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.

Introduction Reduction of forearm and wrist fractures is a common practice in the Emergency Centre (EC). EC doctors must be familiar with the appropriate management thereof. The standard treatment of a fracture involves reduction and immobilization. This study aims to describe the diagnostic and management accuracy of EC clinicians using validated vignettes (also used as the reference standard) of adult patients with closed fractures of the forearm or wrist. Methods This is a prospective, cross-sectional study in the form of an electronic questionnaire to address the study aim. A set of vignettes were created and then validated to serve as the control for the study participants. The study was open to emergency medicine consultants, emergency medicine trainees/registrars, medical officers, and community service medical officers employed at a secondary-level public hospital EC in the Cape Town metropole. Comparison is made by the number and proportions of correct and incorrect answers using the vignette reference standard. Data were analysed using ChiSquare (X2). Results For the diagnosis of forearm and wrist fractures, EC clinicians present 86,8% (1309/1508) correct responses (p=0.68) and, for the course of action, 78% (278/354) correct responses (p=0.09). For the overall management of the fractures (diagnostic and course of action), EC clinicians answered correctly to 84,9% (1585/1866) and incorrectly to 15,1% (281/1866), although the difference by each EC clinician group.was not significant (p=0.72). Conclusion In Western Cape, EC doctors appear to fare better than reported in the literature. However, this can not be shown definitively with this dataset. Regular training is necessary for all clinicians working in EC to improve their skills in managing forearm and wrist fractures, including the interpretation of X-ray imaging. Clear and good notes in the patient folder, top-quality X-ray images, good EC work environment, and improvement between doctors communication are other sets of requirements important to help to avoid errors in fracture management.

Background Despite privacy and legal concerns, social media is used to provide real-time clinical support to emergency care providers. It can be particularly beneficial for those in Africa, who might lack adequate training or access to information. This PhD aimed to describe the use of social media as a point-of-care telemedicine tool in facility-based emergency care in Africa, to further inform its use. Methods A scoping review was conducted to map available literature on use, benefits, and risks associated with social media as a point-of-care platform. A mixed methods approach was then taken using a cross-sectional survey and semi-structured interviews to obtain a comprehensive description of use of social media as a point-of-care tool in facility-based emergency care in Africa. Results The scoping review identified 13 publications describing use of social media as a point-of-care tool in emergency medical settings. No studies were located in low-income countries. All studies evaluated WhatsApp use for real-time consultations, and those that assessed reliability found it to be highly reliable for consultations. A total of 70 emergency care providers in African facilities responded to the survey; nearly all worked in low- or lower-middle-income countries. Responses showed that clinicians use social media multiple times each day, primarily to share and receive advice. The majority felt social media positively impacts patient and provider experiences and improves speed and safety. Finally, eight African emergency care providers were interviewed to gain an in-depth understanding of how social media use impacts emergency care. All participants noted routine use for a range of professional purposes, including consultations, administrative tasks, and education. Concerns were mentioned by all participants, including legality, privacy, and lack of employer regulations. Conclusions This dissertation provides insight into social media use of African emergency care physicians, showing that social media use in this group is ubiquitous. Most clinicians use social media multiple times each day for a range of point-of-care purposes, and many feel social media is positively impacting both the patient and provider experiences. Post-doctoral work will focus on developing a framework to guide use of social media in facility-based emergency care in the African setting.

Background The COVID-19 pandemic has profoundly impacted some of the most vulnerable populations in low-resource settings (LRS) across the globe. These settings tend to have underdeveloped healthcare systems that are exceptionally vulnerable to the strain of an outbreak such as SARS-CoV-2. LRS-based clinicians are in need of effective and contextually appropriate triage and assessment tools that have been purpose-designed and validated to aid in evaluating the severity of potential COVID-19 patients. In the context of the COVID-19 crisis, a low-input severity scoring tool could be a cornerstone of ensuring timely access to appropriate care and justified use of critically limited resources. Machine learning was used on data from a retrospective cohort of Sudanese COVID-19 patients to derive a contextually appropriate mortality scale for COVID-19, the African Federation for Emergency Medicine COVID-19 Mortality Scale (AFEM-CMS) model. This MSc aimed to validate the AFEM-CMS, to assist frontline providers in rapidly predicting severe COVID-19 disease in LRS emergency units (EUs) in Sudan. Methods A retrospective quantitative analysis of data collected on adult patients aged 18 years and older screened as potentially positive for COVID-19 was undertaken to validate the AFEMCMS in the same Sudanese setting from which it was derived. Data for this study were collected retrospectively by non-clinical personnel from four government referral hospitals in Sudan's Khartoum State from 01 September 2020 and 31 January 2021. This study's primary outcome was in-hospital mortality due to SARS-CoV-2 infection. A set of predictor variables was collected for all patients based on the requisite inputs for the AFEMCMS tool. The predictor variables comprise demographic and historical data (age and sex), the number of existing comorbidities a patient has on presentation, and a number of clinical inputs (GCS, systolic blood pressure, respiratory rate, heart rate, and pulse oximetry). The AFEM-CMS was validated using C-index measurements (area under the receiver operator curve (AUROC)) in the validation dataset. All analyses were performed in R (version 4.1.0, © The R Foundation) with the dplyr, finalfit, glmnet, mice, pROC, rmda, and tidyverse packages. 4 Missing datapoints were managed using multiple imputation by chained equations (MICE), which imputed values for predictor variables with less than 33% of data points missing. Ethical approvals for this study were obtained from the University of Cape Town and the Sudanese Ministry of Health. Results In this study, the AFEM-CMS was validated against a 936-patient cohort, all of whom All of these included cases met the WHO definitions for suspected, probable, or confirmed SARSCoV-2 infection. Similar to initial derivation outcomes, the tool was found to have reasonable discriminatory power in identifying those at greatest risk of death from COVID-19: The model including pulse oximetry had a C-statistic of 0.732 (95% CI: 0.687-0.777) and the model excluding pulse oximetry had a C-statistic of 0.696 (0.645-0.747). Conclusions This dissertation establishes what is, to our knowledge, the validation of the first COVID-19 mortality prediction tool intentionally designed for frontline providers in LRS. The validation of the AFEM-CMS highlights the feasibility and potential impact of real-time development of clinical tools to improve patient care, even in times of surge in LRS. This study is just one of hundreds of efforts across all resource levels suggesting that rapid use of machine learning methodologies holds promise in improving responses to pandemics and other emergencies. It is our hope that, in future health crises, LRS-based clinicians and researchers can refer to these techniques to inform contextually and situationally appropriate clinical tools and reduce morbidity and mortality.

Thesis (M. P. A.)--Texas State University-San Marcos, 2006. / "Spring 2006." Includes bibliographical references (leaves 50-53).