Emergency Medical Services Practitioners Research Articles

Technology commitment of emergency medical service practitioners and dispatchers

Background: Digitalisation and artificial intelligence (AI) have entered the emergency medical service (EMS). Successful use of them depends on employees' personal attitudes towards modern technology and its use. Aims: This study explored the technology commitment of EMS professionals, dispatchers and emergency physicians, including towards AI systems. Methods: To assess attitudes in the context of AI systems in EMS, employees were asked to answer an online questionnaire between October 2021 and March 2022. Findings: A total of 510 participants, including 184 EMS professionals, 199 dispatchers and 68 emergency physicians, participated. These professionals had moderate to high technology commitment values with minor differences. Technology commitment correlated negatively with age. Gender had no effect. Conclusion: The EMS provides fertile ground for AI systems. It is important to keep in mind that people with uncertainties and reservations need support. The scales in the questionnaire proved to be reliable and validt.

Drive-thru continuing education to meet learners’ needs

BackgroundContinuing education is a requirement for emergency medical services practitioners in Ohio, and simulation-based learning has been effective for this purpose. Limitations to providing simulation for emergency medical services practitioners include a lack of simulation resources or equipment and a lack of trained simulationists to adequately use existing equipment, such as high-fidelity manikins. Here, we sought to provide simulation-based learning in the ambulance bays of our local hospitals to meet these needs. MethodsThe OhioHealth simulation team, in conjunction with OhioHealth Emergency Medical Services, conducted simulation-based education sessions in ambulance bays scheduled in 2-h blocks for 3 consecutive days at 3 different hospitals in Columbus, Ohio. The outcomes of the education sessions were evaluated based on the ability to meet the educational objectives and the suitability of the environment for learning. In total, 171 learners completed educational sessions and evaluations. ResultsModified Likert scale surveys were completed by learners to assess their confidence in the learning objectives. For each session, the learners were able to meet the determined learning objectives after the education. Regarding the feasibility of using ambulance bays for education, 90% of learners (155/171) responded that they “Agree” or “Strongly Agree” that the environment was conducive to learning. ConclusionUsing care site ambulance bays with simulation staff and content experts, we were able to effectively deliver simulation-based education. Based on learner perception and ability for education to meet its determined objectives, the ambulance bay provides a feasible way to address existing barriers (cost, access to equipment, and trained staff) to simulation-based education for emergency medical services practitioners.

Examining Workflow for Simulated Pediatric Emergency Medical Services Care

Purpose: Workflow analysis is an important approach for understanding clinical care in complex systems. This is particularly true for low frequency events such as the care of children in the out-of-hospital setting. The purpose of this study was to characterize emergency medical service (EMS) workflow in the care of children during simulated emergency, prehospital encounters.
 Methods: This is a secondary analysis exploring high-fidelity videorecorded simulations, performed by emergency personnel. Two scenarios were used in 19 simulations which consisted of a 15-month and a 1-month old with respiratory decompensation and shock requiring intravenous fluid, respiratory support, and medication administration. One trained investigator performed review of the videos of teams EMS practitioners, quantifying the sequence and number of tasks performed and time to completion of the simulated intervention. The variance in sequence of tasks was quantified using the Levenshtein distance. We quantified the proportion of time with no activity (idle time) and temporal overlap (team multitasking time).
 Results: We identified 17 types of distinct tasks performed during the simulation. There was high variability across simulations in the sequences, types, and number of tasks performed. Team multitasking was noted in all scenarios, with a mean of 99% multitasking ratio (range: 52-202%). Mean proportion of idle time was 4% (range: 0-11%). Weight estimate, intravenous or intraosseous access, radio report, blood glucose level (BGL), medication administration, pulse check and respiration check were observed in all videos. Other tasks were observed in only a proportion of scenarios with varying frequencies. Median number of differences in sequence of tasks between scenarios was 15.
 Conclusions: Our analysis found a high percentage of team multitasking and significant variability in frequency and sequence of task completion. Further research is needed to assess the reasons and effect of this degree of variability on the efficiency and effectiveness of prehospital interventions.

Technology commitment of emergency medical service practitioners and dispatchers

Background Digitalization and artificial intelligence (AI) have entered the emergency medical service (EMS). Successful use of them depends on employees’ personal attitudes towards modern technology and its use. Aims This study explored the technology commitment of EMS professionals, dispatchers and emergency physicians, including towards AI systems. Methods To assess attitudes in the context of AI systems in EMS, employees were asked to answer an online questionnaire between October 2021 and March 2022. Findings A total of 510 participants, including 184 EMS professionals, 199 dispatchers and 68 emergency physicians, participated. These professionals had moderate to high technology commitment values with minor differences. Technology commitment correlated negatively with age. Gender had no effect. Conclusion The EMS provides fertile ground for AI systems. It is important to keep in mind that people with uncertainties and reservations need support. The scales in the questionnaire proved to be reliable and valid.

Sustainable Resilience in Healthcare Delivery: A Comparative Study on Safety Awareness in Hospital-Based and Pre-Hospital EMS in Times of Crisis

This research initiates a comprehensive evaluation of safety awareness among emergency medical service (EMS) practitioners in Riyadh, Saudi Arabia, an area experiencing substantial academic and regulatory transformation. By employing the Safety Attitudes Questionnaire, the study explores safety awareness across various EMS domains, unveiling a significant consistency that is unaffected by the work environment, professional tenure, or gender. Importantly, there are no significant disparities in safety awareness between hospital-based EMS practitioners and their pre-hospital counterparts, regardless of their tenure or gender. The findings highlight a homogenous safety awareness landscape among Riyadh’s EMS practitioners, suggesting strategies to sustain and strengthen patient safety culture irrespective of workspace, experience, or gender. This research not only presents these key findings but also advocates for sustainable resilience in healthcare delivery. It emphasizes the need for continued efforts to instill a culture of safety, underpinned by regular training and the adoption of swift response strategies, ensuring a sustainable approach to patient safety in times of crisis.

Widespread Misinterpretation of Advance Directives and Portable Orders for Life-Sustaining Treatments Threatens Patient Safety and Causes Undertreatment and Overtreatment.

Widespread Misinterpretation of Advance Directives and Portable Orders for Life-Sustaining Treatments Threatens Patient Safety and Causes Undertreatment and Overtreatment.

Characteristics of Stroke in Prehospital Settings in Saudi Arabia: A Descriptive Analysis

Background: Stroke is considered a time-sensitive emergency; thus, early recognition of this condition is a crucial function of emergency medical services (EMS) and medical practitioners. In this study, we aimed to assess the characteristics observed by EMS practitioners in stroke-suspected cases. Methodology: This is a retrospective observational study, using the data available in the registry of the Saudi Red Crescent Authority (SRCA). We collected data from the beginning of January 2018 to the end of December 2020. Results: We reviewed 753 patients who met the study’s inclusion criteria. Participants aged 61-70 years represented 29% of the study group, and 66% of the group were male. Patients living in Makkah constituted 32.9%, while most of the patients (71.7%) were Saudi nationals. Weakness was the most common complaint, reported in 45% of patients. The most associated disease was hypertension (54.4%), whereas hypoglycaemic patients represented 0.4% of the group. Conclusion: Weakness was the most prevalent complaint among stroke-suspected patients, and hypertension was the most associated risk factor. Blood glucose measurement and neurological examination were both included in the EMS assessment of stroke-suspected patients. This might indicate the high quality of the EMS assessment for stroke and stroke-mimickers.

Prehospital Stroke Care Part 2: On-Scene Evaluation and Management by Emergency Medical Services Practitioners.

The prehospital phase is a critical component of delivering high-quality acute stroke care. This topical review discusses the current state of prehospital acute stroke screening and transport, as well as new and emerging advances in prehospital diagnosis and treatment of acute stroke. Topics include prehospital stroke screening, stroke severity screening, emerging technologies to aid in the identification and diagnosis of acute stroke in the prehospital setting, prenotification of receiving emergency departments, decision support for destination determination, and the capabilities and opportunities for prehospital stroke treatment in mobile stroke units. Further evidence-based guideline development and implementation of new technologies are critical for ongoing improvements in prehospital stroke care.

Burnout and Workplace Incivility Among Emergency Medical Services Practitioners: A Preliminary Report

Objective Burnout has detrimental consequences for health care organizations, clinicians, and the quality of care that patients receive. Prior work suggests that workplace incivility (negative interpersonal acts) contributes to burnout. While workplace incivility is linked to EMS practitioner job dissatisfaction, absenteeism, and planned attrition, the relationship between workplace incivility and burnout has not been evaluated among EMS practitioners. This study aimed to characterize the prevalence and association of burnout and workplace incivility among EMS practitioners. Methods A cross-sectional survey of EMS personnel in King County, Washington was performed in January to March of 2021 with burnout as the primary outcome and workplace incivility as a secondary outcome. Multivariable logistic regression was used to evaluate associations between outcomes and EMS practitioner factors that included age, sex, race/ethnicity, years of EMS experience, and current job role. Results 835 completed surveys were received (response rate 25%). The prevalence of burnout was 39.2%. Women were more likely to have burnout than men (59.3% vs. 33.7%, aOR 2.2, 95% CI 1.3–3.7). Workplace incivility was experienced weekly by 32.1% of respondents, with women more likely to experience incivility compared to men (41.9% vs. 27.2%, aOR 2.0, 95% CI 1.2–3.3). Respondents who experienced frequent workplace incivility were more likely to have burnout than those who did not experience frequent incivility (61.9% vs. 38.1%, OR 4.0, 95% CI 3.0–5.5). Conclusions The prevalence of burnout and workplace incivility were concerning among EMS practitioners, with women more likely to experience both compared to men. EMS practitioners who experienced frequent workplace incivility were also more likely to have burnout than those who did not experience frequent incivility.

Tradeoffs in Triage of Motor Vehicle Trauma by Rural 911 Emergency Medical Services Practitioners.

Identification and triage of severely injured patients to trauma centers is paramount to survival. Many patients are undertriaged in rural areas and do not receive proper care. The decision-making processes involved in triage are not well understood and should be assessed to improve the triage process and outcomes. Triage decision-making processes were explored through emergency medical services (EMS) practitioner focus groups and a discrete choice experiment (DCE). Attributes of trauma determined from focus groups and the literature included patient demography, injury mechanism, and trauma center distance. DCE data were analyzed using mixed logit models. High-risk mechanism, decreased age, multiple comorbidities, and pregnancy were found to increase the preference for triage. Greater trauma center distance was found to decrease preference for triage, but practitioners were willing to trade off up to 2 h of travel time to transport a third-trimester pregnancy and 48 min of travel time to transport a 25-y-old than they would a 50-y-old with the same comorbidities, injuries, and stability. Our findings suggest that current forms of EMS protocols may not be appropriately tailored to support the mechanisms underlying practitioner decision making. Public health professionals and researchers should consider using DCEs to better understand EMS practitioner decision making and identify structures and incentives that may improve patient outcomes and optimally guide appropriate triage decisions. Discrete choice experiments are an effective method to elicit prehospital practitioners' preferences around transport of the traumatized patient.Practitioner biases observed in EMS transport data are recovered in stated preference models incorporating individual preference heterogeneity.There is a discrepancy between the triage priorities recommended by protocol and those measured from prehospital practitioners' decisions-this may have implications in over- and undertriage rates and prehospital protocol design.

Characteristics and Challenges of Clinical Documentation in Self-Organized Fast-Paced Medical Work

Clinical documentation is a time-consuming and challenging task, especially in time-critical medical settings. Even with a dedicated scribe person, timely and accurate documentation under time constraints is never easy. In this work, we present a unique type of fast-paced medical team--emergency medical services (EMS)--which has no designated role for documentation while constantly working outside in the field to provide urgent patient care. Through interviews with 13 EMS practitioners, we reveal several interesting and prominent characteristics of EMS documentation practice as well as their associated challenges: EMS practitioners self-organize and collaborate on documentation while in the meantime being both physically and cognitively preoccupied with high-acuity patients, having limited capability to use handheld documentation systems in real-time, and being overwhelmed by strict documentation requirements and regulations. Lastly, we use our findings to discuss both technical and non-technical implications to support timely and collaborative documentation in dynamic medical contexts while accounting for care providers' physical and cognitive constraints in using computing devices.

Factors which affect the application and implementation of a spinal motion restriction protocol by prehospital providers in a low resource setting: A scoping review.

The safety and effectiveness of prehospital clinical c-spine clearance or spinal motion restriction (SMR) decision support tools are unclear. The present study aimed to examine the available literature on clinical cervical spine clearance and selective SMR decision support tools to identify possible barriers to implementation, safety, and effectiveness when used by emergency medical service (EMS) practitioners. We performed a focused scoping review of published literature on the prehospital use of clinical c-spine clearance and SMR decision tools in adult blunt trauma patients. The Medline, Embase, Cochrane Library, Cumulative Index of Nursing and Allied Health Literature, Web of Science, Turning Research into Practice and EBSCOhost online databases were searched (February 2021). The type of decision support tool and facilitators and barriers to its use were extracted from each included publication in accordance with a modified descriptive-analytical framework. Extracted data were subjected to thematic analysis. Following screening, forty-two articles were included in this scoping review. No studies conducted specifically in low resource settings were found. The majority of articles (57%) evaluated the use of specific SMR decision support tools, such as the National Emergency X-Radiography Utilization Study (NEXUS) and the Canadian C-spine Rule (CCR). Potential facilitators of safe and effective use were identified in 60%, and potential barriers to safe and effective use in 55% of included articles. Only one study evaluated the CCR when used by EMS practitioners, making it difficult to determine its appropriateness for implementation in the prehospital setting. This is the first scoping review, to our knowledge, that has attempted to identify the possible barriers and facilitators to their implementation, safety, and effectiveness when used by EMS practitioners. Key issues identified included terminology, guideline compliance and implementation, and a lack of context-specific evidence. These may provide important considerations for future guideline development.

Mental Health and Resilience in Emergency Medical Services Practitioners During the COVID-19 Pandemic

Background: The prevalence of the Coronavirus disease 2019 (COVID-19) pandemic, as one of the biggest global health threats, has had psychological impacts on healthcare workers (HCWs) and all aspects of their mental health, particularly resilience. Objectives: This study aimed to investigate the relationship between mental health and resilience in prehospital emergency medical services (EMS) practitioners. Methods: This descriptive/analytical cross-sectional study was conducted in 2020 using a web-based questionnaire, wherein the data were collected from a total number of 115 EMS practitioners working in 115 EMS stations in Golestan province, northern Iran, selected using convenience sampling. The data collection tools were also the General Health Questionnaire-28 (score range: 0 - 84) and the Connor-Davidson Resilience Scale (score range: 0 - 100). The relationship between both questionnaires was then examined by structural equation modeling via maximum likelihood estimation. In addition, multiple linear regression (MLR) was applied to reflect on the factors affecting the resilience mean score. Results: The mental health and resilience mean scores in the EMS practitioners were 25.73 ± 8.90 and 72.25 ± 12.63, respectively. Furthermore, 43.5% and 49.6% of the subjects had good and mild mental health conditions, respectively. The correlation coefficient between both questionnaires (-0.51) revealed that mental health deterioration diminished resilience in the EMS practitioners. Additionally, the type of employment and mental health mean score had a significant effect on the resilience mean value (R2 in MLR = 0.54). Conclusions: The study results demonstrated that more than half of the EMS practitioners had moderate mental health status, and their resilience mean score was high. Therefore, it is suggested to evaluate the prevalence of other common types of mental problems, such as anxiety, depression, and sleep disorders, in HCWs during the COVID-19 pandemic at the national level in future studies.

Prehospital portable ultrasound for safe and accurate prehospital needle thoracostomy: a pilot educational study

BackgroundSimulated needle thoracostomy (NT) using ultrasound may reduce potential injury, increase accuracy, and be as rapid to perform as the traditional landmark technique following a brief educational session. Our objective was to determine if the use of an educational session demonstrating the use of handheld ultrasound to Emergency Medical Services (EMS) staff to facilitate NT was both feasible, and an effective way of increasing the safety and efficacy of this procedure for rural EMS providers.MethodsA pre/post-educational intervention on a convenience sample of rural North American EMS paramedics and nurses. Measurement of location and estimated depth of placement of needle thoracostomy with traditional landmark technique was completed and then repeated using handheld ultrasound following a training session on thoracic ultrasound and correct placement of NT.ResultsA total of 30 EMS practitioners participated. Seven were female (23.3%). There was a higher frequency of dangerous structures underlying the chosen location with the landmark technique 9/60 (15%) compared to the ultrasound technique 1/60 (1.7%) (p = 0.08). Mean time-to-site-selection for the landmark technique was shorter than the ultrasound technique at 10.7 s (range 3.35–45 s) vs. 19.9 s (range 7.8–50 s), respectively (p < 0.001). There was a lower proportion of correct location selection for the landmark technique 40/60 (66.7%) when compared to the ultrasound technique 51/60 (85%) (p = 0.019). With ultrasound, there was less variance between the estimated and measured depth of the pleural space with a mean difference of 0.033 cm (range 0–0.5 cm) when ultrasound was used as compared to a mean difference of 1.0375 cm (range 0–6 cm) for the landmark technique (95% CI for the difference 0.73–1.27 cm; p < 0.001).ConclusionsTeaching ultrasound NT was feasible in our cohort. While time-to-site-selection for ultrasound-guided NT took longer than the landmark technique, it increased safe and accurate simulated NT placement with fewer identified potential iatrogenic injuries.

Recognizing and Responding to Elder Mistreatment: Developing and Testing an Online Training for EMS Practitioners

Elder mistreatment is an urgent and under recognized public health concern with devastating consequences for older adults, families, and health systems. Risk for elder mistreatment has increased during the COVID-19 pandemic, further highlighting the urgency to address it. Prehospital emergency medical service (EMS) practitioners have unique opportunities to recognize signs of elder mistreatment but often lack the training and tools required to facilitate consistent identification and intervention. To address this gap, Education Development Center collaborated with a team of expert advisors and EMS practitioners to develop and pilot test Recognizing and Responding to Elder Mistreatment: An Online Training for EMS Practitioners with funding from the RRF Foundation for Aging. This training aims to prepare EMS practitioners to recognize potential mistreatment and report suspected elder mistreatment in line with state laws and their professional code of ethics. In this presentation, we will describe the iterative development process, present results from a pilot test conducted with EMS practitioners in Massachusetts and share strategies and progress for disseminating the training nationally. The pilot study utilized a pre-post design to assess changes in knowledge, attitudes, and practices at baseline, immediately after and two months following participation in the training. Results indicate statistically significant improvements in knowledge related to elder mistreatment identification and response from pre- to post-training and maintenance of these improvements two months later. Participants reported feeling more prepared to address elder mistreatment in their work as EMS practitioners and applying their new knowledge and skills during the two months following the training.

Clinical Care and Restraint of Agitated or Combative Patients by Emergency Medical Services Practitioners

The National Association of EMS Physicians (NAEMSP) has had a position statement on patient restraint since 2002 (1), which was updated in 2017 (2). This document updates and replaces these previou...

Emergency Medical Services Communication Barriers and the Deaf American Sign Language User

Objective: We sought to identify current Emergency Medical Services (EMS) practitioner comfort levels and communication strategies when caring for the Deaf American Sign Language (ASL) user. Additionally, we created and evaluated the effect of an educational intervention and visual communication tool on EMS practitioner comfort levels and communication. Methods: This was a descriptive study assessing communication barriers at baseline and after the implementation of a novel educational intervention with cross-sectional surveys conducted at three time points (pre-, immediate-post, and three months post-intervention). Descriptive statistics characterized the study sample and we quantified responses from the baseline survey and both post-intervention surveys. Results: There were 148 EMS practitioners who responded to the baseline survey. The majority of participants (74%; 109/148) previously responded to a 9-1-1 call for a Deaf patient and 24% (35/148) reported previous training regarding the Deaf community. The majority felt that important details were lost during communication (83%; 90/109), reported that the Deaf patient appeared frustrated during an encounter (72%; 78/109), and felt that communication limited patient care (67%; 73/109). When interacting with a Deaf person, the most common communication strategies included written text (90%; 98/109), friend/family member (90%; 98/109), lip reading (55%; 60/109), and spoken English (50%; 55/109). Immediately after the training, most participants reported that the educational training expanded their knowledge of Deaf culture (93%; 126/135), communication strategies to use (93%; 125/135), and common pitfalls to avoid (96%; 129/135) when caring for Deaf patients. At 3 months, all participants (100%, 79/79) reported that the educational module was helpful. Some participants (19%, 15/79) also reported using the communication tool with other non-English speaking patients. Conclusions: The majority of EMS practitioners reported difficulty communicating with Deaf ASL users and acknowledged a sense of patient frustration. Nearly all participants felt the educational training was beneficial and clinically relevant; three months later, all participants found it to still be helpful. Additionally, the communication tool may be applicable to other populations that use English as a second language.

Predicting emergency medical service call demand: A modern spatiotemporal machine learning approach

The primary goal of emergency medical service (EMS) agencies is to effectively allocate the ambulances and personnel required to provide sufficient geographic coverage of a service area while minimizing response times to high-priority call requests. Given that the demand for ambulances is known to fluctuate spatially and temporally based on the time of day and day of the week, EMS practitioners depend on call volume forecasts to develop staffing and dynamic redeployment plans. In this study, a series of daily, hourly, and spatially distributed hourly call volume predictions are generated using a multi-layer perceptron (MLP) artificial neural network model following feature selection using an ensemble-based decision tree model. For spatially distributed predictions, K-Means clustering is applied to produce heterogeneous spatial clusters based on call location and associated call volume densities. The predictive performance of the MLP model is benchmarked against both a selection of traditional time-series forecasting techniques and a common industry method. Results show that MLP models outperform time-series and industry forecasting methods, specifically at finer levels of spatial granularity where the need for more accurate call volumes forecasts is more essential.

Evidence-Based Guidelines for EMS Administration of Naloxone

The opioid crisis is a growing concern for Americans, and it has become the leading cause of injury-related death in the United States. An adjunct to respiratory support that can reduce this high mortality rate is the administration of naloxone by Emergency Medical Services (EMS) practitioners for patients with suspected opioid overdose. However, clear evidence-based guidelines to direct EMS use of naloxone for opioid overdose have not been developed. Leveraging the recent Agency for Healthcare Research and Quality (AHRQ) systematic review on the EMS administration of naloxone for opioid poisonings, federal partners determined the need for a clinical practice guideline for EMS practitioners faced with suspected opioid poisoning. Project funding was provided by the National Highway Traffic Safety Administration, Office of EMS, (NHTSA OEMS), and the Health Resources and Services Administration, Maternal and Child Health Bureau’s EMS for Children Program (EMSC). The objectives of this project were to develop and disseminate an evidence-based guideline and model protocol for administration of naloxone by EMS practitioners to persons with suspected opioid overdose. We have four recommendations relating to route of administration, all conditional, and all supported by low or very low certainty of evidence. We recommend the intravenous route of administration to facilitate titration of dose, and disfavor the intramuscular route due to difficulty with titration, slower time to clinical effect, and potential exposure to needles. We equally recommend the intranasal and intravenous routes of administration, while noting there are variables which will determine which route is best for each patient. Where we are unable to make recommendations due to evidence limitations (dosing, titration, timing, and transport) we offer technical remarks. Limitations of our work include the introduction of novel synthetic opioids after many of the reviewed papers were produced, which may affect the dose of naloxone required for effect, high risk of bias and imprecision in the reviewed papers, and the introduction of new naloxone administration devices since many of the reviewed papers were published. Future research should be conducted to evaluate new devices and address the introduction of synthetic opioids.

Pre-hospital intercostal chest drains in South Africa: A modified Delphi study.

IntroductionTrauma is one of the most common causes of death in low- and middle-income countries, with thoracic injury accounting for 20–25% of these deaths worldwide. The current management of a life-threatening pre-hospital pneumothorax is with a needle chest decompression, however, definitive care for a pneumothorax and/or haemothorax is still the insertion of an intercostal chest drain. The aim of this study was to seek expert opinion and consensus on the placement of ICDs in the pre-hospital emergency care setting in South Africa.MethodsA three-round modified Delphi study was undertaken with an expert panel drawn from local emergency care experts consisting of physicians and emergency medical service practitioners. Participants supplied opinion statements in round 1 under headings derived from common emerging themes found in the literature. During round 2 participants used a 9-point Likert scale to rate their consensus on each statement and in round 3 they were able to change their position based on the earlier panel distributions. A consensus percentage of 60% was set within a narrow margin of ‘strongly agree’ or ‘strongly disagree’.ResultsA total of 22 experts took part as panel members. There were 123 opinion statements produced from round 1, of which 21 (17%) reached consensus in round 2. At the end of round 3 another four statements reached consensus, bringing the total up to 25 (20%).ConclusionDefinitive care of a life-threating pneumothorax and/or haemothorax must be sought emergently. The insertion of an ICD, under select conditions, may be required in the pre-hospital setting in South Africa.