Browsing by Subject "Emergency Medicine"

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    Open Access
    A 12-month retrospective descriptive analysis of a single helicopter emergency medical service operator in four South-African provinces
    (2023) Vlok, Neville; Stassen, Willem; Wylie Craig
    Introduction: Helicopter Emergency Medical Services (HEMS) forms an important role in integrated modern emergency medical services and have a suggested mortality benefit in certain patient populations, such as those affected by severe trauma or with time-sensitive pathologies in rural areas. Despite this, HEMS is an expensive resource used in South Africa and appropriate use and feasibility in low-to-middle income countries (LMIC) is highly debated. To maximise benefit, it is essential that the right patients be selected for HEMS. In order to evaluate this, the current practices first need to be described. The aim of this study was to describe a population of patients being transported by HEMS in South Africa, in terms of flight data, patient demographics, provisional diagnosis and clinical characteristics and interventions. Methods: A retrospective flight- and patient-chart review were conducted, extracting clinical and mission data of a private, single aeromedical operator in South Africa, over a 12-month period (July 2017 – June 2018) in Gauteng, Free State, Mpumalanga and North-West. Results: A total of 916 cases were included (203 primary cases, 713 interfacility transport (IFT)). The majority of the patients were male (n=548, 59.8%), suffered blunt trauma (n=379, 41.4%) followed by medical pathology (n=247, 27%) and neonatal transfers (n=184, 20.1%). Most flights occurred in daylight hours (n=729, 79.6%). Median mission times were 1-hour 53minutes for primary missions, and 3 hours 10 minutes for IFT cases. Median on-scene times were 26 minutes for primary cases and 55 minutes for IFT cases. Although many patients were transported with an endotracheal tube (n=428, 46.7%), more than a third did not have an advanced airway and received supplemental oxygen via other means (n=348, 37.9%). Almost half of patients received no respiratory support (n=414, 45.2%). No patients received fibrinolysis, defibrillation, cardioversion or cardiac pacing. Almost all patients received intravenous fluid therapy (n=867, 94.7%). The administration of sedation (n=430, 46.9%) and analgesia (n=329, 35.9%) were also common interventions. Conclusion: By describing current HEMS transport practices in one of the largest cohorts in Africa to date, a better understanding is gained of how HEMS is utilised daily. Apart from the lack of universal call out criteria and response to the high burden of trauma, HEMS seem to fulfil an important critical care transport role. Due to the lack of coordinated coronary care networks, it seems that cardiac pathologies are under-represented in this study and might have an important implication for crew training requirements.
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    Open Access
    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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    Open Access
    A comparison of critical care transportation modules taught in bachelor's degrees in emergency medical care in South Africa
    (2020) Conradie, Nathan John; Stassen, Willem; Vincent-Lambert, Craig
    The aim of this literature review was to collect and appraise literature related to curricula in critical care transportation and retrieval, pre-hospital care, and aeromedical transportation. The search strategy was twofold. Firstly peer-reviewed published literature was sourced from established platforms. Secondly, grey literature was sourced from internet sources. An assessment of reliability and validity was performed on peer-reviewed literature in the appraisal process. The results of the literature review show that there is a paucity of literature describing critical care modules of pre-hospital educational programmes in South Africa. This lack of literature has led the authors of this review to conclude that there is a potential for insufficient benchmarking and standardisation of the critical care module between universities. The results of this study could allow stakeholders to begin the process of academic standardisation. To provide a comprehensive background on the field of critical care transportation and retrieval and specifically education and training, this literature review starts by describing the field locally. It then attempts to outline the risks associated with critical care retrieval and thereby demonstrating the importance of quality education and regulation that can guide practitioners who perform retrievals. It then seeks to understand the importance of standardsetting within education broadly and the role of curricula in standard-setting. Finally, it provides an overview of methods for comparing curricula. After the background sections, the gathered literature was grouped into themes according to the types of curricula included in the literature. All these types of curricula form part of the critical care transportation and retrieval field, as graduates from these programmes are usually involved in the transportation of critically ill patients between facilities.
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    Open Access
    A critical realist study into the emergence and absence of academic success among Bachelor of Emergency Medical Care students
    (2018) Sobuwa, Simpiwe; Bruijns, Stevan R; Lord, Bill
    This critical realist thesis explores academic success in the four-year Bachelor of Emergency Medical Care degree in South Africa. The Bachelor of Emergency Medical Care degree is a relatively new degree that is offered at four universities in South Africa. In view of the existing shortage of paramedics both in South Africa and on the African continent, an understanding of the factors that play a role in academic success may lead to an increase in the number of emergency care providers. Accordingly, this study was conceptualised to explore the reasons why academic success is either evident or absent among Bachelor of Emergency Medical Care students. The study utilised a sequential, explanatory, mixed methods research design. The quantitative phase consisted of an online survey that was disseminated to Bachelor of Emergency Medical Care students in South Africa with the aim of gaining an insight into their socio-cultural history. Continuous and categorical variables were described using basic descriptive statistics. The Pearson’s chi-square and Fisher’s exact test were used to test associations between the various survey variables and repeating a year. A p-value of less than 0.05 was considered to be statistically significant. During the qualitative phase focus groups were held with students while semi-structured interviews were conducted with lecturing staff members. The aim of the qualitative approach was to explore the causal powers and generative mechanisms that give rise to or enable the emergence or absence of academic success among Bachelor of Emergency Medical Care students. Thematic analysis was used to analyse results from the focus groups and semistructured interviews. A critical realist concept of the laminated system was also used to explore the themes that emerged. A total of 176 participants from an available sample of 408 students responded to the survey. Not repeating a year was significantly associated with two important variables, namely, the possession of a pre-existing emergency care qualification and not being a white student. The results revealed that the following interactive generative mechanisms played a role in the lack of academic success, namely, biological, socioeconomic, socio-cultural, normative, psychosocial and psychological factors while the following interactive generative mechanisms facilitated the emergence of academic success – psychological, psycho-social, normative and socioeconomic factors.
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    Open Access
    A descriptive analysis of emergency care provided in Northern Somalia
    (2019) Muange, Dennis; Wallis, Lee; Wachira, Benjamin
    Emergency care is an integral part of an effective healthcare system. However, emergency care systems remain largely underdeveloped in low- and middle-income countries, particularly in Sub-Saharan Africa. Somalia is in the horn of Africa. Decades of civil war, political instability, and terrorism insurgency have greatly hampered healthcare in the country, and the country does not have a formal emergency care system. The aim of the study was to assess the current provision of emergency care in healthcare facilities in northern Somalia, namely Somaliland and Puntland. This was a cross-sectional descriptive study carried out in all emergency units in Hargeisa and Garowe, the capital cities of Somaliland and Puntland respectively. A standardised WHO emergency care assessment tool was used to assess the performance of emergency care procedures in the emergency units. Simple descriptive statistics were used to analyse the data. Six facilities - two in Puntland, and four in Somaliland - participated in the study. Two of these were regional referral public facilities, while the rest were private. The performance of sixty emergency care procedures was assessed. Absent equipment was the main reason (47%, n=60 for the non-performance of these emergency care procedures. Lack of training (29%), stock out of supplies (13%), and lack of skilled personnel (10%) were the other reasons for the non-performance of these emergency care procedures. The findings of this study underscore the need for more resource allocation with a focus on equipping emergency units and having adequate supplies. The study also highlights the need for training of healthcare providers who routinely provide care in emergency units.
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    Open Access
    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 demographics, triage allocations and patient outcomes for a private emergency centre in Pretoria for 2018
    (2020) Hedding, Kirsty; Dippenaar, Enrico; Wallis, Lee
    Background Triage aims to detect critically ill patients and to prioritise those with time-sensitive needs. It also contributes to the overall efficiency of an emergency centre (EC). International systems have been relatively well researched; however, no data exists on the use of the SATS score in private healthcare settings in SA. Objectives This study aimed to describe the demographics, triage allocations, time spent in EC and disposition of all patients presenting to a private hospital EC in Pretoria, South Africa in 2018. Methods A retrospective descriptive study was undertaken. Data relating to demographics, triage, and hospital disposition were collected on all patients presenting to the EC during the 2018 calendar year. Descriptive data analyses were conducted in Microsoft Excel. Results A total of 29 055 patients were included in this study. More than half (57.6%) were adults aged 18 to 60 years and approximately one-fourth (27.5%) were paediatrics (<18 years). The majority of patients were triaged yellow (73.5%); 17.4% were triaged as red and orange. It took, on average, 28 minutes to be seen by a provider and patients spent an average of 2 hours and 20 minutes in the EC. Delays to be seen exceeded standards for red and orange patients at 8 and 18 minutes respectively, and the mean time these patients spent in the EC was higher (2h 51 minutes and 2h 47 minutes respectively). Most patients (76.1%) were discharged; 5.6% were admitted to ICU/high care, 14.4% to the general ward, and 3.9% either absconded or refused hospital treatment. Of patients triaged red and orange, 11.1% and 49.3% were discharged respectively, and these patients used the most resources . Conclusion This study found that most of the patients were triaged into low acuity categories (yellow and green) and discharged home. High acuity patients were usually admitted to ICU or high care; however, these patients experienced delays in being treated and admitted. Causes of these issues, and implications on patient outcomes remain unknown. Large numbers of high acuity patients were ultimately discharged home. Further studies are needed to understand the influence of triage accuracy on these patients' outcomes.
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    Open Access
    A descriptive study of patients presenting with a chief complaint of seizures to the prehospital emergency care practitioner of the Western Cape
    (2019) Bester, Beatrix Hendrina; Saunders, Collen; Allgaier, Rachel
    Background Seizures are considered one of the most common time-sensitive and potentially life-threatening medical emergencies presenting to emergency centres and attended to by prehospital emergency care practitioners. These require a rapid response, prompt identification and appropriate management. There is a paucity of information describing the demographics and prehospital management of patients presenting with seizures in South Africa. Objectives The aim of this study was to describe the demographics and prehospital management of patients presenting with a chief complaint of seizures and/or convulsions to prehospital emergency care practitioners within the Western Cape Government Emergency Medical Services. Methods This retrospective study included all Western Cape Government Emergency Medical Services calls indicating a chief complaint of seizures and/or convulsions between August 2017 and July 2018. Descriptive statistics were performed to describe basic demographics in this population. A sample of emergency calls originating within the City of Cape Town was selected for a clinical chart review to describe on-scene clinical presentation and vitals, response times, and prehospital treatment provided. Results A total of 24 746 seizure and/or convulsion cases were recorded during the study period. The highest frequency of patients was in the 21 - 40 year age group (31%), and 57% of patients were male. The subsample (n=3 075) yielded 1 571 cases with completed electronic patient care records. The mean dispatch and response times were 20 (±36) and 14 (±10) minutes respectively with a mean on-scene time of 25 (±13) minutes. No on-scene vital signs were recorded in 11.3% of patients. Recorded on-scene vitals indicated that 36% of patients presented with a tachycardia, 14% had an oxygen saturation of < 95%. Airway manoeuvres were performed in 30% of cases, and 50% of patients presenting with a SpO2 < 95% received supplemental oxygen. The benzodiazepine Diazepam was the most common medication administered, and 83% of medications were administer through the intravenous route. Conclusions Seizures are a recognised time-sensitive emergency, however in this sample of patients we observed a longer than expected dispatch time. Although the importance of recording baseline vital signs is recognised, there was a large proportion of undocumented vital signs 35 within the sample. Despite consensus recommendations that intramuscular midazolam are the preferred medication and route, IV diazepam was the most frequently administered. Seizures are an under-recognised burden on Emergency Medical Services within the Western Cape. This study provides an initial description of the epidemiology within this population, allowing for optimization of recognition and management in these patients.
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    A descriptive study of the standard operating procedures for disaster response in the Saudi Arabian military health services
    (2019) Alshaabani, Tariq Lafi; Wallis, Lee; Alshahrani, Mohammad
    Background Saudi Arabia has suffered from disasters commonly in the last decade. The Saudi military medical services play a major role in confronting these events, but there are anecdotal challenges with their planning and response systems. Currently, disaster planning in Saudi Arabia appears to be undertaken in some detail, but the medical response to disasters is fragmented. This study aimed to review and assess the standard operating procedures for disaster response in the Saudi Arabian military health services. Methods We undertook a prospective, survey-based assessment of disaster response. We sought all disaster plans and Standard Operating Procedures from management and emergency department leadership at each of the 13 Military hospitals. We used a standardised survey tool to evaluate facility disaster planning. This tool gathers quantitative data using close-ended questions and open-ended commentary surrounding a hospital’s disaster response operating procedures. Results There was wide variability in the hospitals across the 20 themes in the survey. While most hospitals have a disaster plan, an up to date version was not always available. Key issues were identified in: management of contaminated patients; coordination of visitors, volunteers and extra staff; media management, and collaboration with other agencies. Conclusion The study highlighted a number of strengths in facility disaster preparedness, and a number of aspects where concerted efforts are required to improve the situation. In general, most hospitals had reasonable disaster plans in place, although none covered all the recommended areas in sufficient detail.
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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 Four-Year Descriptive Analysis of Stroke in a Private Hospital in the Western Cape
    (2022) Govender, Sarojini; Stassen, Willem
    Background: Stroke is the second leading cause of death and disability globally, with an estimated 26% increase in stroke deaths between 1990 and 2010. The World Stroke Society estimated that one in six people will suffer a stroke in their lifetime. In 2010, stroke accounted for 5.9 million deaths, 71% of which was in low- to middle-income countries (LMICs) and is a major public health concern for Africa and other LMICs together with other non-communicable diseases. Communicable diseases such as HIV/AIDS, malaria, tuberculosis etc. are prioritised in Sub-Saharan Africa (SSA) and the healthcare expenditure has been mostly allocated to treat these. The cost of stroke care in hospital and out of hospital is quite alarming and the burden of stroke places an added burden on an already stretched healthcare budget. Objectives: To identify the different stroke types, risk factors, burden of stroke in a private hospital in terms of gender, age, and length of stay and to identify any associations of risk factors, age, types of strokes, mortality and treatment given. Methods: This descriptive study involved retrospective data from an electronic database which captured all stroke patients seen in the emergency unit during the study period. Data was verified, diagnosis made by CT, MRI scans or both. Results: The total number of 576 cases was included, 278 (48%) for ischaemic stroke, 72(12.5% for haemorrhagic stroke and 226 (39%) for TIA. No difference between gender and type of stroke was observed. Mortality was low, with 21 cases with a mortality rate of 3.6%. Given this low mortality rate, meaningful analyses on mortality could not be done. The most prevalent risk factors were hypertension (59.7%), diabetes (21.7%), hyperlipidaemia (29%), atrial fibrillation (11.1%) and ischaemic heart disease (10.8%). Following logistic regression, atrial fibrillation was found to be associated with ischaemic stroke (p = 0.01), and TIA (p = 0.08). No other risk factors had a statistically significant association with type of stroke in this sample. Conclusion: Ischaemic stroke is more prevalent compared to haemorrhagic stroke. As the population grows and life expectancy increases, the burden of stroke and its complications will also increase. Managing the modifiable risk factors may be key to managing the burden of stroke in Sub-Saharan Africa.
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    A retrospective descriptive analysis of critical care transfers in the private sector of South Africa
    (2022) Venter, Monique; Stassen, Willem
    Background: Critical Care Transfers (CCTs) are necessitated by the growing prevalence of high acuity patients who require upgrade of care to multidisciplinary teams from less equipped referring facilities. Due to the high acuity of the critical care transfer patient, specialised teams with advanced training and equipment are called upon to undertake these transfers. The specialised and dedicated teams are utilized to mitigate and treat adverse events during transfers, which is found in the especially vulnerable, high acuity patients. Internationally, the insufficient data relating to CCTs has been repeatedly reported as a concern due to the increased number of critical care transfers being undertaken and the high acuity of the patients, along with the reported high number of adverse events that occur during such transfers. The inherent understanding of the potential effects, and therefore needs of the critical care transfer patient, are affected due to the paucity of international, but more specifically, local data relating to CCTs. Methods: This observational cohort study with a retrospective descriptive design samples all non-neonatal, critical care transfers completed for a one-year period (1 January 2017 – 31 December 2017) from the dedicated CCT of the two largest national emergency medical services in South Africa. Data were extracted from patient report forms by trained data extractors and subjected to descriptive analysis. Results: A total of 1839 patients were transferred between the two services (excluding the neonatal cohort). A total of 3143 diagnoses were recorded, yielding an average of ~2 diagnoses per patient. The most prevalent primary diagnosis was Cardiovascular Disease (n=457, 25%), followed by infection (n=180, 10%) and Head Injury (n=133, 7%). Patients had an average of ~3 attachments, with the most prevalent being patient monitoring (n=2856, 155%). The second most prevalent attachment was Peripheral Intravenous Lines (n=794, 43%) of patients, followed by mechanical ventilation (n=496, 27%). A total of 2152 medications were required during transport, yielding an average of ~1 medication or infusion per patient transported. The most common medications recorded were CNS Depresants (n=588; 32%), followed by Analgesics (n=482, 26%), and a further 17% of patients required Inotropic / Vasoactive agents (n=320, 17%). Conclusion: This study provides insight into the demographics, most prevalent diagnoses and interfacility transfer monitoring needs of patients being transported in South Africa by two private dedicated critical care transport services. The results of this study should be used to inform future specialised critical care transport courses and qualifications, as well as the scopes of practice of providers undertaking critical care transfers.
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    A retrospective evaluation of the impact of a dedicated Obstetric and Neonatal transport service on transport times within an Urban setting
    (2009) de Vries, Shaheem
    Objective: To determine whether the establishment of a dedicated obstetric and neonatal flying squad resulted in improved performance within the setting of a major metropolitan area. Design and Setting: The Cape Town metropolitan service of the Emergency Medical Services was selected for a retrospective review of the transit times for the newly implemented Flying Squad programme. Data were imported from the Computer Aided Dispatch programme. Dispatch, Response, Mean Transit and Total Pre-hospital times, relating to the obstetric and neonatal incidents was analysed for 2005 and 2008. Results: There was a significant improvement between 2005 and 2008 in all incidents evaluated. Flying Squad dispatch performance improved from 11.7% to 46.6% of all incidents dispatched within 4 minutes (p< 0.0001). Response time performance at the 15- minute threshold did not demonstrate a statistically significant improvement (p=0.4 .. ) although the improvement in the 30-minute performance category was statistically significant in both maternity and neonatal incidents. Maternity incidents displayed the greatest improvement with the 30-minute performance increasing from 30.3 % to 72,9%. The analysis of the mean transit times demonstrated that neonatal transfers displayed the longest status time in all but one of the categories. Even so, the introduction of the Flying Squad programme resulted in a reduction in a total pre-hospital time from 298 minutes to 184 minutes. Conclusion: The introduction of the Flying Squad programme has resulted in significant improvement in the transit times of both neonatal and obstetric incidents. In spite of the severe resource constraints facing developing nations, the model employed offers significant gains.
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    A Trigger-Tool-based Description of Adverse Events in Helicopter Emergency Medical Services in Qatar
    (2021) Heuer, Calvin; Stassen, Willem; Howard, Ian
    Introduction Adverse Events (AEs) in Helicopter Emergency Medical Services (HEMS) remains poorly reported, despite the potential for harm to occur. The Trigger Tool (TT) represents a novel approach to AE detection in healthcare. The aim of this study was to retrospectively describe the frequency of AEs and their Proximal Causes (PCs) in Qatar HEMS. Methods Using the Pittsburgh Adverse Event Tool (PittAETool) to identify AEs in HEMS, we retrospectively analyzed 804 records within an existing AE TT database (21-month period). We calculated outcome measures for Triggers, AEs, and Harm per 100 patient encounters, plotted measures on Statistical Process Control (SPC) charts, and conducted a multivariate analysis to report harm associations. Results We identified 883 Triggers in 536 patients, with a rate of 1.1 Triggers per Patient Encounter, where 81.2% had Documentation Errors (n=436). An AE and Harm rate of 27.7% and 3.5% respectively was realized. The leading PC was Actions by HEMS Crew (81.6%; n=182). The majority of harm (57.1%) stemmed from the Intervention and Medication triggers (n=16), where Deviation from Standard of Care was common (37.9%; n=11). Age and diagnosis adjusted odds was significant in the Patient Condition (6.50; 95% CI, 1.71-24.67; P= 0.01) and Interventional (11.85; 95% CI, 1.36-102.92; P= 0.03) trigger groupings, while age and diagnosis had no effect on Harm. Conclusion The TT methodology is a robust, reliable, and valid means of AE detection in the HEMS domain. Whilst an AE rate of 27.7% is high, more research is required to understand prehospital clinical decision-making and reasons for guideline deviance. Furthermore, focused quality improvement initiatives to reduce AEs and Documentation errors should also be addressed in future research.
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    Aetiology and outcome of patients burned from 2003 to 2008 at the Tygerberg Hospital burns unit, Western Cape, SA
    (2013) Maritz, David
    Rural to urban migration to major cities in South Africa continues to lead to the proliferation of informal settlements. There is little recent published data on the epidemiology of adult burns in the Western Cape, South Africa. The prediction of outcome in severe burns is important to aid in clinical decision making, improve scarce resource allocation and allow comparisons between different burn units. Age, burn size and the presence of inhalational injury have been determined to be the most important factors in predicting mortality. There is little published data on the outcome of severe burns in the Southern African region. A retrospective review of patients on the Burn Unit database was undertaken, looking at patients admitted to the Burn Unit between January 2003 and December 2008. This study discusses the characteristics and outcome of patients who were treated at the Tygerberg Burn unit. A total of 1908 patients were admitted to the burn unit during the 6 year period under review. Most fatal injuries occurred in the 20 to 40 year age group. Injuries due to shack fires and fuel stoves comprised 21% (399) of all admissions. Mortality due to these injuries comprised 28% (137) of total mortality. Gas stoves accounted for 24% with kerosene stoves accounting for 71% of injuries. The burn death rate in this study (25%) was found to have increased dramatically from the last audit done from 1986 to 1995 in which a burn death rate of 7.5% was observed. Reasons for this are explored. A stepwise logistic regression analysis was done on the derivation cohort where age, gender, TBSA% and presence of inhalational injury were identified as significant for predicting death. A mortality prediction model is presented which was internally validated on the validation cohort. An easy to use EXCEL calculator was created to estimate the probability of death. Shack fires and injuries due to fuel stoves are a common reason for admission to the burn unit and mostly involve young male individuals. Other research from the Southern African region does not mention shack fires as a separate entity making it difficult to obtain an accurate idea of the scale of the problem. Their injuries are severe with a high mortality. The use of kerosene stoves are a major contributing factor. Recommendations include enforceable legislation to promote safer stove design, research into safer bio fuels and materials for building shacks as well promoting fire safety among schoolchildren in the community. Further research is needed to determine the impact of HIV/AIDS on the outcome of acute burn injuries within the Southern African region. Further interventions are needed to tackle this serious public health issue. A mortality prediction model is proposed for use in the burn unit, but needs external validation before being adopted into clinical practice. Further research is needed to improve data capturing in the burn unit.
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    An analysis of the descriptors of acute myocardial infarction used by South Africans when calling for an ambulance from a National Emergency Call Centre
    (2019) Buma, Chloe Ashton; Saunders, Collen; Stassen, Willem
    Introduction Acute Myocardial Infarction (AMI) is a time sensitive emergency. In resource limited settings such as South Africa, prompt identification and management of these patients in the pre-hospital setting may minimise the negative consequences of an overburdened emergency medical and hospital service. Expedited care thus, in part, relies on the dispatch of appropriate pre-hospital medical providers by emergency medical dispatchers. Identification of these patients in the call centre is challenging due to a highly diverse South African society, with multiple languages, cultures, and levels of education. The aim of this study was therefore, to describe the terms used by members of the South African public when calling for an ambulance for patients suffering an AMI. Methodology In this qualitative study, we performed content analysis to identify keywords and phrases that callers used to describe patients who were experiencing an AMI. Using the patient report form number of randomly selected paramedic- diagnosed AMI cases, original voice recordings between the caller and call centre operators at the time of the emergency were extracted and transcribed verbatim. Descriptors of AMI were identified, coded and categorised using content analysis, and quantified. Results Of the 50 randomly selected calls analysed, 5 were not conducted in English. The descriptors (meaning units) used by callers were and found to fall into three categories; Pain: Thorax, No pain: Thorax and Ill- health. The code that occurred most often was no pain, heart related (n=16; 23.2%), followed by the code describing pain in the chest (n=15; 21.7%). Conclusion South African callers use a consistent set of descriptors when requesting an ambulance for a patient experiencing an AMI. The most common of these are non- pain descriptors related to the heart (“heart attack”). These descriptors may ultimately be used in developing validated algorithms to assist dispatch decisions. In this way, we hope to expedite the correct level of care to these time- critical patients and prevent the dispatching of resource limited advanced life support paramedics to inappropriate cases.
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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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    An analysis of the clinical practice of emergency medicine in emergency centres in the Western Cape
    (2010) Cohen, Kirsten Lesley
    To determine whether the current South African Emergency Medicine Curriculum is appropriate for the burden of disease seen by registrars in Cape Town Emergency Centres, a cross- sectional retrospective audit of 1283 clinical presentations from three secondary level ECs in Cape Town was done. The type of clinical presentations, investigations done and procedures per- formed were analysed. Basic descriptives are presented. The curriculum did not cover all the clinical conditions, procedures and investigations encountered by EM registrars in Cape Town. There were also multiple categories in the curriculum that were not encountered in EM practice at all. The investigations section correlated particularly poorly with the skills needed for the burden of disease seen in ECs in Cape Town. The curriculum should be redrafted guided by a practice analysis of EM.