OpenUCT :: Browsing by Author "Wallis, Lee A"

Browsing by Author "Wallis, Lee A"

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Open Access
Assessing the cost-effectiveness of facility-based emergency care in low resource settings
(2021) Werner, Kalin; Wallis, Lee A; Lin, Tracy Kuo; Reynolds,Teri A; Risko, Nicholas
Background Emergency conditions comprise nearly half of the total global burden of disease, and disproportionately affect low-resource settings (LRS). This burden of life-threatening yet treatable conditions can be ameliorated by effective, timely emergency care (EC) interventions, so significantly that the Disease Control Priorities project estimates over half of deaths in the lowest-income countries could be addressed though the implementation of effective EC. Interest in developing better facility-based EC is expanding rapidly, yet there is a large gap in the cost-effectiveness literature to support informed resource allocation. Distinguishing the "value for money" of EC is crucial, especially in contexts of extreme resources limitations. Developing robust and setting-specific data on the cost of implementing EC cultivates the ability to understand the impacts of, and plan improvements in, EC in LRS. The aim of this thesis was to investigate the cost-effectiveness of interventions forming a systematic approach to EC in health facilities in LRS. Aims and Objectives The primary aim of this research was to investigate the cost-effectiveness of implementing the WHO emergency care toolkit to reduce mortality related to emergency conditions in health facilities in an LRS. To achieve this aim, the following objectives were established: synthesise evidence relating to the costeffectiveness of EC in LRS, enumerate context specific costs of delivering facility-based EC, and retrospectively study the impact of implementing a low-cost set of EC interventions in low-resource EC naïve health facilities on cost and outcome (mortality), to derive a measure of cost effectiveness. Methods The dissertation is comprised of 3 studies. First, Chapter 3 undertakes a systematic review of literature on EC interventions in LRS, using PRISMA guidelines and the Consolidated Health Economics Evaluation Reporting Standards (CHEERS) checklist. Secondly, to enumerate context specific costs of delivering facility-based EC, data were collected over a 4-week period in Uganda using direct activity-based costing and presented in Chapter 6. Measures of central tendency were derived by condition and by intervention. Variations in cost between conditions were explored using a Kruskal-Wallis H test and a post-hoc Nemenyi test were performed to make pairwise comparisons between conditions. Third, in Chapter 7 a cost-effectiveness analysis model was developed using Microsoft Excel to calculate both the costs and effects of scalable investments strengthening facility-based EC on morbidity and mortality. Costs and consequences associated with piloting the WHO Emergency Care Toolkit package of interventions in Uganda were analysed using the decision tree model. Pre- and post-intervention groups were compared from a societal perspective. Cost and health outcomes were discounted using a microsimulation and parameter uncertainty assessed using Monte-Carlo simulation probabilistic sensitivity analyses. Results 35 studies were included in the final review; most were methodologically weak and focused on singleintervention analyses rather than intervention packages or system changes. This body of literature represented only 24 of 137 low- and middle-income countries (LMICs) globally, and was heterogeneous in methods, settings, and presentation of results of the identified studies. Accordingly, formulating a general conclusion about the wider implication of the findings on the cost–effectiveness of EC is problematic. The overall median (IQR) cost of care across all conditions was $15.53 (14.44 to 19.22). A Krauskal-Wallis test yielded statistically significant difference in cost values between sentinel conditions (H=94.89, p=1.20E-19). At a P value of < .05, the post-hoc Nemenyi test revealed paediatric diarrhoea has a statistically significant lower median cost compared to all other conditions, but did not yield any significant differences in median cost between the remaining four sentinel conditions. In running the decision tree model with a 1753 patient cohort, sampled 10000 times, the intervention averted 509 DALYs over standard care. The model found implementing the WHO Toolkit saved $664,231 ($658,552 to $669,910), and yielded an additional 27 lives saved, or an additional 1,826 life years. Conclusions and relevance This dissertation makes important conceptual, analytical and empirical contributions in exploring the application of local economic evidence-informed priority setting to ensure that decisions made around EC are guided by the populations they serve. In conducting one of the first cost-effectiveness analyses of investments that create a systematic approach to facility-based EC, we found that this is a very low-cost, high-yield intervention. In many cases it may not only be cost-effective, but actually cost saving. This finding is especially relevant in LRS contexts where associated additional costs may be considered affordable given the high burden of emergency conditions.
Open Access
Assessment of hospital-based adult triage at emergency receiving areas in hospitals in Northern Uganda
(2016) Opiro, Keneth; Wallis, Lee A; Ogwang, Martin
Background: Limited health service resources must be used in a manner which does "the most for the most". This is partly achieved through the use of a triage system, but health workers must understand it, and it must be used routinely. Whereas efforts have been made to introduce paediatric triage in Uganda, such as Emergency Triage Assessment and Treatment Plus (ETAT+), there is no unified adult triage system being used in Uganda, and it is not clear if hospitals have local protocols being used in each setting. There are limited data on adult triage systems in Uganda. This study aimed at determining how adult hospital-based triage is performed in hospitals in northern Uganda. Methodology: This was a descriptive study. Allocating numbers to the three sub-regions in the northern region, and using a random number generator, we randomly selected the Acholi sub-region for the study. The study was conducted in 6 of the 7 hospitals in the region - one hospital declined to grant permission for the research. It was a written questionnaire survey under supervision of the investigator. In each hospital, at least one representative of nurses in various duty shifts (night, morning and evening shifts), the nursing in-charge/leader, at least one doctor (head of department or any doctor on duty, if available) and a clinical officer (physician assistant, if available), making a minimum of 5-6 study participants who were health professional staff working in emergency receiving areas from each hospital consented and participated in the study. Results: Thirty-three participants from 6 hospitals including 5 doctors, 4 physician assistants, 11 registered nurses, 9 enrolled nurses and 4 nursing assistants consented and participated in the study. Experience of staff working in emergency receiving areas varied with 15(45.5%) greater than 2 years, 7(21.2%) 1-2 years, 5(15.2%) 6 - <12 months and 6(18.2%) for less than 6 months. Only one hospital (16.7%) of the 6 hospitals surveyed had a formal adult hospital-based triage protocol in place. The triage guide/protocol/charts were kept in drawers, had 3 colours - red, yellow and green. Staff rated it as "good", and all staff acknowledged the need to improve it. Only 2 (33.3%) hospitals had an allocated emergency department, the rest receive emergency patients/perform triage from Out Patient Department (OPD) and wards. Lack of training, variation of triage protocols from hospital to another, shortage of staff on duty, absence of national guidelines on triage and poor administrative support were the major barriers to improving/developing formal triage in all these hospitals. Conclusion: Formal adult, hospital-based triage is widely lacking in northern Uganda, and staff do perform subjective "eyeball" judgments to make triage decisions. Most hospitals do not have specifically allocated emergency department which risks disorganization in the flow of patients, crowding and consequently worse patient outcomes.
Open Access
Caregivers' experiences of pathways to care for seriously ill children in Cape Town, South Africa: A qualitative investigation
(Public Library of Science, 2016) Jones, Caroline H D; Ward, Alison; Hodkinson, Peter W; Reid, Stephen J; Wallis, Lee A; Harrison, Sian; Argent, Andrew C
Purpose Understanding caregivers' experiences of care can identify barriers to timely and good quality care, and support the improvement of services. We aimed to explore caregivers' experiences and perceptions of pathways to care, from first access through various levels of health service, for seriously ill and injured children in Cape Town, South Africa, in order to identify areas for improvement. METHODS: Semi-structured, qualitative interviews were conducted with primary caregivers of children who were admitted to paediatric intensive care or died in the health system prior to intensive care admission. Interviews explored caregivers' experiences from when their child first became ill, through each level of health care to paediatric intensive care or death. A maximum variation sample of transcripts was purposively sampled from a larger cohort study based on demographic characteristics, child diagnosis, and outcome at 30 days; and analysed using the method of constant comparison. RESULTS: Of the 282 caregivers who were interviewed in the larger cohort study, 45 interviews were included in this qualitative analysis. Some caregivers employed 'tactics' to gain quicker access to care, including bypassing lower levels of care, and negotiating or demanding to see a healthcare professional ahead of other patients. It was sometimes unclear how to access emergency care within facilities; and non-medical personnel informally judged illness severity and helped or hindered quicker access. Caregivers commonly misconceived ambulances to be slow to arrive, and were concerned when ambulance transfers were seemingly not prioritised by illness severity. Communication was often good, but some caregivers experienced language difficulties and/or criticism. CONCLUSIONS: Interventions to improve child health care could be based on: reorganising the reception of seriously ill children and making the emergency route within healthcare facilities clear; promoting caregivers' use of ambulances and prioritising transfers according to illness severity; addressing language barriers, and emphasising the importance of effective communication to healthcare providers.
Open Access
A cross sectional study of procedural sedation in adults in emergency departments with full time clinicians in the Cape Town metropole
(2007) Hodkinson, Peter William; Mansel, Michael Frank; Wallis, Lee A
The aims of this study were to describe procedural sedation practice in EDs, with specific emphasis on facilities for PS, characteristics of clinicians performing PS, monitoring equipment and personnel, drug regimes, complications and clinician satisfaction with present PS practice. A second aim was to propose evidence-based protocols for the use of PS for those EDs where current practices are found to be outdated and not evidence based.
Open Access
Describing the use of social media as a point-of-care tool in facility-based emergency care in Africa
(2023) Abdelrahman, Abdelmonim; Saunders, Colleen; Wallis, Lee A
Background Despite privacy and legal concerns, social media is used to provide real-time clinical support to emergency care providers. It can be particularly beneficial for those in Africa, who might lack adequate training or access to information. This PhD aimed to describe the use of social media as a point-of-care telemedicine tool in facility-based emergency care in Africa, to further inform its use. Methods A scoping review was conducted to map available literature on use, benefits, and risks associated with social media as a point-of-care platform. A mixed methods approach was then taken using a cross-sectional survey and semi-structured interviews to obtain a comprehensive description of use of social media as a point-of-care tool in facility-based emergency care in Africa. Results The scoping review identified 13 publications describing use of social media as a point-of-care tool in emergency medical settings. No studies were located in low-income countries. All studies evaluated WhatsApp use for real-time consultations, and those that assessed reliability found it to be highly reliable for consultations. A total of 70 emergency care providers in African facilities responded to the survey; nearly all worked in low- or lower-middle-income countries. Responses showed that clinicians use social media multiple times each day, primarily to share and receive advice. The majority felt social media positively impacts patient and provider experiences and improves speed and safety. Finally, eight African emergency care providers were interviewed to gain an in-depth understanding of how social media use impacts emergency care. All participants noted routine use for a range of professional purposes, including consultations, administrative tasks, and education. Concerns were mentioned by all participants, including legality, privacy, and lack of employer regulations. Conclusions This dissertation provides insight into social media use of African emergency care physicians, showing that social media use in this group is ubiquitous. Most clinicians use social media multiple times each day for a range of point-of-care purposes, and many feel social media is positively impacting both the patient and provider experiences. Post-doctoral work will focus on developing a framework to guide use of social media in facility-based emergency care in the African setting.
Open Access
Descriptive study of maternal outcomes in a near-miss cohort at Kagadi District Hospital, Uganda
(2016) Suuna, Micheal; Wallis, Lee A; Florence, Mirembe
Background: An understanding of pregnancy related morbidity (obstetric near miss) provides valuable information that can be used in reduction of maternal mortality. This study aims to (i) Describe the prevalence and short term outcomes of obstetric near misses (ii) Evaluate the level of care through comparative analysis of obstetric near misses and maternal mortality in Kagadi district hospital, Uganda Methods: A facility based retrospective review of obstetric near miss cases and maternal deaths that occurred between 1st January 2015 and 31st December 2015. Obstetric near miss case definition was based on disease-specific criteria including: haemorrhage, hypertensive disorders of pregnancy, dystocia, infection and anaemia. Main outcome measures included the frequency of near-miss in each disease specific group, duration of hospital stay and maternal death. Secondary outcome measures included distribution of referral categories, caesarean section rate, hysterectomy and foetal outcomes measures i.e live births, still births, abortions, neonatal deaths. A comparative analysis of obstetric near miss and maternal mortality was done to determine the maternal near miss incidence ratio (MNMR), maternal mortality ratio (MMR) and Mortality indices. The maternal near miss to mortality ratio for the period of study was calculated. Results: There were 7169 admissions to the maternity ward with 4366 deliveries, 752 near misses and 12 maternal deaths. The prevalence of maternal near misses was 10.7%. Maternal near miss and maternal mortality ratio were 177.1 per 1000 and 282 per 100,000 live births respectively. The near miss to mortality ratio was 63:1. Dystocia (69.3%) was the most common near miss event, followed by haemorrhage (19.5%), infection (5.2%), anaemia (4.5%) and hypertension (1.5%). The mortality indices were 27.3%, 4.1%, 2.9%, 2.5% and 0.2% for hypertension, haemorrhage, anaemia, infection and dystocia respectively. Most complications developed at home (46.7%) while 36.5% and 16.5% occurred at the study site and other public facilities respectively. The mean duration of hospital stay was 3.6 days. The caesarean section rate was 12% of all hospital deliveries and 6 near misses had hysterectomy. Foetal outcomes were 78.4%, 14.2%, 5.6% and 1.8% for live births, abortions, fresh still births and neonatal deaths respectively. Conclusion: There is a high occurrence of near miss events at the health facility. Dystocia is the leading cause of obstetric near miss but hypertension and haemorrhage are associated with poor maternal outcome. Although most obstetric complications develop at home, a comparative analysis of morbidity and mortality at the health facility shows substandard care. In order to improve the quality of care there is need for advocacy for hospital delivery, development evidence management based protocols and routine audit of near miss.
Open Access
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.
Open Access
Development and usability testing of a data visualisation platform for an African trauma data registry
(2018) Griffith, Bridget Catherine Hamilton; Wallis, Lee A; Reynolds, Teri
Introduction Trauma is a significant contribution to the global burden of mortality and disease, especially in sub-Saharan Africa. The methods for tracking, recording, and analysing the incidence and causes of trauma are underdeveloped. To address this, The African Federation for Emergency Medicine (AFEM) developed a trauma form and Trauma Data Registry to collect trauma data in multiple sites in sub-Saharan Africa. We undertook a study to create, and assess the usability and functionality of, a trauma data visualisation platform for use in conjunction with the Trauma Data Registry. Methods We created a web-based trauma data visualisation platform for use with the AFEM Trauma Data Registry. This study involves a usability assessment of the AFEM Trauma Data Visualisation Platform to determine the specific website features and analytical needs of African trauma research facilities. This was done by surveying individuals from healthcare facilities that are currently using the AFEM Trauma Form. Two types of questionnaires were administered: Questionnaire I gathered information on the study population and their expectations for the platform, and Questionnaire II assessed the usability of the platform after it was introduced. Surveys took place in person and online, with the last group of questionnaires being administered on-site at the healthcare facility. Data were captured via Survey Monkey online and paper survey. The results were entered into Excel and analysed using descriptive statistics using Stata Version 14. Results A total of 45 healthcare practitioners from eight countries participated in the background survey. The greatest proportion were trained in Tanzania (14, 31.1%) and Ethiopia (14, 31.1%). The mean age of participants was 32.6 (SD=6.6). The mean number of years reported for working at their current facility is 3.7 (SD=3.5). The greatest number of participants in the survey were physicians (22, 48.9%) and specialists (11, 24.4%). Over half (53.3%, n=24) selected that they had moderate experience with data analysis, and the majority reported that they had less than three publications. A total of 34 HCPs participated in the usability study. The mean scores for the usability questionnaire portion were high, with all of the scores being above 6. Major positive themes of the participant comments included easy to use and time saving, major negative themes included feasibility concerns, and comments specific variable to add were common. Discussion There is a lot of heterogeneity in the data analysis and technology experience of participants. The participants were overall satisfied with the Trauma Data Platform. Participants’ comments and suggestions on elements to add indicate that there is still work to be done to design a Trauma Data Platform that is suitable for this setting. Conclusions Overall satisfaction with the Trauma Data Platform was high, and the user comments and suggestions will be incorporated into future versions of the platform. This research highlights the importance of considering the feasibility of health technology in its introduction.
Open Access
Disaster preparedness and response capacity of regional hospitals in Tanzania: a descriptive cross-sectional study
(BioMed Central, 2018-11-06) Koka, Philip M; Sawe, Hendry R; Mbaya, Khalid R; Kilindimo, Said S; Mfinanga, Juma A; Mwafongo, Victor G; Wallis, Lee A; Reynolds, Teri A
Background Tanzania has witnessed several disasters in the past decade, which resulted in substantial mortality, long-term morbidity, and significant socio-economic losses. Health care facilities and personnel are critical to disaster response. We assessed the current state of disaster preparedness and response capacity among Tanzanian regional hospitals. Methods This descriptive cross-sectional survey was conducted in all Tanzanian regional hospitals between May 2012 and December 2012. Data were prospectively collected using a structured questionnaire based on the World Health Organization National Health Sector Emergency Preparedness and Response Tool. Trained medical doctors conducted structured interviews and direct observations in each hospital. Results We surveyed 25 regional hospitals (100% capture) in mainland Tanzania, in which interviews were conducted with 13-hospital doctors incharge, 9 matrons and 4 heads of casualty. All the hospitals were found to have inadequate numbers of all cadres of health care providers to support effective disaster response. 92% of hospitals reported experiencing a disaster in the past 5 years; with the top three being large motor vehicle accidents 22 (87%), floods 7 (26%) and infectious disease outbreaks 6 (22%). Fifteen hospitals (60%) had a disaster committee, but only five (20%) had a disaster plan. No hospital had all components of surge capacity. Although all had electricity and back-up generators, only 3 (12%) had a back-up communication system. Conclusion This nationwide survey found that hospital disaster preparedness is at an early stage of development in Tanzania, and important opportunities exist to better prepare regional hospitals to respond to disasters.
Open Access
Emergency care assessment tool for health facilities: a validity study in Cameroon
(2018) Kim, Paul; Wallis, Lee A; Hynes, Emilie Calvello
Background To date, health facilities in Sub-Saharan Africa have not had an objective measurement tool for evaluating comprehensive emergency service provision. One major obstacle is the lack of consensus on a standardised evaluation framework, applicable across a variety of resource settings. The African Federation for Emergency Medicine (AFEM) developed an assessment tool specifically for these settings - the Emergency Care Assessment Tool (ECAT) - that assesses provision of key medical interventions. These interventions are referred to as signal functions for the six sentinel conditions that occur prior to death: respiratory failure, shock, altered mental status, severe pain/trauma, and dangerous fever. A signal function represents the culmination of knowledge of interventions, supplies, and infrastructure capable for the management of an emergent condition. Previous studies aimed at the refinement and context modification of the ECAT have already been performed in multiple African countries. We undertook a validation study to help determine the applicability of the tool in assessment of emergency services throughout the continent. Aims and Objectives The aim of this study was to determine the content, construct, and face validity of the AFEM Emergency Care Assessment Tool in Cameroon. To achieve this, the study had the following objectives: (1) Employ the ECAT in district, regional, and central hospitals in Cameroon. (2) Use direct observation to determine whether the signal functions can be performed in these facilities. Methods This was an observational study at a convenience sample of five hospitals in Cameroon: three district, one regional, and one central. The goal of this study was to validate the instrument, not the facility, and so the sample size was related to the number of signal functions witnessed rather than the number of facilities visited. The tool was administered with the Head of Emergency at each facility. This completed ECAT was then compared with direct observations of the signal functions, a process which was conducted by the partner local emergency care specialists accompanied by the ECAT researcher. Results In general, the higher the level of facility, the greater the emergency care capacity and the greater the number of signal functions that could be performed correctly and consistently. Discrepancies in funding, supplies, resource allocation, and care delivery ability were apparent through ECAT results, expounding on barriers to care delivery, and direct observation. McNemar tests on the ECAT results versus direct observation at each facility yielded statistically significant support for tool validation at the national level emergency unit as well as two of the district level emergency units. Concordance between reported and observed signal functions could not be achieved at the regional facility and one of the district facilities. Conclusions The ECAT has good potential for facility level assessment of emergency care provision, and collects meaningful information that can guide effective improvements in the delivery of emergency care.
Open Access
Emergency department patients' perception of care: do doctors understand their patients?
(2011) Mahomed, Zeyn; Wallis, Lee A
The aim of my study is to directly compare the patient’s perceptions of care received in the emergency department to that of the attending physician’s. The aim is to give us better insight into how the patient experiences their care, with a view to improving the level of care offered. The study elucidates the emphasis a patient places on aspects of their care such as empathy, communication, waiting times, etc. The study was conducted at GF Jooste Emergency Department over a period of eight weeks. Patients voluntarily, and with full anonymity, filled in a short questionnaire. The attending physician did the same. Questionnaires were collected and data fed into a database, analyzed and the results interpreted.
Open Access
Emergency unit and disaster preparedness: A study of military hospitals in Saudi Arabia
(2022) Alotaibi, Yasir M; Wallis, Lee A; Kattb, Ziad
Background: The objective of this study is to evaluate the emergency and disaster preparedness of military hospital emergency services, and to further, identify strategies for improvement in disaster preparedness and response. Saudi Arabia is prone to various man-made and natural disasters. Among these is the event of the annual pilgrimage termed Hajj, which annually presents the risk of overcrowding. Many of these disasters have resulted in mass casualties. Consequently, there has been increased emphasis on planning by disaster experts to establish and maintain an organized preparation for a wide range of emergencies. Emergency Medical Services (EMS) play a vital role in disaster management. Both pre-hospital EMS and in hospital emergency services are considered inefficient and inadequately prepared in disaster response and management. Most importantly, there is limited data on emergency care (EMS and hospital-based) disaster preparedness and responses in Saudi Arabia. Methods: We undertook a prospective cross-sectional, descriptive survey-based assessment of disaster preparedness. The research focused on collecting and analysing data through quantitative methods. To review the standard operating procedures (SOP), we sought all disaster plans and SOPs from management and emergency unit leadership at each of the 3 Medical Services Directorate (MSD) hospitals. We then undertook a questionnaire assessment, gathering quantitative data using close-ended questions and open-ended commentary surrounding a hospital's disaster response operating procedures. Results: We found a wide variability in the hospitals across the 22 themes in the survey. Most hospital emergency units have a good to excellent disaster plan. There were, however, concerns with the departmental standards with Radiology, Occupational Health, Critical Care, Respiratory Therapy, Pastoral Counselling, and provision made for the preservation of forensic evidence. Internal traffic flow and control issues presented relate to elevators manned and its prioritized usage. It is found that the area demarcated for media liaison needs improvement. Reception of casualties also needs attention and finally, relocation of patients and staff needs prioritisation. Conclusion: The study has highlighted several strengths in facility disaster preparedness and further shared the need for rigorous efforts required to improve the situation at some facilities. In general, most hospitals were found to have a good disaster management plan in place, however, a few covered all the recommended areas in sufficient detail.
Open Access
Facility-based capacity assessment of emergency care services in public hospitals in Zambia
(2017) Chavula, Chancy; Wallis, Lee A
In sub-Saharan Africa, the shift in disease burden from infections to non-communicable disease and injury highlights the need for effective and efficient emergency care. Despite this, emergency care is a neglected sector of the health system in most low and middle-income countries. Funding and resource allocations are often small and have little impact on the development of emergency care systems, and provision of emergency care is therefore frequently left to under-trained and/or under-prepared nurses or clinical officers. In order to develop effective emergency care systems, one must first identify strengths and challenges in existing systems. The aim of this study was to determine facility-based emergency care capacity in public hospitals in Zambia. This descriptive cross-sectional study comprised of a total of 23 facilities: seven districts, 12 general and four central hospitals. Data were collected using a standardised Emergency Care Assessment Tool (ECAT); developed in 2013 by AFEM to ascertain facilities' strengths and weaknesses in the delivery of the emergency care services for five sentinel conditions and maternal health. The ECAT was administered through one-on-one interviews with designated personnel working in emergency receiving areas. The assessment tool consists of six main themes relating to the ability to provide care for patients suffering from respiratory failure, shock, altered mental status, severe pain, trauma and maternal health. The majority of facilities were able to perform almost all the procedures across all themes. However, some procedures, which were highly technical and required personnel with specialist training or specialised equipment, were not performed at all facilities. The level of the facility also dictated whether a procedure could be performed where higher-level health facilities like central hospitals were able to perform more procedures than lower-level facilities due to higher numbers of trained personnel, more equipment and supplies, and better infrastructure. Maternal health was covered in almost all (>90%) hospitals. Across all themes, the most frequent reasons for not performing procedures were lack of supplies (n=137) followed by no training (n=136), no infrastructure (n=35) and no human resources (n=34). At the central level, the most frequent reason for not performing procedures was no supplies (n=16), whereas at district and general levels the most frequent reason was no training. Overall, most facilities were able to offer basic emergency care services. However, there is limited capacity of training and supplies across all facilities, as well as a lack of infrastructure and policies for emergency care in lower-level facilities. Zambian hospitals can provide basic emergency care, but there is need to enhance training and improve on provision of supplies to enable facilities to provide emergency care. Focus must also be on development of policies relating to emergency care to guide and standardise procedures. Capacity building should be more focused at district and general hospitals to improve emergency care across all levels of health facilities, as it will reduce the burden at central level and improve patient outcomes since these are first-line access points for patients.
Open Access
An investigation into recruitment, retention and motivation of advanced life support practitioners in South Africa
(2017) Gangaram, Padarath; Bhagwan, Raisuyah; Wallis, Lee A
Background: Internationally, emergency medical services (EMS) are experiencing problems with recruiting, retaining and motivating advanced life support (ALS) practitioners. The persistent shortage of ALS practitioners in South Africa (SA) poses a challenge to the effective delivery of prehospital emergency medical care. The global demand for SA trained ALS practitioners is steadily increasing. SA EMS organisations are struggling to compete for these practitioners with the international market. The SA EMS industry currently has no effective approach to decrease the loss of ALS practitioners. This research study was therefore conceptualized to investigate factors that influence ALS practitioner recruitment, retention and motivation in an effort to enhance them. Methods: This study followed a sequential, explanatory, mixed method design. The two phase study was non-experimental and descriptive in nature. The quantitative phase was comprised of ALS practitioners (n=1309) and EMS managers (n=60) completing questionnaires. The qualitative phase of the study involved data gathering through focus group (n=7) discussions with ALS practitioners and semi-structured interviews with EMS managers (n=6). Quantitative data was analysed with Statistical Package for the Social Sciences (SPSS). Inferential techniques included the use of correlations and chi squared test values which were interpreted using p-values. Results: The study identified 19 recruitment, 25 retention and 16 motivation factors that influence ALS practitioners. Cumulatively, these factors revolved around the ALS practitioners' work environment, professional development and employment package. Strong recruitment factors that were identified include: ALS practitioner remuneration, skilled EMS management and organisation culture. Similarly, strong ALS practitioner retention factors that were identified include: skilled EMS management, remuneration, resources, availability of health and wellness programmes, recognition of practitioners, working conditions and safety and security. Strong ALS practitioner motivation factors included: remuneration, skilled EMS management and resources. Conclusion: More ALS practitioner training institutions are required to improve the number of these practitioners. EMS organisations must improve the work environment, employment package and professional development opportunities for ALS practitioners. Such practices will encourage ALS practitioner recruitment, retention and motivation.
Open Access
Major incident triage: development and validation of a modified primary triage tool
(2018) Vassallo, James M A; Smith, Jason E; Wallis, Lee A
Introduction A key principle in the effective management of a major incident is triage, prioritising patients on the basis of their clinical acuity. However, existing methods of primary major incident triage demonstrate poor performance at identifying the Priority One patient in need of a life-saving intervention. The aim of this thesis was to derive an improved triage tool. Methods The first part of the thesis defined what constitutes a life-saving intervention. Then using a retrospective military cohort, the optimum physiological thresholds for identifying the need for life-saving intervention were determined; the combination of which was used to define the Modified Physiological Triage Tool (MPTT). The MPTT was validated using a large civilian trauma database and a prospective military cohort. Subsequently, to describe the safety profile of the MPTT, an analysis of the implications of under-triage was undertaken. Finally, pragmatic changes were made to the MPTT (MPTT-24) - in order to provide a more useable method of primary triage. Statistical analysis was conducted using sensitivities and specificities, with triage tool performance compared using a McNemar test. Results 32 interventions were considered life-saving and the optimum physiological thresholds to identify these were a GCS <14, 12 < RR <22 and a HR < 100. Within both the military and civilian populations, the MPTT outperformed all existing methods of triage with the greatest sensitivity and lowest rates of under-triage, but at the expense of over-triage. Applying pragmatic changes, the MPTT-24 had comparable performance to the MPTT and continued to outperform existing methods. Conclusion The priority of primary major incident triage is to identify patients in need of life-saving intervention and to minimise under-triage. Fulfilling these priorities, the MPTT-24 outperforms existing methods of triage and its use is recommended as an alternative to existing methods of primary major incident triage. The MPTT-24 also offers a theoretical reduction in time required to triage and uses a simplified conscious level assessment, thus allowing it to be used by less experienced providers.
Open Access
Mode of transport to hospital among patients with ST Elevation Acute Myocardial Infarction (STEMI) in the Emirate of Abu Dhabi: correlates, physician and patient attitudes, and associated clinical outcomes
(2017) Callachan, Edward; Wallis, Lee A
Introduction: Acute coronary syndromes, including ST-elevation myocardial infarction (STEMI), are a leading cause of morbidity and mortality worldwide. Existing research shows that prehospital care provided by emergency medical services (EMS) can significantly improve outcomes. However, EMS remains grossly underutilised in Abu Dhabi despite a well-established presence. Objectives: In this three-part quantitative, observational study, we sought to (1) assess physicians' perceptions of, and recommendations for, utilization and improvement of EMS, (2) assess patients' awareness of EMS, mode of transport use in decision to seek care and reasons for their decision, and (3) establish if in the current study setting, mode of transport used has implications for in hospital adverse events, as well as short and long term clinical outcomes. The goal was to investigate both physicians' and patients' perceptions of prehospital STEMI care, as well as to assess the clinical correlates of the mode of transport in a patient's decision to seek care. Methods: We conducted the study in three phases. Phase 1: At four government-operated hospitals in Abu Dhabi, we administered surveys to a convenience sample of physicians involved in care of patients with acute coronary syndromes to measure (a) likelihood of recommending EMS, (b) satisfaction with EMS, (c) likelihood of using EMS for self or family, and (d) recommendations for prehospital care of acute coronary syndromes. Phase 2: We gathered mode of transport data from a purposive, non-random sample of 587 consecutive patients with STEMI over an 18-month period and conducted structured follow-up interviews to assess their perceptions of EMS. We conducted analysis to determine whether mode of transport was related to demographic variables. Phase 3: We collected medical records from patient participants and conducted structured follow-up interviews at 1, 6 and 12 months post discharge. We conducted chi square difference testing to determine the relationships among mode of transport, treatment times, and short- and long-term clinical outcomes. Variables included treatment times and associated outcomes. Results: Physician participants (n = 106) were most supportive of prehospital 12-lead ECG for STEMI, but indicated low satisfaction with existing EMS services in Abu Dhabi. Among STEMI patient participants (n = 587), EMS was underutilized in Abu Dhabi; over half (55%) of patients did not know the phone number to contact EMS, and only 14.7% used EMS in their decision to seek care. EMS-transported patients were more likely to receive timely treatment (door-todiagnostic ECG time, door-to-balloon time) and had lower incidence of mortality compared to privately-transported patients. Conclusions: These findings suggest a need to raise public awareness of EMS and its importance for coronary symptoms in Abu Dhabi. Broader application of prehospital ECG, including prehospital activation of cardiac catheterization labs, bypassing non-interventional cardiology centres, and admission directly to facilities that provide these services without initial admission to the emergency department, could help improve physicians' perceptions of EMS and outcomes for patients with STEMI.
Open Access
Perceptions of health providers towards the use of standardised trauma form in managing trauma patients: a qualitative study from Tanzania
(2020-05-01) Sawe, Hendry R; Sirili, Nathanael; Weber, Ellen; Coats, Timothy J; Reynolds, Teri A; Wallis, Lee A
Background Trauma registries (TRs) are essential to informing the quality of trauma care within health systems. Lack of standardised trauma documentation is a major cause of inconsistent and poor availability of trauma data in most low- and middle-income countries (LMICs), hindering the development of TRs in these regions. We explored health providers’ perceptions on the use of a standardised trauma form to record trauma patient information in Tanzania. Methods An exploratory qualitative research using a semi-structured interview guide was carried out to purposefully selected key informants comprising of healthcare providers working in Emergency Units and surgical disciplines in five regional hospitals in Tanzania. Data were analysed using a thematic analysis approach to identify key themes surrounding potential implementation of the standardised trauma form. Results Thirty-three healthcare providers participated, the majority of whom had no experience in the use of standardised charting. Only five respondents had prior experience with trauma forms. Responses fell into three themes: perspectives on the concept of a standardised trauma form, potential benefits of a trauma form, and concerns regarding successful and sustainable implementation. Conclusion Findings of this study revealed wide healthcare provider acceptance of moving towards standardised clinical documentation for trauma patients. Successful implementation likely depends on the perceived benefits of using a trauma form as a tool to guide clinical management, standardise care and standardise data reporting; however, it will be important moving forward to factor concerns brought up in this study. Potential barriers to successful and sustainable implementation of the form, including the need for training and tailoring of form to match existing resources and knowledge of providers, must be considered.
Open Access
Prehospital triage tools across the world: a scoping review of the published literature
(2022-04-27) Bhaumik, Smitha; Hannun, Merhej; Dymond, Chelsea; DeSanto, Kristen; Barrett, Whitney; Wallis, Lee A; Mould-Millman, Nee-Kofi
Background: Accurate triage of the undifferentiated patient is a critical task in prehospital emergency care. However, there is a paucity of literature synthesizing currently available prehospital triage tools. This scoping review aims to identify published tools used for prehospital triage globally and describe their performance characteristics. Methods: A comprehensive search was performed of primary literature in English-language journals from 2009 to 2019. Papers included focused on emergency medical services (EMS) triage of single patients. Two blinded reviewers and a third adjudicator performed independent title and abstract screening and subsequent full-text reviews. Results: Of 1521 unique articles, 55 (3.6%) were included in the final synthesis. The majority of prehospital triage tools focused on stroke (n = 19; 35%), trauma (19; 35%), and general undifferentiated patients (15; 27%). All studies were performed in high income countries, with the majority in North America (23, 42%) and Europe (22, 40%). 4 (7%) articles focused on the pediatric population. General triage tools aggregate prehospital vital signs, mental status assessments, history, exam, and anticipated resource need, to categorize patients by level of acuity. Studies assessed the tools’ ability to accurately predict emergency department triage assignment, hospitalization and short-term mortality. Stroke triage tools promote rapid identification of patients with acute large vessel occlusion ischemic stroke to trigger timely transport to diagnostically- and therapeutically-capable hospitals. Studies evaluated tools’ diagnostic performance, impact on tissue plasminogen activator administration rates, and correlation with in-hospital stroke scales. Trauma triage tools identify patients that require immediate transport to trauma centers with emergency surgery capability. Studies evaluated tools’ prediction of trauma center need, under-triage and over-triage rates for major trauma, and survival to discharge. Conclusions: The published literature on prehospital triage tools predominantly derive from high-income health systems and mostly focus on adult stroke and trauma populations. Most studies sought to further simplify existing triage tools without sacrificing triage accuracy, or assessed the predictive capability of the triage tool. There was no clear ‘gold-standard’ singular prehospital triage tool for acute undifferentiated patients. Trial registration Not applicable.
Open Access
Prioritization of critically unwell children in low resource primary healthcare centres in Cape Town, South Africa
(2017) Hansoti, Bhakti; Wallis, Lee A; Maconochie, Ian
Background: Every day, sick children die from time sensitive preventable illnesses. Due to an inadequate number of trained healthcare workers and high volumes of children presenting to Primary Healthcare Centres (PHC), waiting times remain high and often result in significant delays for critically ill children. Delays in the recognition of critically unwell children are a key contributing factor to avoidable childhood mortality in Cape Town, South Africa. Methodology: A stepped implementation approach was undertaken to develop and evaluate a context-appropriate prioritization tool to identify and expedite the care of critically ill children PHC in Cape Town, South Africa. Aim 1: To conduct a systematic review of paediatric triage and prioritization tools for low resource settings in order to evaluate the evidence supporting the use of these tools. Aim 2: To perform an exploratory study, to identify barriers to optimal care for critically ill children in the pre-hospital setting in Cape Town, South Africa. Aim 3: To develop an implementable context-appropriate tool to identify and expedite the care of critically ill children in PHC in the City of Cape Town, South Africa. Aim 4: Evaluate the reliability of this tool compared to established triage tools currently used in this setting. Aim 5: Evaluate the impact of implementing this tool, on waiting times for children presenting for care to PHC. Aim 6: Evaluate the effectiveness of this tool post real-world implementation in identifying and expediting the care for critically ill children. Findings: Post real world implementation SCREEN was able to significantly reduce waiting times in PHC for critically ill children. Compared to pre-SCREEN implementation, post-SCREEN the proportion of critically ill children who saw a PN within 10 minutes increased tenfold from 6.4% (pre-SCREEN) to 64% (post-SCREEN) (p<0.001). SCREEN is also able to accurately identify critically ill children, in an audit of 827 patient-charts SCREEN had a sensitivity of 94.2% and a specificity of 88.1% when compared to IMCI. Interpretation: The SCREEN program when implemented in a real-world setting has shown that it can effectively identify and expedite the care of critically ill children in PHC.
Open Access
Recommendations on the safety and effectiveness of Ketamine for induction to facilitate advanced airway management in head injured patients in South Africa by pre-hospital professionals: A rapid review
(2016) Smit, Pierre Christo; McCaul, Michael Gilbert; Wallis, Lee A
Background: The South African 2006 Advanced Life Support and Emergency Care Practitioner protocols do not currently reflect the latest, best evidence-based practices for emergency care, specifically regarding induction agents in head injury patients. Recent evidence has challenged some preconceptions regarding the use and safety of Ketamine in head injuries. In response to this, the Health Professions Council of South Africa Professional Board for Emergency Care (HPCSA PBEC) has requested a review of the emergency care protocols. Objectives: To determine the evidence of effectiveness and safety of intravenous/intraosseous (IV/IO) Ketamine as an induction agent for adult patients with traumatic brain injury, the authors aimed to determine the all-cause mortality at 30 days, adverse events/effects, morbidity and rate of successful intubation associated with ketamine administration, as compared to standard induction agents. Research Question: What is the evidence of effectiveness and safety of IV/IO Ketamine in adult patients with head injury, for pre-hospital induction in advanced airway management, compared to standard therapy? Methods: The review followed a tiered approach, where three different tiers of searches were performed for articles relevant to the research question. Two authors independently and in induplicate performed title, abstract and full-text review for each potentially included article, as well as critical appraisal of 3 CPGs found in the tier 1 searches. Tier 1 searched for Clinical Practice Guidelines (CPGs), tier 2 for Systematic Reviews (SRs) and tier 3 for Randomised Controlled Trials (RCTs) relating to the research question. No grey literature searches were performed, but reference lists of included articles were searched for relevant articles. Main Results: The authors could not find any studies to include (CPGs, SRs or RCTs) in this review which would answer the research question. However, several articles were found which describe ketamine use in the Intensive Care Unit (ICU) and surgical patients with regards to intracranial pressure, cerebral perfusion pressure and general haemodynamic effects. Another article (RCT) was found which used ketamine as an induction agent compared to etomidate to facilitate intubation in critically ill patients. These articles provide some helpful insights as to ketamine's effectiveness and safety for induction to facilitate intubation in traumatic brain injury patients in the pre-hospital setting. Conclusions: The authors could not make any recommendations regarding the research question, and the safety and effectiveness of ketamine for induction to facilitate intubation in adult traumatic brain injury remains unclear. A lack of empirical evidence at RCT level has led to substantial knowledge gaps regarding our understanding of Ketamine and its effects in traumatic brain injury patients.