African Emergency Research Articles

Spatial patterns of rural opioid-related hospital emergency department visits: A machine learning analysis

As opioid-related overdose emergency department visits continue to rise in the United States, there is a need to understand the location and magnitude of the crisis, especially in at-risk rural areas. We analyzed sets of ZIP code level electronic health records for emergency department visits from 6 hospitals for two rural regions of Maryland with higher opioid-related overdose rates. Analysis of the demographics of visits found Black or African American emergency department visits in both rural regions were higher than the proportion of their population per region. We trained random forest models with socio-demographic factors and health risk factors on the visits data to understand drivers and risk factors for opioid misuse. The models ranked factors relating to opioid prescribing rates, race, housing, and poor mental health as highly important. Factors associated with opioid-related overdose emergency department visits were found to vary by race, gender, and location and may provide useful insights for designing mitigation initiatives.

Can plethysmographic capillary refill time predict lactate during sepsis? An observational study from Morocco

IntroductionBlood lactate is a marker of tissue hypoxia while capillary refill time (CRT) is a surrogate of tissue perfusion. Measuring these parameters is recommended for assessing circulatory status and guiding resuscitation. However, blood lactate is not widely available in African emergency departments. Additionally, CRT assessment faces challenges related to its precision and reproducibility. This study aims to evaluate the accuracy of visual CRT(V-CRT) compared to plethysmographic CRT (P-CRT) in predicting lactate levels among septic patients. MethodsThis prospective observational study enrolled consecutive patients with sepsis or septic shock over a 6-month period from a tertiary hospital in Marrakech, Morroco. V-CRT and P-CRT were evaluated upon admission, and simultaneous measurements of arterial lactate levels were obtained. The precision of V-CRT and P-CRT in predicting arterial lactate was assessed using ROC curve analysis. ResultsForty-three patients aged of 64±15 years, of whom 70 % were male, were included in the study. Of these, 23 patients (53 %) had sepsis, and 20 patients (47 %) experienced septic shock. Both V-CRT and P-CRT demonstrated statistically significant correlations with arterial lactate, with correlation coefficients of 0.529 (p < 0.0001) and 0.517 (p = 0.001), respectively. ROC curve analysis revealed that V-CRT exhibited satisfactory accuracy in predicting arterial lactate levels >2 mmol/l, with an area under the curve (AUC) of 0.8 (95 % CI=0.65 – 0.93; p < 0.0001). The prediction ability of P-CRT was lower than V-CRT with an AUC of 0.73 (95 % CI: 0.57–0.89; p = 0.043). The optimal thresholds were determined as 3.4 s for V-CRT (sensitivity = 90 %, specificity = 58 %) and 4.1 s for P-CRT (sensitivity = 85 %, specificity = 62 %). ConclusionThese findings suggest that the plethysmographic evaluation did not improve the accuracy of CRT for predicting lactate level. However, V-CRT may still serve as a viable surrogate for lactate in septic patients in low-income settings.

The knowledge and skills of emergency department registered nursing staff at an academic hospital in South Africa, on endotracheal tube cuff manometry, before and after a training session

IntroductionAccurate management of endotracheal tube cuff pressure is essential to prevent patient morbidity and mortality. Due to increased length of stay of critically ill patients in emergency departments, it has become an increasingly important skill among Emergency Department nurses. MethodsThis prospective longitudinal interventional study was performed among registered nurses at the emergency departments in a Johannesburg Academic Hospital. The study aimed to determine their current knowledge and practical skills on endotracheal tube cuff manometry and assess the effectiveness of a training program. The training program was provided once, in the form of a narrated PowerPoint presentation developed by the researchers and involved theoretical and practical components. The participants' theoretical knowledge and practical skills were measured by using questionnaires and skill assessments. The theoretical and practical scores were compared pre- and post-training. ResultsOf the 63 registered nurses employed in the emergency departments, 95 % (60) participated in this study. 86 % reported having never received any formal training on endotracheal tube cuff manometry. Only 38.9 % used cuff manometry as standard practice and only 12.8 % checked it at appropriate 12-hourly intervals. The pre-training median score on theory was 4.5 (IQR=3.0) and improved to 7.0 (IQR=3.0) post-training. The maximum achievable score was 11 with a pre-training average of 41.8 % and post-training of 64.5 % (p = 0.001).The practical pre-training median score was 1.0 (IQR=8.0) and improved to 12.0 (IQR=2.0) post-training. The maximum achievable score was 12 with a pre-training average of 29.1 % and a post-training average of 93.3 % (p = 0.001). ConclusionThis study showed inadequate knowledge and skills on endotracheal cuff pressure manometry among registered nurses in the emergency department. It also correlates with other evidence that supports the need for ongoing training programs. Our training program led to significant improvement among participants in both knowledge and practical skills. This training program was well received by participants and deemed to be practice changing. The recommendation after this study will be for South African emergency units to consider using this study and training material as a guide for annual in-service training.

The barriers and facilitators to initiation of telephone-assisted bystander cardiopulmonary resuscitation for patients experiencing out-of-hospital cardiac arrest in a private emergency dispatch centre in South Africa

BackgroundThe 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. MethodsThis 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. ResultsSaturation 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. ConclusionNumerous 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.

Risk factors for mortality in an African pediatric emergency department: case of Sourô Sanou Hospital, a prospective, cross-sectional study.

Childhood mortality rates remain high in sub-Saharan Africa. This study aimed to assess the causes and associated factors of pediatric emergency mortality at the Sourô Sanou University Hospital of Bobo-Dioulasso. This was a cross-sectional study with prospective collection from June to August 2020. We documented and analyzed demographic and clinical characteristics by means or proportions. Logistic regression was performed to identify the factors associated with childhood mortality. From 618 pediatric patients admitted to pediatric emergency unit, 80 (12.9%) were documented as death outcomes. The mean age was 34.10 ± 36.38 months. The male sex represented 51.25%. The main diagnoses were severe malaria (61.25%), acute gastroenteritis (11.25%) and pneumonia (10%); 48.75% of the patients were malnourished and only 55% were fully immunized. The average length of hospitalization was 2.73 ± 3.03 days. Mortality was a strongly significant association with late come to the emergency unit (AOR = 1.11, CI = 1.04-1.18), young maternal age (AOR = 0.95, CI = 0.92-0.99) and incomplete vaccination (AOR = 1.94, CI = 1.13-3.31). The in-hospital mortality rate was 12.94%; younger maternal age, delay in consultation, unimmunized or incompletely immunized status and shorter hospital stays were significantly associated with death.

Quality of systematic reviews in African emergency medicine: a cross-sectional methodological study

IntroductionReliable systematic reviews are essential to inform clinical practice guidelines, policies and further research priorities in Africa. For systematic review findings to be trustworthy, they need to be conducted with methodological rigour and reported transparently. We assessed the methodological quality of systematic reviews published in African emergency medicine journals, comparing them to those published in international emergency medicine journals. Additionally, we describe the types of review literature published in the African journals. MethodsWe performed a cross-sectional methodological study of systematic reviews published in selected African and international emergency medicine journals from 2012 to 2021. Studies were eligible if they were i) a systematic review on an emergency medicine topic, ii) published in one of the top five emergency medicine journals in the African region or internationally and iii) published between January 2012 and December 2021 in English or French. We searched PubMed, Web of Science and Scopus databases and hand-searched selected journals. Two authors screened titles, abstracts and full texts independently and in duplicate. Data extraction was performed by one reviewer, using a standardised form, after completing a calibration exercise. We described the characteristics of systematic reviews and assessed methodological quality using AMSTAR II. ResultsWe identified 34 (37%) African and 511 (54%) international systematic reviews from 92 and 948 review articles respectively across 10 journals. We included all 34 African and a random sample of 100 international systematic reviews. Methodological quality was low or critically low for all the African systematic reviews (n=34, 100%) and all but three international systematic reviews (n=97, 97%). The median number of critical domain weaknesses was 4 (IQR 4;5) and 2 (IQR 2;4) for African and international systematic reviews respectively. The most common weaknesses across both African and international systematic reviews were i) not establishing a priori review protocols, ii) unclear selection of study designs iii) not providing a list of excluded studies and iv) unclear reporting on funding sources for included studies. ConclusionEmergency medicine systematic reviews published in African and international journals are lacking in methodological quality. Reporting an a priori protocol, developing a comprehensive search strategy, appropriate evidence synthesis and adequate assessment of risk of bias, heterogeneity and evidence certainty may improve the quality of systematic reviews.

Burnout in emergency department staff: The prevalence and barriers to intervention.

Burnout impacts patient care and staff well-being. Emergency department (ED) staff are at an elevated risk for burnout. Despite an acceleration in burnout research due to the coronavirus disease 2019 (COVID-19) pandemic, there is limited data on the nature and prevalence of burnout in the South African emergency medicine setting. This study determined the prevalence of burnout in ED staff (doctors, nurses and non-clinical staff) at Tygerberg Hospital and explored staff awareness and utilisation of interventions. The study was conducted at Tygerberg Hospital, South Africa. This cross-sectional study used the Maslach Burnout Inventory to assess burnout via a self-administered electronic survey in a convenience sample of 109 ED staff. Quantitative data were analysed with descriptive and inferential statistics. Qualitative data were analysed using thematic analysis. A total of 46 participants (45.10%) experienced burnout, with 73 participants (71.57%) at high risk for emotional exhaustion or depersonalisation. The prevalence of burnout in doctors was 57.89%, non-clinical staff was 25.93%, and nursing staff was 50.00%. Burnout was higher in doctors and nursing staff compared to non-clinical staff, with high emotional exhaustion and depersonalisation found in interns and specialist professional nurses. The level of intervention awareness was 41.8% and the level of intervention utilisation was 8.82%. Thematic analysis identified awareness, accessibility and reactive utilisation as barriers to utilisation with opportunities to reduce burnout and enhance resilience. Coordinated health system and organisational efforts are required to optimise intervention strategies to reduce burnout. Guidance on the design and planning of intervention strategies considering at risk groups, intervention-related factors, and non-clinical staff.

Early North African Acheulean techno-economic systems at Thomas Quarry I - L1 (Casablanca, Morocco).

North Africa is a key area for understanding cultural processes that led to the Acheulean pan - African emergence and expressions and the related hominin population dynamics. Unfortunately, little is known about the early Acheulean in this vast area of the African continent due to the scarceness of archaeological sites in stratigraphic context with reliable chronometric data, human remains, and technological analyses of the lithic industries. Here, we present the first comprehensive techno-economic analysis of the early Acheulean assemblage from Thomas Quarry I - Unit L1 (ThI-L1, Casablanca, Morocco), which is the earliest Acheulean site of North Africa, unambiguously dated to 1.3 Ma. Fieldwork has unearthed faunal remains and a lithic collection containing over 3800 artefacts, which represents one of the largest series for the early African Acheulean. The assemblage is mainly composed of quartzites and to a lesser extent of silicites, both abundantly available near the site. Previously published results of the silicite study revealed two different productions for the extraction of small flakes and of bladelet-like flakes. In this work, we analyse the techno-economic systems of the quartzite assemblage. Two distinct quartzite productions co-occur, one devoted to the manufacture of Large Cutting Tools (LCTs), the other focused on the extraction of small-medium sized flakes. LCTs were usually produced from large cobbles, less often from large flakes detached mainly using the entame core method. The main technical objective was to obtain large pointed tools and, more rarely, large tools with a transversal cutting edge. Results support the existence of a strong synergy between conceptual and operational schemes regulated by the ability to anticipate the final tool morphology and to apply standardized shaping procedures to manufacture recurrent morphotypes. Quartzite small-medium sized flakes were produced by a diversity of flaking methods adapted to the cobble blank morphologies and were not retouched. The results allow to assess that the earliest technical expression of the Acheulean in North Africa is characterised by a high diversification of the stone knapping outcomes, the complexity of the mental templates, and the flexible structure of the operational schemes.

Evolution and spread of Plasmodium falciparum mutations associated with resistance to sulfadoxine–pyrimethamine in central Africa: a cross-sectional study

Efficacy of sulfadoxine-pyrimethamine, the malaria chemoprophylaxis used in pregnant women, and in children when combined with amodiaquine, is threatened by the accumulation of mutations in the Plasmodium falciparum dihydropteroate synthase (pfdhps) and dihydrofolate reductase (pfdhfr) genes. Data on the prevalence of resistant alleles in central Africa and the new pfdhps I431V mutation, particularly associated with other mutations to form the pfdhps vagKgs allele, are scarce. We explored the frequency and geographical distribution of pfdhps and pfdhfr mutations in central Africa in 2014-18, and assessed the evolutionary origin of the vagKgs allele. Samples were collected at 18 health-care centres in seven countries (Angola, Cameroon, Central African Republic, Democratic Republic of the Congo, Gabon, Nigeria, and Republic of the Congo) from patients who showed possible symptoms of malaria between March 1, 2014, and Oct 31, 2018. Samples that were positive for P falciparum were transported to a laboratory in Toulouse, France, and genotyped. The frequency of pfdhfr and pfdhps mutations was studied in 1749 samples. Microsatellites in pfdhps flanking regions and whole-genome analysis compared with parasite genomes from the data-sharing network MalariaGEN were performed on samples carrying the vagKgs allele. Mapping of the prevalence of single nucleotide polymorphisms and corresponding alleles of pfdhfr and pfdhps showed a substantial spread of alleles associated with sulfadoxine-pyrimethamine resistance in central Africa during the 2014-18 period, especially an increase going west to east in pfdhps alleles carrying the K540E and A581G mutations. A high prevalence of the pfdhps I431V mutation was observed in Cameroon (exceeding 50% in the northern region) and Nigeria. Genomic analysis showed a recent African emergence and a clonal expansion of the most frequent pfdhps vagKgs allele. Reduced sulfadoxine-pyrimethamine efficacy due to increased resistance is a worrying situation, especially because the malaria transmission level is high in central Africa. Although the resistance phenotype remains to be confirmed, the emergence and spread of the vagKgs allele in west and central Africa could challenge the use of sulfadoxine-pyrimethamine. Toulouse Institute for Infectious and Inflammatory Diseases.

Modelling African horse sickness emergence and transmission in the South African control area using a deterministic metapopulation approach.

African horse sickness is an equine orbivirus transmitted by Culicoides Latreille biting midges. In the last 80 years, it has caused several devastating outbreaks in the equine population in Europe, the Far and Middle East, North Africa, South-East Asia, and sub-Saharan Africa. The disease is endemic in South Africa; however, a unique control area has been set up in the Western Cape where increased surveillance and control measures have been put in place. A deterministic metapopulation model was developed to explore if an outbreak might occur, and how it might develop, if a latently infected horse was to be imported into the control area, by varying the geographical location and months of import. To do this, a previously published ordinary differential equation model was developed with a metapopulation approach and included a vaccinated horse population. Outbreak length, time to peak infection, number of infected horses at the peak, number of horses overall affected (recovered or dead), re-emergence, and Rv (the basic reproduction number in the presence of vaccination) were recorded and displayed using GIS mapping. The model predictions were compared to previous outbreak data to ensure validity. The warmer months (November to March) had longer outbreaks than the colder months (May to September), took more time to reach the peak, and had a greater total outbreak size with more horses infected at the peak. Rv appeared to be a poor predictor of outbreak dynamics for this simulation. A sensitivity analysis indicated that control measures such as vaccination and vector control are potentially effective to manage the spread of an outbreak, and shortening the vaccination window to July to September may reduce the risk of vaccine-associated outbreaks.

The views and experiences of candidates and graduates from a South African emergency medicine doctoral programme.

With the emergency medicine speciality in its nascency in Africa, EM doctoral programmes will need to be developed to facilitate the establishment of an evidence base that is responsive to the African populace. This study aimed to understand the thoughts, experiences, and opinions of current and past candidates of a South African EM PhD programme. Descriptive, qualitative, semi-structured interviews were used to gather data on PhD EM candidates and graduates. Four candidates, and four graduates were interviewed. Four categories emerged from the data 1) interviewees had various motivations for starting a PhD in EM, 2) candidate expectations and learning needs were not always aligned with reality, and the challenges and opportunities for success in the PhD programme are related both 3) intrinsically (candidate) and 4) extrinsically (system). Many of the barriers noted by the participants can be related to the nascency of the EM in Africa. Participants felt underprepared for their doctorate in terms of their baseline research literacy and skill. Candidates did not receive the level of student-supervisor engagement they desired. Candidates who are also clinicians faced both academic challenges and a resource-limited healthcare system. Pre-doctoral training may upskill prospective candidates in research literacy before they officially register. Distance-learning can be sub-optimal in terms of social interaction and collaboration. A well-curriculated, competency-based programme with clear outcomes, structured teaching-learning opportunities, intentional academic support throughout the programme, can mitigate the above. Protected academic time, promotion criteria which acknowledges academic contributions, financial incentives and more joint positions between universities and clinical services are potential solutions for clinician researcher challenges. An African PhD EM programme should produce graduates who are independent researchers, skilled in academic supervision and who are impactful to African needs when contributing to the African EM knowledge economy.

Paediatric procedural sedation and analgesia in a South African emergency centre: a single-centre, descriptive study

BackgroundProcedural sedation and analgesia are considered a core competency in emergency medicine as patients present to the emergency centre on an unscheduled basis, often with complex complaints that necessitate emergent management. Previous evidence has consistently shown that procedural sedation and analgesia in the emergency centre in the paediatric population, even the very young, are safe if appropriate monitoring is performed and appropriate medications are used. The aim of the study was to describe the indications for procedural sedation and analgesia, the fasting status of paediatric patients undergoing procedural sedation and analgesia and the complications observed during procedural sedation and analgesia in the paediatric population at a single emergency centre in Cape Town, South Africa.MethodsA retrospective, descriptive study was conducted at Mitchells Plain Hospital, a district-level hospital situated in Mitchells Plain, Cape Town. All paediatric patients younger than 13 years of age who presented to the emergency centre and received procedural sedation and analgesia during the study period (December 2020–April 2021) were included in the study. Data was extracted from a standardised form, and simple descriptive statistics were used.ResultsA total of 113 patients (69% male) were included: 13 infants (< 1 year of age), 47 young children (1–5 years of age) and 53 older children (5–13 years of age). There was only 1 (0.9%) complication documented, which was vomiting and did not require admission. The majority of patients received ketamine (96.5%). The standardised procedural sedation and analgesia form was completed in 49.1% of cases. Indications included burns debridement (11.5%), suturing (17.7%), fracture reduction (23.9%), lumbar punctures (31.9%) and others (15.0%). The indications for procedural sedation and analgesia varied between the different age groups. The majority of patients in this study did not have their fasting status documented (68.1%), and 18.6% were not appropriately fasted as per American Society of Anaesthesiology guidelines. Despite this, there was an extremely low rate of documented complications of 0.9%.ConclusionThe study findings are in accordance with previous international literature reporting low complication rates. Although fasting status was unknown in the majority of patients, there was an extremely low rate of documented complications and no interventions required. Safe, timely procedural sedation and analgesia with minimal pain and unnecessary suffering can become the norm in emergency medicine practice in South Africa.

Clinical emergency care quality indicators in Africa: a scoping review and data summary

ObjectivesEmergency care services are rapidly expanding in Africa; however, development must focus on quality. The African Federation of Emergency Medicine consensus conference (AFEM-CC)-based quality indicators were published in 2018. This...

Emergency medicine doctoral education in Africa: a scoping review of the published literature

BackgroundWhile Africa accounts for a significant proportion of world population, and disease and injury burden, it produces less than 1% of the total research output within emergency care. Emergency care research capacity in Africa may be expanded through the development of doctoral programmes that aim to upskill the PhD student into an independent scholar, through dedicated support and structured learning. This study therefore aims to identify the nature of the problem of doctoral education in Africa, thereby informing a general needs assessment within the context of academic emergency medicine.MethodsA scoping review, utilising an a priori, piloted search strategy was conducted (Medline via PubMed and Scopus) to identify literature published between 2011 and 2021 related to African emergency medicine doctoral education. Failing that, an expanded search was planned that focused on doctoral education within health sciences more broadly. Titles, abstracts, and full texts were screened for inclusion in duplicate, and extracted by the principal author. The search was rerun in September 2022.ResultsNo articles that focused on emergency medicine/care were found. Following the expanded search, a total of 235 articles were identified, and 27 articles were included. Major domains identified in the literature included specific barriers to PhD success, supervision practices, transformation, collaborative learning, and research capacity improvement.ConclusionsAfrican doctoral students are hindered by internal academic factors such as limited supervision and external factors such as poor infrastructure e.g. internet connectivity. While not always feasible, institutions should offer environments that are conducive to meaningful learning. In addition, doctoral programmes should adopt and enforce gender policies to help alleviate the gender differences noted in PhD completion rates and research publication outputs. Interdisciplinary collaborations are potential mechanisms to develop well-rounded and independent graduates. Post-graduate and doctoral supervision experience should be a recognised promotion criterion to assist with clinician researcher career opportunities and motivation. There may be little value in attempting to replicate the programmatic and supervision practices of high-income countries. African doctoral programmes should rather focus on creating contextual and sustainable ways of delivering excellent doctoral education.

A retrospective review of post-intubation sedation and analgesia practices in a South African private ambulance service.

Adequate post-intubation sedation and analgesia (PISA) practices are important in the pre-hospital setting where vibration and noise of the transport vehicle may contribute to anxiety and pain in the patient. These practices are poorly described in the pre-hospital setting. This study aims to describe the current pre-hospital PISA practices in a private South African (SA) emergency medical service. Patient report forms (PRF) of intubated patients between 1 Jan 2017 and 31 Dec 2017 from a private ambulance service were reviewed. The data were analysed descriptively. Correlations between receiving PISA and various predictive factors were calculated with Spearman's Rank correlations and differences between intubation method were calculated with independent t-tests and Mann-Whitney U tests. A binomial regression model was used to determine predictive factors of receiving PISA. The number of PRFs included for analysis was 437. Of these, 69% of patients received PISA. The estimated time from intubation to 1st PISA ranged from 9 to 12min. There were statistically significantly more PISA interventions in patients who had received Rocuronium (p < 0.01). There was weak correlation between the number of interventions and the mean arterial pressure, (p < 0.05) and with the transport time to hospital (rs=-0.77, p < 0.01). Sixty nine percent of patients who are intubated pre-hospital receive PISA, which leaves up to 30% without PISA. The time to 1st PISA appears to be shorter in the SA setting. There is an increased number of interventions in the patients who received Rocuronium, which may indicate practitioners being mindful of wakeful paralysis. Patients intubated with RSI are more likely to receive PISA and practitioners take the blood pressure prior to and after intubation into account when administering PISA. Longer transport times attribute to patients receiving more PISA interventions.

Adopting a ‘System of Caring' as a leadership strategy toward professionalisation within South African emergency medical services: A grounded theory

Professionalization is a key agenda within South African prehospital care. Emergency Medical Services (EMS) agencies continue to grapple with operationalising the process of professionalising, with a number approaches described in literature. This research presents a System of Caring developed within the context of EMS as an approach to achieving professionalization. Methods: A qualitative research design in the form of constructivist grounded theory design was used. Participants were enrolled using purposive and theoretical sampling. Data were analysed using coding procedures in a constant comparative analysis approach supported by theoretical sensitivity. Analytical diagrams consistent with grounded theory methodology were also employed, primarily in the form of inter-relational diagraphs. Results: Six main categories were established with associated coding lists. Coding lists were used to develop groups of propositions that were then abstracted to construct final analytical labels that captured the elements of the System of Caring. These elements include caring for the leaders, caring for the team, caring for the patient, caring for each other (collegial) and caring for self. The components of each element were also abstracted, and the System of Caring developed. Conclusion: While there are various well-established definitions for the term care, within the context of the perceptions of the participants of this study, care (and caring) means a combination of constructed environmental conditions and people-process practices that recognises the well-being of the people within the processes. This 'System of Caring' offers a practicable way to operationalise caring into the workforce and move toward exploring how to promote professionalism within the workforce, through a 'System of Caring'. While this may have been reasonably extrapolated before, this research allows for a poignant insight into how EMS agencies can promote professionalization within EMS systems within South Africa, through the 'System of Caring'.

Performance of the South African triage score among HIV positive individuals presenting to an emergency department

Over a quarter of patients presenting to South African Emergency Centres (EC) have concurrent human immunodeficiency virus (HIV), yet it is unclear how this impacts their presenting complaints, the severity of illness, and overall resource needs in the EC. The primary objective of this study was to compare the performance of the South African Triage Score (SATS) in people living with HIV (PLWH) compared to HIV-negative patients. Secondary objectives included comparing the presentation characteristics and resource utilisation of these populations. A prospective cross-sectional observational study was conducted in the Livingstone Hospital EC, Gqeberha, South Africa, to compare triage designation and clinical outcomes in PLWH and HIV-negative patients. In this six-week study, all eligible patients received point-of-care HIV testing and extensive data abstraction, including SATS designation and EC clinical course.Descriptive statistical analysis was completed, and a log-binomial model was used to examine the association between HIV status and clinical outcomes using crude (unadjPR) and adjusted prevalence ratios (adjPR). During the study period, 755 adult patients who consented to a POC HIV test were enrolled, of which 193 (25.6%) were HIV positive. HIV-positive patients were significantly more likely to be admitted compared to their HIV-negative counterparts when triaged as low acuity (adjPR 1.48, 95% CI 1.14-1.92, (p=0.003)). HIV-positive patients were also significantly more likely to receive laboratory testing when triaged as low acuity (adjPR 1.31, 95% CI 1.08-1.59 (p=0.006)) and as high acuity (adjPR 1.38, 95% CI 1.08-1.59 (p=0.034)) compared to HIV negative patients of the same triage categories. In our study, PLWH, compared to HIV-negative patients in the same category, were more likely to be admitted and require more EC resources, thus alluding to possible under triage of HIV-positive patients under the current SATS algorithm.

CT Utilization in a Level One Trauma Center in South Africa.

IntroductionComputed tomography (CT) imaging forms an important component in the evaluation and management of patients with traumatic injuries. Many South African emergency departments (EDs) have a significant trauma-related workload, especially in the public sector, where there are limitations in resources relating to CT scanners. It is important to gauge the impact of traumatic injuries on CT utilization. The primary objectives were to quantify the number and type of CT imaging studies trauma patients received, as well as to determine the frequency of radiologically significant findings in a level one trauma center. The secondary objectives were to determine the CT utilization rate and describe the demographics of patients who received imaging.MethodsThis was a retrospective, quantitative, descriptive, cross-sectional study undertaken over two months at the level one trauma center of a tertiary, academic, public sector teaching hospital in Johannesburg, South Africa. The radiology department’s picture archiving and communication system (PACS) was used to evaluate the reports of trauma patients who were referred for a CT scan. The trauma center register was used to calculate the CT utilization rate.ResultsThere were 5,058 trauma patients seen in the two months. A total of 1,277 CT scans were performed on 843 patients. CT brain accounted for 52% of all scans performed. Radiologically significant findings were demonstrated in 407 scans (354 patients), i.e. 31.9% of scans and 42% of patients. CT chest and peripheral angiogram demonstrated radiologically significant findings in 60.5% and 50.9% of scans respectively. Assault accounted for 55.8% of the injuries sustained and road traffic accidents accounted for 33.2%. The overall CT utilization rate was 16.7% i.e. 843 out of the 5,058 trauma patients underwent a CT scan.ConclusionsSouth Africa has a substantial trauma burden which commonly necessitates CT utilization. It is concerning that blunt and penetrating assault continues to dominate these traumatic presentations. Worldwide, there is a broad range of described CT utilization rates and the findings at this level one trauma center fall within that range. ED clinicians are encouraged to continue carefully using this scarce resource in the trauma setting.

Human errors and factors that influence patient safety in the pre-hospital emergency care setting: Perspectives of South African emergency care practitioners.

BackgroundDelivering pre-hospital emergency care has the potential to be hazardous. Despite this, little is known about the factors that precipitate human errors and influence patient safety in the pre-hospital care setting, in contrast to in-hospital care. Similarly, limited report on patient safety and human error issues in the pre-hospital emergency care setting exist in South Africa.AimThis study investigated the perspectives of emergency care personnel (ECP) in South Africa on the types of human errors and factors that precipitate human errors that influence patient safety in the pre-hospital emergency care setting in South Africa.SettingThis study was conducted in the pre-hospital emergency care environment in South Africa.MethodsThis research was designed as an exploratory study that made use of a semi-structured questionnaire administered to 2,000 emergency care personnel.ResultsA response rate of 76% was obtained. According to the participants, errors relating to poor judgement, poor skill or knowledge, fatigue, and communication, and individual error are common during pre-hospital care. Inadequate equipment, environmental factors, and personal safety concerns were reported as some of the factors that influence patient safety in the pre-hospital emergency care setting.ConclusionImplementation of strategies that enhances education and training, clinical skill development, teamwork skills, fatigue management, and leadership skills can help prevent some of the errors identified in this study.ContributionThis study identifies the types of human errors, and factors that precipitate human errors that influence patient safety in the pre-hospital emergency care setting in South Africa.

The role of pathogen-mediated insect superabundance in the East African emergence of a plant virus.

One of the major crops for food security is cassava. Superabundant Bemisia tabaci whitefly, comprising unusually high landscape populations of the insect, have been implicated in cassava virus emergence. Studies have been unable to select from several hypotheses, however, as to the dynamic drivers of superabundant whitefly associated with the emergence in East Africa of severe cassava mosaic disease. One possibility is that pathogenic modification of infected plants can itself increase the growth of insect vector colonies on infected plants.Through the modelling of population processes at the landscape scale we introduce a framework for analysing patterns in the association of disease and insect waves.Our analyses demonstrate the role of pathogen‐mediated insect superabundance in a plant disease invasion. Synthesis. An elevated abundance of insects at the landscape scale is frequently implicated in invasions of the plant pathogens that they carry. We advance ecological understanding of plant disease invasions by showing how landscape data can be used to investigate the causes of insect vector superabundance.