Emergency Centre-based paediatric procedural sedation: current practice and challenges in Cape Town

Background: The aims and objectives of this survey of the current practice of doctors working in Emergency Centres (ECs) in the Cape Town metropole was to assess clinical practice and attempt to identify obstacles to the practice of paediatric procedural sedation and analgesia (PPSA). This was considered essential to establish a baseline for quality assurance purposes and improvement. Methods: After institutional ethics approval, a cross-sectional descriptive study was performed in 25 ECs in both private and government sectors in Cape Town. Specific aspects of PPSA practice were analysed after the anonymous completion of a specifically designed questionnaire, by full-time doctors working at each EC. The doctors' grade and training, practice preferences, medication and use of monitoring, and any perceived challenges to performing PPSA were assessed. Results: Sixteen ECs agreed to be part of the study and 62 questionnaires were completed (a 64% response rate). Procedural sedation and analgesia was performed at all the participating ECs, by medical practitioners of varying experience. Doctors' awareness of unit protocols was inconsistent. Common indications were orthopaedic interventions, radiological investigations and surgical procedures. Medications used were similar in the responding units, but dosages varied. Monitoring was poor compared with local and international standards. The obstacles reported predominantly related to a lack of training and formal protocols. Conclusions: This study was the first to evaluate the practice of Emergency Centre paediatric procedural sedation and analgesia practice in a South African setting. The lack of a formal system of training and accreditation, for both doctors and facilities, and the need for institutional and nationwide PPSA guidelines were highlighted

Essential medicines for emergency care in Africa

Essential medicines lists (EMLs) are efficient means to ensure access to safe and effective medications.The WHO has led this initiative, generating a biannual EML since 1977. Nearly all countries have implemented national EMLs based on the WHO EML. Although EMLs have given careful consideration to many public health priorities, they have yet to comprehensively address the importance of medicines for treating acute illness and injury.Methods:We undertook a multi-step consensus process to establish an EML for emergency care in Africa. After a review of existing literature and international EMLs, we generated a candidate list for emergency care. This list was reviewed by expert clinicians who ranked the medicines for overall inclusion and strength of recommendation. These medications and recommendations were then evaluated by an expert group. Medications that reached consensus in both the online survey and expert review were included in a draft emergency care EML, which underwent a final in-person consensus process.Results:The final emergency care EML included 213 medicines, 25 of which are not in the 2017 WHO EML but were deemed essential for clinical practice by regional emergency providers. The final EML has associated recommendations of desirable or essential, and is subdivided by facility level. Thirty-nine medicines were recommended for basic facilities, an additional 96 for intermediate facilities (e.g. district hospitals), and an additional 78 for advanced facilities (e.g. tertiary centres).Conclusion:The 25 novel medications not currently on the WHO EML should be considered by planners when making rational formularies for developing emergency care systems. It is our hope that these resource-stratified lists will allow for easier implementation, and will be a useful tool for practical expansion of emergency care delivery in Africa