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).

Includes bibliographical references (leaves 68-73).

Introduction Maintaining the airway is an essential element in the care of any ill or injured patient. Inadequate management of the airway may lead to hypoxia and hypercarbia with subsequent secondary brain injury, cardiopulmonary arrest, and ultimately death. The aim of the study was to identify which airway devices are available in public emergency centres of referral hospitals in Namibia and to determine the perceived level of knowledge of use regarding these devices. Methods A cross-sectional study was conducted in four emergency centres of referral hospitals in Namibia. Data regarding the availability of airway devices were collected on a standardised data sheet by means of a site inspection. A questionnaire was also distributed to emergency centre doctors to assess their perceived knowledge of use of airway devices. Descriptive statistics of all variables are reported. Results Twenty-two different airway devices were documented at study hospitals. All centres had some form of basic airway devices. Only one (25%) had venturi-masks. Two centres (50%) had one type of introducer (Gum elastic bougie) whilst none of the centres had video laryngoscopes, surgical airway devices or laryngeal tubes. Twelve participants (32.4%) had received formal training on airway devices (senior clinicians n=6, junior clinicians n=6), and 25 (67.6%) had no formal training (senior clinicians n=11, junior clinicians n=12). Majority of the clinicians lacked perceived knowledge in the use of alternative airway devices which were not available in their respective emergency centres, with a frequency of 81.4%. Conclusion The study indicates that basic airway devices are available in referral emergency centres in Namibia, however most of the alternative airway devices are not adequately stocked in the sampled emergency centres. Furthermore, a large number of clinicians had perceived knowledge of the basic airway devices. However, the perceived level of knowledge of use in alternative airway devices was inadequate.

Background Simulation learning is an educational strategy that has been used in South African Emergency Care Practitioner training for at least a decade. No authors had previously measured the satisfaction of South African ECP students with simulation learning. Objective The objectives of this study were to explore the simulation satisfaction of students from two universities in South Africa, and to describe the simulation satisfaction using descriptive statistics. Methods This cross-sectional, descriptive, quantitative study used an English, electronic version of the SSES with one item from the tool deleted. Results A total of 81 students participated in the study - 32 from Nelson Mandela University (NMU) (39.5%) and 49 (60.5%) from the University of Johannesburg (UJ). Statistically significant differences were noted between the two groups in all three factors between the students from NMU and UJ: debriefing and reflection (median = 3.5 vs median = 4.2; p = 0.000; r = 0.5), clinical reasoning (median = 3.6 vs median = 4.0; p=0.002; r = 0.3.) and clinical learning (median = 3.7 vs median = 4.0; p=0.005; r = 0.3). Conclusions Students from both universities have had an overall positive experience of simulation learning, the students from UJ reported higher levels of satisfaction with simulation. These data provide important information for ECP student educators and highlight areas of satisfaction as well as dissatisfaction with simulation learning. This study also indicates that further research is required into the ECP student experiences of simulation learning in South Africa.

Background: Tuberculosis (TB) is a major healthcare problem worldwide and is endemic to Cape Town, South Africa. Health Care Workers in Emergency Centers (ECs) are at high risk of nosocomial TB infection. The aim of this study was to determine whether the isolation rooms (IRs)in emergency centers, for patients with diagnosed or suspected TB, comply with set National Core Standards. Methods: This was a cross-sectional descriptive study of ECs in the Cape Town Metropolitan area. .The characteristics of IRs with regards to air changes per hour (ACH), negative pressure ventilation with relation to the surrounding areas and appropriate discharge of air outdoors or via filters before recirculation was measured using standard objective engineering methods. Results: 19 IRs in 8 ECs were evaluated, none of which complied with the National Core Standard's ideal requirements for IRs. Five complied with minimal requirements . Eleven (57,9%) IRs were designed to have negative pressure; and 8 (42,1%) rooms were not designed for isolation purposes, . IR volumes ranged from 15,5 m³ to 67,2 m³ (median 35,6 m³). Five (26,3%) IRs were under negative pressure; 7 (36,8%) had erratic air flow; and 7 (36,8%) showed positive airflow from the IR into adjacent clinical areas. Fifteen (78,9%) IRs had central provision of air via a ventilation system; 6 (31,6%) had central air extraction; 6 (31,6%) had local extraction; and 7 (36,8%) used natural ventilation only. Four local extraction units had zero flow rate. Airflow in naturally ventilated IRs was significantly lower than flow with other systems (p = 0,0002). The ACH ranged from 0 (n=4) to 112.37 (median 11,9); and was significantly greater in rooms ventilated with central extraction compared to other systems (p = 0,00002). Discussion: The ventilation aspects of airborne infectious disease control are generally poorly implemented. This may contribute to, and fail to mitigate, the high risk of nosocomial transmission of airborne infectious diseases to staff and other patients utilising emergency facilities in the TB endemic areas of Cape Town. Conclusion: Existing ECs should improve adherence to standards of airborne infectious disease transmission prevention in order to protect patients and staff from nosocomial airborne transmitted diseases, such as TB. New Hospitals should place a high priority on the amount, positioning and maintenance of IRs when planning their facility.

Includes abstract. Includes bibliographical references.