Prioritising the care of critically ill children: a pilot study using SCREEN reduces clinic waiting times

Objective In low-resource settings, childhood mortality secondary to delays in triage and treatment remains high. This paper seeks to evaluate the impact of the novel Sick Children Require Emergency Evaluation Now (SCREEN) tool on the waiting times of critically ill children who present for care to primary healthcare clinics in Cape Town, South Africa. Methods We used a pre/postevaluation study design to calculate the median waiting times of all children who presented to four randomly chosen clinics for 5 days before, and 5 days after, the implementation of SCREEN. Findings The SCREEN programme resulted in statistical and clinically significant reductions in waiting times for children with critical illness to see a professional nurse (2 hours 45 min to 1 hour 12 min; p<0.001). There was also a statistically significant reduction in the proportion of children who left without being seen by a professional nurse (25.8% to 18.48%; p<0.001). Conclusions SCREEN is a novel programme that uses readily available laypersons, trained to make a subjective assessment of children arriving at primary healthcare centres, and provides a low cost, simple methodology to prioritise children and reduce waiting times in low-resource healthcare clinics

One in four die from acute infectious illness in an emergency department in Eastern Cape Province, South Africa

Background. Despite the breadth of data supporting evidence-based practice for sepsis care in high-resource settings, there are relatively few data to guide the management of sepsis in low-resource settings, particularly in areas where HIV and tuberculosis (TB) are prevalent. Furthermore, few studies had broadened sepsis parameters to include all patients with acute infectious illness or followed patients up after hospital discharge. Understanding the epidemiology and outcomes of acute infections in a local context is the critical first step to developing locally informed targeted management strategies.Objectives. To quantify and describe the incidence of and risk factors for mortality in a cohort of patients with undifferentiated acute infectious illnesses who presented to an emergency department (ED) in the Eastern Cape region of South Africa (SA).Methods. In this prospective cohort study, patients with suspected acute infectious illness were enrolled at a district casualty ward in Mthatha, SA, between 1 July and 1 September 2017. Demographic data, interventions, diagnostic studies and disposition were prospectively collected during the initial encounter and during the hospital stay. Follow-up was conducted both in hospital and via phone interviews 30 days after the index visit.Results. A total of 301 patients presented to the ED with acute infectious illness during the study period, of whom 54.8% had complete 30-day follow-up. Of the study population, only 5.7% had a complete set of vital signs (heart rate, respiratory rate, blood pressure and temperature) documented. Of the cohort, 51.8% had HIV and 32.9% active or treated TB; 25.2% of patients died within 30 days. Accounting for medical history, diagnosis and ED interventions, risk of mortality was independently associated with age (odds ratio (OR) 1.03; 95% confidence interval (CI) 1.00 - 1.06), HIV-positive status (OR 4.10; 95% CI 1.44 - 11.67) and Quick Sequential (Sepsis-Related) Organ Failure Assessment (qSOFA) score (OR 1.90; 95% CI 1.14 - 3.19) in an adjusted model. No ED interventions were protective for mortality, with intravenous fluid administration associated with increased 30-day mortality in this cohort (OR 3.65; 95% CI 1.38 - 9.62).Conclusions. Among adults with suspected acute infectious illness in Mthatha, SA, 30-day mortality was concerningly high. Mortality was highest in patients with concomitant HIV infection. In particular, vital sign assessment to identify possible sepsis in this cohort is crucial, as it affects mortality to a meaningful extent, yet is often unavailable. Future research is needed on the management of sepsis in low-resource settings, particularly in HIV-positive individuals

We need to target trauma: A prospective observational study in Eastern Cape Province, South Africa

Background. Emergency medicine accounts for a large proportion of medical care in many low- and middle-income countries. A better understanding of the burden of disease will guide training and resource allocation priorities, but lack of electronic medical records and standardised data collection systems makes it difficult to obtain this information.Objectives. To draw attention to the proportionally large burden of trauma in emergency centres (ECs) throughout Eastern Cape Province, South Africa (SA), in the hope of influencing resource allocation and medical provider training protocols accordingly.Methods. A secondary data analysis was performed from information gathered in HIV testing studies in two large tertiary care centres and one regional hospital in the Eastern Cape region of SA. All patients presenting to the ECs during the 6-week study period who met the inclusion criteria were approached and requested to provide consent for point-of-care HIV testing and collection of demographic information. Information collected included patient demographics, presenting complaints and final diagnoses. Simple descriptive statistics were used to analyse the data.Results. Data were collected from 4 271 patients across three study sites: Frere Hospital (n=2 391), Nelson Mandela Academic Hospital (n=622) and Mthatha Regional Hospital (n=1 258). At the two tertiary care centres, most patients were between the ages of 18 and 30 years (41.2% and 32.6%, respectively) and male (57.8% and 60.2%), and 70.4% and 41.5% had traumatic injuries. The most common complaints were stab/gunshot wounds (18.3% and 20.2%). At the district hospital, the majority of patients were female (57.2%), 40.1% were between 18 and 30 years old, and 27.3% presented with traumatic injuries. Stab/gunshot wounds were the second most common complaint (7.2%) after lower respiratory tract infections (8.7%).Conclusions. From the proportion of presenting individuals sampled, we can conclude that a large proportion of care delivered in ECs in the Eastern Cape is for trauma. Local clinical capacitation efforts must focus on trauma training.

Determining the prevalence of tuberculosis in emergency departments in the Eastern Cape region of South Africa and the utility of the World Health Organization tuberculosis screening tool

Background. South Africa (SA) faces a significant tuberculosis (TB) burden complicated by high rates of HIV-TB co-infection. In SA, emergency departments (EDs) play an important role in screening for TB.Objectives. To determine the prevalence of TB in the ED and the effectiveness of the World Health Organization (WHO) TB screening tool.Methods. This was a cross-sectional observational study, conducted in the ED at Livingstone Hospital, Port Elizabeth, from 4 June to 15 July 2018. All patients aged &gt;18 years and able to consent were administered the WHO TB screening questions and underwent a point-of-care HIV test and demographic data collection. Patients were followed up for 1 year and tracked in the National Health Laboratory Service database to determine TB status using laboratory testing.Results. Over the study period, 790 patients were enrolled. Overall, 121 patients (15.3%) were TB-positive, with 46 (38.0%) diagnosed after presenting to the ED and 75 (62.0%) with a previous TB history determined by self-report or confirmed laboratory testing. A greater proportion of the TB-positive patients were HIV-positive (49.6%) compared with the TB-negative population (24.8%). TB-positive individuals were more likely to present to the ED with a chief complaint of shortness of breath (SoB) (18.2%) compared with the TB-negative population (10.5%). Overall, the WHO TB screening tool had poor sensitivity (46.5%) and specificity (62.5%) for identifying TB-positive patients in the ED. A multiple logistic regression analysis, controlled for age and sex, showed HIV status (odds ratio (OR) 2.81; p&lt;0.001) and SoB (OR 2.19; p&lt;0.05) to be significant predictors of TB positivity. Adding positive HIV status and a presenting complaint of SoB increased sensitivity to 78.3%.Conclusions. EDs in SA face a high burden of TB. While WHO screening guidelines identify some of these patients, including routine HIV testing in the ED could significantly affect the number of TB diagnoses made

Determining the prevalence of tuberculosis in emergency departments in the Eastern Cape region of South Africa and the utility of the World Health Organization tuberculosis screening tool

Background. South Africa (SA) faces a significant tuberculosis (TB) burden complicated by high rates of HIV-TB co-infection. In SA, emergency departments (EDs) play an important role in screening for TB. Objectives. To determine the prevalence of TB in the ED and the effectiveness of the World Health Organization (WHO) TB screening tool. Methods. This was a cross-sectional observational study, conducted in the ED at Livingstone Hospital, Port Elizabeth, from 4 June to 15 July 2018. All patients aged &gt;18 years and able to consent were administered the WHO TB screening questions and underwent a point-of-care HIV test and demographic data collection. Patients were followed up for 1 year and tracked in the National Health Laboratory Service database to determine TB status using laboratory testing. Results. Over the study period, 790 patients were enrolled. Overall, 121 patients (15.3%) were TB-positive, with 46 (38.0%) diagnosed after presenting to the ED and 75 (62.0%) with a previous TB history determined by self-report or confirmed laboratory testing. A greater proportion of the TB-positive patients were HIV-positive (49.6%) compared with the TB-negative population (24.8%). TB-positive individuals were more likely to present to the ED with a chief complaint of shortness of breath (SoB) (18.2%) compared with the TB-negative population (10.5%). Overall, the WHO TB screening tool had poor sensitivity (46.5%) and specificity (62.5%) for identifying TB-positive patients in the ED. A multiple logistic regression analysis, controlled for age and sex, showed HIV status (odds ratio (OR) 2.81; p&lt;0.001) and SoB (OR 2.19; p&lt;0.05) to be significant predictors of TB positivity. Adding positive HIV status and a presenting complaint of SoB increased sensitivity to 78.3%. Conclusions. EDs in SA face a high burden of TB. While WHO screening guidelines identify some of these patients, including routine HIV testing in the ED could significantly affect the number of TB diagnoses made

The impact of HIV knowledge and attitudes on HIV testing acceptance among patients in an emergency department in the Eastern Cape, South Africa

Background: Transmission of HIV in South Africa continues to be high due to a large proportion of individuals living with undiagnosed HIV. Uptake of HIV testing is influenced by a multitude of factors including the patient’s knowledge and beliefs about HIV. Methods: This study sought to quantify the impact of knowledge and attitudes on HIV testing acceptance in an emergency department by co-administering a validated HIV knowledge and attitudes survey to patients who were subsequently offered HIV testing. Results: During the study period 223 patients were interviewed and offered HIV testing. Individuals reporting more negative overall attitudes (p = 0.006), higher levels of stigma to HIV testing (p < 0.001), and individuals who believed their test was confidential (p < 0.001) were more likely to accept an HIV test. Conclusions: Interventions focused on improving patient perceptions around testing confidentiality will likely have the greatest impact on testing acceptance in the emergency department

The impact of HIV knowledge and attitudes on HIV testing acceptance among patients in an emergency department in the Eastern Cape, South Africa

Background: Transmission of HIV in South Africa continues to be high due to a large proportion of individuals living with undiagnosed HIV. Uptake of HIV testing is influenced by a multitude of factors including the patient’s knowledge and beliefs about HIV. Methods: This study sought to quantify the impact of knowledge and attitudes on HIV testing acceptance in an emergency department by co-administering a validated HIV knowledge and attitudes survey to patients who were subsequently offered HIV testing. Results: During the study period 223 patients were interviewed and offered HIV testing. Individuals reporting more negative overall attitudes (p = 0.006), higher levels of stigma to HIV testing (p < 0.001), and individuals who believed their test was confidential (p < 0.001) were more likely to accept an HIV test. Conclusions: Interventions focused on improving patient perceptions around testing confidentiality will likely have the greatest impact on testing acceptance in the emergency department