Critical care transfers (CCTs) are necessitated by the growing prevalence of high-acuity patients who require upgrade of care to multidisciplinary teams from less-equipped referring facilities. Owing to the high acuity of the critical care patient, specialised teams with advanced training and equipment are called upon to undertake these transfers. The inherent understanding of the potential effects, and therefore the needs of the critical care patient during transfer, are affected owing to the paucity of international, but more specifically, local data relating to CCTs.To describe a cohort of patients who underwent CCT by dedicated critical care retrieval services (CCRS) in the private sector in South Africa (SA).This retrospective, descriptive study sampled all paediatric and adult CCTs completed over a 1-year period (1 January 2017 - 31 December 2017) from the dedicated CCRS of two national emergency medical services in SA. All neonatal patients were excluded. Data were extracted from patient report forms by trained data extractors and subjected to descriptive analysis.A total of 1 839 patients were transferred between the two services. A total of 3 143 diagnoses were recorded, yielding an average of ~2 diagnoses per patient. The most prevalent primary diagnosis was cardiovascular disease (n=457, 25%), followed by infection (n=180, 10%) and head injury (n=133, 7%). Patients had an average of ~3 attachments, with the most prevalent being patient monitoring (n=2 856, 155%), peripheral intravenous access (n=794, 43%) and mechanical ventilation (n=445, 24%). A total of 2 152 instances of medication infusion or administration were required during transport, yielding an average of ~1 medication or infusion per patient transported. The most common medications recorded were central nervous system depressants (n=588, 32%), followed by analgesics (n=482, 26%) and inotropic or vasoactive agents (n=320, 17%).This study provides insight into the demographics, most prevalent diagnoses and interfacility transfer monitoring needs of patients being transported in SA by two private dedicated CCRS. The results of this study may be used to inform future specialised critical care transport courses and qualifications, equipment procurement and scopes of practice for providers undertaking critical care transfers.
The incidence of cardiovascular diseases, and with it out-of-hospital cardiac arrest (OHCA), is on the increase in low- to middle-income countries (LMICs), like South Africa. Interventions such as mass public cardiopulmonary resuscitation (CPR) training campaigns and public access defibrillators are expensive and out of reach for many LMICs. Telephone-assisted CPR (tCPR) is a cost-effective, scalable alternative. This study explored the barriers and facilitators to tCPR uptake in OHCA in a private South African emergency dispatch centre. This qualitative study applied inductive dominant content analysis to emergency call recordings of OHCA cases into a private emergency dispatch centre. Calls were analysed to the latent level to identify barriers and facilitators. Cases were sampled randomly, until data saturation. Saturation occurred after the analysis of 25 recordings. A further three recordings were analysed to confirm saturation of the facilitators; yielding a final sample size of 28 calls. Overall, t-CPR was offered in 23 (82.1%) cases, but only initiated in 8 (34.8%) of these calls. Five barriers ("Poor Communication"; "Lack of Support"; "Caller Hesitance or Uncertainty;" "Emotionality"; and "Practical Barriers") and three facilitators ("Caller Willingness"; "Support" and "CPR in Progress") were extracted. Numerous barriers limit the initiation of tCPR in the South African private sector EMS. It is crucial to address these barriers and leverage the facilitators in order to improve tCPR uptake. This study highlights the importance of using specific language techniques and developing tailored tCPR algorithms to overcome these barriers, which is underpinned by standardised training of call-takers.
Background. Stroke is a potentially life-threatening, time-dependent event that requires urgent management to reduce morbidity and mortality. It has been suggested that earlier recognition by ambulance personnel and transport to stroke centres may significantly reduce treatment delays. For this reason it is vitally important that ambulance personnel are able to accurately diagnose stroke. Methods. A series of vignettes were created that included images, video and audio displaying either signs or symptoms of stroke or those of another condition. Ambulance personnel were asked to review each vignette and state whether the patient described was suffering from a stroke or not. Further investigation was sought by requesting each individual to motivate their answer, mentioning upon what their diagnosis was based. Results. A total of 40 basic life support (BLS) and intermediate life support (ILS) personnel from different sites diagnosed 280 vignettes. BLS personnel were able to diagnose stroke with a sensitivity of 85.3% and a specificity of 89.9% (positive predictive value (PPV) 86.7%, negative predictive value (NPV) 88.8%), while ILS achieved a sensitivity of 98.2% and specificity of 94.0% (PPV 91.7%, NPV 98.8%). The combined sensitivity and specificity were 91.5% and 92.0%, respectively (PPV 89.2%, NPV 93.8%). In order to aid their diagnosis, only 5% of BLS and 18.34% of ILS utilised validated stroke screening tools. Conclusion. Despite not using validated screening tools, the ambulance personnel sampled in this study were able to identify stroke with high accuracy. Further studies should be considered to identify how these diagnoses were reached in order to identify training needs.
Background. An estimated 56.8 million people require palliative care annually, while only 14% receive such care. This imbalance is particularly acute in low-to middle-income countries (LMICs), where up to 80% of patients requiring palliative care reside. To correct this imbalance, integration between palliative services and other disciplines has been recommended. While improved palliative care integration is a priority in the South African (SA) LMIC context, emergency medical services (EMS) and palliative care remain non-integrated. This has resulted in poor palliative situation management by EMS and a lack of research concerning their intersection. Objective. To examine EMS use for palliative situations in the Western Cape (WC) Province of SA by describing frequency of intersection, patient characteristics and outcomes.Methods. An observational, descriptive, retrospective patient record review was employed at two hospitals with palliative care services in the WC. All patient records of those who arrived at the hospitals between 1 January 2020 and 31 December 2020 via EMS conveyance leading to palliative care provision were included in the study. Results. In total, 1 207 unique patients received palliative care services at both hospitals during the study period. Of these, 395 (33%) made use of EMS for hospital conveyance on 494 occasions. The median (range) patient age was 60 (20 - 93) years, and most transports involved male patients (54%, n=265). Family members were the primary caregivers in most instances (89%, n=440), dyspnoea was the chief complaint (36%, n=178) and cancer was the most frequent diagnosis (32%, n=159). The median length of hospital stay was 6 days, with most patients discharged home (60%, n=295). Conclusion. EMS in SA frequently encounter palliative situations for symptoms that may be managed within their scope of practice. Consequently, it appears that EMS have an important role to fulfil in the care of patients with palliative needs. Integrating EMS and palliative care may result in improved palliative care provision and, therefore, EMS and palliative care integration would be beneficial in SA.
Objectives To develop and validate a simplified Bleeding Audit Triage Trauma (sBATT) score for use by lay persons, or in areas and environments where physiological monitoring equipment may be unavailable or inappropriate. Design The sBATT was derived from the original BATT, which included prehospital systolic blood pressure (SBP), heart rate, respiratory rate, Glasgow Coma Scale (GCS), age and trauma mechanism. Variables suitable for lay interpretation without monitoring equipment were included (age, level of consciousness, absence of radial pulse, tachycardia and trapped status). The sBATT was validated using data from the UK Trauma Audit Research Network (TARN) registry. Setting Data sourced from prehospital observations from multiple trauma systems in the UK. Participants 70 027 motor vehicle collision (MVC) patients from the TARN registry (2012–2019). Participants included were those involved in MVCs, with exclusion criteria being incomplete data or non-trauma-related admissions. Interventions Not applicable. Primary and secondary outcome measures Death within 24 hours of MVC. Secondary: need for trauma intervention. Results In a cohort of 70 027 MVC patients, 1976 (3%) died within 24 hours. The sBATT showed an area under receiver operating characteristic curve of 0.90 (95% CI: 0.90 to 0.91) for predicting 24-hour mortality, surpassing other trauma scores such as the Shock Index and Assessment of Blood Consumption score. Sensitivity was 96% and specificity 72%, with a negative likelihood ratio below 0.1, indicating strong rule-out capability. Sensitivity analyses confirmed consistent performance across varying SBP and GCS thresholds. The sBATT was equally effective across sexes with no significant predictive discrepancies. Conclusions The sBATT is a novel, simplified tool that performs well at predicting early death in the TARN dataset. It demonstrates high predictive accuracy for 24-hour mortality and need for trauma intervention. Further research should validate sBATT in diverse populations and real-world scenarios to confirm its utility and applicability.
Abstract Background Rapid sequence intubation (RSI) is an advanced airway skill commonly performed in the pre-hospital setting globally. In South Africa, pre-hospital RSI was first approved for non-physician providers by the Health Professions Council of South Africa in 2009 and introduced as part of the scope of practice of degree qualified Emergency Care Practitioners (ECPs) only. The research study aimed to investigate and describe, based on the components of the minimum standards of pre-hospital RSI in South Africa, specific areas of interest related to current pre-hospital RSI practice. Methods An online descriptive cross-sectional survey was conducted amongst operational ECPs in the pre-hospital setting of South Africa, using convenience and snowball sampling strategies. Results A total of 87 participants agreed to partake. Eleven (12.6%) incomplete survey responses were excluded while 76 (87.4%) were included in the data analysis. The survey response rate could not be calculated. Most participants were operational in Gauteng ( n = 27, 35.5%) and the Western Cape ( n = 25, 32.9%). Overall participants reported that their education and training were perceived as being of good quality. The majority of participants ( n = 69, 90.8%) did not participate in an internship programme before commencing duties as an independent practitioner. Most RSI and post-intubation equipment were reported to be available; however, our results found that introducer stylets and/or bougies and end-tidal carbon dioxide devices are not available to some participants. Only 50 (65.8%) participants reported the existence of a clinical governance system within their organisation. Furthermore, our results indicate a lack of clinical feedback, deficiency of an RSI database, infrequent clinical review meetings and a shortage of formal consultation frameworks. Conclusion The practice of safe and effective pre-hospital RSI, performed by non-physician providers or ECPs, relies on comprehensive implementation and adherence to all the components of the minimum standards. Although there is largely an apparent alignment with the minimum standards, recurrent revision of practice needs to occur to ensure alignment with recommendations. Additionally, some areas may benefit from further research to improve current practice.
Abstract 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.
One of the most important benefits of helicopter emergency medical services (HEMS) is a time benefit, either through expedited access to the casualty or a reduction in the transport time to definitive care. However, HEMS utilization does not come without risk to the public and crew or at an insignificant cost. Cost is an essential consideration for health policy decisions, especially in low- to middle-income countries, such as South Africa. The aim of this study was to determine whether there is a time benefit of HEMS dispatch in South Africa compared with simulated driving time. A secondary aim was to determine the distance from the incident site to the hospital at which a time benefit can be guaranteed.A retrospective study was undertaken by comparing the prehospital times of patients who underwent HEMS transportation with simulated ground emergency medical services (GEMS) transportation times. Handwritten patient records of actual flights were reviewed and analyzed. The actual flight times recorded were used to calculate the helicopter transport time, activation to scene time, scene time, and scene to hospital time. Times were assigned based on a nonsimultaneous dispatch model, as is used in South Africa. For each helicopter mission, Google Maps (Google Inc, Mountain View, CA) was used to simulate the fastest ground route from the same location of the incident to the same receiving hospital corrected for typical traffic trends. The actual HEMS and simulated GEMS times were compared using the paired t-test. Linear regression analysis was performed to determine a minimum driving distance at which HEMS provides a time benefit.A total of 118 HEMS transports were analyzed, the majority of which were trauma related (n = 115, 97%). HEMS transport resulted in a mean time deficit of -15 minutes (95% confidence interval, -18 to -11; P < .05) compared with simulated GEMS drive times. After regression, HEMS transport provides a time benefit at a driving distance greater than 119 km.The current study demonstrated that there was rarely a time benefit for actual primary emergency responses when HEMS was used compared with simulated driving time of GEMS transport. Using a nonsimultaneous dispatch model, a time benefit only occurs when the driving distance from the incident site to the hospital is greater than 119 km. There is an urgent need to critically evaluate HEMS utilization in the South African context.
Sepsis is an acute, life-threatening condition caused by a dysregulated systemic response to infection. Early medical intervention such as antibiotics and fluid resuscitation can be life-saving. Diagnosis or suspicion of sepsis by an emergency call-taker could potentially improve patient outcome. Therefore, the aim was to determine the keywords used by callers to describe septic patients in South Africa when calling a national private emergency dispatch centre.A retrospective review of prehospital patient records was completed to identify patients with sepsis in the prehospital environment. A mixed-methods design was employed in two-sequential phases. The first phase was qualitative. Thirty cases of sepsis were randomly selected, and the original call recording was extracted. These recordings were transcribed verbatim and subjected to content analysis to determine keywords of signs and symptoms telephonically. Once keywords were identified, an additional sample of sepsis cases that met inclusion and exclusion criteria were extracted and listened to. The frequency of each of the keywords was quantified.Eleven distinct categories were identified. The most prevalent categories that were used to describe sepsis telephonically were: gastrointestinal symptoms (40%), acute altered mental status (35%), weakness of the legs (33%) and malaise (31%). At least one of these four categories of keywords appeared in 86% of all call recordings.It was found that certain categories appeared in higher frequencies than others so that a pattern could be recognised. Utilising these categories, telephonic recognition algorithms for sepsis could be developed to aid in predicting sepsis over the phone. This would allow for dispatching of the correct level of care immediately and could subsequently have positive effects on patient outcome.
'%3e%3cpath fill='%23001489' d='M0 0v6h9V0z'/%3e%3cpath fill='%23e03c31' d='M0 0v3h9V0z'/%3e%3cg stroke='%23fff' stroke-width='2'%3e%3cpath id='d' d='m0 0 4.5 3L0 6m4.5-3H9'/%3e%3cuse xlink:href='%23b' stroke='%23ffb81c' clip-path='url(%23c)'/%3e%3c/g%3e%3cuse xlink:href='%23d' fill='none' stroke='%23007749' stroke-width='1.2'/%3e%3c/g%3e%3c/svg%3e)
'/%3e%3c/defs%3e%3cpath fill='%23012169' d='M0 0h10080v5040H0z'/%3e%3cpath stroke='%23fff' stroke-width='.6' d='m0 0 6 3m0-3L0 3' clip-path='url(%23b)' transform='scale(840)'/%3e%3cpath stroke='%23e4002b' stroke-width='.4' d='m0 0 6 3m0-3L0 3' clip-path='url(%23c)' transform='scale(840)'/%3e%3cpath stroke='%23fff' stroke-width='840' d='M2520 0v2520M0 1260h5040'/%3e%3cpath stroke='%23e4002b' stroke-width='504' d='M2520 0v2520M0 1260h5040'/%3e%3cg fill='%23fff'%3e%3cuse xlink:href='%23d' x='2520' y='3780'/%3e%3cuse xlink:href='%23a' x='7560' y='4200'/%3e%3cuse xlink:href='%23a' x='6300' y='2205'/%3e%3cuse xlink:href='%23a' x='7560' y='840'/%3e%3cuse xlink:href='%23a' x='8680' y='1869'/%3e%3cuse xlink:href='%23e' x='8064' y='2730'/%3e%3c/g%3e%3c/svg%3e)
'%3e%3cpath fill='%23012169' d='M0 0v30h60V0z'/%3e%3cpath stroke='%23fff' stroke-width='6' d='m0 0 60 30m0-30L0 30'/%3e%3cpath stroke='%23C8102E' stroke-width='4' d='m0 0 60 30m0-30L0 30' clip-path='url(%23b)'/%3e%3cpath stroke='%23fff' stroke-width='10' d='M30 0v30M0 15h60'/%3e%3cpath stroke='%23C8102E' stroke-width='6' d='M30 0v30M0 15h60'/%3e%3c/g%3e%3c/svg%3e)
