Background There is a growing need for Emergency Medical Services (EMS) globally and in Africa, as health services develop. The establishment and continued operation of volunteer ambulance services might assist with this need. This study provides a comprehensive overview of the operational activities of a volunteer ambulance service and forms a first step for further studies of this and other volunteer ambulance services. Objectives This study describes and quantifies the operational activities of Hout Bay Volunteer Emergency Medical Service (Hout Bay EMS) a volunteer ambulance service in Cape Town, South Africa for a one year period from 1 January to 31 December 2016. Methods This retrospective study describes call-outs, shifts and service demographics of Hout Bay EMS for 2016, using Provincial EMS dispatch data and shift records from Hout Bay EMS. Performance comparisons are drawn between Hout Bay EMS and Provincial EMS. Outcomes In the study period, there were 682 call-outs involving Hout Bay EMS, a total mission time of 951 hours worked over 119 shifts by 31 active members in 2016. Assault was the leading call-out type (18.40%); 58.24% of call-outs were Priority 2 (less urgent), and 39.30% of call-outs ended in no patient transport. Response times to Priority 1 call-outs were generally shorter for Hout Bay EMS than those of Provincial EMS within the Hout Bay area. Members largely preferred night shift to day shift by a factor of 4:1; the majority of shifts were worked by Basic Life Support (28.57%) and Intermediate Life Support (57.98%) qualified members compared to the relatively few shifts (13.44%) worked by Advanced Life Support members. This study shows that a small volunteer ambulance service mostly active on weekends can successfully complement the efforts of the larger, full-time provincial ambulance service it is dispatched by. This model could be replicated elsewhere to meet the growing need for emergency medical services.

Introduction Triage allows prioritisation of the most severely ill in emergency centres that face a complex and growing burden of disease. The presenting symptom is an independent variable that informs acuity and directs resource allocation. This study describes the most common presenting complaints and linked diagnoses, in total and for each category of the South African Triage Scale (SATS) at Mitchell’s Plain Emergency Centre Methods A retrospective, cross-sectional, chart review was used. The sample consisted of patients who presented to Mitchell’s Plain EC in January and June 2015. Charts were reviewed via the Electronic Content Management system. Data were collected on demographic profile, triage priority, presenting symptoms at triage, and ICD-10 diagnosis on EC disposition. Results 3434 of 4335 charts that were reviewed were suitable for inclusion. Triage acuity was 13.8% (n=475) green, 41.0% (n=1409) yellow, 32.5% (n=1116) orange and 4.3% (n=148) red. Trauma (9.7%) and abdominal pain (8.6%) were the most common presenting complaints- the majority of these were triaged as yellow cases. The most common diagnosis made was pneumonia (3.4%) – most frequently presenting as shortness of breath (14.4%). High acuity complaints were predominantly medical. Triage and clinicians report of the main complaint correlated in 74.3% of cases (r=0.7). The majority of patients and highest proportion of high priority patients presented on Mondays and Saturdays. Conclusion Mitchell’s Plain EC has complex caseload with a significant burden of trauma presentations related to interpersonal violence and penetrating assault. Respiratory and gastrointestinal symptoms due to infections were common across triage acuities, and cardiac or neuropsychiatric complications of chronic diseases presented frequently in high priority categories. Describing these presentations and their linked characteristic diagnoses will allow for further research into clinical flow pathways between arrival and disposition. Staffing requirements may be determined by linking these pathways to reality based time frames.

Background: Limited health service resources must be used in a manner which does "the most for the most". This is partly achieved through the use of a triage system, but health workers must understand it, and it must be used routinely. Whereas efforts have been made to introduce paediatric triage in Uganda, such as Emergency Triage Assessment and Treatment Plus (ETAT+), there is no unified adult triage system being used in Uganda, and it is not clear if hospitals have local protocols being used in each setting. There are limited data on adult triage systems in Uganda. This study aimed at determining how adult hospital-based triage is performed in hospitals in northern Uganda. Methodology: This was a descriptive study. Allocating numbers to the three sub-regions in the northern region, and using a random number generator, we randomly selected the Acholi sub-region for the study. The study was conducted in 6 of the 7 hospitals in the region - one hospital declined to grant permission for the research. It was a written questionnaire survey under supervision of the investigator. In each hospital, at least one representative of nurses in various duty shifts (night, morning and evening shifts), the nursing in-charge/leader, at least one doctor (head of department or any doctor on duty, if available) and a clinical officer (physician assistant, if available), making a minimum of 5-6 study participants who were health professional staff working in emergency receiving areas from each hospital consented and participated in the study. Results: Thirty-three participants from 6 hospitals including 5 doctors, 4 physician assistants, 11 registered nurses, 9 enrolled nurses and 4 nursing assistants consented and participated in the study. Experience of staff working in emergency receiving areas varied with 15(45.5%) greater than 2 years, 7(21.2%) 1-2 years, 5(15.2%) 6 - <12 months and 6(18.2%) for less than 6 months. Only one hospital (16.7%) of the 6 hospitals surveyed had a formal adult hospital-based triage protocol in place. The triage guide/protocol/charts were kept in drawers, had 3 colours - red, yellow and green. Staff rated it as "good", and all staff acknowledged the need to improve it. Only 2 (33.3%) hospitals had an allocated emergency department, the rest receive emergency patients/perform triage from Out Patient Department (OPD) and wards. Lack of training, variation of triage protocols from hospital to another, shortage of staff on duty, absence of national guidelines on triage and poor administrative support were the major barriers to improving/developing formal triage in all these hospitals. Conclusion: Formal adult, hospital-based triage is widely lacking in northern Uganda, and staff do perform subjective "eyeball" judgments to make triage decisions. Most hospitals do not have specifically allocated emergency department which risks disorganization in the flow of patients, crowding and consequently worse patient outcomes.

Emergency care is an integral part of an effective healthcare system. However, emergency care systems remain largely underdeveloped in low- and middle-income countries, particularly in Sub-Saharan Africa. Somalia is in the horn of Africa. Decades of civil war, political instability, and terrorism insurgency have greatly hampered healthcare in the country, and the country does not have a formal emergency care system. The aim of the study was to assess the current provision of emergency care in healthcare facilities in northern Somalia, namely Somaliland and Puntland. This was a cross-sectional descriptive study carried out in all emergency units in Hargeisa and Garowe, the capital cities of Somaliland and Puntland respectively. A standardised WHO emergency care assessment tool was used to assess the performance of emergency care procedures in the emergency units. Simple descriptive statistics were used to analyse the data. Six facilities - two in Puntland, and four in Somaliland - participated in the study. Two of these were regional referral public facilities, while the rest were private. The performance of sixty emergency care procedures was assessed. Absent equipment was the main reason (47%, n=60 for the non-performance of these emergency care procedures. Lack of training (29%), stock out of supplies (13%), and lack of skilled personnel (10%) were the other reasons for the non-performance of these emergency care procedures. The findings of this study underscore the need for more resource allocation with a focus on equipping emergency units and having adequate supplies. The study also highlights the need for training of healthcare providers who routinely provide care in emergency units.

This dissertation seeks primarily to enlighten the medical fraternity about the development of a stroke service at Constantiaberg Medi-Clinic and, additionally, how this has been implemented. The objective is to try to improve the outcome of patients presenting with various types and levels of neurological deficits as a consequence of cerebrovascular accidents.

Includes bibliographical references. / Whilst a disaster is typically thought of as a naturally occurring event (such as an earthquake or tidal wave), a mass casualty situation may occur from a natural or man-made source (such as a mass transportation collision, or industrial fire). In many higher income countries, mass casualty situations tend to be referred to as Major Incidents. Although a standard understanding of what constitutes a major incident has not been agreed, with the term being interchanged with both mass casualty incident and disaster, for health services a major incident may be considered to be: “any occurrence which presents a serious threat to the health of the community, disruption to the service or causes (or is likely to cause) such numbers or types of casualties as to require special arrangements to be implemented by hospitals, ambulance services or health authorities”. (Major incidents for services other than the Emergency Medical Services (EMS) will not affect health providers, and so are not considered in any more detail here.) This definition is intentionally broad, to cover incidents from food poisoning outbreaks to planning for mass gatherings. However, major incidents are generally regarded as events which are unpredictable, sudden and which result in a large number of injured or ill casualties presenting to the emergency services over a short period of time. The alternative term used is Mass Casualty Incidents (MCI), loosely described as “the most demanding and chaotic events a responder will ever be confronted with”, the ultimate goal being to get the greatest number of survivable patients to treatment facilities in the shortest amount of time. The point at which a major incident occurs is dependent upon the ability of health service resources at the time of the incident to cope with the patient workload. Major incidents may therefore occur with relatively small numbers of casualties if resources are scarce: this is particularly likely to occur in low and middle income countries where healthcare resources are limited at the best of times. The health services definition also takes into account the severity of injury, as an incident resulting in a small number of casualties may require a major incident response if they are all severely injured. Currently there does not exist a form of quality measurement for evaluation of a response to a major incident but emergency services aim for an early activation of sufficient personnel, rapid access to a secured scene and efficient patient evacuation to the correct facility. In the Western Cape a major incident is declared at the discretion of the most senior Emergency Medical Services (EMS) staff who are present at the scene. Usually this includes: where the resources used are more than 2 ambulances, other agencies are involved (Fire and Rescue) or 3 or more patients, 5 most commonly though the MIMMS definition is used “any incident where the location, number, severity or type of live casualties requires extraordinary resources”. The objectives of this study were (i) to describe the incident type related to total number in the study, (ii) to describe the severity in relation to total number of patients, (iii) to describe the weather conditions prevalent at incidents, (iv) to determine weather conditions associated with red triage category, and (v) to determine which vehicle types are involved in MVC’s. This is the first study to describe major incidents in an African setting. Understanding the types of incidents responded to and the injury severity of patients, will allow more robust planning for future similar incidents. Further to this prevalence of incidents in particular traffic related “hot spots” can be identified and problems rectified.

Background KwaZulu-Natal (KZN), a large province of South Africa has vast distances to referral centres and time to definitive treatment is key in trauma care. Helicopter Emergency Medical Service (HEMS) is an invaluable prehospital asset for the transport of time sensitive trauma. This study reviews the impact of HEMS in the management of trauma at Inkosi Albert Luthuli hospital (IALCH) which is the only public accredited level one trauma centre in the province. Methods A retrospective descriptive study of polytrauma patients transported by HEMS in KZN to IALCH over a three-year period from 01 January 2014 to 01 January 2017. Data was collected around patient demographics, transfer details and patient outcomes. Results Over the three-year period, 117 HEMS transfers were reviewed, with the majority being male (90.6%). Just 26% of HEMS transfers were direct from the scene, with the balance being interhospital transfers largely from distant regional hospitals around the province. Some 60% of injuries were causes by vehicle crashes, and 31% by intentional injury. Mortality was 30% which is reflective of the high severity of injury of the cohort. The injury severity scores (ISS) (median 26 overall) of those who died was higher (median 38) (p-value= 0.0002), and there were more interventions before and during transfer such as thoracostomy, ventilation and immobilization. Some 88% were admitted to ICU at IALH. Conclusions: HEMS in the KwaZulu Natal province was mainly used for long-distance transfer of major trauma patients which is an appropriate use of this essential service, given the single major trauma centre in the province. The majority of patients that were transported by HEMS had severe injury, which was also associated with increased mortality outcomes. Rational use of this essential but expensive resource will require clear policy around the role of HEMS and call out criteria in each setting.

Objective: To determine whether the establishment of a dedicated obstetric and neonatal flying squad resulted in improved performance within the setting of a major metropolitan area. Design and Setting: The Cape Town metropolitan service of the Emergency Medical Services was selected for a retrospective review of the transit times for the newly implemented Flying Squad programme. Data were imported from the Computer Aided Dispatch programme. Dispatch, Response, Mean Transit and Total Pre-hospital times, relating to the obstetric and neonatal incidents was analysed for 2005 and 2008. Results: There was a significant improvement between 2005 and 2008 in all incidents evaluated. Flying Squad dispatch performance improved from 11.7% to 46.6% of all incidents dispatched within 4 minutes (p< 0.0001). Response time performance at the 15- minute threshold did not demonstrate a statistically significant improvement (p=0.4 .. ) although the improvement in the 30-minute performance category was statistically significant in both maternity and neonatal incidents. Maternity incidents displayed the greatest improvement with the 30-minute performance increasing from 30.3 % to 72,9%. The analysis of the mean transit times demonstrated that neonatal transfers displayed the longest status time in all but one of the categories. Even so, the introduction of the Flying Squad programme resulted in a reduction in a total pre-hospital time from 298 minutes to 184 minutes. Conclusion: The introduction of the Flying Squad programme has resulted in significant improvement in the transit times of both neonatal and obstetric incidents. In spite of the severe resource constraints facing developing nations, the model employed offers significant gains.

Introduction: Helicopter Emergency Medical Services (HEMS) forms an important role in integrated modern emergency medical services and have a suggested mortality benefit in certain patient populations, such as those affected by severe trauma or with time-sensitive pathologies in rural areas. Despite this, HEMS is an expensive resource used in South Africa and appropriate use and feasibility in low-to-middle income countries (LMIC) is highly debated. To maximise benefit, it is essential that the right patients be selected for HEMS. In order to evaluate this, the current practices first need to be described. The aim of this study was to describe a population of patients being transported by HEMS in South Africa, in terms of flight data, patient demographics, provisional diagnosis and clinical characteristics and interventions. Methods: A retrospective flight- and patient-chart review were conducted, extracting clinical and mission data of a private, single aeromedical operator in South Africa, over a 12-month period (July 2017 – June 2018) in Gauteng, Free State, Mpumalanga and North-West. Results: A total of 916 cases were included (203 primary cases, 713 interfacility transport (IFT)). The majority of the patients were male (n=548, 59.8%), suffered blunt trauma (n=379, 41.4%) followed by medical pathology (n=247, 27%) and neonatal transfers (n=184, 20.1%). Most flights occurred in daylight hours (n=729, 79.6%). Median mission times were 1-hour 53minutes for primary missions, and 3 hours 10 minutes for IFT cases. Median on-scene times were 26 minutes for primary cases and 55 minutes for IFT cases. Although many patients were transported with an endotracheal tube (n=428, 46.7%), more than a third did not have an advanced airway and received supplemental oxygen via other means (n=348, 37.9%). Almost half of patients received no respiratory support (n=414, 45.2%). No patients received fibrinolysis, defibrillation, cardioversion or cardiac pacing. Almost all patients received intravenous fluid therapy (n=867, 94.7%). The administration of sedation (n=430, 46.9%) and analgesia (n=329, 35.9%) were also common interventions. Conclusion: By describing current HEMS transport practices in one of the largest cohorts in Africa to date, a better understanding is gained of how HEMS is utilised daily. Apart from the lack of universal call out criteria and response to the high burden of trauma, HEMS seem to fulfil an important critical care transport role. Due to the lack of coordinated coronary care networks, it seems that cardiac pathologies are under-represented in this study and might have an important implication for crew training requirements.

Background: Access block is one of the most serious and frequently encountered system problems in the specialty of Emergency Medicine and, although well described internationally, within the South African setting limited research has been performed on the phenomenon. Objectives: To describe the total access block of adult patients and per specialty, the monthly variation of the degree of access block and its correlation to the monthly Emergency Centre head count, hospital bed occupancy rate and monthly patient days and the effect of any interventions made during the study period in an Emergency Centre (EC) at a regional hospital in Cape Town, South Africa. Methods: The study was a retrospective descriptive study of a pre-existing database of EC access block, monthly EC head count, hospital bed occupancy and hospital patient days from April 2015 to March 2017. Results: A total of 700 discrete data sets were analysed. The study period of 24 months was divided into two 12-month periods to allow year-on-year comparison – April 2015 to March 2016 (Year 1) and April 2016 to March 2017 (Year 2). The mean access block (SD) for the total study period was 109% (17.7) ranging from 69% to 139%, with a Mean Access Block of 106% for Year 1 and 113% for Year 2. Patients of the Internal Medicine Department made up the largest proportion of boarders in each month of the study period. The comparison of the month-to-month variation of MAB over the study period to the variation of the EC monthly head count showed a weak correlative trend between the two variables with regards to large month-on-month changes, but with no absolute correlation for discrete monthly comparisons (r(22) = .14, p = .53). Across the study period there was a direct correlation between BOR and PD (r(22) = .90, p< 0.001), and neither showed a significant correlation with the Mean Access Block. The Mean Access Block was 110% prior to the appointment of a dedicated Bed Manager in August 2016 and increased to 115% afterwards. The Bed Occupancy Rate also increased from 89% prior to 92% after the appointment. Conclusions: The severity of access block was demonstrated using a basic system of recording Mean Access Block for a 24-month period and demonstrated that, on average, all available space was occupied by boarding patients. Whilst the hospital's patient ‘flow' system should address increased access block, the systems employed mostly failed. Although it had no direct positive effect on the Mean Access Block, a dedicated bed manager appeared to make a positive change in how the inpatient system compensated for access block.