The prevalence of hypotension and hypoxaemia in the prehospital setting of traumatic brain injury in Johannesburg, Gauteng

Includes abstract. Includes bibliographical references

Coronary care networks in the resource-limited setting : systems of care in South Africa

BACKGROUND: Owing to an epidemiological transition observed throughout Sub- Saharan Africa, South Africa is experiencing an increase in the incidence of myocardial infarction. ST-elevation myocardial infarction (STEMI) occurs commonly in South Africa and at much younger ages than observed elsewhere in the world. Emergent treatment in the form of coronary reperfusion is required to reduce morbidity and mortality following STEMI. Political and socio-economic factors have led to large disparities in emergency healthcare access for many South Africans. Well organised networks of care (coronary care networks, CCNs) that seamlessly integrate prehospital care, in-hospital assessment and percutaneous coronary intervention is recommended to reduce mortality for these patients. CCNs are underdeveloped and under-studied in South Africa. To this end, the aims of this project was to examine the current state of Coronary Care Networks in South Africa, a low- to middle income country and to provide recommendations for future development of such networks. METHODS: This project was comprised of four studies. Study I was a cross-sectional descriptive study that aimed at determining the current PCI-capable facilities in South Africa and sought correlations between the resources, population, poverty and insurance status using Spearman’s Rho. Study II utilised proximity analysis to determine the average drive times of South African municipal wards (geopolitical subdivisions used for electoral purposes) to the closest PCI-capable facility for each South African province. It further determined the proportion of South Africans living within one and two hours respectively, from such a facility. Study III combined data obtained from Studies I and II with network optimisation modelling to propose an optimised reperfusion strategy for patients with STEMI, based on proximity, using the North West province as a case study. Finally, Study IV employed qualitative methodology to determine the barriers and facilitators to developing CCNs in South Africa by performing interviews with individuals working with the South African contexts of coronary care. RESULTS: South Africa has 62 PCI-capable facilities, with most PCI-facilities (n=48; 77%) owned by the private healthcare sector. A disparity exists between the number of private and state-owned PCI-facilities when compared to the poverty (r=0.01; p=0.17) and insurance status of individuals (r=-0.4; p=0.27) (Study I). This means that reperfusion by PCI is likely inaccessible to many despite approximately, 53.8% and 71.53% of the South African population living within 60 and 120 minutes of a PCI facility (Study II). Yet, we provide an efficient and swift model that provides a recommendation for the best reperfusion strategy even in the instance of a large amount of ward data with these additional constraints. This model can be run in realtime and can guide reperfusion decisions at the bedside or form the basis of regional reperfusion guidelines, and CCN development priorities (Study III). When considering the local CCN, we found an under-resourced CCN that is not prioritised by policymakers and displays considerable variation in performance based on time of day and geographic locale. Specific barriers to the development of CCNs in South Africa included poor recognition and diagnosis of STEMI, inappropriate transport and treatment decisions, and delays. Facilitators to the development of CCNs were regionalised STEMI treatment guidelines, further research and prehospital thrombolysis programmes (Study IV). CONCLUSION: South Africa has a shortage of PCI facilities. Even in areas with high concentrations of PCI facilities. In addition, many patients may not be able to access care due to socio-economic status. When considering proximity alone, most South Africans are able to access PCI within guideline timeframes. Despite this, prehospital thrombolysis should still be considered in some areas – as demonstrated by a novel approach that combines geospatial analysis and network optimisation modelling. This approach is able to efficiently determine the optimum reperfusion strategy for each geographic locale of South Africa. Current CCNs in South Africa are under-resourced, over-burdened and not prioritised. Future efforts should aim at improving STEMI recognition and diagnosis to decrease delays to reperfusion. The findings described should be considered and integrated into a future model of CCNs within South Africa, towards improving reperfusion times and finally morbidity and mortality

Telephonic descriptions of out-of-hospital cardiac arrest by laypersons calling the dispatch centre of a private emergency medical service in South Africa

Background: The incidence of out-of-hospital cardiac arrest (OHCA) is expected to increase in South Africa. In order to encourage bystander cardiopulmonary resuscitation (CPR), international guidelines recommend call-taker recognition of the arrest and the initiation of telephone-guided CPR. One of the only ways that a call-taker can identify OHCA is through the description of the incident offered by the caller. The aim of this study was to identify the keywords and phrases that are used by callers to describe patients who are experiencing OHCA during calls made to a South African private Emergency Medical Service (EMS). Methods: A qualitative exploratory design was used and employed inductive dominant content analysis to identify the keywords and phrases that are used by callers to describe patients who are experiencing OHCA during calls made to a South African private EMS. The initial sampling frame was all cases of the “Cardiac Arrest” incident type recorded between 1 January 2019 and 31 December 2019. Results: A total of 28 call recordings were analysed. Keywords and phrases were organised into five categories: 1) Cardiac activity; 2) Level of consciousness; 3) Breathing descriptors; 4) Ill health; and 5) Clinical features. Conclusion: Callers into a private emergency dispatch centre used consistent descriptors of OHCA, which were similar to those found in previous South African studies. Future research should focus on determining the accuracy of these descriptors to differentiate between OHCA and other conditions, and integrate them into OHCA recognition algorithms, call-taker training and telephone-guided CPR protocols

Percutaneous coronary intervention still not accessible for many South Africans

Introduction: The incidence of myocardial infarction is rising in Sub-Saharan Africa. In order to reduce mortality, timely reperfusion by percutaneous coronary intervention (PCI) or thrombolysis followed by PCI is required. South Africa has historically been characterised by inequities in healthcare access based on geographic and socioeconomic status. We aimed to determine the coverage of PCI-facilities in South Africa and relate this to access based on population and socio-economic status. Methods: This cross-sectional study obtained data from literature, directories, organisational databases and correspondence with Departments of Health and hospital groups. Data was analysed descriptively while Spearman's Rho sought correlations between PCI-facility resources, population, poverty and medical insurance status. Results: South Africa has 62 PCI-facilities. Gauteng has the most PCI-facilities (n = 28) while the Northern Cape has none. Most PCI-facilities (n = 48; 77%) are owned by the private sector. A disparity exists between the number of private and state-owned PCI-facilities when compared to the poverty (r = 0.01; p = 0.17) and insurance status of individuals (r = -0.4; p = 0.27). Conclusion: For many South Africans, access to PCI-facilities and primary PCI is still impossible given their socio-economic status or geographical locale. Research is needed to determine the specific PCI-facility needs based on geographic and epidemiological aspects, and to develop a contextualised solution for South Africans suffering a myocardial infarction. (C) 2017 African Federation for Emergency Medicine. Publishing services provided by Elsevier B.V.Peer reviewe

The accuracy of Bloemfontein-based Emergency Medical Services providers in recognising sepsis

Background: Sepsis is considered a severe life-threatening medical emergency and globally carries a high mortality. Research suggests early recognition of sepsis can lead to early initiation of treatment and effective communication of this condition to the receiving facility by pre-hospital emergency care (PEC) providers. Depending on system operations, this has been shown to improve patient outcomes. However, sepsis often presents non-specifically, and in the absence of validated pre-hospital sepsis screening tools, less than half of sepsis patients seen by PEC providers are recognised. This study aimed to determine the accuracy with which Bloemfontein-based PEC providers recognise sepsis in a series of patient vignettes. Methods: A series of seven case vignettes were presented to a convenient sample of advanced life support (ALS) and intermediate life support (ILS) PEC providers. The PEC providers were asked to review each vignette and indicate whether the patient described had sepsis or not. The vignettes consisted of a clinical case description with signs and symptoms of patients presenting with or without sepsis, and images were shown where relevant. Elements of the Robson Prehospital Severe Sepsis Screening (RPSS) tool were used to populate the sepsis vignettes. Results: A total of 27 ILS and ALS PEC providers in the Bloemfontein area partook in the research study. Thus, a total of 189 vignettes were evaluated for sepsis. PEC providers, both ILS and ALS, recognised sepsis with a sensitivity of 69.63% and a specificity of 37.04% (PPV 73.44%, NPV 32.79%), indicating an accuracy of 60.32%. Although all participants mentioned some motivations for their answers, none of the participants gave specific cut-off value ranges at which point they would suspect sepsis. Conclusion: This vignette-based study found that PEC providers can recognise sepsis with modest accuracy, echoing previous work on this topic. In addition, the study provides a platform for similar studies, which, in turn, could aid in the development of a validated, pre-hospital sepsis screening tool.&nbsp

The proportion of South Africans living within 60 and 120 minutes of a percutaneous coronary intervention facility

Abstract: Introduction: Timely reperfusion (preferably via percutaneous coronary intervention (PCI)) following myocardial infarction improves mortality. Emergency medical services play a pivotal role in recognising and transporting patients with ST-elevation myocardial infarction directly to a PCI facility to avoid delays to reperfusion. Access to PCI is, in-part, dependant on the geographic distribution of patients around PCI facilities. The aim of this study was to determine the proportion of South Africans living within 60 and 120 minutes to a PCI facility. Methods: PCI facility and population data were subjected to proximity analysis to determine the average drive times from municipal ward centroids to PCI facilities for each province in South Africa. Thereafter, the population of each ward living within 60 and 120 minutes of a PCI facility was extrapolated. Results: Approximately, 53.8% and 71.53% of the South African population lives within 60 and 120 minutes of a PCI facility. The median (IQR, range) drive times and distances to a PCI facility are 100 minutes (120.4 min, 0.7 min – 751.8 min) across 123.6km (157.6km, 0.3km – 940.8km).. Conclusion: Based on the proximity of South Africans to PCI facilities, it seems possible that most patients could receive timely PCI within 120 minutes of first medical contact. However, this may be unlikely for some due to a lack of medical insurance, under-developed referral networks or other system delays. Coronary..

Attitudes of prehospital providers on transport decision-making in the management of patients with a suicide attempt refusing care: A survey based on the Mental Health Care Act of 2002

Background: Given the frequency of suicidal patients making attempts prior to a completed suicide, emergency access to mental health care services could lead to significant reduction in morbidity and mortality for these patients. Aim: To describe the attitudes of prehospital providers and describe transport decision-making around the management of patients with a suicide attempt. Setting: Cape Town Metropole. Methods: A cross-sectional, vignette-based survey was used to collect data related to training and knowledge of the Mental Health Care Act, prehospital transport decision-making and patient management. Results: Patients with less dramatic suicidal history were more likely to be discharged on scene. Few respondents reported the use of formal suicide evaluation tools to aid their decision. Respondents displayed negative attitudes towards suicidal patients. Some respondents reported returning to find a suicidal patient dead, while others reported patient attempts at suicide when in their care. Eighty per cent of respondents had no training in the management of suicidal patients, while only 7.0% had specific training in the Mental Health Care Act. Conclusion: A critical lack in the knowledge, training and implementation of the Mental Health Care Act exists amongst prehospital providers within the Western Cape. A further concern is the negative feelings towards suicidal patients and the lack of commitment to transporting patients to definitive care. It is essential to urgently develop training programmes to ensure that prehospital providers are better equipped to deal with suicidal patients

Maximum movement and cumulative movement (travel) to inform our understanding of secondary spinal cord injury and its application to collar use in self-extrication

BACKGROUND: Motor vehicle collisions remain a common cause of spinal cord injury. Biomechanical studies of spinal movement often lack “real world” context and applicability. Additional data may enhance our understanding of the potential for secondary spinal cord injury. We propose the metric ‘travel’ (total movement) and suggest that our understanding of movement related risk of injury could be improved if travel was routinely reported. We report maximal movement and travel for collar application in vehicle and subsequent self-extrication. METHODS: Biomechanical data on application of cervical collar with the volunteer sat in a vehicle were collected using Inertial Measurement Units on 6 healthy volunteers. Maximal movement and travel are reported. These data and a re-analysis of previously published work is used to demonstrate the utility of travel and maximal movement in the context of self-extrication. RESULTS: Data from a total of 60 in-vehicle collar applications across three female and three male volunteers was successfully collected for analysis. The mean age across participants was 50.3 years (range 28–68) and the BMI was 27.7 (range 21.5–34.6). The mean maximal anterior–posterior movement associated with collar application was 2.3 mm with a total AP travel of 4.9 mm. Travel (total movement) for in-car application of collar and self-extrication was 9.5 mm compared to 9.4 mm travel for self-extrication without a collar. CONCLUSION: We have demonstrated the application of ‘travel’ in the context of self-extrication. Total travel is similar across self-extricating healthy volunteers with and without a collar. We suggest that where possible ‘travel’ is collected and reported in future biomechanical studies in this and related areas of research. It remains appropriate to apply a cervical collar to self-extricating casualties when the clinical target is that of movement minimisation

South African paramedic perspectives on prehospital palliative care

Abstract Background Palliative care is typically performed in-hospital. However, Emergency Medical Service (EMS) providers are uniquely positioned to deliver early palliative care as they are often the first point of medical contact. The aim of this study was to gather the perspectives of advanced life support (ALS) providers within the South African private EMS sector regarding pre-hospital palliative care in terms of its importance, feasibility and barriers to its practice. Methods A qualitative study design employing semi-structured one-on-one interviews was used. Six interviews with experienced, higher education qualified, South African ALS providers were conducted. Content analysis, with an inductive-dominant approach, was performed to identify categories within verbatim transcripts of the interview audio-recordings. Results Four categories arose from analysis of six interviews: 1) need for pre-hospital palliative care, 2) function of pre-hospital healthcare providers concerning palliative care, 3) challenges to pre-hospital palliative care and 4) ideas for implementing pre-hospital palliative care. According to the interviewees of this study, pre-hospital palliative care in South Africa is needed and EMS providers can play a valuable role, however, many challenges such as a lack of education and EMS system and mindset barriers exist. Conclusion Challenges to pre-hospital palliative care may be overcome by development of guidelines, training, and a multi-disciplinary approach to pre-hospital palliative care