Introduction: The skill of endotracheal intubation to achieve a definitive airway for critically ill and injured patients in the prehospital setting is frequently performed by advanced life support providers. Several methods may be utilised, including intubation without the use of medication, the use of sedatives or a rapid sequence intubation. There is a paucity of data available that assesses prehospital advanced airway intubation practices in South Africa. The aim of this study is to describe the advanced airway management practices of advanced life support providers across South Africa. Methods: A retrospective, observational study method was used (chart review). Electronic patient care records were sourced from private and public emergency medical services companies and collated accordingly. Results: A total of 704 cases were included. Intubation during cardiac arrest was the most common approach to airway management (n=280, 40%) followed by rapid sequence intubation (n=202, 28%), medication-facilitated intubations (n=152, 22%) and a nomedication approach (n=70, 10%). Successful intubation using an endotracheal tube was reported in 197 (98%) of rapid sequence intubation cases, 134 (88%) of the medication facilitated cases, 61 (87%) of no-medication cases and 228 (81%) of cardiac arrest cases. A first-pass success rate was described in 260 (79%) cases, with the cardiac arrest group having a first-pass success of 85%, followed by the rapid sequence intubation group (83%), the nomedication group (71%) and the medication facilitated group (61%). Hypotension and cardiac arrest were the most common adverse events. A total of 496 (70%) patients were alive at hospital handover. The average scene time and transportation time was 42 minutes and 24 minutes respectively for the rapid sequence intubation group, 42min and 27min for the medication facilitated group, 44min and 25min for the no-medication group and 57min and 16min for the cardiac arrest group. Discussion: The study described the prehospital airway management practices by advanced life support providers in South Africa. Rapid sequence intubation had the highest endotracheal intubation success rate overall and the lowest prevalence of adverse events. There was no statistical difference in survival between the rapid sequence intubation, medication facilitated and no-medication group. Due to a lack in standardised treatment guidelines, differences in fluid administration, post-intubation care, confirmation of placement and ventilation were noted. No standard approach to record keeping was found, with the quality of patient care records being variable. A standardised advanced airway management report would be beneficial as it would improve the quality of data recorded and allow for better comparisons to be made.

Background Communication is vital to patient-doctor interactions especially in emergency centres (EC). It is evident from international and South African studies that language barriers result in suboptimal clinical outcomes, increased use of already limited resources and poor patient satisfaction. In the Western Cape, initiatives such as community trained interpreters, telephonic services and multilingual language policies have been implemented to improve communication between doctors and patients. Objectives This study was done to ascertain to what extent language barriers are perceived to still exist by doctors in emergency centres in secondary public hospitals in Cape Town. Methods A quantitative on-line survey of full time doctors in the ECs of six urban secondary public hospitals in Cape Town was conducted in October 2019. Data was collected over a 5 week period and covered demographics, languages spoken, (self-reported) fluency of languages spoken, languages encountered, perceived occurrence of language barriers, perceived impact of language barriers and strategies currently implemented to overcome these barriers. Results Of the 119 doctors invited to complete the survey, 74 eligible responses were received. Language barriers still exist in secondary public hospitals in the Western Cape. The majority of doctors spoke Afrikaans and no isiXhosa speaking doctors took part in the survey. Half of the doctors surveyed stated they would not be able to take a history in isiXhosa without an interpreter. Most (97%) of doctors had not heard of community trained interpreters and only 23% had ever used the telephone interpretation service available. Perceived consequences of language barriers include: inability or longer duration to get a history, increased use of resources, and patients returning because they did not fully understand the treatment plan. Informal interpreters such as nursing staff and family members were used most often to overcome language barriers. No official interpreters were available to assist in person and doctors are either unaware of telephonic interpreting services or woefully under-using this service. Due to language barriers, doctors are left feeling frustrated with themselves or sad for the patients that they are meant to be helping due to language barriers. Conclusion Reintroduction of community based interpreters, teaching doctors more languages and investment into technologyaided translation services are possibilities that have been suggested by doctors and could be researched further to help improve the current situation.

Background: Burn care in resource-constrained settings represents a significant challenge. Mobile health (mHealth) could have useful advantages by providing timely expert advice. As part of a larger study on teleconsultation in burn care, a mobile application – the Vula App – was developed and tested in the Western Cape. This study gauges healthcare providers' intention to use this mHealth technology and factors influencing its adoption. Methods: 48 healthcare providers working in Emergency Centres of three health facilities answered a questionnaire immediately after being trained in the use of the app. The survey was based on the Technology Acceptance Model of Davis and included the constructs of ease of use, usefulness, design quality, impact on care, compatibility, and behavioural intention to adopt. Descriptive statistics were used for data analysis. Results: The mean age of participants was 29.5 years old and the male-to-female ratio was 1:2. 73.9% of respondents were doctors and the remainder nurses. 93.4% of them already owned and used smartphones, with 76% using them in medical practice. 93% of respondents thought the app was easy to use and 91.3% found it useful. 17.8% found it incompatible with their routine work. 84.8% of participants expressed their intention to adopt and use the system. 4.3% of participants rejected it and 10.9%remained undecided. Conclusion: The majority of participants already used smartphones and found the Vula app useful, easy to use, well designed, beneficial in burn care and compatible with their routine work. These factors led them to express the intention to use the app. This significantly predicts actual future use and is essential to the successful implementation of mHealth.

Background and Objectives: While trauma is currently the second leading cause of death in Saudi Arabia, little statistical information is available about injury rates and related patient outcomes. There is a need to understand trauma epidemiology to determine strategies that can be put in place to prevent and treat such trauma. We aimed to describe trauma rates, types of injuries, demographic distribution of injury and body regions affected by trauma in King Fahad Hospital in the city of Medina. Methods: The study was undertaken in King Fahad Hospital, the first multi-speciality reference hospital in the Medina region and the only trauma centre in the city. We collected retrospective data on all the trauma victims who visited the Emergency Department from 1st January to 31st December 2018. Simple descriptive statistics were calculated. Trauma mortality was compared with trauma scores with Receiver Operator Curves. Results: During the study period, 8793 patients were evaluated, 5846 (66.5%) males. The mean age was 27.5 years. 5608 (64%) were admitted in one of the in-hospital departments and rest were referred to OPD. Traffic-related injuries (4086; 46.5%) and falls (2993; 34%) were the most common causes of injury. Extremities injury (5929; 67.5%) was recorded as the most common body part. From the in-hospital patients, 5077 (90.5%) were discharged home and 167 (3%) died. Considering the mortality prediction accuracy of RTS and NTS. The RTS score of ≤9 had sensitivity and specificity of 90.2% and 90.4%, respectively, in predicting mortality in >5-year-old patients. NTS score of ≤13 had 90% sensitivity and 97.3% specificity in predicting mortality in the age group of 0-5 year-old. Conclusion: This descriptive study is a crucial step in addressing the burden of trauma in Saudi Arabia. Information related to the characteristics of injuries and relevant patient 2 outcomes may assist in further research into possible causal factors. It may contribute to the creation of new protocols in preventing and managing injuries more efficiently.

Background: Despite practicing resuscitation skills in a simulation environment, medical students often express anxiety about having to participate in patient resuscitation in the clinical environment. This fear can lead to an unwillingness to initiate or participate in resuscitations, and a decreased confidence in their skills. Exploring the perceptions of final year medical students can provide valuable insight for improving the current simulation programme at the University of Cape Town. Aim: The aim of the study is to explore 6th year medical students' perceptions and self-reported competence for clinical practice after receiving Resuscitation-Based Simulation training.

In sub-Saharan Africa, the shift in disease burden from infections to non-communicable disease and injury highlights the need for effective and efficient emergency care. Despite this, emergency care is a neglected sector of the health system in most low and middle-income countries. Funding and resource allocations are often small and have little impact on the development of emergency care systems, and provision of emergency care is therefore frequently left to under-trained and/or under-prepared nurses or clinical officers. In order to develop effective emergency care systems, one must first identify strengths and challenges in existing systems. The aim of this study was to determine facility-based emergency care capacity in public hospitals in Zambia. This descriptive cross-sectional study comprised of a total of 23 facilities: seven districts, 12 general and four central hospitals. Data were collected using a standardised Emergency Care Assessment Tool (ECAT); developed in 2013 by AFEM to ascertain facilities' strengths and weaknesses in the delivery of the emergency care services for five sentinel conditions and maternal health. The ECAT was administered through one-on-one interviews with designated personnel working in emergency receiving areas. The assessment tool consists of six main themes relating to the ability to provide care for patients suffering from respiratory failure, shock, altered mental status, severe pain, trauma and maternal health. The majority of facilities were able to perform almost all the procedures across all themes. However, some procedures, which were highly technical and required personnel with specialist training or specialised equipment, were not performed at all facilities. The level of the facility also dictated whether a procedure could be performed where higher-level health facilities like central hospitals were able to perform more procedures than lower-level facilities due to higher numbers of trained personnel, more equipment and supplies, and better infrastructure. Maternal health was covered in almost all (>90%) hospitals. Across all themes, the most frequent reasons for not performing procedures were lack of supplies (n=137) followed by no training (n=136), no infrastructure (n=35) and no human resources (n=34). At the central level, the most frequent reason for not performing procedures was no supplies (n=16), whereas at district and general levels the most frequent reason was no training. Overall, most facilities were able to offer basic emergency care services. However, there is limited capacity of training and supplies across all facilities, as well as a lack of infrastructure and policies for emergency care in lower-level facilities. Zambian hospitals can provide basic emergency care, but there is need to enhance training and improve on provision of supplies to enable facilities to provide emergency care. Focus must also be on development of policies relating to emergency care to guide and standardise procedures. Capacity building should be more focused at district and general hospitals to improve emergency care across all levels of health facilities, as it will reduce the burden at central level and improve patient outcomes since these are first-line access points for patients.

Introduction Emergency medical services (EMS) play a vital role in addressing the high burden of disease posed by emergency conditions in low-to-medium income countries and it is vital to ensure that EMS care is of a high quality. Complaints and their management are an important mechanism in addressing individual patient concerns and ensuring accountability to the public. Expanding the role of complaints to effectively affect system-wide quality improvement requires knowledge of trends based on aggregated complaint data. This study aims to describe the volume and nature of complaints received by an urban EMS organisation in the Western Cape. Methodology A retrospective analysis was performed of all non-clinical complaints received for the 2018 calendar year by the call centre of a public EMS in Cape Town, South Africa. All complaint documents were collected and collated with the original case dispatch information. Complaints were categorised according to a standardised complaint coding taxonomy published previously. Complaint investigation outcomes and recommendations were analysed by themes identified during the study. Results A total of 156 complaints were received which referred to 172 patients. Complaints originated primarily from healthcare providers (72%) and patients or public (22%). Inter-facility transfers (73%) generated the most complaints. Encoding of complaint narratives revealed 302 individual service issues, which were classified into taxonomy derived domains (Clinical – 36%; Management – 44%; Relationship – 20%). The “Management” domain highlighted delay issues, accounting for 38% (116/302). Conclusion In this urban EMS, the majority of complaints are related to delays. Complaints were primarily lodged by other healthcare providers. Complaint rates lodged by patients and public are low, and would suggest that a unified and well publicised complaint mechanism is necessary, in order to increase public involvement in service quality improvement. Further research is recommended to validate a taxonomy for EMS complaints specifically.

Background Triage aims to detect critically ill patients and to prioritise those with time-sensitive needs. It also contributes to the overall efficiency of an emergency centre (EC). International systems have been relatively well researched; however, no data exists on the use of the SATS score in private healthcare settings in SA. Objectives This study aimed to describe the demographics, triage allocations, time spent in EC and disposition of all patients presenting to a private hospital EC in Pretoria, South Africa in 2018. Methods A retrospective descriptive study was undertaken. Data relating to demographics, triage, and hospital disposition were collected on all patients presenting to the EC during the 2018 calendar year. Descriptive data analyses were conducted in Microsoft Excel. Results A total of 29 055 patients were included in this study. More than half (57.6%) were adults aged 18 to 60 years and approximately one-fourth (27.5%) were paediatrics (<18 years). The majority of patients were triaged yellow (73.5%); 17.4% were triaged as red and orange. It took, on average, 28 minutes to be seen by a provider and patients spent an average of 2 hours and 20 minutes in the EC. Delays to be seen exceeded standards for red and orange patients at 8 and 18 minutes respectively, and the mean time these patients spent in the EC was higher (2h 51 minutes and 2h 47 minutes respectively). Most patients (76.1%) were discharged; 5.6% were admitted to ICU/high care, 14.4% to the general ward, and 3.9% either absconded or refused hospital treatment. Of patients triaged red and orange, 11.1% and 49.3% were discharged respectively, and these patients used the most resources . Conclusion This study found that most of the patients were triaged into low acuity categories (yellow and green) and discharged home. High acuity patients were usually admitted to ICU or high care; however, these patients experienced delays in being treated and admitted. Causes of these issues, and implications on patient outcomes remain unknown. Large numbers of high acuity patients were ultimately discharged home. Further studies are needed to understand the influence of triage accuracy on these patients' outcomes.

Introduction: Acute pain is a common reason for seeking emergency care in the prehospital and emergency centre settings where pain prevalence ranges widely. Pain is a significant global health problem which often goes unnoticed and is undermanaged. To this end, a project consisting of a series of research studies aimed to develop an understanding of acute prehospital pain assessment and management in South Africa was conducted to identify how best to improve this field. Methods: The project consisted of four distinct objectives to be investigated as separate but interconnected studies. The first objective was answered through a secondary research methodology (scoping review) to identify and map the body of evidence on acute prehospital pain assessment and management in Africa. The remaining three objectives were answered using primary research methods in studies conducted in the Western Cape, South Africa. Two observational studies, (i) a cross-sectional online survey and (ii) a retrospective review, respectively, aimed to describe (i) the knowledge, attitudes and practices regarding prehospital acute pain assessment and management among emergency care providers and (ii) current prehospital acute pain assessment and management practices in high acuity trauma patients. The final study employed qualitative research methods using focus groups and content analysis to explore and describe emergency care providers' perspectives of acute pain assessment and management as well as perceived barriers and facilitators to pain management. Main results: In the scoping review, six publications on acute pain research in the African prehospital setting were identified, indicative of the paucity and immaturity of this research area. In the cross-sectional online survey, suboptimal levels of knowledge and attitudes regarding pain (58.01%) were found among emergency care providers, with gaps in all aspects of pain knowledge and attitudes of distrust in self-reported pain identified. The retrospective review recorded pain scores were documented in only 18.1% of the high acuity trauma patients reviewed, while moderate-to-severe pain (78.6%) was prevalent among those who had a pain score documented. Less than 3% of all trauma patients, and less than 8% of those with moderate-to-severe pain received analgesic medication, thus, suggesting less than ideal prehospital pain assessment and management practices. In the final qualitative study, six focus groups and one interview were conducted among 25 emergency care providers. Through content analysis five themes, namely: assessing pain is difficult in this setting; many factors affect clinical reasoning some unique to this (hostile) setting; basic and intermediate life support practitioners' reality of prehospital pain care; the emergency centre does not understand what we do, how we work, what it is like; and how can we do better; emerged from the data. Conclusion: Africa has a scarcity of prehospital pain research with current evidence mainly from South Africa while knowledge of prehospital pain assessment and management in the Western Cape, South Africa proved to be a significant gap. This gap appears to be underpinned by limited educational focus, lack of pain prioritisation in emergency medical services (EMS) organisations, lack of clear evidence-based prehospital pain clinical practice guidelines, and emergency care providers' indifference towards prehospital pain care. A joint approach from EMS organisations and educational institutions, coupled with clinical practice guideline development, as well as interdisciplinary collaboration between prehospital emergency care and emergency medicine, are required. Further research must focus on developing the body of African prehospital pain knowledge to inform clinical practice and advance quality prehospital pain care.

Introduction: Acute coronary syndromes, including ST-elevation myocardial infarction (STEMI), are a leading cause of morbidity and mortality worldwide. Existing research shows that prehospital care provided by emergency medical services (EMS) can significantly improve outcomes. However, EMS remains grossly underutilised in Abu Dhabi despite a well-established presence. Objectives: In this three-part quantitative, observational study, we sought to (1) assess physicians' perceptions of, and recommendations for, utilization and improvement of EMS, (2) assess patients' awareness of EMS, mode of transport use in decision to seek care and reasons for their decision, and (3) establish if in the current study setting, mode of transport used has implications for in hospital adverse events, as well as short and long term clinical outcomes. The goal was to investigate both physicians' and patients' perceptions of prehospital STEMI care, as well as to assess the clinical correlates of the mode of transport in a patient's decision to seek care. Methods: We conducted the study in three phases. Phase 1: At four government-operated hospitals in Abu Dhabi, we administered surveys to a convenience sample of physicians involved in care of patients with acute coronary syndromes to measure (a) likelihood of recommending EMS, (b) satisfaction with EMS, (c) likelihood of using EMS for self or family, and (d) recommendations for prehospital care of acute coronary syndromes. Phase 2: We gathered mode of transport data from a purposive, non-random sample of 587 consecutive patients with STEMI over an 18-month period and conducted structured follow-up interviews to assess their perceptions of EMS. We conducted analysis to determine whether mode of transport was related to demographic variables. Phase 3: We collected medical records from patient participants and conducted structured follow-up interviews at 1, 6 and 12 months post discharge. We conducted chi square difference testing to determine the relationships among mode of transport, treatment times, and short- and long-term clinical outcomes. Variables included treatment times and associated outcomes. Results: Physician participants (n = 106) were most supportive of prehospital 12-lead ECG for STEMI, but indicated low satisfaction with existing EMS services in Abu Dhabi. Among STEMI patient participants (n = 587), EMS was underutilized in Abu Dhabi; over half (55%) of patients did not know the phone number to contact EMS, and only 14.7% used EMS in their decision to seek care. EMS-transported patients were more likely to receive timely treatment (door-todiagnostic ECG time, door-to-balloon time) and had lower incidence of mortality compared to privately-transported patients. Conclusions: These findings suggest a need to raise public awareness of EMS and its importance for coronary symptoms in Abu Dhabi. Broader application of prehospital ECG, including prehospital activation of cardiac catheterization labs, bypassing non-interventional cardiology centres, and admission directly to facilities that provide these services without initial admission to the emergency department, could help improve physicians' perceptions of EMS and outcomes for patients with STEMI.