Injury severity in relation to seatbelt use in Cape Town, South Africa: A pilot study

Background. Injuries and deaths from road traffic collisions present an enormous challenge to the South African (SA) healthcare system. The use of restraining devices is an important preventive measure.Objective. To determine the relationship between seatbelt use and injury severity in vehicle occupants involved in road traffic collisions in Cape Town, SA.Methods. A prospective cohort design was used. Occupants of vehicles involved in road traffic collisions attended to by EMS METRO Rescue were included during the 3-month data collection period. Triage categories of prehospital patients were compared between restrained and unrestrained groups. Patients transferred to hospital were followed up and injury severity scores were calculated. Disposition from the emergency centre and follow-up after 1 week were also documented and compared.Results. A total of 107 patients were included in the prehospital phase. The prevalence of seatbelt use was 25.2%. Unrestrained vehicle occupants were five times more likely to have a high triage score (odds ratio (OR) 5.4; 95% confidence interval (CI) 1.5 - 19.5). Fifty patients were transferred to study hospitals. Although seatbelt non-users were more likely to be admitted to hospital (p=0.002), they did not sustain more serious injuries (OR 0.44; 95% CI 0.02 - 8.8).Conclusion. The prevalence of seatbelt use in vehicle occupants involved in road traffic collisions was very low. The association between seatbelt non-use and injury severity calls for stricter enforcement of current seatbelt laws, together with the development and implementation of road safety interventions specifically focused on high-risk groups

A retrospective descriptive analysis of non-physician-performed prehospital endotracheal intubation practices and performance in South Africa

Introduction Prehospital advanced airway management, including endotracheal intubation (ETI), is one of the most commonly performed advanced life support skills. In South Africa, prehospital ETI is performed by non-physician prehospital providers. This practice has recently come under scrutiny due to lower first pass (FPS) and overall success rates, a high incidence of adverse events (AEs), and limited evidence regarding the impact of ETI on mortality. The aim of this study was to describe non-physician ETI in a South African national sample in terms of patient demographics, indications for intubation, means of intubation and success rates. A secondary aim was to determine what factors were predictive of first pass success. Methods This study was a retrospective chart review of prehospital ETIs performed by non-physician prehospital providers, between 01 January 2017 and 31 December 2017. Two national private Emergency Medical Services (EMS) and one provincial public EMS were sampled. Data were analysed descriptively and summarised. Logistic regression was performed to evaluate factors that affect the likelihood of FPS. Results A total of 926 cases were included. The majority of cases were adults (n = 781, 84.3%) and male (n = 553, 57.6%). The most common pathologies requiring emergency treatment were head injury, including traumatic brain injury (n = 328, 35.4%), followed by cardiac arrest (n = 204, 22.0%). The mean time on scene was 46 minutes (SD = 28.3). The most cited indication for intubation was decreased level of consciousness (n = 515, 55.6%), followed by cardiac arrest (n = 242, 26.9%) and ineffective ventilation (n = 96, 10.4%). Rapid sequence intubation (RSI, n = 344, 37.2%) was the most common approach. The FPS rate was 75.3%, with an overall success rate of 95.7%. Intubation failed in 33 (3.6%) patients. The need for ventilation was inversely associated with FPS (OR = 0.42, 95% CI: 0.20–0.88, p = 0.02); while deep sedation (OR = 0.56, 95% CI: 0.36–0.88, p = 0.13) and no drugs (OR = 0.47, 95% CI: 0.25–0.90, p = 0.02) compared to RSI was less likely to result in FPS. Increased scene time (OR = 0.99, 95% CI: 0.985–0.997, p < 0.01) was inversely associated FPS. Conclusion This is one of the first and largest studies evaluating prehospital ETI in Africa. In this sample of ground-based EMS non-physician ETI, we found success rates similar to those reported in the literature. More research is needed to determine AE rates and the impact of ETI on patient outcome. There is an urgent need to standardise prehospital ETI reporting in South Africa to facilitate future research

Risk factors for Coronavirus disease 2019 (Covid-19) death in a population cohort study from the Western Cape province, South Africa

Risk factors for coronavirus disease 2019 (COVID-19) death in sub-Saharan Africa and the effects of human immunodeficiency virus (HIV) and tuberculosis on COVID-19 outcomes are unknown. We conducted a population cohort study using linked data from adults attending public-sector health facilities in the Western Cape, South Africa. We used Cox proportional hazards models, adjusted for age, sex, location, and comorbidities, to examine the associations between HIV, tuberculosis, and COVID-19 death from 1 March to 9 June 2020 among (1) public-sector “active patients” (≥1 visit in the 3 years before March 2020); (2) laboratory-diagnosed COVID-19 cases; and (3) hospitalized COVID-19 cases. We calculated the standardized mortality ratio (SMR) for COVID-19, comparing adults living with and without HIV using modeled population estimates.Among 3 460 932 patients (16% living with HIV), 22 308 were diagnosed with COVID-19, of whom 625 died. COVID19 death was associated with male sex, increasing age, diabetes, hypertension, and chronic kidney disease. HIV was associated with COVID-19 mortality (adjusted hazard ratio [aHR], 2.14; 95% confidence interval [CI], 1.70–2.70), with similar risks across strata of viral loads and immunosuppression. Current and previous diagnoses of tuberculosis were associated with COVID-19 death (aHR, 2.70 [95% CI, 1.81–4.04] and 1.51 [95% CI, 1.18–1.93], respectively). The SMR for COVID-19 death associated with HIV was 2.39 (95% CI, 1.96–2.86); population attributable fraction 8.5% (95% CI, 6.1–11.1)

Injury severity in relation to seatbelt usage in Cape Town : a pilot study

Article based on this thesis is available at http://hdl.handle.net/10019.1/98154Thesis (MMed)--Stellenbosch University, 2015.ENGLISH SUMMARY : Introduction: Injuries and death from road traffic accidents present an enormous challenge to the South African health care system and creates a significant societal and economic burden in the country. The use of seatbelts and child restraints is one of the most important actions that can be taken to prevent injury in a road traffic accident. Objectives: This pilot study attempted to determine seatbelt prevalence in the Cape Town Metropole and compare injury severity to seatbelt usage. Methods: A prospective cohort design was used. All occupants involved in road traffic accidents in the Cape Town Metropole attended to by EMS Metro Rescue were included during the three month data collection period. Patients, who were admitted, were followed up and injury severity scores calculated using the Injury Severity Score. Disposition from the emergency centre and follow up after one week was compared between restrained and unrestrained occupants. A 5% level of confidence was used to determine whether differences were statistically significant and odds ratios with corresponding 95% confidence intervals were calculated as relative measure of association. Results: A total of 107 patients were included in the pre-hospital phase. The prevalence of seatbelt usage was found to be 25.23% while only 8.3% of rear seat occupants (n = 24) were restrained. A statistically significant association was shown between seatbelt non-use and higher triage category (p=0.006; Odds Ratio (OR) = 5.39, 95% Confidence Interval (CI) 1.49 to 19.47). Trends also suggest associations between seatbelt non-use and young male occupants, as well as early morning and late night driving. A total of 50 patients were followed up during the hospital phase. There was no significant association between seatbelt usage and injury severity, yet all fatalities and seriously injured patients (Injury Severity Score >15) were unrestrained (p=0.29; OR = 0.38, 95%CI 0.019 to 7.588). Unrestrained occupants were also more likely to be admitted (p=0.002). Discussion: Seatbelt prevalence in occupants involved in road traffic accidents was much lower than national and provincial statistical claims. The strong association between seatbelt non-use and road traffic deaths and severe injuries necessitate stricter enforcement of current seatbelt and child restraint laws to improve seatbelt compliance. The information gained from this study could assist with future research projects to possible determine causes of high risk behaviour. It will potentially aid authorities to develop and implement strategies to improve road safety.AFRIKAANSE OPSOMMING : Geen opsomming beskikbaar

The association between length of emergency department boarding and hospital length of stay for patients with mental health and behavioural disorders

Background Psychiatric boarding in Emergency Departments is a global challenge. Patients with mental and behavioural disturbances are disproportionally affected with boarding times up to three times longer than other patients. This retrospective cross-sectional study investigated the impact of an initiative to reduce psychiatric boarding on length of stay and readmission rate, as well as exploring the relationship between boarding times and length of stay. Methods All adult patients referred over a 24-month period (June 2017 – May 2019) for psychiatric admission from the Emergency Department of a Cape Town district hospital were included. This included a 9-month period prior to the initiative, after which inpatient capacity was increased, and inpatient hallway boarding was implemented. Data relating to admission processes and outcomes were extracted from electronic registries. Results In total, 2607 patients were referred for psychiatric admission (2.7% of all Emergency Department patients). The initiative was associated with a decrease of 95% (56 vs 3 hours, p24-hour boarding category (351 vs 360 hours, p=0.047). The readmission rate increased from 12% to 18% post intervention. Conclusion A significant improvement in hospital length of stay and psychiatric boarding times occurred after the initiative was implemented. The benefits should be weighed up against a subsequent higher readmission rate. From a lean- and economical perspective, the results of this study suggest that psychiatric boarding equates to waste as it is independent of ward length of stay. The observational nature of this study precludes concrete conclusions and further investigations into psychiatric inpatient hallway boarding are recommended

The value of electrocardiography in predicting inpatient mortality in patients with acute pulmonary embolism: A cross sectional analysis

Introduction: Pulmonary embolism (PE) is a significant global cause of mortality, ranking third after myocardial infarction and stroke. ECG findings may play a valuable role in the prognostication of patients with PE, with various ECG abnormalities proving to be reasonable predictors of haemodynamic decompensation, cardiogenic shock, and even mortality. This study aims to assess the value of electrocardiography in predicting inpatient mortality in patients with acute pulmonary embolism, as diagnosed with computed tomography pulmonary angiogram. Method: This study was a cross sectional analysis based at Tygerberg Hospital, Cape Town, South Africa. Eligible patients were identified from all CT-PA performed between 1 January 2017 and 31 December 2019 (2 years). The ECGs were independently screened by two blinded emergency physicians for predetermined signs that are associated with right heart strain and higher pulmonary artery pressures, and these findings were analysed to in-hospital mortality. Results: Of the included 81 patients, 61 (75 %) were female. Of the 41 (51 %) patients with submassive PE and 8 (10 %) with massive PE, 7 (17 %) and 3 (38 %) suffered inpatient mortality (p = 0.023) respectively. Univariate ECG analysis revealed that complete right bundle branch block (OR, 8.6; 95 % CI, 1.1 to 69.9; p = 0.044) and right axis deviation (OR, 5.6; 95 % CI, 1.4 to 22.4; p = 0.015) were significant predictors of inpatient mortality. Conclusion: Early identification of patients with pulmonary embolism at higher risk of clinical deterioration and in-patient mortality remains a challenge. Even though no clinical finding or prediction tool in isolation can reliably predict outcomes in patients with pulmonary embolism, this study demonstrated two ECG findings at presentation that were associated with a higher likelihood of inpatient mortality. This single-centre observational study with a small sample precludes concrete conclusions and a large follow-up multi-centre study is advised

Access to acute care resources in various income settings to treat new-onset stroke: A survey of acute care providers

Introduction: Stroke affects 15 million people annually and is responsible for 5 million deaths per annum globally. In contrast to the trend in low- and middle-income countries (LMICs), stroke mortality is on the decline in high-income countries (HICs). Even though the availability of resources varies considerably by geographic region and across LMICs and HICs, evidence suggests that material resources in LMICs to implement recommendations from international guidelines are largely unmet. This study describes and compares the availability of resources to treat new-onset stroke in countries based on the World Bank’s gross national incomes, using recommendations of the American Heart Association and the American Stroke Association 2013 update. Methods: A self-reported cross-sectional survey was conducted of delegates that attended the April 2016 International Conference on Emergency Medicine using the web-based e-Survey client, Survey Monkey Inc. The survey assessed both pre-hospital and in-hospital settings and was piloted before implementation. Results: The survey was distributed and opened by 955 delegates and 382 (40%) responded. Respondents from LMICs reported significantly less access to a prehospital service (p < 0.001) or a national emergency number (p < 0.001). Access to specialist neurology services (p < 0.001) and radiology services (p < 0.001) were also significantly lower in LMICs. Conclusion: The striking finding from this study was that there was essentially very little difference between the responses between LMIC and HIC respondents with a few notable exceptions. The findings also propose a universal lack of adherence to the 2013 AHA/ASA stroke management guideline by both groups, in contrast to the good reported knowledge thereof. Carefully planned qualitative research is needed to identify the barriers to achieving the 2013 AHA/ACA recommendations. Keywords: Emergency, Low resource, Access, Stroke, Cerebrovascular acciden