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.

Introduction The benefits of family presence during adult resuscitation (FPDR) are well documented in the literature. However, despite apparent value, FPDR is not always practised. The purpose of this study was to evaluate the perceptions of Emergency Medicine physicians and specialist trainees regarding FPDR in South African public sector Emergency Centres. Method A descriptive study was undertaken, using an electronic survey which consisted of both open and closed-end questions. The Survey was distributed via email to 157 Emergency Medicine physicians and specialist trainees in South Africa. The data was collected and subjected to descriptive statistical analysis. Results Most South African Emergency Medicine physicians and trainees did not feel that FPDR interrupted patient care; did not feel it hindered the teams’ productivity; and did not believe it increases complaints about the quality of patient care. Despite this, practice of FPDR was found to be uncommon. Knowledge regarding FPDR guidelines was poor. Discussion The views of South African Emergency Medicine physicians and specialist trainees regarding FPDR is in keeping with other pro-FPDR countries. However, these views do not seem to translate into practice. FPDR education and development of local guidelines are recommended.

Background: Calling an ambulance is the first line for citizens in dealing with many healthcare emergencies. It is crucial for the caller to convey correct information regarding the patient’s emergency and on-scene location to the emergency services, resulting in prompt dispatch of correct emergency resources to the exact location. Although there is a good deal of focus on emergency medicine time parameters and outcomes, little is known about the experiences, perceptions and satisfaction level from those who have accessed pre-hospital Emergency Medical Services. Methods: A telephonic survey was conducted on individuals who had recently called for an ambulance, from the urban township of Langa, Cape Town. Surveys were conducted in the caller’s home language, using a standardized tool for collecting quantitative data around the call process, caller satisfaction, outcomes of the call, and issues experienced. Results: During June 2018, 50 callers completed the survey (69% response rate). Most callers (88%) used a personal mobile phone, and 83% called predominantly for medical problems in the daytime. Callers accessed the service by dialling a variety of emergency phone numbers. Callers were largely satisfied with the call (66%), and there were fewer language mismatches than expected. A need for better communication regarding ambulance status and over the phone medical advice was identified. A substantial number of inconsistencies were reported between callers’ outcomes and those from emergency communication centre which require further analysis. These inconsistencies, pointed into gaps within the emergency communication centre’s collecting and database system Conclusion: The study provided the first insight into pre-hospital emergency caller experiences and perceptions, highlighting important aspects perhaps not revealed through other metrics. Measurement of caller satisfaction can be a useful quality improvement tool, and would seem feasible without substantial resources. Further investigation into data capturing system and identification of call outcomes are recommended.

Introduction: Emergency medical services (EMS) who attend to natural disasters are at a high risk of experiencing numerous psychological and physical conditions that adversely affect their health and safety as well as their ability to serve their purpose. This study aimed to identify factors that affect EMS responders' health and safety in natural disasters and provide information to mitigate harm in future natural disasters. Methods: A scoping review was conducted to identify literature published between 2000 and 2020 relating to EMS responder safety in natural disasters according to a predetermined search strategy. Titles and abstracts were first screened, whereafter full texts were reviewed and extracted. Results: In total, 49 articles were identified and 22 articles were ultimately included. The findings from the research identified numerous factors and outcomes that affect the health and safety of responders attending to disasters. These could be categorised into mental and psychological issues (PTSD, suicidal ideation, depression) and physical issues (environmental, infectious, and traumatic conditions). Conclusion: Numerous health and safety hazards befall responders attending to natural disasters and the variability of their incidence commands case-specific prevention and mitigation strategies. There is poor monitoring of factors affecting the health and safety of responders as well as their consequences, making current mitigation and prevention strategies ineffective. Enhanced surveillance and reporting systems should be developed and implemented to inform and improve mitigation strategies.

Background: The objective of this study is to evaluate the emergency and disaster preparedness of military hospital emergency services, and to further, identify strategies for improvement in disaster preparedness and response. Saudi Arabia is prone to various man-made and natural disasters. Among these is the event of the annual pilgrimage termed Hajj, which annually presents the risk of overcrowding. Many of these disasters have resulted in mass casualties. Consequently, there has been increased emphasis on planning by disaster experts to establish and maintain an organized preparation for a wide range of emergencies. Emergency Medical Services (EMS) play a vital role in disaster management. Both pre-hospital EMS and in hospital emergency services are considered inefficient and inadequately prepared in disaster response and management. Most importantly, there is limited data on emergency care (EMS and hospital-based) disaster preparedness and responses in Saudi Arabia. Methods: We undertook a prospective cross-sectional, descriptive survey-based assessment of disaster preparedness. The research focused on collecting and analysing data through quantitative methods. To review the standard operating procedures (SOP), we sought all disaster plans and SOPs from management and emergency unit leadership at each of the 3 Medical Services Directorate (MSD) hospitals. We then undertook a questionnaire assessment, gathering quantitative data using close-ended questions and open-ended commentary surrounding a hospital's disaster response operating procedures. Results: We found a wide variability in the hospitals across the 22 themes in the survey. Most hospital emergency units have a good to excellent disaster plan. There were, however, concerns with the departmental standards with Radiology, Occupational Health, Critical Care, Respiratory Therapy, Pastoral Counselling, and provision made for the preservation of forensic evidence. Internal traffic flow and control issues presented relate to elevators manned and its prioritized usage. It is found that the area demarcated for media liaison needs improvement. Reception of casualties also needs attention and finally, relocation of patients and staff needs prioritisation. Conclusion: The study has highlighted several strengths in facility disaster preparedness and further shared the need for rigorous efforts required to improve the situation at some facilities. In general, most hospitals were found to have a good disaster management plan in place, however, a few covered all the recommended areas in sufficient detail.

Background Psychiatric boarding in Emergency Departments is a global challenge. Patients with mental and behavioural disturbances are disproportionally affected with boarding times up to three times longer than other patients. This retrospective cross-sectional study investigated the impact of an initiative to reduce psychiatric boarding on length of stay and readmission rate, as well as exploring the relationship between boarding times and length of stay. Methods All adult patients referred over a 24-month period (June 2017 – May 2019) for psychiatric admission from the Emergency Department of a Cape Town district hospital were included. This included a 9-month period prior to the initiative, after which inpatient capacity was increased, and inpatient hallway boarding was implemented. Data relating to admission processes and outcomes were extracted from electronic registries. Results In total, 2607 patients were referred for psychiatric admission (2.7% of all Emergency Department patients). The initiative was associated with a decrease of 95% (56 vs 3 hours, p24-hour boarding category (351 vs 360 hours, p=0.047). The readmission rate increased from 12% to 18% post intervention. Conclusion A significant improvement in hospital length of stay and psychiatric boarding times occurred after the initiative was implemented. The benefits should be weighed up against a subsequent higher readmission rate. From a lean- and economical perspective, the results of this study suggest that psychiatric boarding equates to waste as it is independent of ward length of stay. The observational nature of this study precludes concrete conclusions and further investigations into psychiatric inpatient hallway boarding are recommended.