The epidemiology of major incidents in the Western Cape Province, South Africa

Background. Major incidents put pressure on any health system. There are currently no studies describing the epidemiology of major incidents in South Africa (SA). The lack of data makes planning for major incidents and exercising of major incident plans difficult.Objective. To describe the epidemiology of major incidents in the Western Cape Province, SA.Methods. A retrospective analysis of the Western Cape Major Incident database was conducted for the period 1 December 2008 - 30 June 2014. Variables collected related to patient demographics and incident details. Summary statistics were used to describe all variables.Results. Seven hundred and seventy-seven major incidents were reviewed (median n=11 per month). Most major incidents occurred in the City of Cape Town (57.8%, n=449), but the Central Karoo district had the highest incidence (11.97/10 000 population). Transport-related incidents occurred most frequently (94.0%, n=730). Minibus taxis were involved in 312 major incidents (40.2%). There was no significant difference between times of day when incidents occurred. A total of 8 732 patients were injured (median n=8 per incident); ten incidents involved 50 or more victims. Most patients were adults (80.0%, n=6 986) and male (51.0%, n=4 455). Of 8 440 patients, 630 (7.5%) were severely injured. More than half of the patients sustained minor injuries (54.6%, n=4 605).Conclusion. Major incidents occurred more often than would have been expected compared with other countries, with road traffic crashes the biggest contributor. A national database will provide a better perspective of the burden of major incidents

Emergency care research priorities in South Africap

Background. Emergency care research is rarely undertaken in low- and middle-income countries. A manageable ‘road map’ for research in South African (SA) emergency care is needed to address research gaps.Objective. To identify, collate and prioritise research topics from identified knowledge gaps in emergency care in SA.Methods. Seventy-six individuals were invited to participate in a modified Delphi study. Participants were requested to suggest important research topics before rating them. Consensus was achieved when >75% of participants strongly agreed or disagreed. Participants then ranked the agreed statements before selecting the most appropriate methodology relating to study design, funding and collaboration.Results. Three hundred and fifty topics were suggested by 31 participants. Topics were collated into 123 statements before participants rated them. Consensus was achieved for 39 statements. The highest-ranked priority in the prehospital group was to determine which prehospital interventions improve outcomes in critically ill patients. The competence of emergency care providers in performing common lifesaving skills was deemed the most important in clinical emergency care. Implementing and reviewing quality improvement systems scored the highest under general systems and safety management. Only 22 statements achieved consensus regarding study design. The National Department of Health was the preferred funding source, while private organisations and emergency care societies were identified as possible collaborative partners.Conclusion. This study provides expert consensus on priority research areas in emergency care in SA as a guide for emergency care providers to ensure evidence-based care that is relevant to the SA population

A multi-parameter diagnostic clinical decision tree for the rapid diagnosis of tuberculosis in HIV-positive patients presenting to an emergency centre

CITATION: Van Hoving, Daniël Jacobus et al. 2020. A multi-parameter diagnostic clinical decision tree for the rapid diagnosis of tuberculosis in HIV-positive patients presenting to an emergency centre. Wellcome Open Research, 5:72, doi:10.12688/wellcomeopenres.15824.1.The original publication is available at: https://wellcomeopenresearch.orgBackground: Early diagnosis is essential to reduce the morbidity and mortality of HIV-associated tuberculosis. We developed a multi-parameter clinical decision tree to facilitate rapid diagnosis of tuberculosis using point-of-care diagnostic tests in HIV-positive patients presenting to an emergency centre. Methods: A cross-sectional study was performed in a district hospital emergency centre in a high-HIV-prevalence community in South Africa. Consecutive HIV-positive adults with ≥1 WHO tuberculosis symptoms were enrolled over a 16-month period. Point-of-care ultrasound (PoCUS) and urine lateral flow lipoarabinomannan (LF-LAM) assay were done according to standardized protocols. Participants also received a chest X-ray. Reference standard was the detection of Mycobacterium tuberculosis using Xpert MTB/RIF or culture. Logistic regressions models were used to investigate the independent association between prevalent microbiologically confirmed tuberculosis and clinical and biological variables of interest. A decision tree model to predict tuberculosis was developed using the classification and regression tree algorithm. Results: There were 414 participants enrolled: 171 male, median age 36 years, median CD4 cell count 86 cells/mm3. Tuberculosis prevalence was 42% (n=172). Significant variables used to build the classification tree included ≥2 WHO symptoms, antiretroviral therapy use, LF-LAM, PoCUS independent features (pericardial effusion, ascites, intra-abdominal lymphadenopathy) and chest X-ray. LF-LAM was positioned after WHO symptoms (75% true positive rate, representing 17% of study population). Chest X-ray should be performed next if LF-LAM is negative. The presence of ≤1 PoCUS independent feature in those with ‘possible or unlikely tuberculosis’ on chest x-ray represented 47% of non-tuberculosis participants (true negative rate 83%). In a prediction tree which only included true point-of-care tests, a negative LF-LAM and the presence of ≤2 independent PoCUS features had a 71% true negative rate (representing 53% of sample). Conclusions: LF-LAM should be performed in all adults with suspected HIV-associated tuberculosis (regardless of CD4 cell count) presenting to the emergency centre.Publisher's versio

A 5-year analysis of the helicopter air mercy service in Richards Bay, South Africa

Background. A helicopter emergency medical service (HEMS) was established in 2005 in Richards Bay, KwaZulu-Natal, South Africa, to provide primary response and inter-facility transfers to a largely rural area with a population of 3.4 million people.Objective. To describe the first 5 years of operation of the HEMS.Methods. A chart review of all flights from 1 January 2006 to 31 December 2010 was conducted.Results. A total of 1 429 flights were undertaken; 3 were excluded from analysis (missing folders). Most flights (88.4%) were inter-facility transfers (IFTs). Almost 10% were cancelled after takeoff. The breakdown by age was 61.9% adult, 15.1% paediatric and 21.6% neonate. The main indications for IFTs were obstetrics (34.5%), paediatrics (27.9%) and trauma (15.9%). For primary response most cases were trauma (72.9%) and obstetrics (11.3%). The median on-scene time for neonates was significantly longer (48 min, interquartile range (IQR) 35 - 64 min) than that for adults (36 min, IQR 26 - 48; p<0.001) and paediatrics (36 min, IQR 25 - 51; p<0.02). On-scene times for doctor-paramedic crews (45 min, IQR 27 - 50) were significantly longer than for paramedic-only crews (38 min, IQR 27 - 57; p<0.001). Conclusion. The low flight-to-population ratio and primary response rate may indicate under-utilisation of the air medical service in an area with a shortage of advanced life support crews and long transport distances. Further studies on HEMSs in rural Africa are needed, particularly with regard to cost-benefit analyses, optimal activation criteria and triage systems.

Toward an Appropriate Point-of-Care Ultrasound Curriculum: A Reflection of the Clinical Practice in South Africa

Background: Point-of-care ultrasound has become an essential skill in the armory of modern physicians. The South African point-of-care ultrasound curriculum reflects that of the United Kingdom by including five module applications, namely, extended focused assessment of sonography in trauma (eFAST), abdominal aorta aneurysm, central and peripheral venous access, focused emergency echocardiography in resuscitation (FEER), and deep venous thrombosis (DVT). A recent descriptive study demonstrated marked discrepancies between the current five point-of-care ultrasound curriculum application modules trained and the disease burden faced by doctors within Cape Town Emergency Centers during their daily clinical practice. The motivation for conducting this study is to extend the study location beyond Cape Town. The objective was to establish whether the clinical practice exposure of South African certified point-of-care ultrasound providers reflects the current curriculum content. Methods: An online survey was conducted. All South African certified emergency medicine point-of-care ultrasound providers were eligible for inclusion. Cases with incomplete data and providers practicing outside South Africa were excluded. Summary statistics were used to describe all variables. Results: Forty-four providers completed the survey (52.4% response rate), but only 37 responses were analyzed [currently working outside South Africa (n = 5); incomplete responses (n = 2)]. Most respondents were female (n = 20, 54.1%); aged > 35 years (n = 22, 59.5%); working in the Western Cape Province (n = 29, 78.4%); and emergency medicine specialists (n = 22, 59.5%). The eFAST (35.9%), DVT (24.4%), and FEER (14.3%) application modules were the most frequently used. The top five modules selected that best match the participants' perceived burden of disease were eFAST (89.2%), DVT (86.5%), FEER (64.9%), first-trimester pregnancy (56.8%), and focused assessment with sonography for human immunodeficiency virus/tuberculosis (43.2%). Most respondents (n = 27, 73%) indicated that the curriculum should be expanded to include more than five application modules. Conclusions: This study indicates a mismatch between the current point-of-care ultrasound curriculum and the clinical burden of disease experienced. Disease burden, disease impact, technical difficulty of ultrasound applications, and logistical barriers need to be incorporated when considering a change in the curriculum to make it more appropriate for the South African setting

Emergency care research priorities in South Africa

CITATION: Van Hoving, D.J., Barnetson, B.K. & Wallis, L. 2015. Emergency care research priorities in South Africap. South African Medical Journal, 105(3):202-208, doi:10.7196/SAMJ.8967.The original publication is available at http://www.samj.org.za/index.php/samj/indexENGLISH SUMMARY : Background. Emergency care research is rarely undertaken in low- and middle-income countries. A manageable ‘road map’ for research in South African (SA) emergency care is needed to address research gaps. Objective. To identify, collate and prioritise research topics from identified knowledge gaps in emergency care in SA. Methods. Seventy-six individuals were invited to participate in a modified Delphi study. Participants were requested to suggest important research topics before rating them. Consensus was achieved when >75% of participants strongly agreed or disagreed. Participants then ranked the agreed statements before selecting the most appropriate methodology relating to study design, funding and collaboration. Results. Three hundred and fifty topics were suggested by 31 participants. Topics were collated into 123 statements before participants rated them. Consensus was achieved for 39 statements. The highest-ranked priority in the prehospital group was to determine which prehospital interventions improve outcomes in critically ill patients. The competence of emergency care providers in performing common lifesaving skills was deemed the most important in clinical emergency care. Implementing and reviewing quality improvement systems scored the highest under general systems and safety management. Only 22 statements achieved consensus regarding study design. The National Department of Health was the preferred funding source, while private organisations and emergency care societies were identified as possible collaborative partners. Conclusion. This study provides expert consensus on priority research areas in emergency care in SA as a guide for emergency care providers to ensure evidence-based care that is relevant to the SA population.Publishers versio

Poor adherence to Tranexamic acid guidelines for adult, injured patients presenting to a district, public, South African hospital

Introduction: In South Africa’s high injury prevalent setting, it is imperative that injury mortality is kept to a minimum. The CRASH-2 trial showed that Tranexamic acid (TXA) in severe injury reduces mortality. Implementation of this into injury protocols has been slow despite the evidence. The 2013 Western Cape Emergency Medicine Guidelines adopted the use of TXA. This study aims to describe compliance. Methods: A retrospective study of TXA use in adult injury patients presenting to Khayelitsha Hospital was done. A sample of 301 patients was randomly selected from Khayelitsha’s resuscitation database and data were supplemented through chart review. The primary endpoint was compliance with local guidance: systolic blood pressure 110 or a significant risk of haemorrhage. Injury Severity Score (ISS) was used as a proxy for the latter. ISS >16 was interpreted as high risk of haemorrhage and ISS <8 as low risk. Linear regression and Fischer’s Exact test were used to explore assumptions. Results: Overall compliance was 58% (172 of 295). For those without an indication, this was 96% (172 of 180). Of the 115 patients who had an indication, only eight (18%) received the first dose of TXA and none received a follow-up infusion. Compliance with the protocol was significantly better if an indication for TXA did not exist, compared to when one did (p 15 (p < 0.001). Discussion: TXA is not used in accordance with local guidelines. It was as likely not to be used when indicated than when not indicated. Reasons for this are multifactorial and likely include stock levels, lack of administration equipment, time to reach definitive care, poor documentation and hesitancy to use. Further investigation is needed to understand the barriers to administration