This study explores how Community Emergency Response Teams (CERTs) were integrated within local emergency management systems pre-disaster. Semi-structured interviews were conducted following Rubin and Rubin’s (2005) Responsive Interviewing Model with 21 CERT team coordinators in FEMA Region VII (Iowa, Kansas, Missouri, and Nebraska). It found that teams varied with regard to integration, and this variance could be explained by a number of related factors. Results suggest that if a team has a skilled leader, stability as an organization, and acceptance by the local emergency management system, they are more likely to be integrated than a team that is lacking some or all of the aforementioned factors. This study categorizes teams on a continuum according to their integration. Finally, this study concludes with a discussion of implications for practice, policy, and research, as well as recommendations for practice and research.

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.

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.