The barriers and facilitators to initiation of telephone-assisted bystander cardiopulmonary resuscitation for patients experiencing out-of-hospital cardiac arrest in a private emergency dispatch centre in South Africa.

Background: The incidence of cardiovascular diseases, and with it out-of-hospital cardiac arrest (OHCA), is on the increase in low- to middle-income countries (LMICs), like South Africa. Interventions such as mass public cardiopulmonary resuscitation (CPR) training campaigns and public access defibrillators are expensive and out of reach for many LMICs. Telephone-assisted CPR (tCPR) is a cost-effective, scalable alternative. This study explored the barriers and facilitators to tCPR uptake in OHCA in a private South African emergency dispatch centre. Methods: This qualitative study applied inductive dominant content analysis to emergency call recordings of OHCA cases into a private emergency dispatch centre. Calls were analysed to the latent level to identify barriers and facilitators. Cases were sampled randomly, until data saturation. Results: Saturation occurred after the analysis of 25 recordings. A further three recordings were analysed to confirm saturation of the facilitators; yielding a final sample size of 28 calls. Overall, t-CPR was offered in 23 (82.1%) cases, but only initiated in 8 (34.8%) of these calls. Five barriers ("Poor Communication"; "Lack of Support"; "Caller Hesitance or Uncertainty;" "Emotionality"; and "Practical Barriers") and three facilitators ("Caller Willingness"; "Support" and "CPR in Progress") were extracted. Conclusion: Numerous barriers limit the initiation of tCPR in the South African private sector EMS. It is crucial to address these barriers and leverage the facilitators in order to improve tCPR uptake. This study highlights the importance of using specific language techniques and developing tailored tCPR algorithms to overcome these barriers, which is underpinned by standardised training of call-takers.

A national retrospective descriptive analysis of critical care transfers in the private sector in South Africa.

BACKGROUND: Critical care transfers (CCTs) are necessitated by the growing prevalence of high-acuity patients who require upgrade of care to multidisciplinary teams from less-equipped referring facilities. Owing to the high acuity of the critical care patient, specialised teams with advanced training and equipment are called upon to undertake these transfers. The inherent understanding of the potential effects, and therefore the needs of the critical care patient during transfer, are affected owing to the paucity of international, but more specifically, local data relating to CCTs. OBJECTIVES: To describe a cohort of patients who underwent CCT by dedicated critical care retrieval services (CCRS) in the private sector in South Africa (SA). METHODS: This retrospective, descriptive study sampled all paediatric and adult CCTs completed over a 1-year period (1 January 2017 - 31 December 2017) from the dedicated CCRS of two national emergency medical services in SA. All neonatal patients were excluded. Data were extracted from patient report forms by trained data extractors and subjected to descriptive analysis. RESULTS: A total of 1 839 patients were transferred between the two services. A total of 3 143 diagnoses were recorded, yielding an average of ~2 diagnoses per patient. The most prevalent primary diagnosis was cardiovascular disease (n=457, 25%), followed by infection (n=180, 10%) and head injury (n=133, 7%). Patients had an average of ~3 attachments, with the most prevalent being patient monitoring (n=2 856, 155%), peripheral intravenous access (n=794, 43%) and mechanical ventilation (n=445, 24%). A total of 2 152 instances of medication infusion or administration were required during transport, yielding an average of ~1 medication or infusion per patient transported. The most common medications recorded were central nervous system depressants (n=588, 32%), followed by analgesics (n=482, 26%) and inotropic or vasoactive agents (n=320, 17%). CONCLUSION: This study provides insight into the demographics, most prevalent diagnoses and interfacility transfer monitoring needs of patients being transported in SA by two private dedicated CCRS. The results of this study may be used to inform future specialised critical care transport courses and qualifications, equipment procurement and scopes of practice for providers undertaking critical care transfers.

Developing a South African curriculum for education in neonatal critical care retrieval: An initial exploration.

BACKGROUND: Owing to limited or centralised neonatal critical care resources, the interfacility transfer of neonates is inevitable. In many high-income settings, dedicated Critical Care Retrieval Services (CCRS) with additional education and training undertake neonatal critical care retrieval (CCR). In South Africa, however, these transfers are mostly conducted by advanced paramedics with limited education in neonatal care, and this may lead to high adverse event rates. In SA, a shortage of skilled neonatal interfacility transport services has been identified as one of the top ten avoidable causes of under-5 mortality. In order to address this gap in neonatal transfer education for paramedics in South Africa, the aim of this study is to develop a curriculum for neonatal critical care retrieval in South Africa. METHODS: Using Kern's approach to curriculum development, a general and targeted needs assessment was conducted through semi-structured interviews with experts in the field and a focus group discussion with a prospective student group. Interviews were preceded and informed by a literature review and retrospective chart review of neonates who underwent CCR in SA over a one-year period. Audio recordings of interviews were transcribed verbatim and subjected to inductive-dominant content analysis. Finally, qualitative codes were expanded into course outcome and a curriculum map was developed. RESULTS: Six experts in neonatal critical care and retrieval participated in semi-structured interviews with a mean duration of 59 minutes. Following transcription and analysis, 372 codes were developed. Seven prehospital providers (prospective students) who are involved in neonatal transfers in South Africa participated in a focus group discussion with a duration of 91 minutes. The audio recording was transcribed and analysed with 97 codes extracted. The main categories were: Current status of neonatal CCR in South Africa; learning and education in neonatal CCR; and proposed curriculum structure. The proposed curriculum structure described 13 broad course outcomes to be delivered as a blended postgraduate programme. Participants noted that funding, employer buy-in and internet resources would be required. The targeted prospective student group should be all Advanced Life Support (ALS) providers with a change in their scope of practice on completion. CONCLUSION: This study described the need for additional education in neonatal critical care retrieval due to the limitations in the current and past education systems. This study provides a curriculum structure with course outcomes that can be used as a basis for the development of a complete curriculum for education in neonatal CCR, with the potential to greatly reduce adverse event rates.

The use of emergency medical services for palliative situations in Western Cape Province, South Africa: A retrospective, descriptive analysis of patient records.

BACKGROUND: An estimated 56.8 million people require palliative care annually, while only 14% receive such care. This imbalance is particularly acute in low-to middle-income countries (LMICs), where up to 80% of patients requiring palliative care reside. To correct this imbalance, integration between palliative services and other disciplines has been recommended. While improved palliative care integration is a priority in the South African (SA) LMIC context, emergency medical services (EMS) and palliative care remain non-integrated. This has resulted in poor palliative situation management by EMS and a lack of research concerning their intersection. OBJECTIVE: To examine EMS use for palliative situations in the Western Cape (WC) Province of SA by describing frequency of intersection, patient characteristics and outcomes. METHODS: An observational, descriptive, retrospective patient record review was employed at two hospitals with palliative care services in the WC. All patient records of those who arrived at the hospitals between 1 January 2020 and 31 December 2020 via EMS conveyance leading to palliative care provision were included in the study. RESULTS: In total, 1 207 unique patients received palliative care services at both hospitals during the study period. Of these, 395 (33%) made use of EMS for hospital conveyance on 494 occasions. The median (range) patient age was 60 (20 - 93) years, and most transports involved male patients (54%, n=265). Family members were the primary caregivers in most instances (89%, n=440), dyspnoea was the chief complaint (36%, n=178) and cancer was the most frequent diagnosis (32%, n=159). The median length of hospital stay was 6 days, with most patients discharged home (60%, n=295). CONCLUSION: EMS in SA frequently encounter palliative situations for symptoms that may be managed within their scope of practice. Consequently, it appears that EMS have an important role to fulfil in the care of patients with palliative needs. Integrating EMS and palliative care may result in improved palliative care provision and, therefore, EMS and palliative care integration would be beneficial in SA.

The lived experiences of emergency care personnel in the Western Cape, South Africa during the COVID-19 pandemic: A longitudinal hermeneutic phenomenological study.

In March 2020, the World Health Organisation declared COVID-19 a global pandemic. Shortly after the first case of COVID-19 was reported in South Africa, the Western Cape province experienced a rapid growth in the number of cases, establishing it as the epicentre of the disease in South Africa. The aim of this study was to explore emergency care personnel's lived experiences and their perceptions thereof within the context of the COVID-19 pandemic in the Western Cape province. This study followed a longitudinal hermeneutic phenomenological approach. The convenience sample included prehospital and emergency centre medical personnel. Data were collected over a 4-month period using both one-on-one interviews and participant recorded voice recordings. Data were analysed following Ricoeur's theory of interpretation. Four themes were generated during the data analysis: 1) In the beginning, waiting for the unknown; 2) Next, change and adaptation in the workplace; 3) My COVID-19 feelings; 4) Support and connection. Participants discussed the uncertainty associated with responding to an unknown threat and a need to keep up with constant change in an overburdened work environment. Results showed high levels of uncertainty, restriction, fear, anxiety, and exhaustion. Despite these difficulties, participants demonstrated resilience and commitment to caring for patients. A need for support was also highlighted. Results indicated that change, over time, resulted in adaptation to a new way of practising and keeping safe. Healthcare workers experienced intersecting consequences as frontline healthcare workers and members of the public, all of which impacted their well-being. The importance of compassion and encouragement as forms of support was highlighted in the study. Robust and sustained support structures in a time of change, low mood, and exhaustion are essential.

A comparison of the content taught in critical care transportation modules across South African bachelor's degrees in emergency medical care.

Background and objective: Critical care transport (CCT) involves the movement of critically ill patients between healthcare facilities. South Africa (SA), like other low- to middle-income countries, has a relative shortage of ICU beds, making CCT an inevitability. In SA, CCTs are mostly done by emergency care practitioners; however, it is unclear how universities offering Bachelor in Emergency Medical Care (BEMC) courses approach their teaching in critical care and whether the content taught is consistent between institutions. In our study we formally evaluate and compare the intensive and critical care transport modules offered at SA universities in their BEMC programmes. Methods: The electronic version of curricula of the critical care transport modules from higher education institutes in SA offering the BEMC were subjected to document analysis. Qualitative (inductive content analysis) and quantitative (descriptive analysis) methods were used to describe and compare the different components of the curriculum. Curricula were assigned into components and sub-components according to accepted definitions of curricula. The components included: aims, goals, composition and objectives of the course; content or teaching material and work-integrated learning. Results: The four universities that offer BEMC programmes were invited to participate, and three (75%) consented and provided data. The duration of the modules ranged from 6 to 12 months, corresponding with notional hours of 120 - 150. A total of 83 learning domains were generated from the coding process. These domains included content on mechanical ventilation, patient monitoring, arterial blood gases, infusions and fluid balance, and patient preparation and transfer. Two universities had identical structures and learning outcomes, while one had a different structure and outcomes; it corresponded with a 58% similarity. Clinical placements were in critical and emergency care units, operating theatres and prehospital clinical services. Conclusion: In all components compared, the universities offering BEMC were more similar than they were different. It is unclear whether the components taught are relevant to the SA patient population and healthcare system context, or whether students are adequately prepared for clinical practice. Postgraduate educational programmes might need to be developed to equip emergency care practitioners to function in this environment safely. Contributions of the study: Owing to the limited availability of ICU beds in South Africa, optimising and standardising critical care transport is an important consideration. This study identifies important elements for improving emergency medical care training in South Africa, as well as areas needing further research.

A national retrospective review of neonatal critical care transfers in dedicated critical care transport services in the private sector.

BACKGROUND: South Africa (SA) has a shortage of dedicated neonatal critical care services, which are mostly concentrated in urban areas, thus illustrating the need for neonatal critical care transport (CCT) services. Neonates who are transported by teams without the requisite experience and knowledge in neonatal care are at risk of severe adverse events during transport. This has led to the development of dedicated CCT teams by some emergency medical services. There is a paucity of national literature describing the neonatal population who undergo CCT in dedicated services. OBJECTIVES: To describe a sample of neonates who underwent CCT transfer by dedicated CCT services in the private sector in SA. METHODS: This observational cohort study with a retrospective descriptive design sampled all neonatal transfers completed during 1 year (1 January 2017 - 31 December 2017) from the dedicated CCT of the two largest national emergency medical services in SA. Data were extracted from patient report forms by trained data extractors, and subjected to descriptive analysis. RESULTS: A total of 444 neonates were transferred between the two services. A total of 760 diagnoses were recorded, yielding an average of ~2 diagnoses per patient. The most prevalent diagnosis was respiratory distress syndrome (n=139, 31%), followed by congenital heart defects (n=123, 28%) and prematurity (n=81, 18%). Patients had an average of ~4 attachments, with the most prevalent being patient monitoring (n=677, 152%). Just under half (n=182, 41%) of patients required ventilatory support. A total of 422 medications were required during transport, yielding a rate of ~1 medication or infusion per neonate transported. The most common infusion was maintenance (n=199, 45%), while almost 1 in 10 neonates required inotropic support (n=33, 7%). CONCLUSIONS: This study provides insight into the demographics, most prevalent diagnoses, and interfacility transfer monitoring needs of neonates being transported in SA by two private dedicated CCT services. The results of this study should be used to inform future specialised neonatal CCT courses and qualifications, as well as the scopes of practice of providers transporting neonates.

Dos and don'ts for mHealth-based clinical support among clinicians in South Africa: Results from a 1-day workshop.

Digital technologies continue to penetrate the South African (SA) healthcare sector at an increasing rate. Clinician-to-clinician diagnostic and management assistance through mHealth is expanding rapidly, reducing professional isolation and unnecessary referrals, and promoting better patient outcomes and more equitable healthcare systems. However, the widespread uptake of mHealth use raises ethical concerns around patient autonomy and safety, and guidance for healthcare workers around the ethical use of mHealth is needed. This article presents the results of a multi-stakeholder workshop at which the 'dos and don'ts' pertaining to mHealth ethics in the SA context were formulated and aligned to seven basic recommendations derived from the literature and previous multi-stakeholder, multi-country meetings.

The accuracy of the FAST stroke assessment in identifying stroke at initial ambulance call into a South African private emergency call centre.

Background: Stroke is a potentially life-threatening, time-dependent event, and one of the leading causes of mortality and lasting morbidity in South Africa (SA). It is of vital importance that Emergency Medical Services (EMS) call-takers accurately recognise stroke symptoms and prioritise time as well as adequate care. EMS call-takers are the first link in stroke care and improving call-taker recognition of stroke signs and symptoms can drastically improve patient outcome. The Newcastle Face Arm Speech Time (FAST) test is a mnemonic aimed at improving diagnostic accuracy of stroke. Objectives: To assess the use of the FAST test at a call-taker level to raise early suspicion of stroke and appropriately allocate resources to increase awareness of time and decrease delays on scene. Methods: A retrospective diagnostic study to determine the accuracy of the FAST mnemonic at identifying stroke when applied at EMS call-taker level. The outcome of the FAST assessment was compared with EMS stroke diagnosis for cases of a private SA EMS over a three-month period (N=146). Results: Using FAST, call-takers were able to identify stroke with a sensitivity of 87.5% and a specificity of 17.4% (positive predictive value 34%, negative predictive value 74%). This yielded an overall accuracy of 40.41%. Conclusion: FAST is a useful screening tool for identifying stroke at call-taker level. FAST has acceptable sensitivity when used as a screening tool; however, specificity and diagnostic effectiveness are lacking. Further studies should be considered to determine call-taker as well as general public knowledge of stroke risk factors and presentation. Contributions of the study: Stroke is one of the leading causes of death and lasting morbidity in South Africa (SA) and is increasing in incidence. Early recognition of stroke at initial emergency call may expedite treatment, thus improving outcomes. This study demonstrates that the application of the FAST assessment at emergency contact centre level in SA, might be useful at identifying stroke early. Future research should investigate barriers to its use.

The prevalence of hypotension and hypoxaemia in blunt traumatic brain injury in the prehospital setting of Johannesburg, South Africa: A retrospective chart review.

BACKGROUND: Each year, ~89,000 (180/100,000) new cases of head injury are reported in South Africa (SA), with the majority of patients being in the economically active population. Hypotension and hypoxaemia significantly increase the morbidity and mortality in patients who have suffered a traumatic brain injury (TBI). Cerebral tissue is particularly vulnerable to these secondary insults in the period immediately following a TBI, emphasising the importance of prehospital care in TBI. OBJECTIVE: To establish the prevalence of prehospital hypotension and hypoxaemia in moderate to severe blunt TBI in greater Johannesburg, Gauteng, SA. METHODS: The records of adult patients who sustained a moderate to severe TBI between 1 January and 31 December 2011 were retrospectively reviewed for hypotension (systolic blood pressure <90 mmHg) and hypoxaemia (oxygen saturation <90%) during their prehospital phase of care. These results were subject to descriptive analysis. RESULTS: A total of 299 records were identified, 66 of which met the inclusion criteria. The prevalence of prehospital hypotension and hypoxaemia were 33.3% (n=22) and 37.9% (n=25), respectively, while 21.2% (n=14) of patients suffered double insults of hypotension and hypoxaemia. Hypotension and hypoxaemia were associated with haemorrhage (p=0.011) and chest injuries (p=0.001), respectively. CONCLUSION: The prevalence of hypotension in this study was similar to that observed in international studies, but the prevalence of hypoxaemia was much higher. There is a need for local guidelines to be developed to inform the quality of TBI care in the context of the developing world.

Serial determinations of the amino-terminal peptide of type III procollagen in severe chronic active hepatitis.

To evaluate the diagnostic significance of the amino-terminal propeptide of procollagen type III (P-III-P) in monitoring chronic liver disease, serum P-III-P concentrations were measured in 46 patients with severe chronic active hepatitis (CAH) at entry and at remission during a therapeutic clinical trial. Coded sera were analyzed for P-III-P concentrations by both a standard radioimmunoassay and a recently developed and potentially more precise radioimmunoassay that uses Fab fragments rather than intact antibodies for binding antigen. As compared with conditions in 22 normal controls, P-III-P concentrations were elevated in 98% and 72% of patients with CAH by use of the standard and Fab radioimmunoassays, respectively. With treatment, P-III-P levels fell at remission to levels that were not significantly different from control values, as measured by both assays. The Fab radioimmunoassay, either alone or combined with the standard radioimmunoassay, provided no advantage over the standard radioimmunoassay alone. Serum P-III-P levels, as measured by either assay, correlated poorly or not at all with standard liver function tests and with histologic grade of disease. These data suggest that P-III-P serum levels are abnormal in severe CAH but normalize when remission of disease has been achieved. Consequently, serum P-III-P levels may be a diagnostic aid in the sequential evaluation of patients with severe CAH requiring treatment, and this test deserves further investigation. In this regard, the standard P-III-P assay has greater diagnostic accuracy than the Fab assay.(ABSTRACT TRUNCATED AT 250 WORDS)

Serum type III procollagen peptide concentrations in severe chronic active hepatitis: relationship to cirrhosis and disease activity.

To analyze the correlations between the presence of cirrhosis and hepatocellular inflammation and the serum concentrations of the amino-terminal peptide of procollagen type III in chronic liver disease, we measured procollagen type III concentrations in paired serum samples from 46 patients (17 had cirrhosis) with severe chronic active hepatitis during a therapeutic treatment trial. Coded sera were analyzed for procollagen type III concentrations using both a standard and a recently described Fab radioimmunoassay to compare their relative diagnostic accuracy. Mean procollagen type III levels were elevated to the same extent in the cirrhotic and noncirrhotic groups at entry into the study. In response to immunosuppressive therapy, the initially elevated procollagen type III levels improved to normal values at remission in both groups. Qualitatively, the results were similar using either assay, but the standard assay was more sensitive for identifying the clinical stage of disease (i.e., active disease vs. disease in remission) than the Fab assay. Since both procollagen type III levels and standard liver function tests correlated well individually with the presence or absence of active disease, they also correlated with each other when both entry and remission values were considered. However, procollagen type III levels correlated poorly with indicators of inflammation (histologic grade and serum transaminase levels) during active disease. It is concluded that procollagen type III levels change in concert with standard liver function tests but do not quantitatively reflect inflammation or static measurements of hepatic fibrosis in severe chronic active hepatitis. However, these preliminary results suggest that procollagen type III can distinguish active disease from chronic active hepatitis in remission.(ABSTRACT TRUNCATED AT 250 WORDS)

Immediate diagnostic criteria for bacterial infection of ascitic fluid. Evaluation of ascitic fluid polymorphonuclear leukocyte count, pH, and lactate concentration, alone and in combination.

We prospectively evaluated the ascitic fluid (AF) polymorphonuclear cell (PMN) count, pH, and lactate concentration in single ascitic fluids from 60 patients to determine their relative predictive values for the immediate diagnosis of ascitic fluid infection. Nine of the 60 ascitic fluids were malignant. Of the remaining 51 samples, nine from cirrhotic patients were infected. The mean AF pH, lactate concentration, and PMN count in the infected group were 7.20 +/- 0.19, 80 +/- 51 mg/dl, and 18,199 +/- 19,650 cells/mm3, respectively, and all were significantly different from the corresponding values in noninfected ascites. Mean arterial blood-ascitic fluid (B-AF) pH and lactate gradients in the infected group were 0.23 +/- 0.17 and -46 +/- 31 mg/dl, respectively, and were significantly different from the corresponding values in noninfected ascites (p less than 0.05). Significant differences were not found between infected and malignant ascites, except for the AF PMN count (p less than 0.001). In cirrhosis with ascites, an AF pH less than or equal to 7.34 was the most specific single test (100%) and had the highest diagnostic accuracy (98%). In the larger group of patients with ascites of diverse etiology, a B-AF pH gradient greater than or equal to 0.10 or an AF PMN count greater than or equal to 500 cells/mm3 were the single tests with the highest diagnostic accuracy (92%). Combining an AF PMN count greater than 500 cells/mm3 with any of the other diagnostic criteria increased the specificity and diagnostic accuracy (up to 98%) compared to the best single criterion. Although our data support the use of a number of different combinations of AF measurements for the immediate diagnosis of infection, the simplest and most readily obtainable measurements are the pH and PMN count. Therefore, in the clinical setting we recommend the use of either an AF pH less than or equal to 7.34 or a B-AF pH gradient greater than or equal to 0.10 in combination with an AF PMN count greater than 500 cells/mm3 to obtain the highest degree of accuracy in the immediate diagnosis of ascitic fluid infection.

Spontaneous bacterial peritonitis caused by Neisseria gonorrhoeae. Evidence for a transfallopian route of infection.

We describe the clinical and laboratory features of a case of spontaneous bacterial peritonitis caused by Neisseria gonorrhoeae in a sexually active woman with Laennec's cirrhosis, ascites, and asymptomatic cervical gonorrhea. Treatment of the infection with high-dose parenteral penicillin was associated with resolution of the infection. This first report of spontaneous gonococcal peritonitis provides highly suggestive evidence that the transfallopian route is a mechanism whereby bacteria may enter the peritoneal cavity. Appropriate cultures for this organism should be included when a woman with chronic liver disease, who is sexually active, presents with spontaneous peritonitis.

Epilepsy and coeliac disease.

A number of neurological disorders have been described in association with coeliac disease, including epilepsy. A review of 177 patients with coeliac disease failed to show an increased prevalence of epilepsy. This is contrary to the findings of other workers, and requires further investigation.