The appropriateness of emergency medical service responses in the eThekwini district of KwaZulu-Natal, South Africa

Introduction. Emergency medical services (EMS) are sometimes required to respond to cases that are later found not to be emergencies, resulting in high levels of inappropriate responses. This study evaluated the extent to which this occurs.Methods. All cases dispatched over 72 hours by the eThekwini EMS in Durban, South Africa, were prospectively enrolled in a quantitative descriptive study. Vehicle control forms containing dispatch data were matched and compared with patient report forms containing epidemiological and clinical data to describe the nature and extent of inappropriate responses based on patient need. Data were subjected to simple descriptive analysis, correlations and χ2 testing.Results. A total of 1 385 cases met the study inclusion criteria. Marked variations existed between dispatch and on-scene priority settings, most notably in the highest priority ‘red-code’ category, which constituted >56% of cases dispatched yet accounted for <2% at the scene (p<0.001). Conversely, >80% of ‘red-code’ dispatches required a lower priority response. When comparing resource allocation according to patient interventional needs, >58% of cases required either no intervention or transport only and almost 36% required basic life support intervention only (p<0.001). Moreover, <12% of advanced life support dispatches were for patients found to be ‘red code’ at the scene.Conclusion. There is a significant mismatch between the dispatch of EMS resources and actual patient need in the eThekwini district, with significantly high levels of inappropriate emergency responses

Engagement of families in ICU from the nursing staff perspective

Background: Family engagement in intensive care units (ICU) is proposed as a way to increase active partnership with patients and move away from paternalism (Burns et al 2018). Family engagement and family-centred care are closely linked to improve the quality of care. The term and practice of ‘family engagement’ is complex but Burns et al (2018) viewed patient and family engagement as a way to achieve family centred care. Promoting family engagement within the ICU setting is recognised as more challenging to nursing practice because of the added emotional aspects for families of acutely ill patients (Brown et al 2015). This research was part of an international collaboration supported by the Family Care in Acute and Critical Illness Research Cluster which is supported by the International Family Nursing Association. This presentation will focus on the findings of the UK aspect of the research. Research Question: How do nurses from one English setting describe their nursing engagement with families of adults admitted in intensive care units? Methods: A social ecological approach (Bronfenbrenner, 1979) was used for this study. Social ecology acknowledges that families are complex groups that interact with other people and their world to provide meaning. Data were collected including demographic information, individual semi-structured qualitative interviews which were transcribed, and a questionnaire ‘Factors That Influence Family Engagement (QFIFE)’ (Hetland, Hickman, McAndrew, & Daly, 2017). One intensive care unit in the South East of England was used for this study. Permanent members of the nursing team were invited to participate. Analysis was undertaken using a statistic package (SPSS version 21) for questionnaire data and a content analysis approach for qualitative data. Ethical approval was gained from the University and Gray Area Project approval from the healthcare organisation. Results: Seven participants completed all aspects of the data collection. All participants rated that family engagement was important. Engagement varied depending of the acuity of the patient with nurses deciding the level of family engagement at a particular point in the patient journey. As the patients’ illness stabilised the involvement of the family was promoted. The family engagement role can be described as observers, encouragers, supporter or active participants in patient care. Staff were particularly concerned about maintaining the safety of the patient during any family activities and developing good communication. Initial analysis suggests that nurses regulate family engagement to ensure safety of patients and to promote recovery. Families need encouragement from ICU nurses to engage in a meaningful way. Building rapport and setting boundaries are skills needed by nurses and families value explanation of care. Conclusions: Family engagement needs careful consideration about the amount and type of activities that are appropriate and safe for families to undertake at a particular point. However, family engagement is seen as positive contribution to the patient recovery journey. This international project will continue to compare and combine results across the world. Consideration of future initiatives to family engagement in ICU will be further outlined

Effectiveness and feasibility of telepsychiatry in resource constrained environments? A systematic review of the evidence

Objective: A review of systematic reviews of the effectiveness and feasibility of videoconference-based telepsychiatry services for resource constrained environments was conducted. Specifically with the aim of producing an evidence-based review of the effectiveness and feasibility of videoconference-based telepsychiatry services in resource constrained countries like South Africa.Methods: Eight key questions on telepsychiatry effectiveness and feasibility were identified and inclusion and exclusion criteria were developed. Review of citations from 2000-2011 from CINAHL, Medline, Pubmed, PsycInfo, EBSCOhost, SABINET, Cochrane Database of Systematic Reviews (CCTR), Cochrane Controlled Trial Registry (CCTR), Database of Abstracts of Reviews of Effectiveness (DARE), unpublished abstracts through NEXUS and internet search engines (Google/Google scholar) was conducted. Results: Ten systematic reviews were included for review. Despite the methodological limitations and heterogeneity of the systematic reviews, there appears to be good evidence of effectiveness (reliability and improved outcomes) and feasibility (use, satisfaction, acceptability and cost) for videoconference-based telepsychiatry internationally. The application of this evidence in lower middle income countries is dependent on the integration of telepsychiatry into local health system contexts. Conclusion: Based on the evidence, resource constrained countries such as South Africa should be encouraged to develop telepsychiatry programs along with rigorous evaluation methods.Keywords: Videoconferencing; Psychiatry; Education; South Afric

Creating an instrument to measure perceptions about access to health-related higher education programmes in South Africa

Background: The South African government has created countless policies that support the need to admit and graduate students who had been excluded from health-science programmes in higher education settings during the apartheid era.Objective: to develop a questionnaire that could be used by various stakeholders to obtain their perceptions about access to health sciences education in higher education settings.Method: A mixed methods design was used; the qualitative stage allowed for the identification of themes while the quantitative stage used measurement theory, to develop an instrument based on those themes.Results: The overarching theme was Achieving equity of access for success is multi-factorial and has diverse and complex challenges and eight sub-themes emerged which were used to create a 17-item questionnaire that has good content validity and reliability (Cronbach alpha=.767).Conclusion: Further psychometric testing with larger, more diverse samples will result in a refined instrument that can be administered to various stakeholder groups, such as current and potential health sciences students and faculties, and used in programme evaluation. Health science programmes can use the instrument to measure access within different disciplines and possible changes over time as innovations are piloted. Different health sciences programmes can be compared and contrasted and objective data can be used to make systematic organizational changes

Family-witnessed resuscitation in emergency departments: Doctors’ attitudes and practices

Background. Resuscitation of patients occurs daily in emergency departments. Traditional practice entails family members remaining outside the resuscitation room. Objective. We explored the introduction of family-witnessed resuscitation (FWR) as it has been shown to allow closure for the family when resuscitation is unsuccessful and helps them to better understand the last moments of life. Results. Attending medical doctors have concerns about this practice, such as traumatisation of family members, increased pressure on the medical team, interference by the family, and potential medico-legal consequences. There was not complete acceptance of the practice of FWR among the sample group. Conclusion. Short-course training such as postgraduate advanced life support and other continued professional development activities should have a positive effect on this practice. The more experienced doctors are and the longer they work in emergency medicine, the more comfortable they appear to be with the concept of FWR and therefore the more likely they are to allow it. Further study and course attendance by doctors has a positive influence on the practice of FWR

Familycentred practices of healthcare professionals in three emergency departments in KwaZuluNatal South Africa

Background. Emergency healthcare professionals can practise family-centred care (FCC) by engaging in active partnerships with families. In a chaotic environment, which challenges communication and supportive behaviours, responding to and acknowledging families’ individuality enhance positive family outcomes. Objective. To describe the adherence of emergency healthcare professionals to family-centred practices in some emergency departments in KwaZulu-Natal, South Africa. Methods. A quantitative survey was conducted among healthcare professionals in three emergency departments. A previously published checklist was used to collect data on adherence to relational and participatory family-centred practices. Results. A total of 77 completed questionnaires were received from the 79 participants surveyed, giving a response rate of 97.5%. Analysis showed that healthcare professionals endeavour to practise FCC, but that their implementation of practice indicators of family-centred care is inconsistent. Results suggested that healthcare professionals used relational practices to a larger extent than participatory practices. Conclusion. In the emergency department, collaboration and partnering with families should be emphasised to ensure that principles of FCC are practised as a standard. Keywords. Family, health care professionals, emergency department, relational practices, participatory practices

Exploring the role of the ICU nurse in the antimicrobial stewardship team at a private hospital in KwaZulu-Natal, South Africa

Background. Care of the critically ill patient has become increasingly challenging, with a rising incidence of resistant pathogens resulting in the ineffectiveness of many antibiotics. Severe infection is associated with prolonged intensive care unit (ICU) length of stay, and increased morbidity, mortality, and healthcare costs. Antimicrobial stewardship (AMS) aims to prevent resistance and protect patients and the wider community by promoting correct antimicrobial use. The current AMS literature has failed to describe the role of the ICU nurse in this important initiative.Objective. To explore the perceptions of AMS team members regarding the role of the ICU nurse in the AMS team.Methods. Using a qualitative research approach, purposive sampling was used to identify participants in an ICU. Semi-structured interviews were conducted with 15 participants, including ICU shift-leader nurses, nursing management, surgeons, anaesthetists, physicians, microbiologists and pharmacists. Data were analysed and categorised using content analysis. The study was conducted in a general ICU in the private healthcare sector in KwaZulu-Natal, South Africa.Results. Participants representing various disciplines of the AMS team felt that the role of the ICU nurse within the team was an important part of the AMS programme. Four categories that emerged from the data are discussed: organisational, advocacy, clinical and collaborative roles.Conclusion. The role of the ICU nurse was found to be essential to the success of AMS in the ICU. These findings provide implications for practice, which, if recognised and supported by all healthcare stakeholders from ICU and hospital management, could improve AMS in this acute care area

The appropriateness of emergency medical service responses in the eThekwini district of KwaZulu-Natal, South Africa

Introduction. Emergency medical services (EMS) are sometimes required to respond to cases that are later found not to be emergencies, resulting in high levels of inappropriate responses. This study evaluated the extent to which this occurs.Methods. All cases dispatched over 72 hours by the eThekwini EMS in Durban, South Africa, were prospectively enrolled in a quantitative descriptive study. Vehicle control forms containing dispatch data were matched and compared with patient report forms containing epidemiological and clinical data to describe the nature and extent of inappropriate responses based on patient need. Data were subjected to simple descriptive analysis, correlations and χ2 testing.Results. A total of 1 385 cases met the study inclusion criteria. Marked variations existed between dispatch and on-scene priority settings, most notably in the highest priority ‘red-code’ category, which constituted >56% of cases dispatched yet accounted for <2% at the scene (p<0.001). Conversely, >80% of ‘red-code’ dispatches required a lower priority response. When comparing resource allocation according to patient interventional needs, >58% of cases required either no intervention or transport only and almost 36% required basic life support intervention only (p<0.001). Moreover, <12% of advanced life support dispatches were for patients found to be ‘red code’ at the scene.Conclusion. There is a significant mismatch between the dispatch of EMS resources and actual patient need in the eThekwini district, with significantly high levels of inappropriate emergency responses

The spectrum and outcome of paediatric traumatic brain injury in KwaZulu-Natal Province, South Africa has not changed over the last two decades

Objectives. This retrospective review of a prospectively entered and maintained hybrid electronic trauma registry was intended to develop a comprehensive overview of traumatic brain injury (TBI) in children and adolescents and to compare it with previous audits from our local environment and from other developing world centres. All TBI patients admitted to hospital were included in this study. We reviewed the age, gender, outcomes, radiological findings and treatment of the patients.Methods. All patients aged ≤18 years old who were admitted by the Pietermaritzburg Metropolitan Trauma Service (PMTS) with TBI between December 2012 and December 2016 were included in this audit.Results. During the 4-year period under review, a total of 563 children and adolescents were treated for TBI by the PMTS. The median age was 6.4 years and 29% (n=165) were females. The mechanism of TBI was blunt trauma in 96% (n=544) of cases, with 4% (n=19) suffering penetrating trauma. The penetrating mechanisms included impalement by a cow horn and miscellaneous injuries due to saws, axes, barbed wire, spades, stones and knives. The blunt mechanisms included falls (n=102), assaults (n=108), collapse of a building (n=28), bicyclerelated injury (n=14), falling off a moving vehicle (n=280), motor vehicle accident (MVA; n=59), pedestrian vehicle accident (PVA; n=183) and animal-related injuries (n=8). There were 454 (80%) mild, 67 (12%) moderate and 42 (7%) severe cases of TBI. A total of 48 patients were admitted to the intensive care unit and 23 were admitted to the high care unit. Nine patients died. All the deaths were in the MVA and PVA group. The spectrum of TBI as diagnosed on computed tomography scans was nonspecific cerebral contusion (n=92), depressed skull fracture (n=70), sub-arachnoid haemorrhage (n=60), extradural haemorrhage (n=41), intracerebral haemorrhage (n=19), free air (n=19),subdural haemorrhage (n=13), intraventricular haemorrhage (n=9). A total of 62 (11%) patients required surgery.Conclusion. There is a significant burden of paediatric TBI in Pietermaritzburg. The majority of TBI was related to blunt trauma and assaults were very common. Although the short-term outcomes are good, the long-term consequences are poorly understood. Injury prevention programmes are needed to help reduce this burden of disease and a nationwide trauma registry is long overdue

Validation of the Simplified Motor Score in patients with traumatic brain injury at a major trauma centre in South Africa

Background. This study used data from a large prospectively entered database to assess the efficacy of the motor score (M score) component of the Glasgow Coma Scale (GCS) and the Simplified Motor Score (SMS) in predicting overall outcome in patients with traumatic brain injury (TBI).Objective. To safely and reliably simplify the scoring system used to assess level of consciousness of trauma patients in the acute setting.Methods. A retrospective observational review of the Pietermaritzburg Metropolitan Trauma Service hybrid electronic medical registry database was performed during the period January 2013 - December 2015. Patients were classified into three groups using their GCS as an injury severity score. These were mild TBI (GCS 13 - 15), moderate TBI (GCS 9 - 12) and severe TBI (GCS <9). The Glasgow M score was specifically evaluated to determine the relationship between the individual motor component and patient outcome.Results. GCS scores and M scores were analysed in a total of 830 patients. There was a decline in survival rate when the M score on admission was ≤4. The decline was more significant when the M score was ≤3. Survival rates were 26.8% (11/41) for patients with an M score of 1, 63.6% (14/22) for those with a score of 2, 56.5% (13/23) for those with a score of 3, 80.0% (20/25) for those with a score of 4, and 95.5% (121/128) for those with a score of 5. Of 591 patients with an M score of 6, 580 (98.1%) survived. Mortality rose dramatically with declining SMS. This was highly significant. When the M score was plotted against mortality in 830 patients, there was a correct prediction in 769 cases (accuracy 92.7%, sensitivity 67.6%, specificity 95%). The area under the receiver operating characteristic (ROC) curve was 0.9037, with a standard deviation (area) of 0.0227. When comparing the SMS against mortality, the accuracy was 77.1%, the sensitivity 84.5% and the specificity 76.4%. The fitted ROC area was 0.891 and the empirical ROC area 0.86.Conclusion. The M score component of the GCS and the SMS accurately predict outcome in patients with TBI. In cases where the full GCS is difficult to assess, the M score and SMS can be used safely as a triage tool