Doctors’, nurses’ and clinical associates’ understanding of emergency care practitioners

Background: Healthcare professionals’ understanding of the knowledge, skills and training of their counterparts from other disciplines cultivates appreciation and respect within the workplace. This, in turn, results in better teamwork and improved patient care. Emergency departments are places where emergency care practitioners (ECPs) engage with doctors, nurses and clinical associates. Whilst the importance of inter-professional communication and teamwork between in-hospital professionals and pre-hospital emergency care providers is acknowledged, no literature could be found describing exactly how much these in-hospital professionals understand about the training and capabilities of their ECP colleagues. Aim: The aim of this study was to assess the level of understanding that prospective doctors, nurses and clinical associates have regarding the training and capabilities of ECPs. Setting: The research was conducted in Johannesburg, South Africa, at two universities. Methods: Seventy-seven participants completed a purpose-designed questionnaire assessing their understanding regarding the education and clinical capabilities of ECPs. Results: In total, 64% of participants demonstrated a poor understanding of the level of education and clinical capabilities of ECPs. The remaining 36% showed only moderate levels of understanding. Conclusion: Medical, nursing and clinical associate graduates have a generally poor understanding of the education and clinical capabilities of their ECP colleagues who practise predominantly in the pre-hospital environment. This lack of understanding can become a barrier to effective communication between ECPs and in-hospital staff during patient handover in emergency departments. Contribution: This research highlights a lack of understanding about the role and function of South African ECPs as pre-hospital emergency care providers and the need for more effective inter-professional education

Student compliance with taught indications for intravenous cannulation during clinical learning

Abstract: One of the guiding principles behind the teaching and performance of a medical intervention is to “firstly do no harm”. Gaining access to a patient’s circulatory system for the purposes of administering fluid and / or medications is commonly achieved through a procedure that involves piercing the skin with a needle and inserting a cannula into a vein. Whilst intravenous (IV) cannulation remains a relatively common procedure, routinely performed by a number of health care professionals, it has the potential to create unintended adverse effects. Subjecting patients to medical procedures in the absence of a clearly established need may be considered an unethical form of “overtreatment”. Conversely, failing to perform an intervention when it is clearly indicated is equally undesirable. For this reason, it is important that medical professionals and educators ensure a real need or indication for IV cannulation exists prior to the performance of the procedure by students. The University of Johannesburg (UJ) is one of four higher education institutions in South Africa that currently offer a four-year professional bachelor degree in emergency medical care. Intravenous cannulation is a clinical procedure that is taught in the second year of study. The didactic approach followed at the UJ is to firstly teach and assess theoretical knowledge and understanding relating to the procedure with regard to the technique, indications, risks and benefits. The procedure is then demonstrated, practiced and assessed in a simulated environment making use of an intravenous trainer (medium fidelity manikin). Thereafter students are required to demonstrate performance of the procedure a set number of times on real patients. Whilst this naturally creates a desire in students to perform IV cannulation when the opportunity presents itself, as mentioned above, seeking clear indications for the performance of the procedure is essential to prevent unnecessary exposure of patients to potential adverse effects. The Department of Emergency Medical Care at the UJ currently teaches four indications for intravenous cannulation in the pre-hospital setting which are well supported by literature. These include: a) the administration of intravenous fluid in an effort to reverse hypovolaemic and associated dehydrated states, b) administration of intravenous medications, c) securing intravenous access in the case of acutely-ill, high-acuity “priority 1” or “code red” patients and d) obtaining blood samples/specimens for further laboratory testing. The authors aimed to assess the extent to which emergency medical care students may have been establishing IV access on patients during the course of their clinical learning without a clear indication

Risk factors for diabetic foot ulceration in diabetic patients presenting at primary healthcare clinics in South Africa

Abstract: Objective: The main purpose of the study was to investigate the need for podiatrists as members of the primary healthcare team. One of the objectives of the study was to determine the percentage of patients presenting at the two Primary Healthcare clinics who are at risk of developing foot complications as a result of an underlying concomitant systemic disease. Research design and methods: A descriptive cross-sectional study in which data was collected from patients presenting at two homogeneously selected Primary Healthcare (PHC) clinics in Johannesburg. Nursing staff assisted by a final year podiatry student collected data using a self-constructed data collection form (DCF) from each consenting patients as part of their routine patient consultation. Simple descriptive statistics were used for data analysis. Results: Data was collected and analysed from 1077 patients and showed that 29% of the patients had diabetes. Diabetic foot ulceration risk factors that were recorded included peripheral neuropathy in 74% of diabetic patients, structural foot deformities in 47%, peripheral vascular symptoms in 39% and foot ulcer in 28% of the diabetic patients. Conclusion: Early identification of diabetic patients who are at high risk of diabetic foot ulceration is important and can be achieved via a mandatory diabetic foot screening with subsequent multidisciplinary foot-care interventions. Understanding the factors that place patients with diabetes at high risk of ulceration, together with an appreciation of the links between different aspects of the disease process and foot function, is essential to the prevention and management of diabetic foot complications. Significance of the study • There is limited data available on diabetic foot risk factors across all levels of care in South Africa. • The study found that up to 74% of patients presenting at PHC facilities in this study had symptoms of diabetic peripheral neuropathy and 28% had foot ulcers. • The findings are suggestive of a need for diabetic foot assessment to be mandated at PHC level as part of the routine diabetic patient assessment and for Podiatrists to be involved at this level of care

On-scene discharge by Emergency Care Practitioners – a viable option for South Africa?

Background: In South Africa, the national public health sector provides healthcare to the majority of the population, yet many hospitals are in a state of crisis. On-scene discharge or patient non-conveyance to hospital by Emergency Care Practitioners (ECP) may serve as a means for patients to access healthcare services while alleviating the burden on the hospitals. Aim: The aim of this study was to determine the number of patients being transported by ambulance to a public sector Emergency Department (ED) who could have potentially been managed and discharged on-scene by a South African pre-hospital ECP. Methods: This was a prospective, descriptive and quantitative study of patients brought to the ED by ambulance over a 72-hour weekend period. The medical care that was provided in the ED was compared to the existing ECP scope of practice. The patients’ disposition was also used as a surrogate to determine whether transportation to hospital was required.Results: A total of 118 patients were transported to the ED by ambulance, and 85 of these patients consented to participate in the study. Overall, 62.4% of these patients were ultimately discharged from the hospital (60.4% of discharged patients being trauma-related). Most of the treatment modalities prescribed for the discharged patients were within the ECP scope of practice.Conclusion: Pre-hospital on-scene discharge by ECPs may be a mechanism to alleviate hospital overcrowding in a failing public healthcare system. However, if an ambulance service condones the concept of on-scene discharge, they need to implement monitoring strategies to assess the subsequent outcomes for those patients discharged at the scene

The cost-effectiveness of upfront point-ofcare testing in the emergency department : a secondary analysis of a randomised, controlled trial

Abstract: Background: Time-saving is constantly sought after in the Emergency Department (ED), and Point-of-Care (POC) testing has been shown to be an effective time-saving intervention. However, when direct costs are compared, these tests commonly appear to be cost-prohibitive. Economic viability may become apparent when the timesaving is translated into financial benefits from staffing, time- and cost-saving. The purpose of this study was to evaluate the cost-effectiveness of diagnostic investigations utilised prior to medical contact for ED patients with common medical complaints. Methods: This was a secondary analysis of data from a prospective, randomised, controlled trial in order to assess the cost-effectiveness of upfront, POC testing. Eleven combinations of POC equivalents of commonly-used special investigations (blood tests (i-STAT and complete blood count (CBC)), electrocardiograms (ECGs) and x-rays (LODOX® (Low Dose X-ray)) were evaluated compared to the standard ED pathway with traditional diagnostic tests. The economic viability of each permutation was assessed using the Incremental Cost Effectiveness Ratio and Cost- Effectiveness Acceptability Curves. Expenses related to the POC test implementation were compared to the control group while taking staffing costs and time-saving into account. Results: There were 897 medical patients randomised to receive various combinations of POC tests. The most costeffective combination was the i-STAT+CBC permutation which, based on the time saving, would ultimately save money if implemented. All LODOX®-containing permutations were costlier but still saved time. Non-LODOX® permutations were virtually 100% cost-effective if an additional cost of US$50 per patient was considered acceptable. Higher staffing costs would make using POC testing even more economical. Conclusions: In certain combinations, upfront, POC testing is more cost-effective than standard diagnostic testing for common ED undifferentiated medical presentations – the most economical POC test combination being the i- STAT + CBC. Upfront POC testing in the ED has the potential to not only save time but also to save money

Emergency care practitioners’ views on the use of ultrasound in pre-hospital acute care settings

Background: Ultrasound may assist in the detection of life-threatening conditions and evolving pathologies. South African emergency care practitioners (ECPs) working in pre-hospital contexts have historically not used ultrasound to diagnose and treat patients. However, recently published clinical practice guidelines from the Health Professions Council of South Africa (HPCSA) suggest that ultrasound be considered as an adjunct in the provision of pre-hospital emergency care. Our study investigated ECPs’ views and perceptions of introducing ultrasound to their scope of practice. Method: A qualitative prospective approach was followed, using semi-structured interviews with a purposefully selected sample of practising ECPs to investigate and describe their views and perceptions of the use of ultrasound in local pre-hospital emergency care contexts. The interviews were audio recorded and transcribed. Transcripts were critically read before being manually coded to identify core themes and categories. Results: ECPs recognise the potential value of ultrasound for a subset of patients within specific pre-hospital contexts. Concerns around the introduction of ultrasound as a diagnostic adjunct included the potential to create delays in treatment and transportation. Implementation challenges included cost implications and the need for additional education and training. Conclusion: ECPs practising in South African pre-hospital acute care contexts support the use of ultrasound, provided they are adequately trained, and its use does not lead to delays in treatment and arrival at receiving facilities. Additional training on the use of ultrasound may be necessary for ECPs. Further research is required to explore the benefits of ultrasound concerning patient-specific outcomes and the associated costs in resource-constrained pre-hospital emergency care settings

Emergency Medical Service response and mission times in an African metropolitan setting

Background: Emergency Medical Services (EMS) aim to respond to emergencies, treat and transport patients efficiently thus ensuring the ambulance call or “mission” is completed with ambulances available to service the next call as soon as possible. A typical mission may be divided into activities, each linked to a set time interval. The response time interval starts from the time a call is received by the call centre until the ambulance arrives on scene. The patient care interval includes the time taken to treat and transport the patient to hospital. The total mission time can be viewed as the time from when a call is first received by the call centre until the ambulance dispatched to that incident is again available to service the next call. The aim of this study was to describe response interval, patient care interval and total mission times routinely associated with servicing emergency incidents within a metropolitan public sector EMS in South Africa. Methods: A quantitative, prospective, descriptive design was followed wherein time intervals associated with 784 missions were analysed to document and describe response time interval, patient care interval and total mission times. Results: On average crews took 0h 23:16 to respond to incidents before spending an additional 0h 43:20 treating and transporting their patients. Lengthy delays were noted between arrival at hospital andcrews booking available for the next call. This led to total mission times averaging 2h 11:00. Conclusion: Average response and patient care time intervals noted in our study were longer than national and international norms and standards. Delays between arrival at hospital and crews booking available to service the next call led to average mission times of over 2 hours. This negatively impacts on availability of ambulances. Further studies are recommended to explore factors that may be contributing to the lengthy response and mission times reported in this study

Hypothermia in trauma patients arriving at an emergency department by ambulance in Johannesburg, South Africa : a prospective study

Abstract: Introduction: Normal body temperature is considered to be between 36 and 38°C. Temperatures that are too low may negatively affect physiological functions. In trauma cases, factors that promote the development of hypothermia include concomitant hypoxia, hypotension, decreased levels of consciousness, contact with cold surfaces, exposure to low ambient temperatures and the administration of cold fluids. Studies on emergency department related hypothermia in Africa are sparse. This study investigated instances of hypothermia in a sample of trauma cases arriving by ambulance to an emergency department in Johannesburg, South Africa. Methods: Core body temperatures of 140 trauma cases were measured upon arrival and 30 minutes later. Ambient temperatures outside the hospital, inside the ED and in the resuscitation areas were also recorded. Additional information was gathered describing the equipment available to the ambulance crews for temperature, control and rewarming. Results: Seventy-two (51%) of the cases were found to have core body temperatures less than 36°C upon arrival. Twenty-nine (21%) the cases were considered clinically hypothermic (core temperatures of less than <35°C). After 30 minutes, 79 (56%) of the participants had core body temperatures of less than 36°C and 39 (28%) remained lower than 35°C. Patients were not warming up in the ED as expected. Rather, some had become colder. The study also found that the ambient temperature in the triage area fluctuated and was recorded as less than the recommended 21°C in 95 (68%) of the cases. In addition, the majority of ambulances that transported these cases lacked appropriate equipment on board to properly facilitate temperature control and rewarming. Conclusion: Fifty-one percent of the trauma cases arriving by ambulance had core temperature <36°C. Many became even colder in the ED. Attention needs to be given to the early identification of hypothermia, the regulation of ambient temperatures inside the ED including the provision of appropriate heating and rewarming devices on ambulances

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..

Emergency care education in South Africa and the unique requirement of physical preparedness : a scoping review

Abstract: The Bachelor of Health Sciences Degree in Emergency Medical Care (BEMC) is a unique program in that students operate in both emergency care and rescue contexts, unlike international paramedic degree programs which focus only on emergency care. The learning activities associated with the rescue content are physically strenuous and therefore BEMC students need to be physically and mentally prepared to engage in diverse austere environments. Although South African BEMC programs have a common medical rescue curriculum, approaches to the training and assessment of physical preparedness vary between the institutions. The objective of this research was to explore the knowledge gap through the review of literature that describes the unique physical preparedness requirements in the field of emergency care education