Includes abstract. Includes bibliographical references (leaves 51-58).

Includes bibliographical references.

Background: The City of Cape Town, South Africa, has a large youth violence problem with the highest percentage of non-natural deaths per age group in Cape Town occurring between 15 and 24 years of age. Many authorities suggest that youth violence is preventable and there is a fast growing international knowledge base on how emergency centres (ECs) and EC personnel can contribute to youth violence prevention (YVP). In order to utilise this opportunity most effectively, it is important to understand the challenges faced by EC staff, their perceptions of youth violence, and their willingness to engage in YVP interventions in the EC. There is currently no known EC-based YVP intervention in South Africa. Objectives: This study explored the perceptions and attitudes of Cape Town emergency medicine doctors on youth violence, their role in YVP and how it applies to their practice in the EC. Methods: Semi-structured focus groups, each with 3-5 Cape Town emergency medicine (EM) registrars, were conducted, using five basis questions for discussion to elicit participants' perceptions of and attitudes towards YVP. Data saturation was reached after three focus groups. Thematic analysis as described by Braun and Clarke was carried out on the focus group data sets. Results: The three focus groups were all diverse in terms of race, gender, and level of training. In terms of the "Extent of the problem" themes around acceptability and increased burden were explored."Youth Violence Prevention in the EC" focused on the need for a champion, role of the emergency doctor vs. other stakeholders and sustainability issues. Conclusions: EM registrars in Cape Town have a very limited knowledge of YVP in general and specific to the EC. They are faced with immense challenges that relate to patient load, violence directed to EC personnel, and a sense of despair or despondence in terms of ability to effect change. Concerns about the possible implementation of YVP interventions were sustained funding and sustainability in general. These and other factors influenced attitudes towards EC initiated YVP. Notwithstanding challenges, this study has shown an overwhelmingly positive attitude of EM registrars towards the concept of YVP intervention in the EC, and them being the champion or co-champion of it. Recommendations: It is recommended that EM registrars in their training time should receive theoretical and practical training on YVP which can lead to increased awareness of YVP issue, the need to know resources in the community, and in the future will make it easier to implement a pilot intervention project in a selected EC. Further research is needed on a relevant screening tool to identify high risk patients in local ECs.

Objectives: To determine the case mix and workload of patients presenting to three private emergency centres in Cape Town Design: A Prospective cross sectional observational study was undertaken Setting and subjects: A convenience sample of all prospective patients that presented to three private emergency centres namely Melomed Gatesville, Melomed Bellville and Melomed Mitchell's plain during the month of September 2013 The outcome measures included the following:- ● Determining basic metrics across all three units over study time ● Determining the triage parameters for patients sampled across three units ● Direct time study of patients through unit ● Determining Doctor to patient workloads ● Determining Nurse to patient workloads ● Determining average number of patients receiving special investigations Results: Third party funding was responsible for 91 % of patients seen. The patient profiles consisted primarily of lower acuity presentations. There were clear peaks of attendance with lower acuity presentations decreasing after 10 pm. The majority of patients were discharged and very few required specialist follow up. Conclusions: This study provides valuable information with regards to private emergency centres in the predominantly low income and low socio economic sectors of the Western Cape, Cape town thus allowing a greater focus on the operational aspects of Emergency Centres In these areas and to assist with future planning of the management and running of similar Emergency Centres.

Background Uganda lacks formal emergency care training programs to address its high burden of acute illness and injury. The Ugandan Ministry of Health (MoH) rolled out the World Health Organization’s (WHO) Basic Emergency Care (BEC) course, the first openaccess short course to provide comprehensive basic emergency training for health workers in low-resource settings. The BEC and its new online cases both require further evaluation. Aim and Objectives The study aimed to assess the BEC course and online cases’ impact with the following objectives: 1. Determine participants’ knowledge acquisition and self-efficacy in emergency care. 2. Evaluate BEC participants’ perceptions of the course and online cases. 3. Assess the online cases’ impact on participants’ knowledge and self-efficacy in emergency care. Methods Mixed methods design explored the BEC’s impact. MCQs and Likert scales assessed knowledge and self-efficacy, respectively, among 137 participants pre-BEC, post-BEC and six-months post-BEC using mixed model analysis of variance (ANOVA). FGDs assessed perceptions of the course and online cases post-BEC and six-months postBEC among 74 participants using thematic content analysis. Results Participants gained and maintained significant increases in MCQ averages and Likert scores. The pre-course cases group scored significantly higher on the pre-test MCQ than controls (p=0.004) and found cases most useful pre-BEC. Nurses experienced more significant initial gains and long-term decays in MCQ and self-rated knowledge than doctors (p=0.009, p< 0.05). Providers valued the ABCDE approach and reported improved emergency care management post-BEC. Resource constraints, untrained colleagues and knowledge decay limited the course’s utility. Conclusions Basic emergency care courses for low-resource settings can increase frontline providers’ long-term knowledge and self-efficacy in emergency care. Nurses experience greater initial gains and long-term losses in knowledge than doctors. Online adjuncts can enhance health professional education in LMICs. Future efforts should focus on increasing trainings and determining the need for re-training.

The aim of this literature review was to collect and appraise literature related to curricula in critical care transportation and retrieval, pre-hospital care, and aeromedical transportation. The search strategy was twofold. Firstly peer-reviewed published literature was sourced from established platforms. Secondly, grey literature was sourced from internet sources. An assessment of reliability and validity was performed on peer-reviewed literature in the appraisal process. The results of the literature review show that there is a paucity of literature describing critical care modules of pre-hospital educational programmes in South Africa. This lack of literature has led the authors of this review to conclude that there is a potential for insufficient benchmarking and standardisation of the critical care module between universities. The results of this study could allow stakeholders to begin the process of academic standardisation. To provide a comprehensive background on the field of critical care transportation and retrieval and specifically education and training, this literature review starts by describing the field locally. It then attempts to outline the risks associated with critical care retrieval and thereby demonstrating the importance of quality education and regulation that can guide practitioners who perform retrievals. It then seeks to understand the importance of standardsetting within education broadly and the role of curricula in standard-setting. Finally, it provides an overview of methods for comparing curricula. After the background sections, the gathered literature was grouped into themes according to the types of curricula included in the literature. All these types of curricula form part of the critical care transportation and retrieval field, as graduates from these programmes are usually involved in the transportation of critically ill patients between facilities.

Includes abstract. Includes bibliographical references (leaves 67-72).

Background: The emergency centre (EC) is a vibrant and challenging environment from both an operational and clinical perspective. Emergency centre crowding has been referred to as one of the biggest challenges confronting policy-makers, emergency healthcare professionals (including physicians and nursing staff) and their patients globally. Elsewhere, EC crowding has been thoroughly studied. Resource restrictions render more detailed flow studies less achievable locally. Anecdotally, our local ECs are perceived to be fairly crowded. This study aimed to describe the EC crowd at Khayelitsha hospital by establishing the number and different categories of people at predefined times during the day over a four week period. Method: A prospective, cross-sectional, design was used. Headcounts were made by predefined groups at 09:00, 14:00 and 21:00 every day for four weeks. Predefined groups included doctors, nurses, visitors, patients, and other allied health staff. Summary statistics were used to describe the data and precision were described using the 95% confidence interval. Results: There were 37, 34 and 27 different people categories found in the EC during the three different shifts respectively. A total of 16353 people were counted during the study period. On average 6370 (39%) of the groups were staff, 5231 (32%) were patients and 4752 (29%) were visitors. Of the staff, 1488 (9%) were EC nurses, 733 (4.4%) were non-EC doctors, 586 (3.6%) were EC doctors, and 445 (3%) were non-EC nurses. The EC was consistently crowded – average occupancy: 130%. Notably, Mondays had the highest occupancy of 144% and Sundays had the lowest of 130%. Conclusion: Describing the people categories that contribute to the EC crowd in a low-to-middle income setting may provide a uniform template in defining EC crowding. In our study, we can conclude that the main findings were: Staff levels fluctuated predictably with less staff at night and over weekends whilst patients remained constant. Non-EC doctors more than doubled during the day on week shifts, in significantly more numbers than EC doctors, suggesting that many of the patients in the EC were likely to be admissions without a place to be admitted to. Although clinical staff numbers did not reduce during the busiest visitor times (afternoons), given the huge amount of crowding at this time care was likely to suffer. Further research is recommended to describe the findings in more detail including some of the limitations mentioned in this thesis.

Includes abstract. Includes bibliographical references.

Background Emergency centres (ECs) serve as a main entry point for patients into hospitals, and patients that present here are undifferentiated with varying levels of acuity. Uncertainty, interruptions, multiple – often conflicting – priorities, and gaps in information flow are inherent to EC work practices, making it a high-risk environment for operational failure. The EC team, the core of which is formed by doctors and nurses, needs the ability to collaboratively and reliably sense and respond to the constant change and flux of information. This depends on the interactions and sense-making of the EC team. Objectives People give meaning to situations through the process of sense-making; they then subjectively construct their reality and share it via plausible stories regarding their situation and environment. The main objective of this study was to explore the collective team-based sense-making of the operational challenges and decisions within the EC. This interprofessionalstudy focused on the dynamics and negotiations within the EC as a complex adaptive system. Methods This exploratory study used narrative-based inquiry with abductive reasoning to meet the objectives. It was divided into two sections. The first was a thick description of the EC context, daily operations and processes. Then, using the SenseMaker® tool, we captured stories about a situation that stood out to participants, and thus mattered to them. Using this novel method, once they told their story, the storytellers self-analysed their stories within a specially designed framework. The results were then explored to find patterns based on the perspectives of sense-making. Results There is no proof of interprofessional sense-making in the EC, and if it occurs it is due to the informal networks between doctors and nurses, and despite formal structure. There is an operational disconnect between doctors, nurses and management, which is caused by information asymmetry, poor feedback loops and disparate communication channels. Because there is no collective sense-making, the EC team is vulnerable to operational failure and crises. Currently, they respond to operational challenges via quick fixes that result in constant firefighting, the impact of which could be seen by the extensive use of war-related metaphors in their stories.