Introduction:Evidence based medicine is the standard of modern health care practices. Ongoing biomedical research is needed to expand existing knowledge and improve quality of care, but it needs to reach clinicians to drive change. Journal articles and conference presentations are dissemination tools. The aim of the study was to establish the publication rate of scientific abstracts presented at the first and second African Conference of Emergency Medicine. The secondary objectives were establishing nonpublication dissemination and the factors associated with publication and non-publication. Determining non-publication dissemination patterns and the factors associated with reasons for publishing or non-publication were also investigated. Methods:Presenters of the 129 scientific abstracts from the first and second African Conference of Emergency Medicine were invited to participate in an online survey. The survey was followed by a manual literature search to identify published manuscripts of authors that did not complete the survey, to determine the most accurate publication rate. Results:Thirty-one presenters responded (24%), of which 18 published in a peer-reviewed journal. An additional 25 publications were identified by the literature search. The overall publication rate was 33.3% (26.9% from 2012 and 40.3% from 2014). Oral presentations were more likely to be published (p=0.09). Sixteen manuscripts (37.2%) were published in the African Journal of Emergency Medicine. Presentations at local academic meetings were the most used platform beyond publication (43%). The main reason to publish was to add to the body of knowledge (100%), while lack of time (57%) was the major obstacle for not publishing.Conclusion:The overall publication rate for the first and second Africa Conferences of Emergency Medicine iscomparable to other non-African Emergency Medicine conferences. The increasing publication trendbetween conferences might reflect the development of regional research capacity. EmergencyMedicine providers in Africa need to be encouraged to participate in high quality, locally relevant research and to distribute those findings through accessible formats.

Includes bibliographical references / To date, health facilities in Africa have not had an objective measurement tool for evaluating essential emergency service provision. One major obstacle is the lack of consensus on a standardized evaluation framework, applicable across a variety of resource settings. The African Federation for Emergency Medicine has developed an assessment tool, specifically for low- and middle-income countries, via consensus process that assesses provision of key medical interventions. These interventions are referred to as essential emergency signal functions. A signal function represents the culmination of knowledge of interventions, supplies, and infrastructure capable for the management of an emergent condition. These are evaluated for the six specific clinical syndromes, regardless of aetiology, that occur prior to death: respiratory failure, shock, altered mental status, severe pain, trauma, and maternal health. These clinical syndromes are referred to as sentinel conditions. This study used the items deemed "essential", developed by consensus of 130 experts at the African Federation for Emergency Medicine Consensus Conference 2013, to develop a tool, the Emergency Care Assessment Tool (ECAT), incorporating these using signal functions for the specific emergency sentinel conditions. The tool was administered in a variety of settings to allow for the necessary refinement and context modifications before and after administering in each country. Four countries were chosen: Cameroon, Uganda, Egypt, and Botswana, to represent West/Central, East, North, and Southern Africa respectively. To enhance effectiveness, ECAT was used in varying facility levels with different health care providers in each country. This pilot precedes validation studies and future expansive roll out throughout the region.

Prolonged seizures are a medical emergency and require immediate treatment to prevent complications. Benzodiazepines (BDZ's) are integral to acute seizure management. The most commonly used BDZs are Lorazepam, Diazepam and Midazolam. Lorazepam is often perceived as the superior choice but recent studies have challenged this but results appear inconclusive and contradictory. This study aims to consolidate the available literature and formulate recommendations for the use of BDZs in the emergency setting for children. Methods A rapid review methodology with a tiered approach was used. This approach uses high quality guidelines as the first tier, review of reviews (second tier) then systematic reviews and the fourth and final tier uses randomized control trials as primary data. The Australian National Health Medical Research Council's matrix for grading and developing guidelines was used to grade quality of recommendations.

Introduction - Helicopter search and rescue in Africa is conducted primarily by military organizations. Since 2002 the Western Cape of South Africa has had a dedicated contracted civilian helicopter emergency medical service (HEMS) conducting air ambulance, terrestrial and aquatic rescue. This is the first description of the operations of an African helicopter rescue service. Objective - To describe the terrestrial and aquatic helicopter rescue activity of a civilian operated HEMS in the Western Cape, South Africa from 1 January 2012 – 31 December 2016. Methods - A five-year retrospective review was conducted using data from the organization's operational database, aviation documents, rescue reports and patient care records. Patient demographics and activity at time of rescue, temporal and geographical distribution, crewing compositions, patient injury, triage, clinical interventions and rescue techniques were analysed. Results – A total of 581 search and rescue missions were conducted, of which 451 were terrestrial and 130 aquatic rescues. The highest volume of rescues was conducted within the urban Cape Peninsula. Hoisting using a rescue harness was the most common rescue technique used. 644 patients were rescued. Uninjured or minorly injured persons represented 79% of the sample. Trauma (33%, 196/644) was the most common medical reason for rescue, with lower limb trauma predominant (15%, 90/644). The most common clinical interventions performed were intravenous access (108, 24%), spinal immobilization (92, 21%), splinting (76, 17%) and analgesia administration (58, 13%). Conclusions - The patient demographics and rescue activity described are similar to those described in high-income settings.

Introduction Adverse Events (AEs) in Helicopter Emergency Medical Services (HEMS) remains poorly reported, despite the potential for harm to occur. The Trigger Tool (TT) represents a novel approach to AE detection in healthcare. The aim of this study was to retrospectively describe the frequency of AEs and their Proximal Causes (PCs) in Qatar HEMS. Methods Using the Pittsburgh Adverse Event Tool (PittAETool) to identify AEs in HEMS, we retrospectively analyzed 804 records within an existing AE TT database (21-month period). We calculated outcome measures for Triggers, AEs, and Harm per 100 patient encounters, plotted measures on Statistical Process Control (SPC) charts, and conducted a multivariate analysis to report harm associations. Results We identified 883 Triggers in 536 patients, with a rate of 1.1 Triggers per Patient Encounter, where 81.2% had Documentation Errors (n=436). An AE and Harm rate of 27.7% and 3.5% respectively was realized. The leading PC was Actions by HEMS Crew (81.6%; n=182). The majority of harm (57.1%) stemmed from the Intervention and Medication triggers (n=16), where Deviation from Standard of Care was common (37.9%; n=11). Age and diagnosis adjusted odds was significant in the Patient Condition (6.50; 95% CI, 1.71-24.67; P= 0.01) and Interventional (11.85; 95% CI, 1.36-102.92; P= 0.03) trigger groupings, while age and diagnosis had no effect on Harm. Conclusion The TT methodology is a robust, reliable, and valid means of AE detection in the HEMS domain. Whilst an AE rate of 27.7% is high, more research is required to understand prehospital clinical decision-making and reasons for guideline deviance. Furthermore, focused quality improvement initiatives to reduce AEs and Documentation errors should also be addressed in future research.

Background Emergency conditions comprise nearly half of the total global burden of disease, and disproportionately affect low-resource settings (LRS). This burden of life-threatening yet treatable conditions can be ameliorated by effective, timely emergency care (EC) interventions, so significantly that the Disease Control Priorities project estimates over half of deaths in the lowest-income countries could be addressed though the implementation of effective EC. Interest in developing better facility-based EC is expanding rapidly, yet there is a large gap in the cost-effectiveness literature to support informed resource allocation. Distinguishing the "value for money" of EC is crucial, especially in contexts of extreme resources limitations. Developing robust and setting-specific data on the cost of implementing EC cultivates the ability to understand the impacts of, and plan improvements in, EC in LRS. The aim of this thesis was to investigate the cost-effectiveness of interventions forming a systematic approach to EC in health facilities in LRS. Aims and Objectives The primary aim of this research was to investigate the cost-effectiveness of implementing the WHO emergency care toolkit to reduce mortality related to emergency conditions in health facilities in an LRS. To achieve this aim, the following objectives were established: synthesise evidence relating to the costeffectiveness of EC in LRS, enumerate context specific costs of delivering facility-based EC, and retrospectively study the impact of implementing a low-cost set of EC interventions in low-resource EC naïve health facilities on cost and outcome (mortality), to derive a measure of cost effectiveness. Methods The dissertation is comprised of 3 studies. First, Chapter 3 undertakes a systematic review of literature on EC interventions in LRS, using PRISMA guidelines and the Consolidated Health Economics Evaluation Reporting Standards (CHEERS) checklist. Secondly, to enumerate context specific costs of delivering facility-based EC, data were collected over a 4-week period in Uganda using direct activity-based costing and presented in Chapter 6. Measures of central tendency were derived by condition and by intervention. Variations in cost between conditions were explored using a Kruskal-Wallis H test and a post-hoc Nemenyi test were performed to make pairwise comparisons between conditions. Third, in Chapter 7 a cost-effectiveness analysis model was developed using Microsoft Excel to calculate both the costs and effects of scalable investments strengthening facility-based EC on morbidity and mortality. Costs and consequences associated with piloting the WHO Emergency Care Toolkit package of interventions in Uganda were analysed using the decision tree model. Pre- and post-intervention groups were compared from a societal perspective. Cost and health outcomes were discounted using a microsimulation and parameter uncertainty assessed using Monte-Carlo simulation probabilistic sensitivity analyses. Results 35 studies were included in the final review; most were methodologically weak and focused on singleintervention analyses rather than intervention packages or system changes. This body of literature represented only 24 of 137 low- and middle-income countries (LMICs) globally, and was heterogeneous in methods, settings, and presentation of results of the identified studies. Accordingly, formulating a general conclusion about the wider implication of the findings on the cost–effectiveness of EC is problematic. The overall median (IQR) cost of care across all conditions was $15.53 (14.44 to 19.22). A Krauskal-Wallis test yielded statistically significant difference in cost values between sentinel conditions (H=94.89, p=1.20E-19). At a P value of < .05, the post-hoc Nemenyi test revealed paediatric diarrhoea has a statistically significant lower median cost compared to all other conditions, but did not yield any significant differences in median cost between the remaining four sentinel conditions. In running the decision tree model with a 1753 patient cohort, sampled 10000 times, the intervention averted 509 DALYs over standard care. The model found implementing the WHO Toolkit saved $664,231 ($658,552 to $669,910), and yielded an additional 27 lives saved, or an additional 1,826 life years. Conclusions and relevance This dissertation makes important conceptual, analytical and empirical contributions in exploring the application of local economic evidence-informed priority setting to ensure that decisions made around EC are guided by the populations they serve. In conducting one of the first cost-effectiveness analyses of investments that create a systematic approach to facility-based EC, we found that this is a very low-cost, high-yield intervention. In many cases it may not only be cost-effective, but actually cost saving. This finding is especially relevant in LRS contexts where associated additional costs may be considered affordable given the high burden of emergency conditions.

Transitions in care – including at the point of discharge from a hospital - may potentially place patients in a position of increased risk and vulnerability.(1) This is recognised to be of particular concern for paediatric patients, compounded by the fact that no widely accepted or used standards of care for paediatric discharge exist. Current research and quality improvement efforts to optimize care transitions in children are considered an essential contributor to reducing post hospitalization morbidity and improving family centred care. (2)(3) Care transitions are also considered especially challenging during the discharge process from the Emergency Centre. Effective patient education and follow-up arrangements may be compromised in the frequently fast paced, high patient volume environment often characterised by interruptions and distractions thus increasing the risk of medical error. This is further complicated by shift working healthcare providers who are required to treat unfamiliar patients of varying clinical acuity who present for care.(1)(4)(5)

Includes bibliographical references. / Background: Disasters occur without warning; they have the potential to cause chaos and destruction in unsuspecting communities and on the environment. The personnel of the Western Cape Emergency Medical and Rescue Services are suitably trained to respond to major incidents or disasters, but lack the support of a standardised medical cache. This in turn compromises the preparedness of such a team to deploy to major incidents and or disasters inside and outside the provincial boundaries. Aim: This study was to obtain consensus regarding what such a medical cache should be comprised of, specifically regarding medical equipment and pharmacological agents. Methodology: A three iteration modified Delphi study was conducted over ten months. During this time selected experts who are currently working in the field of disaster response and emergency medicine, were asked to voluntarily and anonymously complete three iterations of questionnaires. After each iteration the primary researcher collected and analysed the responses for consensus. Consensus was set at 85% so as to formulate the questionnaires for the subsequent iterations. Results: Consensus was achieved with items like the laryngoscope; rugged electrocardiogram with extra-long leads; scoop stretcher; stokes basket and a KEO. Other items such as the Arterial Blood Gas (ABG) machine and the Ultrasound machine did not achieve consensus. Disposable equipment like endotracheal tubes; bandages; intravenous administration sets and dial-a-flow devices were amongst the items to be included in the medical cache, these were based on existing research regarding disposable equipment. The majority of pharmacological agents, such as broad spectrum Antibiotics, Suxamethonium and Fentanyl achieved consensus early on; while other pharmacological agents like Ondansetron and Thrombolytic agents did unsurprisingly not achieve consensus across any of the iterations. Conclusion: This study assisted in identifying the necessary medical equipment and pharmacological agents to be included in a medical cache, which would enable medical rescue teams to be prepared prior and during deployment, whether in or outside the borders of the Western Cape, South Africa or internationally.

Includes bibliographical references (leaves 73-80).

Includes bibliographical references (leaf 43).