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

Cross-sectional survey of patients presenting to a South African urban emergency centre.

OBJECTIVES: To describe the demographics, referral mechanism and outcome of the emergency consultation in patients presenting to a secondary hospital emergency centre (EC). DESIGN: An observational study of patients presenting to an EC in a 1-month period from 19 November to 20 December 2007. SETTING: New Somerset Hospital, Cape Town, South Africa. SUBJECTS: All patients presenting alive to the EC during the study period who were seen by an EC doctor. OUTCOME MEASURES: A data collection form was completed by EC doctors at the time of the initial EC consultation documenting patient demographics, time and delay periods, South African Triage Score (SATS), initial diagnosis, transport and referral mechanisms and outcome of EC consultation. RESULTS: Data on 2646 patient presentations were described with a mix of SATS acuity levels (green: routine care; yellow: urgent; orange: very urgent; red: immediate), with more than one-third of presentations scoring an orange or red SATS. Most patients presented in the daytime, with an increase in more ill patients (higher SATS) later in the day and at night. The peak age group was 20-40 years, with 39% resident in informal settlements within 15 km of the hospital. The initial diagnosis was trauma in 26% of presentations, with a wide spread of other presentations. Patients were transported by ambulance to the EC in 39% of presentations, 41% were self-referred and 41% were referred by a primary health care practitioner. Fifty-three percent of presentations were either admitted to hospital or kept in the EC for further investigations, and the remainder were discharged from the EC. CONCLUSIONS: Clear trends are seen for patient demographics and temporal attendance patterns which are important for resource allocation and planning. Many low-acuity patients, largely non-referred, are being seen in the EC and should be managed by primary health care level staff outside the EC.

Emergency department procedural sedation practice in Cape Town, South Africa.

BACKGROUND: There are no general policies or protocols for procedural sedation in the emergency department and no literature on present practice in South Africa. AIMS: To investigate procedural sedation (PS) practice in adults in emergency departments (EDs) in Cape Town, South Africa. METHODS: A cross-sectional descriptive study was performed by interviewing all ED managers and ED doctors in Cape Town meeting the criteria (open 24 h a day, staffed by full-time doctors, seeing adult patients and doctors who practice primarily emergency medicine and have performed at least one PS in the last 3 months). RESULTS: Data were collected from 13 units (5 public, 8 private) and 76 clinicians (48 public, 28 private). PS facilities are generally good in the private sector, but poor in the public sector (lacking in equipment, staff and protocols). Monitoring of patients during PS is often substandard, with only two thirds of clinicians using a minimum of blood pressure and pulse oximetry monitors during PS. Commonly used drugs for PS included midazolam, morphine and propofol (91%, 80% and 28%, respectively). Propofol (use of which is increasing in the international ED) is more likely to be used by experienced clinicians and those in the private sector. Surprisingly, almost half of clinicians would like propofol used on themselves hypothetically, although the majority (62%) said they had no or limited knowledge of its use and were concerned with its safety. CONCLUSIONS: The private sector is generally better serviced for PS than the public sector. Most ED clinicians use morphine and midazolam for PS. However, there is widespread awareness of propofol as an alternative and probably superior PS drug. Recommendations for improving PS include development of general protocols for PS, training of doctors at all levels and optimization of ED facilities and staffing.