Introduction A key principle in the effective management of a major incident is triage, prioritising patients on the basis of their clinical acuity. However, existing methods of primary major incident triage demonstrate poor performance at identifying the Priority One patient in need of a life-saving intervention. The aim of this thesis was to derive an improved triage tool. Methods The first part of the thesis defined what constitutes a life-saving intervention. Then using a retrospective military cohort, the optimum physiological thresholds for identifying the need for life-saving intervention were determined; the combination of which was used to define the Modified Physiological Triage Tool (MPTT). The MPTT was validated using a large civilian trauma database and a prospective military cohort. Subsequently, to describe the safety profile of the MPTT, an analysis of the implications of under-triage was undertaken. Finally, pragmatic changes were made to the MPTT (MPTT-24) - in order to provide a more useable method of primary triage. Statistical analysis was conducted using sensitivities and specificities, with triage tool performance compared using a McNemar test. Results 32 interventions were considered life-saving and the optimum physiological thresholds to identify these were a GCS <14, 12 < RR <22 and a HR < 100. Within both the military and civilian populations, the MPTT outperformed all existing methods of triage with the greatest sensitivity and lowest rates of under-triage, but at the expense of over-triage. Applying pragmatic changes, the MPTT-24 had comparable performance to the MPTT and continued to outperform existing methods. Conclusion The priority of primary major incident triage is to identify patients in need of life-saving intervention and to minimise under-triage. Fulfilling these priorities, the MPTT-24 outperforms existing methods of triage and its use is recommended as an alternative to existing methods of primary major incident triage. The MPTT-24 also offers a theoretical reduction in time required to triage and uses a simplified conscious level assessment, thus allowing it to be used by less experienced providers.

Includes bibliographical references / Background: Emergency care of critically ill or injured children requires prompt identification, high quality treatment and rapid referral. This study examines the critical care pathways in a health system to identify preventable care failures by evaluating the entire pathway to care, the quality of care at each step along the referral pathway, and the impact on patient outcomes. Methods: A year-long cohort study of critically ill and injured children was performed in Cape Town, South Africa, from first presentation until paediatric intensive care unit admission or emergency centre death, using a modified confidential enquiry process of expert panel review and caregiver interview. Outcomes were expert panel assessment of quality of care, avoidability of death or PICU admission and severity at PICU admission, identification of modifiable factors, adherence to consensus standards of care, as well as time delays and objective measures of severity and outcome. Results: The study enrolled 282 children: 85% medical and 15% trauma cases (252 emergency admissions, and 30 children who died at referring health facilities). Global quality of care was graded poor in 57(20%) of all cases and 141(50%) had at least one major impact modifiable factor. Key modifiable factors related to access and identification of the critically ill, assessment of severity, inadequate resuscitation, delays in decision making and referral, and access to paediatric intensive care. Standards compliance increased with increasing level of healthcare facility, as did caregiver satisfaction. Children presented primarily to primary health care (54%), largely after hours (65%), and were transferred with median time from first presentation to PICU admission of 12.3 hours. There was potentially avoidable severity of illness in 74% of children, indicating room for improvement. Conclusions and Relevance: The study presents a novel methodology, examining the quality of paediatric critical care across a health system in a middle income country. The findings highlight the complexity of the care pathway and focus attention on specific issues, many amenable to suggested interventions that could reduce mortality and morbidity, and optimize scarce critical care resources; as well as demonstrating the importance of continuity and quality of care throughout the referral pathway.

Introduction: Upon inspection and evaluation of the Mediclinic Middle East emergency centres in the United Arab Emirates, inconsistencies related to triage were found. Of note, it was found that the use of various international triage systems within and between the emergency centres may have caused potentially harmful patient conditions. The aim of this thesis was to study the reliability and validity of existing triage systems within Mediclinic Middle East, and then to use these systems as a starting point to design, standardise and validate a single, locally appropriate triage system. This single triage system should be able to accurately and safely assign triage priority to adults and children within all of Mediclinic Middle East emergency centres. Methods: A System Development Life Cycle process intended for business and healthcare service improvement was expanded upon through an action research design. Quantitative and qualitative components were used in a five-part study that was conducted by pursuing the iterative activities set by an action research approach to establish the following: the emergency centre patient demographic and application of triage, the reliability and validity of the existing triage systems, a determination of the most appropriate triage system for use in this local environment and development of a best-fit novel triage system, establishment of validation criteria for the novel triage system, and determination of reliability and validity of the novel triage system within Mediclinic Middle East emergency centres. Results: Low-acuity illness profiles predominated the patient demographic; high acuity cases were substantially smaller in number. The emergency centres used a combination of existing international triage systems; this was found to be inappropriate for this environment. Poor reliability and validity performance of the existing triage systems led to the development of a novel, four-level triage system. This novel triage system incorporates early warning scores through vital sign parameters, and clinical descriptors. The novel triage system proved to be substantially more reliable and valid than the existing triage systems within the Mediclinic Middle East emergency centres. Conclusion: Through an initial systems analysis, it became clear that the Mediclinic Middle East emergency centres blindly implemented an array of international triage systems. Using an action research approach, a novel triage system that is both reliable and valid within this local environment was developed. The triage system is fit to be implemented throughout all the Mediclinic Middle East emergency centres and may be transposed to similar emergency centre settings elsewhere.

Background: Internationally, emergency medical services (EMS) are experiencing problems with recruiting, retaining and motivating advanced life support (ALS) practitioners. The persistent shortage of ALS practitioners in South Africa (SA) poses a challenge to the effective delivery of prehospital emergency medical care. The global demand for SA trained ALS practitioners is steadily increasing. SA EMS organisations are struggling to compete for these practitioners with the international market. The SA EMS industry currently has no effective approach to decrease the loss of ALS practitioners. This research study was therefore conceptualized to investigate factors that influence ALS practitioner recruitment, retention and motivation in an effort to enhance them. Methods: This study followed a sequential, explanatory, mixed method design. The two phase study was non-experimental and descriptive in nature. The quantitative phase was comprised of ALS practitioners (n=1309) and EMS managers (n=60) completing questionnaires. The qualitative phase of the study involved data gathering through focus group (n=7) discussions with ALS practitioners and semi-structured interviews with EMS managers (n=6). Quantitative data was analysed with Statistical Package for the Social Sciences (SPSS). Inferential techniques included the use of correlations and chi squared test values which were interpreted using p-values. Results: The study identified 19 recruitment, 25 retention and 16 motivation factors that influence ALS practitioners. Cumulatively, these factors revolved around the ALS practitioners' work environment, professional development and employment package. Strong recruitment factors that were identified include: ALS practitioner remuneration, skilled EMS management and organisation culture. Similarly, strong ALS practitioner retention factors that were identified include: skilled EMS management, remuneration, resources, availability of health and wellness programmes, recognition of practitioners, working conditions and safety and security. Strong ALS practitioner motivation factors included: remuneration, skilled EMS management and resources. Conclusion: More ALS practitioner training institutions are required to improve the number of these practitioners. EMS organisations must improve the work environment, employment package and professional development opportunities for ALS practitioners. Such practices will encourage ALS practitioner recruitment, retention and motivation.

Background: Every day, sick children die from time sensitive preventable illnesses. Due to an inadequate number of trained healthcare workers and high volumes of children presenting to Primary Healthcare Centres (PHC), waiting times remain high and often result in significant delays for critically ill children. Delays in the recognition of critically unwell children are a key contributing factor to avoidable childhood mortality in Cape Town, South Africa. Methodology: A stepped implementation approach was undertaken to develop and evaluate a context-appropriate prioritization tool to identify and expedite the care of critically ill children PHC in Cape Town, South Africa. Aim 1: To conduct a systematic review of paediatric triage and prioritization tools for low resource settings in order to evaluate the evidence supporting the use of these tools. Aim 2: To perform an exploratory study, to identify barriers to optimal care for critically ill children in the pre-hospital setting in Cape Town, South Africa. Aim 3: To develop an implementable context-appropriate tool to identify and expedite the care of critically ill children in PHC in the City of Cape Town, South Africa. Aim 4: Evaluate the reliability of this tool compared to established triage tools currently used in this setting. Aim 5: Evaluate the impact of implementing this tool, on waiting times for children presenting for care to PHC. Aim 6: Evaluate the effectiveness of this tool post real-world implementation in identifying and expediting the care for critically ill children. Findings: Post real world implementation SCREEN was able to significantly reduce waiting times in PHC for critically ill children. Compared to pre-SCREEN implementation, post-SCREEN the proportion of critically ill children who saw a PN within 10 minutes increased tenfold from 6.4% (pre-SCREEN) to 64% (post-SCREEN) (p<0.001). SCREEN is also able to accurately identify critically ill children, in an audit of 827 patient-charts SCREEN had a sensitivity of 94.2% and a specificity of 88.1% when compared to IMCI. Interpretation: The SCREEN program when implemented in a real-world setting has shown that it can effectively identify and expedite the care of critically ill children in PHC.

Includes abstract. Includes bibliographical references.

Introduction Out of hospital emergency medical service patients present unique challenges and ample opportunities for medical error to occur. Identifying medical error is important for mitigating future risk and improving patient safety. Hypothesis/problem Our study describes the adverse event registry of an emergency medical service system in a low resource setting over a six-year period. Methods The Western Cape Emergency Medical Services Adverse Event Registry were reviewed for the period 1 January 2010 to 31 December 2015. From these, all cases classified as an adverse event or near miss were extracted for in depth review. Demographics, type of error, and types of recommendations implemented are reported. Results Altogether 106 (69%) adverse events and 47 (31%) near misses were reported over the six-year period. The mean age of patients was 31 years (standard deviation ±24.8). Of these 65 (42%) cases were adult medical patients, 31 (20%) adult trauma patients, 15 (10%) obstetric patients and 42 (27%) paediatric patients. The caseload was observed to increase over the six-year period, whilst system medical errors decreased and individual medical errors increased over the same period. Conclusion In this low resource emergency medical service system, individual medical errors increased and system medical errors decreased as more recommendations derived from adverse events caused by the system errors were implemented. This created a greater need for individual and group training of EMS clinical providers. We recommend further research in order to adequate describe the reason for the increase individual medical error, as well as to find more effective means of detecting adverse events and near misses in this population.

Includes abstract. Includes bibliographical references.

This critical realist thesis explores academic success in the four-year Bachelor of Emergency Medical Care degree in South Africa. The Bachelor of Emergency Medical Care degree is a relatively new degree that is offered at four universities in South Africa. In view of the existing shortage of paramedics both in South Africa and on the African continent, an understanding of the factors that play a role in academic success may lead to an increase in the number of emergency care providers. Accordingly, this study was conceptualised to explore the reasons why academic success is either evident or absent among Bachelor of Emergency Medical Care students. The study utilised a sequential, explanatory, mixed methods research design. The quantitative phase consisted of an online survey that was disseminated to Bachelor of Emergency Medical Care students in South Africa with the aim of gaining an insight into their socio-cultural history. Continuous and categorical variables were described using basic descriptive statistics. The Pearson’s chi-square and Fisher’s exact test were used to test associations between the various survey variables and repeating a year. A p-value of less than 0.05 was considered to be statistically significant. During the qualitative phase focus groups were held with students while semi-structured interviews were conducted with lecturing staff members. The aim of the qualitative approach was to explore the causal powers and generative mechanisms that give rise to or enable the emergence or absence of academic success among Bachelor of Emergency Medical Care students. Thematic analysis was used to analyse results from the focus groups and semistructured interviews. A critical realist concept of the laminated system was also used to explore the themes that emerged. A total of 176 participants from an available sample of 408 students responded to the survey. Not repeating a year was significantly associated with two important variables, namely, the possession of a pre-existing emergency care qualification and not being a white student. The results revealed that the following interactive generative mechanisms played a role in the lack of academic success, namely, biological, socioeconomic, socio-cultural, normative, psychosocial and psychological factors while the following interactive generative mechanisms facilitated the emergence of academic success – psychological, psycho-social, normative and socioeconomic factors.

Despite several therapeutic advances in cardio-pulmonary resuscitation (CPR), there has been little overall improvement in the out-of-hospital, cardiac arrest (OHCA) survival rates. Reports indicate that, although the incidence and outcome of OHCA vary across the globe, the median reported rates of survival at hospital discharge have remained below 10% for the 30 years preceding this study. One of the factors associated with this low survival rate is the deficient quality of the CPR provided during an OHCA by paramedics. Despite revised training standards, structured CPR training programmes and industry-regulated CPR refresher training schedules, paramedic-delivered CPR (pdCPR) during OHCAs is reported to be both inadequate and rarely in line with established resuscitation guidelines. International resuscitation bodies such as the International Liaison Committee on Resuscitation (ILCOR) postulate the need for tailored CPR training interventions in order to improve CPR performance. The aim of this study was to investigate the impact of a tailored pdCPR training intervention on pdCPR performance. The study was conducted in four phases and, using a mixed-method, multiphase design the study developed, implemented and evaluated the impact of a pdCPR training intervention which had been designed and tailored to improve the acquisition and retention of knowledge and skills by ambulance paramedics (AP). The primary outcome measure used in the study was the achievement of a competent rating which reflected the ability of the AP in question to perform high-quality, effective CPR as determined and evaluated by a 26 measure CPR Rapid Evaluation Tool predicated on variables derived from the globally accepted Cardiff list. Each of the 26 measures represented a treatment element within a pdCPR care bundle and which had been shown to contribute to successful resuscitation.