency care. Research has shown a positive association between healthcare providers’ knowledge of, and attitudes towards pain and pain management practices. This study aimed to describe the knowledge, attitudes, and practices of emergency care providers regarding acute pain assessment and management in the prehospital setting, in the Western Cape, South Africa. The specific objectives were to, identify gaps in pain knowledge; assess attitudes regarding pain assessment and management; describe pain assessment and management behaviours and practices; and identify barriers to and enablers of pain care. Methods A web-based descriptive cross-sectional survey was conducted among emergency care providers of all qualifications, using a face-validated Knowledge, Attitudes and Practices of Pain survey. Results Responses of 100 participants were included in the analysis. The survey response rate could not be calculated. The mean age of respondents was 34.74 (SD 8.13) years and the mean years’ experience 10.02 (SD 6.47). Most respondents were male (69%), employed in the public/government sector (93%) as operational practitioners (85%) with 54% of respondents having attended medical education on pain care in the last 2 years. The mean percentage for knowledge and attitudes regarding pain among emergency care providers was 58.01% (SD 15.66) with gaps identified in various aspects of pain and pain care. Practitioners with higher qualifications, more years’ experience and those who did not attend medical education on pain, achieved higher scores. Alcohol and drug use by patients were the most selected barrier to pain care while the availability of higher qualified practitioners was the most selected enabler. When asked to record pain scores, practitioners were less inclined to assign scores which were self-reported by the patients in the case scenarios. The participant dropout rate was 35%. Conclusion Our results suggest that there is suboptimal knowledge and attitudes regarding pain among emergency care providers in the Western Cape, South Africa. Gaps in pain knowledge, attitudes and practices were identified. Some barriers and enablers of pain care in the South African prehospital setting were identified but further research is indicated.
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    Adapting a community first aid responder programme to increase out-of-hospital capacity in Kinshasa, Democratic Republic of Congo
    (2025) Diango, Ken Ngoy; Hodkinson, Peter; Cunningham, Charmaine; Mafuta, Eric; Wallis, Lee
    In 2023, the seventy-sixth World Health Assembly passed a significant resolution – WHA76.2 – calling for global efforts to strengthen the provision of quality Emergency, Critical, and Operative care (ECO) to address the growing burden of acute and critical illnesses, particularly in low- and middle-income countries (LMICs). In areas where formalised prehospital care systems are being established to improve outcomes, the incorporation of a layperson first responder programme could facilitate greater access to care for individuals in need and serve as an effective initial intervention to bolster out-of-hospital emergency care (OHEC) capacity. WHO developed the Community First Aid Response (CFAR) training program to support this approach. For the course to be appropriately and sustainably implemented, contextual adaptations are necessary. The prerequisites for this country-specific adaptation include, among other factors, a systematic evaluation of the country's emergency care landscape, a needs assessment and understanding the acceptability of the proposed intervention. Aim and Objectives: The aim of the thesis was to adapt a country-specific CFAR program for the Democratic Republic of Congo (DRC) as an initial intervention to increase OHEC capacity. Four studies were planned to fulfil the main objectives. The first was to outline the key functions and related components of the country's emergency care system, identify the gaps, and define priority areas for strengthening. The second was to evaluate community needs for, and the availability of, emergency care services in Kinshasa, DRC, to determine the nature and magnitude of unmet needs, especially in OHEC. The third study was to assess the usefulness and acceptability of an adapted CFAR programme designed to strengthen OHEC capacity in Kinshasa. The fourth and final study was to describe and assess a pilot CFAR course, including the process, resources, curriculum, and teaching methods, while also capturing knowledge and confidence gains from the perspectives of both organisers and participants. Methods: A series of four studies was carried out in Kinshasa, DRC. The first study used a consensus method to describe essential components of the country's emergency care system utilizing the WHO Emergency Care System Assessment (ECSA) tool. The second study involved a household survey that contrasted the needs and availability of emergency care services within Kinshasa's communities. The third utilized focus groups to evaluate the usefulness and acceptability of an adapted CFAR programme. The final study consisted of a feasibility assessment using mixed methods analysis to describe and assess core elements of the implementation of a pilot CFAR training and provide key outcomes. Results: The evaluation of the DRC ECSA revealed several gaps, including an inadequate OHEC capacity. The household survey indicated significant unmet needs in the provision of emergency care, particularly regarding out-of-hospital services. An adapted CFAR program was recognised as a suitable and acceptable strategy to increased OHEC capacity in Kinshasa. Finally, a CFAR pilot was successfully conducted and found to be contextually relevant, representing a potential initial step to address the existing OHEC capacity shortfalls in Kinshasa. Conclusion: This dissertation offers significant conceptual, analytical, and empirical insights into the context-specific adaptation of a CFAR program as an initial intervention to increase OHEC capacity in a nascent emergency care system of a resource-constrained setting. Our results suggest that a comprehensively implemented tailored system could potentially enhance OHEC capacity in low-resource settings and likely impact outcomes.
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    An assessment of emergency care capacity at hospitals in Harare Metropolitan: A descriptive cross-sectional study
    (2025) Deka, Prince; Hodkinson, Peter; Hendrikse, Clint
    Objectives of literature review. The literature review aims to: To describe Zimbabwe's country profile, highlighting key demographic, economic, and social factors impacting its healthcare system. To describe the evolution of emergency medicine in Africa, emphasising the contextual factors derailing its development in Zimbabwe. To give an overview of African EC systems, focusing on Zimbabwe's unique challenges and advancements. To discuss the significance of and tools for appraising EC systems.
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    An evaluation of monitoring of respiratory physiological parameters in patients treated with non-invasive ventilation in the emergency department in Sligo University Hospital in Ireland
    (2021) Matalasi, Retselisitsoe Vincent; Hodkinson, Peter; Sweeney Michael
    Background: Acute respiratory failure is becoming a frequent phenomenon in the emergency department due to increasing life expectancy, and in the last two decades the number of presentations has more than doubled. Non-invasive ventilation has become the treatment modality of choice in selected patients, with a significant reduction of mortality in these cases. However, adequate monitoring of clinical and blood gas parameters is crucial to ensure treatment targets are met. Objective: This study aims to evaluate monitoring of respiratory physiological parameters in patients treated with non-invasive ventilation (NIV) in the ED in Sligo University Hospital. As a secondary objective, the study aims to evaluate how monitoring data influence treatment modification. Methodology: This was a retrospective chart review of 50 patients who presented to the ED in acute respiratory failure and were treated with non-invasive ventilation between September 2017 and March 2019. Results: A total of 50 charts were analysed, 62% female and 38% male. The average age for both genders was 76 years. Results showed that initial and ongoing monitoring of vital signs remained guideline compliant throughout the entire duration of NIV in the ED. All but one patient out of 50 had an initial blood gas analysis done prior to initiation of NIV treatment, while repeat blood gas analysis was inconsistent with 38% (n= 19) who did not have blood gas repeated. Conclusion: The study highlights the discrepancy between monitoring of vital signs and arterial blood gas during treatment of acute respiratory failure patients with non-invasive ventilation in the emergency department. A proforma may help bridge this gap to ensure a standardised care in order to improve treatment outcomes.
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    An exploratory survey: experiences and perceptions of community members who have accessed pre-hospital Emergency Medical Service in Langa, Cape Town
    (2019) Bam, Zina; Hodkinson, Peter
    Background: Calling an ambulance is the first line for citizens in dealing with many healthcare emergencies. It is crucial for the caller to convey correct information regarding the patient’s emergency and on-scene location to the emergency services, resulting in prompt dispatch of correct emergency resources to the exact location. Although there is a good deal of focus on emergency medicine time parameters and outcomes, little is known about the experiences, perceptions and satisfaction level from those who have accessed pre-hospital Emergency Medical Services. Methods: A telephonic survey was conducted on individuals who had recently called for an ambulance, from the urban township of Langa, Cape Town. Surveys were conducted in the caller’s home language, using a standardized tool for collecting quantitative data around the call process, caller satisfaction, outcomes of the call, and issues experienced. Results: During June 2018, 50 callers completed the survey (69% response rate). Most callers (88%) used a personal mobile phone, and 83% called predominantly for medical problems in the daytime. Callers accessed the service by dialling a variety of emergency phone numbers. Callers were largely satisfied with the call (66%), and there were fewer language mismatches than expected. A need for better communication regarding ambulance status and over the phone medical advice was identified. A substantial number of inconsistencies were reported between callers’ outcomes and those from emergency communication centre which require further analysis. These inconsistencies, pointed into gaps within the emergency communication centre’s collecting and database system Conclusion: The study provided the first insight into pre-hospital emergency caller experiences and perceptions, highlighting important aspects perhaps not revealed through other metrics. Measurement of caller satisfaction can be a useful quality improvement tool, and would seem feasible without substantial resources. Further investigation into data capturing system and identification of call outcomes are recommended.
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    An investigation into the prehospital diagnosis, patient characteristics and treatment of cardiogenic acute pulmonary oedema (APO) patients: A scoping review
    (2023) Lackay, Ruth; Hodkinson, Peter
    Introduction A scoping review was conducted to identify current clinical practice guidelines for the diagnosis and treatment of Cardiogenic Acute Pulmonary Oedema (CAPO) in the prehospital setting and to also discuss the application and relevance of these findings to low to middleincome countries (LMICs). Specific practice guideline elements that were reviewed included clinical presentation, timely diagnosis, triage, recommended treatment, and clinical referral pathway. Methods Published literature was systematically searched using the framework developed by Arksey and O'Malley. Using a priori-developed search strategy, electronic searches were performed in PubMed, Africa Wide, Scopus, Medline, and CINHAL databases to identify articles published in English between 2010 and 2022 relevant to Cardiogenic Acute Pulmonary Oedema (CAPO) in the prehospital setting. Two authors independently assessed whether each article met one or more of the five inclusion criteria, with disagreements resolved through either discussion or adjudication of a senior reviewer. A summary of the main themes contained within all eligible articles was developed using descriptive analysis. Results A total of 1193 articles were identified. In the screening process, 13 duplicate articles were removed and 1061 articles were removed based on title and abstract review. During full text review to determine eligibility, 84 articles were removed after review. A total of 35 articles meeting the inclusion criteria were included for final review and analysis. The following three themes were identified during the analysis: Clinical presentation of AHF and risk stratification, prehospital management and care according to best practice recommendations, and clinical referral and transportation pathways. Conclusion: The review highlighted key information on risk-stratifying CAPO patients to guide patientcentered care and transportation decision-making. Interestingly most of the published literature discovered in this scoping review were those published from high-income country settings, this reflects the gap in evidence on best practice recommendations that are contextfit for LMICS.
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    Developing an in-depth understanding of acute pain assessment and management in the prehospital setting in the Western Cape, South Africa, the factors influencing practice and what improvement measures could advance prehospital acute pain management
    (2020) Lourens, Andrit; Hodkinson, Peter; Parker, Romy
    Introduction: Acute pain is a common reason for seeking emergency care in the prehospital and emergency centre settings where pain prevalence ranges widely. Pain is a significant global health problem which often goes unnoticed and is undermanaged. To this end, a project consisting of a series of research studies aimed to develop an understanding of acute prehospital pain assessment and management in South Africa was conducted to identify how best to improve this field. Methods: The project consisted of four distinct objectives to be investigated as separate but interconnected studies. The first objective was answered through a secondary research methodology (scoping review) to identify and map the body of evidence on acute prehospital pain assessment and management in Africa. The remaining three objectives were answered using primary research methods in studies conducted in the Western Cape, South Africa. Two observational studies, (i) a cross-sectional online survey and (ii) a retrospective review, respectively, aimed to describe (i) the knowledge, attitudes and practices regarding prehospital acute pain assessment and management among emergency care providers and (ii) current prehospital acute pain assessment and management practices in high acuity trauma patients. The final study employed qualitative research methods using focus groups and content analysis to explore and describe emergency care providers' perspectives of acute pain assessment and management as well as perceived barriers and facilitators to pain management. Main results: In the scoping review, six publications on acute pain research in the African prehospital setting were identified, indicative of the paucity and immaturity of this research area. In the cross-sectional online survey, suboptimal levels of knowledge and attitudes regarding pain (58.01%) were found among emergency care providers, with gaps in all aspects of pain knowledge and attitudes of distrust in self-reported pain identified. The retrospective review recorded pain scores were documented in only 18.1% of the high acuity trauma patients reviewed, while moderate-to-severe pain (78.6%) was prevalent among those who had a pain score documented. Less than 3% of all trauma patients, and less than 8% of those with moderate-to-severe pain received analgesic medication, thus, suggesting less than ideal prehospital pain assessment and management practices. In the final qualitative study, six focus groups and one interview were conducted among 25 emergency care providers. Through content analysis five themes, namely: assessing pain is difficult in this setting; many factors affect clinical reasoning some unique to this (hostile) setting; basic and intermediate life support practitioners' reality of prehospital pain care; the emergency centre does not understand what we do, how we work, what it is like; and how can we do better; emerged from the data. Conclusion: Africa has a scarcity of prehospital pain research with current evidence mainly from South Africa while knowledge of prehospital pain assessment and management in the Western Cape, South Africa proved to be a significant gap. This gap appears to be underpinned by limited educational focus, lack of pain prioritisation in emergency medical services (EMS) organisations, lack of clear evidence-based prehospital pain clinical practice guidelines, and emergency care providers' indifference towards prehospital pain care. A joint approach from EMS organisations and educational institutions, coupled with clinical practice guideline development, as well as interdisciplinary collaboration between prehospital emergency care and emergency medicine, are required. Further research must focus on developing the body of African prehospital pain knowledge to inform clinical practice and advance quality prehospital pain care.
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    Developing prehospital clinical practice guidelines for resource limited settings: why re-invent the wheel?
    (BioMed Central, 2018-02-05) McCaul, Michael; de Waal, Ben; Hodkinson, Peter; Pigoga, Jennifer L; Young, Taryn; Wallis, Lee A
    Objectives: Methods on developing new (de novo) clinical practice guidelines (CPGs) have received substantial attention. However, the volume of literature is not matched by research into alternative methods of CPG development using existing CPG documents—a specific issue for guideline development groups in low- and middle-income countries. We report on how we developed a context specific prehospital CPG using an alternative guideline development method. Difficulties experienced and lessons learnt in applying existing global guidelines’ recommendations to a national context are highlighted. Results: The project produced the first emergency care CPG for prehospital providers in Africa. It included > 270 CPGs and produced over 1000 recommendations for prehospital emergency care. We encountered various difficulties, including (1) applicability issues: few pre-hospital CPGs applicable to Africa, (2) evidence synthesis: heterogeneous levels of evidence classifications and (3) guideline quality. Learning points included (1) focusing on key CPGs and evidence mapping, (2) searching other resources for CPGs, (3) broad representation on CPG advisory boards and (4) transparency and knowledge translation. Re-inventing the wheel to produce CPGs is not always feasible. We hope this paper will encourage further projects to use existing CPGs in developing guidance to improve patient care in resource-limited settings.
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    Exploring and describing the responsibilities and functions of emergency medical communication centers in South Africa: a modified delphi study
    (2025) Van Schalkwyk, Riekert Dewald; Hodkinson, Peter; Ham-Baloyi, Wilma ten
    Introduction: A significant number of South Africans are reliant on Emergency Medical Services (EMS) for access to Emergency Care, a need compounded by the current quadruple burden of disease. Efficient allocation of EMS resources ensures optimal use in time-critical emergencies. Development and improvement of Emergency Medical Dispatch practices implemented in Emergency Medical Communication Centers (EMCC) have been proposed as a means to improve EMS effectiveness. Establishing priority EMCC functions and responsibilities relevant to South African EMCCs could provide insight into practices requiring further strengthening and development. The aim of this study was to identify and categorise the functions and responsibilities of EMCCs in the South African setting. Methods: A three-round modified E-Delphi was undertaken to establish priority EMCC functions and responsibilities relevant to the South African setting. Fifty-seven statements related to EMCC functions and responsibilities retrieved from the literature review, across six categories, were sent out to 25 EMCC experts from government and private EMSs using LimeSurvey™ software. Results: A total of 68 (88%) out of 77 functions and responsibilities' statements reached consensus (70% agreement) as “essential” to South African EMCCs. Most of the statements related to Systems, Dispatch and Continuous Quality Improvement categories. The remaining 9 (12%) statements did not achieve consensus as essential, desirable or non-applicable, however a clear tendency toward a higher or lower rating of contextual applicability was evident. Conclusion: The majority of EMCC functions and responsibilities described in High-Income Country studies were found to be applicable and were classified by the expert panel as essential for South African EMCC. The methods used as well as the contextualized results could be applied in similar settings to identify developmental priorities. African Relevance Formal EMS systems are in varying stages of development across the African continent. This study sought to establish the important South African relevant Emergency Medical Dispatch elements to address the need for efficient Emergency Medical Services. Although South Africa has had a well-established formal EMS system for the past few decades, the development and functioning of Emergency Medical Call Centres may have been neglected. Understanding and prioritising the functions and responsibilities of such call centres can be extrapolated to other African countries in the early stages of establishing formal EMS systems.
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    Identifying barriers for out of hospital emergency care in low and low-middle income countries: a systematic review
    (BioMed Central, 2018-04-19) Kironji, Antony Gatebe; Hodkinson, Peter; de Ramirez, Sarah S; Anest, Trisha; Wallis, Lee; Razzak, Junaid; Jenson, Alexander; Hansoti, Bhakti
    Background: Tuberculosis (TB) in children is frequently paucibacillary and non-severe forms of pulmonary TB are common. Evidence for tuberculosis treatment in children is largely extrapolated from adult studies. Trials in adults with smear-negative tuberculosis suggest that treatment can be effectively shortened from 6 to 4 months. New paediatric, fixed-dose combination anti-tuberculosis treatments have recently been introduced in many countries, making the implementation of World Health Organisation (WHO)-revised dosing recommendations feasible. The safety and efficacy of these higher drug doses has not been systematically assessed in large studies in children, and the pharmacokinetics across children representing the range of weights and ages should be confirmed. Methods/design: SHINE is a multicentre, open-label, parallel-group, non-inferiority, randomised controlled, two-arm trial comparing a 4-month vs the standard 6-month regimen using revised WHO paediatric anti-tuberculosis drug doses. We aim to recruit 1200 African and Indian children aged below 16 years with non-severe TB, with or without HIV infection. The primary efficacy and safety endpoints are TB disease-free survival 72 weeks post randomisation and grade 3 or 4 adverse events. Nested pharmacokinetic studies will evaluate anti-tuberculosis drug concentrations, providing model-based predictions for optimal dosing, and measure antiretroviral exposures in order to describe the drug-drug interactions in a subset of HIV-infected children. Socioeconomic analyses will evaluate the cost-effectiveness of the intervention and social science studies will further explore the acceptability and palatability of these new paediatric drug formulations. Discussion: Although recent trials of TB treatment-shortening in adults with sputum-positivity have not been successful, the question has never been addressed in children, who have mainly paucibacillary, non-severe smearnegative disease. SHINE should inform whether treatment-shortening of drug-susceptible TB in children, regardless of HIV status, is efficacious and safe. The trial will also fill existing gaps in knowledge on dosing and acceptability of new anti-tuberculosis formulations and commonly used HIV drugs in settings with a high burden of TB. A positive result from this trial could simplify and shorten treatment, improve adherence and be cost-saving for many children with TB. Recruitment to the SHINE trial begun in July 2016; results are expected in 2020. Trial registration: International Standard Randomised Controlled Trials Number: ISRCTN63579542, 14 October 2014. Pan African Clinical Trials Registry Number: PACTR201505001141379, 14 May 2015. Clinical Trial Registry-India, registration number: CTRI/2017/07/009119, 27 July 2017.
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    Inter-facility transfers in the Cape Town Metropole by the Western Cape Government Emergency Medical Service: A retrospective, descriptive study
    (2023) Lemke, Franz; Hodkinson, Peter; Rambharose Sanjeev
    Background The South African health service is built upon a three-tier system, with the result that interfacility transfers (IFTs) are a cornerstone of a functional health ecosystem. Patients are transferred between facilities until their needs are met by the level of care provided. The Western Cape Government annual report of 2017/2018 states that 31.6 % of the workload of the Western Cape Government Emergency Medical Service (WCGEMS), is inter-facility transfers. Objectives This study describes the inter-facility, road-based transfers undertaken by the WCGEMS in the Cape Town metropole. We describe the number and type of transfers between health facilities as well as identifying the most common routes, prioritisation, crew make-up and acuity levels of patients transferred. Methods A retrospective, descriptive, observational study was conducted using the Cape Town Emergency Medical Service inter-facility transfer electronic database for the study period of 1 January 2017 to 31 December 2018. The existing database provided information logged routinely by EMS staff during each transfer and has been analysed using the statistical software Stata. Results Some 231,340 IFTs were included, of which two-thirds were undertaken by the day shift: 160,068 (69%) vs 71,272 (31%). Most emergency transfers were conducted for female patients [50,468 (62%) vs 31,468 (38%)]. Intermediate Life Support (ILS) crew facilitated most of the transfers 106,747 (51%) with Basic Life Support (BLS) crew in 53,165 (26%) and 48,534 (23%) by Advanced Life Support (ALS). The busiest route in the metro was identified as Khayelitsha (Site B) Community Health Centre (CHC) to Khayelitsha Hospital n=12,053, with some 17 transfers conducted per 24-hour period. The busiest routes, Khayelitsha CHC to Khayelitsha Hospital and Mitchells Plain CHC to Mitchells Plain Hospital were also the shortest, at 4.53 km and 2.78 km respectively. In totality, less than a third if IFTs [67,061 (30%)] required the use of stretchers. Conclusion IFTs are an integral part of the South African healthcare system, but the use of a frontline, EMS-driven model to provide IFTs is resource intensive and likely detrimental to overall EMS service delivery given the low acuity of the majority of patients transferred. Consideration should be given to creating, equipping, and adequately funding a separate service to take over responsibility for routine IFTs. This so-called ‘second leg' of EMS should be a dedicated, 24- hour, seven-day-week, low fidelity service, lessening the load on the frontline EMS resources and allowing first responders to focus on their main task—primary medical response.
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    “Language Barriers in the Emergency Centre (EC): A survey of secondary public hospital EC doctors on the perceived presence and impact of language barriers"
    (2020) Docrat, Nasreen; Hodkinson, Peter; Deumert, Ana
    Background Communication is vital to patient-doctor interactions especially in emergency centres (EC). It is evident from international and South African studies that language barriers result in suboptimal clinical outcomes, increased use of already limited resources and poor patient satisfaction. In the Western Cape, initiatives such as community trained interpreters, telephonic services and multilingual language policies have been implemented to improve communication between doctors and patients. Objectives This study was done to ascertain to what extent language barriers are perceived to still exist by doctors in emergency centres in secondary public hospitals in Cape Town. Methods A quantitative on-line survey of full time doctors in the ECs of six urban secondary public hospitals in Cape Town was conducted in October 2019. Data was collected over a 5 week period and covered demographics, languages spoken, (self-reported) fluency of languages spoken, languages encountered, perceived occurrence of language barriers, perceived impact of language barriers and strategies currently implemented to overcome these barriers. Results Of the 119 doctors invited to complete the survey, 74 eligible responses were received. Language barriers still exist in secondary public hospitals in the Western Cape. The majority of doctors spoke Afrikaans and no isiXhosa speaking doctors took part in the survey. Half of the doctors surveyed stated they would not be able to take a history in isiXhosa without an interpreter. Most (97%) of doctors had not heard of community trained interpreters and only 23% had ever used the telephone interpretation service available. Perceived consequences of language barriers include: inability or longer duration to get a history, increased use of resources, and patients returning because they did not fully understand the treatment plan. Informal interpreters such as nursing staff and family members were used most often to overcome language barriers. No official interpreters were available to assist in person and doctors are either unaware of telephonic interpreting services or woefully under-using this service. Due to language barriers, doctors are left feeling frustrated with themselves or sad for the patients that they are meant to be helping due to language barriers. Conclusion Reintroduction of community based interpreters, teaching doctors more languages and investment into technologyaided translation services are possibilities that have been suggested by doctors and could be researched further to help improve the current situation.