Includes abstract. Includes bibliographical references.

Includes bibliographical references / Anecdotally incidents of inappropriate refusal of treatment or transportation by patients referred to hospital under the Mental Healthcare Act of 2002 have been noted. There is little documented about the knowledge and understanding of prehospital providers of the mental healthcare act, their responsibilities and the issues around patient competence and refusal of care. The transportation of patients presenting with a suicide attempt who have not yet been formally assessed for involuntary admission poses a particular problem. Aim: To determine the knowledge of prehospital providers with respect to the transport of patients presenting with suicide attempts and the mental health act and to describe their management of cases where these patients may refuse treatment. Methods: A cross-sectional survey and including open ended questions of 100 prehospital providers in the Western Cape both public and private. The questionnaire will include knowledge testing, vignettes describing patient management and open-ended questions regarding their opinions on suicidal patients. Simple descriptive statistics will be used for the knowledge test. Qualitative data will be coded using a grounded theory approach. Discussion: The findings of the study will be used to determine provider knowledge and attitudes regarding the prehospital management of patients presenting with suicide attempts. Recommendations will be made for provincial EMS guidelines and the results will be disseminated in an article for publication.

Background: Much emphasis has been placed on Quality Measurements or Key Performance Indicators in Emergency Medicine. Internationally, KPI's are used to measure and improve quality of care, with a major emphasis on waiting times, measured as time-based KPI's. These times are related to the various stages of a patient journey through the Emergency Center. In South Africa this has not been routinely done. The Western Cape has conducted audits in recent years to measure these. This study aims to provide a snapshot of waiting times (specifically time to triage, time to doctor, time to disposition decision and time to departure from the EC) within Cape Town public sector Emergency Centres. Methods: This is a retrospective descriptive study of waiting times for all patients presenting to Emergency Centres in the Western Cape in 2013-2014, as per six monthly waiting times audits conducted by the Western Cape Department of Health. A wide variety of emergency centers were audited, from 24 hour clinics to larger acute hospital based ECs. Results: The proportional acuity difference between hospitals and CHC for the first random 100 folders were statistically no different. Arrival to triage times were universally longer than internationally accepted as safe. The mean time for all-comers across all facilities was just under an hour, the higher acuity patients were triaged significantly faster (half an hour) than the lower acuity patients (hour or more). This difference was significant for hospitals, with a non-significant trend for CHCs. At hospital ECs, green patients were triaged significantly faster than yellow patients; this was not the case at CHCs. The mean time from triage to clinician consultation for all-comers across all facilities (over two hours) was significantly longer at hospitals as compared to clinics. Time from triage to clinician consultation, per triage category, were longer than the SATS guide times, although higher acuity cases were seen faster than lower acuity cases in a stepwise fashion. Red patients waited nearly an hour on average, with no significant difference between hospitals and CHCs. Orange patients had to wait one to two hours; this was significantly longer at hospitals. The mean time from assessment and management to a disposal decision for all-comers was significantly longer at hospitals as compared to CHCs across all priorities. Green patients took a lot longer at hospital compared to CHCs. A similar pattern was seen for the disposition decision to leaving time. The mean total time was significantly longer at hospitals as compared to clinics. Orange and yellow cases stayed significantly longer at hospitals as compared to CHCs; red and green cases also stayed longer at hospitals as compared to CHCs, though this was not significant. Red cases appeared to stay the longest at CHCs. Conclusions: Patients attending CHCs and hospitals are of similar illness acuity, despite policies dictating that sicker patients should be seen at hospitals not CHC level. CHCs have limited packages of care (decision making investigations, management options and expertise), and can only manage patients to a defined level. Thus, it takes longer for patients who are moderately or very ill to be seen and sorted in a CHC than a hospital, as at a CHC they are generally referred onwards to a hospital. Their journey through the EC will then begin again, so that for sicker patients the time spent in ECs in this study is underestimated. Models need to be explored so that patients receive care at point of contact as far as possible. Since CHC-based ECs see as many patients who are as ill as those in hospitals, these should have similar resources to hospitals, so that only those requiring definite admission need to be referred onwards. Point of care testing, bedside ultrasound, appropriate medications and EM skills should all be available at facilities closest to the patients with emergency conditions. Green patients, the lowest acuity, also take longer to be seen and sorted at hospitals versus CHCs, because investigations are available that are then done as an emergency versus outpatient basis. Efficient and timely outpatient appointments would help mitigate this.

Includes abstract. Includes bibliographical references.

Increased patient wait times it the emergency department (ED) have been linked to poor patient outcomes and adverse health care events. The purpose of this quality improvement project was to determine if placing a nurse practitioner (NP) in the triage area would reduce door-to-provider times and improve patient throughput within the ED. The primary question for this quality improvement project was whether the use of NPs in the triage area would improve patient throughput and decrease wait times in the ED. A secondary question identified was if implementing an NP in the triage area would decrease patient length of stay in the ED. Rogers's diffusion of innovations model was used as a theoretical framework for the project. To evaluate the improvement in patient throughput in the ED, data were gathered for 12 months prior to and 12 months after the placement of an NP in the triage area. Data collection included door-to-provider times and door-to-discharge times. Analysis of the data using independent t tests showed no statistically significant reduction in door-to-provider times (p = .278) or overall lengths of stay in the ED (p = .235). There was an overall reduction in door-to-provider times of 11% and a 5% reduction in door-to-discharge times during the intervention. The implications of this project for social change include evidence that NPs are beneficial to the ED when used in the triage area. Based on the findings of this quality improvement project, it is recommended that an NP be placed in the triage area to decrease door-to-provider and door-to-discharge times, and to continue to improve the culture of the ED team to promote the use of NPs within the ED.

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfilment of the requirements for the degree of Master of Medicine (MMed) in the Division of Emergency Medicine. Johannesburg, 2014 / Introduction: Over-triage and access-block are worldwide phenomena which critically compromise patient care and increase morbidity and mortality. Triage is designed to place the patient in the right place at the right time with the right resources. We sought to determine and evaluate the application reliability of the South African Triage Score/Scale (SATS) in adult emergency cases presenting to a central academic hospital and to identify which factors may have influenced this. Methods: Emergency department (ED) triage data for adult patients at a central academic hospital in Johannesburg over a seven day period were captured retrospectively. The investigator applied the SATS 2008 to each triage form. Triage scores and colour banding for the trieur versus the investigator were compared and the overall degree of triage concordance and discordance observed. Results: A total sample size of 1758 cases was recorded. Moderate agreement (quadratically weighted  0.524 at 95%CI 0.450-0.598) for the overall triage banding assignment revealed rates of concordance of 50.6%, discordance of 49.4%, over-triage of 28.5% and under-triage of 20.9%. Tuesday showed the highest patient load with 21.3% of the weekly total. The mean daily and hourly patient loads were 285 and 14 respectively. Time of day analysis showed a daytime predominance of 2/3 of total presentations and a peak hour between 08h00-09h00. Conclusions: The over-triage (28.5%) rate fell within the American College of Surgeons Committee on Trauma’s (ACSCOT) accepted rate of 30-50%, while under-triage (20.9%) exceeded the accepted ACSCOT levels (<10%). When the triage score was calculated and recorded there was improved concordance, interrater reliability and reduced over-triage. The discordance levels of over-triage decreased and under-triage increased respectively with increasing patient acuity. There was no significant correlation between the extent of triage concordance or discordance and patient load.

Thesis (M.Sc.(Med.) Emergency Medicine--University of the Witwatersrand, Faculty of Health Sciences, 2014. / This study was designed to investigate how confident South African medical interns are to perform emergency medical procedures and to investigate how their experiences or demographic differences might influence these confidences. A transverse descriptive study using a cross sectional questionnaire was undertaken. A combination of the paper-based and electronic questionnaires were distributed to doctors currently performing their internship in South Africa. The data were analysed using a Fishers exact test and applying a Bonferroni correction where necessary. The study showed a high level of confidence in the majority of procedures studied and identified some points of influence on this confidence. The confidence of South African interns compares favourably with international colleagues at a similar qualification level.

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfilment of the requirements for the degree of Master of Medicine in Emergency Medicine, Johannesburg / Introduction Point-of-care ultrasound (PoCUS) is a widely utilized tool in Emergency Medicine (EM). The core PoCUS curriculum in South Africa (SA) does not currently include lung ultrasound or basic bedside echocardiography, although the burden of disease in a typical South African Emergency Department (ED) is skewed towards respiratory and cardiac pathologies. This study was undertaken to determine the profile of PoCUS examinations actually performed and potentially indicated in this ED, and whether current training in PoCUS is meeting the need in clinical practice. Methods This was a prospective observational audit of bedside PoCUS examinations actually performed, and potentially indicated, over a two-week period in the Helen Joseph Hospital ED in Johannesburg. Results The study included 372 patients. Ultrasound aided in the diagnosis and management of 107 (28,8%) of the patients. A total of 137 PoCUS investigations were performed. A total of 38,9% of the patients had positive ultrasound findings. The most frequently performed PoCUS applications were e-FAST (extended focused assessment by sonography in trauma) (32,8%), DVT assessment (13,9%) and procedural guidance (10,9%). A total of 758 PoCUS examinations were indicated in 307 (82,5%) of the patients. Overall, 18,1% of the potentially indicated PoCUS investigations were performed. The most frequently potentially indicated PoCUS applications were lung ultrasound (28,2%), basic cardiac (28%) and haemodynamic assessments (20,4%). Conclusions These findings reflect the high number of respiratory and cardiac cases seen in South African EDs. This highlights the consequent need for additional ultrasound skills to assist in the emergency management of such cases. Training of future South African EM specialist consultants should include both lung ultrasound and basic bedside echocardiography. It is time to update to the South African core PoCUS curriculum. / LM2019

Firefighting is a dangerous and difficult task. Simulation affords researchers and practitioners the ability to examine performance and training in adverse conditions while preserving life, offering repeatable scenarios, and reducing costs. Multiple Resource Theory is used in this study as a model for assessing alternate sensory channels for information delivery when the optimal channel is not available. Specifically, this study tests the influence of a waist-worn vibrotactile display to assist navigation when visibility is reduced in a firefighter simulation. The present study measures participants' objective performance and self-reported workload while navigating a simulated fireground. Results from 70 research participants revealed statistically significant differences between the experimental and control conditions for completion time and overall workload scores. Workload and performance emerged as significantly correlated in both the experimental and control conditions; however, no statistically significant correlations were found for the spatial anxiety hypotheses. The results of this study indicate that participants engaged in a simulated search and rescue task in a low visibility environment benefit from the assistance of a vibrotactile display as a tool. Participants' performance scores and self-reports show that they had more mental resources to engage in the search and rescue task more quickly when assisted by a vibrotactile tool. Evidence was found to demonstrate a statistically significant association between workload and performance. The implications of this study have real world consequences for training for dangerous tasks to maximize performance and save lives while minimizing risks to personnel.

One of the greatest hazards from hurricanes is the flooding due to storm surge. Emergency managers traditionally plan for storm surge by looking at the worst possible impact and design their plans accordingly. This is a safe course of action, but can also be a wasted expense if the worst case does not occur. Risk-based planning is a way to incorporate the likelihood or probability of an impact occurring into emergency planning. With respect to storm surge, though, there is very little information regarding probability of occurrence. This research uses data from a commonly accepted storm surge model, SLOSH from the National Weather Service, to develop probabilities of impact. The process and products are prototypes utilizing data from the 2007 SLOSH model run for the New Orleans basin. Products developed include a map of probability, probabilities of exceedance, and a list of model storms that generate surge at given locations.