Current use and perceived barriers of emergency point-of-care ultrasound by African health care practitioners.

Introduction: The African Federation of Emergency Medicine (AFEM) recommends the use of emergency point-of-care ultrasound (ePOCUS) as a core skill for health care practitioners in Africa. The study explored the use of ePOCUS by health care practitioners among AFEM members who work across Africa. Methods: An anonymous online survey was distributed to individual members of AFEM and affiliated organisations. The questionnaire was tested by the AFEM Scientific Committee for potential content modifications prior to distribution. Summary statistics are presented. Results: Of the 220 participants that were analysed, 148 (67.3%) were using ePOCUS. The mean age was 36 years; 146 (66%) were male; and 198 (90%) obtained their primary medical qualification in Africa. In total, 168 (76%) were doctors, and most participants (n = 204, 93%) have worked in Africa during the last 5 years. Reasons for not using ePOCUS mainly related to lack of training and problems with ultrasound machines or consumables. Most ePOCUS users (116/148, 78%) attended courses with hands-on training, but only 65 (44%) participants were credentialed (by 18 different organizations). The median score for self-perceived level of ePOCUS skills was 75 in credentialed users versus 50 in those that were not credentialed. Ultrasound in trauma was the most frequently used module (n = 141, 99%), followed by focused cardiac assessment (n = 128, 90%) and thoracic (including lung) assessment (n = 128, 90.1%). The FASH-module (Focused Assessment with Sonography for HIV/TB) was the least used (n = 69, 49%). Conclusion: Access barriers to ePOCUS training, mentorship, equipment and consumables are still relevant in Africa. The low credentialing rate and the potential discordance between local burden of disease and ePOCUS training requires further investigation.

The characteristics of geriatric patients managed within the resuscitation unit of a district-level emergency centre in Cape Town.

INTRODUCTION: The world's population is aging and this trend is also seen in South Africa. This increase will invariably affect acute care services. The geriatric population attending emergency centres have not been described in the South African setting. The objective was to describe the characteristics of geriatric patients presenting to the resuscitation unit of a district-level hospital in Cape Town. METHODS: All patients (≥65 years) managed within the resuscitation unit of Khayelitsha Hospital over an 8-month period (01 January-30 August 2018) were retrospective analysed. Data were collected from the Khayelitsha Hospital Emergency Centre database and by means of a retrospective chart review. Summary statistics are presented of all variables. RESULTS: A total of 225 patients were analysed. The median age was 71.1 years, 148 (65.8%) were female and all were residing in their family home. The majority (n = 162, 72%) presented outside office hours, 124 (55.1%) arrived by ambulance, and 94 (41.8%) had presented to the emergency centre within the previous year. Only half the patients (n = 114, 50.7%) were triaged as very urgent or higher. Most patients (n = 169, 75.1%) were admitted by in-hospital services and the in-hospital mortality was 21.8% (n = 49). Diseases related to the circulatory system (n = 54, 24.0%) were the most frequent primary diagnosis and acute kidney injury were the most frequent secondary diagnosis (n = 101, 44.9%). The most common comorbidities were hypertension (n = 176, 78.2%) and diabetes (n = 110, 48.9%), and 99 (44%) had three or more comorbidities. Polypharmacy (≥5 medications) occurred in 100 (44.4%) patients with 114 (50.7%) using medications from three or more different classes. The prevalence of hypernatremia was 2.6% and for hyponatremia 54.4%. CONCLUSION: Geriatric patients managed within the resuscitation unit of a district-level hospital had a high return rate, multiple comorbidities and a high prevalence of polypharmacy and hyponatraemia.

Point-of-Care Ultrasound Predictors for the Diagnosis of Tuberculosis in HIV-Positive Patients Presenting to an Emergency Center.

BACKGROUND: The performance of point-of-care ultrasound (PoCUS) to diagnose HIV-associated tuberculosis has not been evaluated in large prospective studies. We determined the diagnostic accuracy of individual PoCUS features, performed an external validation of the focused assessment with sonography for HIV/TB (FASH) protocol, and determined independent PoCUS predictors of HIV-associated tuberculosis appropriate for use by emergency center practitioners. SETTING: A cross-sectional diagnostic study was performed at the emergency center of Khayelitsha Hospital (Cape Town, South Africa). METHODS: HIV-positive adults with the suspicion of having tuberculosis were prospectively enrolled. PoCUS was performed according to a standardized protocol. Reference standard was the detection of Mycobacterium tuberculosis using Xpert MTB/RIF or culture. RESULTS: We enrolled 414 participants: 243 female, median age 36 years, median CD4 cell count 86/mm, and 172 (42%) had tuberculosis. Sensitivity and specificity were ≥1 individual PoCUS feature [73% (95% CI: 65 to 79), 54% (95% CI: 47 to 60)], FASH protocol [71% (95% CI: 64 to 78), 57% (95% CI: 50 to 63)]. Independent PoCUS predictors identified were intra-abdominal lymphadenopathy of any size (aDOR 3.7 (95% CI: 2.0 to 6.7)], ascites [aDOR 3.0 (95% CI: 1.5 to 5.7)], and pericardial effusion of any size [aDOR 1.9 (95% CI: 1.2 to 3.0)]. The c-statistic for the derivation model was 0.680 (95% CI: 0.631 to 0.729), compared with 0.630 (95% CI: 0.576 to 0.684) of the FASH protocol. Two or more independent PoCUS predictors had 91% (95% CI: 86 to 94) specificity. CONCLUSION: The presence of 2 or more independent PoCUS predictors (intra-abdominal lymphadenopathy, ascites, and pericardial effusion) had moderate discrimination for HIV-associated tuberculosis in patients presenting to the emergency center.

A multi-parameter diagnostic clinical decision tree for the rapid diagnosis of tuberculosis in HIV-positive patients presenting to an emergency centre.

Background: Early diagnosis is essential to reduce the morbidity and mortality of HIV-associated tuberculosis. We developed a multi-parameter clinical decision tree to facilitate rapid diagnosis of tuberculosis using point-of-care diagnostic tests in HIV-positive patients presenting to an emergency centre. Methods: A cross-sectional study was performed in a district hospital emergency centre in a high-HIV-prevalence community in South Africa. Consecutive HIV-positive adults with ≥1 WHO tuberculosis symptoms were enrolled over a 16-month period. Point-of-care ultrasound (PoCUS) and urine lateral flow lipoarabinomannan (LF-LAM) assay were done according to standardized protocols. Participants also received a chest X-ray. Reference standard was the detection of Mycobacterium tuberculosis using Xpert MTB/RIF or culture. Logistic regressions models were used to investigate the independent association between prevalent microbiologically confirmed tuberculosis and clinical and biological variables of interest. A decision tree model to predict tuberculosis was developed using the classification and regression tree algorithm. Results: There were 414 participants enrolled: 171 male, median age 36 years, median CD4 cell count 86 cells/mm 3. Tuberculosis prevalence was 42% (n=172). Significant variables used to build the classification tree included ≥2 WHO symptoms, antiretroviral therapy use, LF-LAM, PoCUS independent features (pericardial effusion, ascites, intra-abdominal lymphadenopathy) and chest X-ray. LF-LAM was positioned after WHO symptoms (75% true positive rate, representing 17% of study population). Chest X-ray should be performed next if LF-LAM is negative. The presence of ≤1 PoCUS independent feature in those with 'possible or unlikely tuberculosis' on chest x-ray represented 47% of non-tuberculosis participants (true negative rate 83%). In a prediction tree which only included true point-of-care tests, a negative LF-LAM and the presence of ≤2 independent PoCUS features had a 71% true negative rate (representing 53% of sample). Conclusions: LF-LAM should be performed in all adults with suspected HIV-associated tuberculosis (regardless of CD4 cell count) presenting to the emergency centre.

Cross-sectional study of paediatric case mix presenting to an emergency centre in Cape Town, South Africa, during COVID-19.

OBJECTIVE: To describe and compare the effect of level 5 lockdown measures on the workload and case mix of paediatric patients presenting to a district-level emergency centre in Cape Town, South Africa. METHODS: Paediatric patients (<13 years) presenting to Mitchells Plain Hospital were included. The level 5 lockdown period (27 March 2020-30 April 2020) was compared with similar 5-week periods immediately before (21 February 2020-26 March 2020) and after the lockdown (1 May 2020-4 June 2020), and to similar time periods during 2018 and 2019. Patient demographics, characteristics, International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) diagnosis, disposition and process times were collected from an electronic patient tracking and registration database. The χ2 test and the independent samples median test were used for comparisons. RESULTS: Emergency centre visits during the lockdown period (n=592) decreased by 58% compared with 2019 (n=1413) and by 56% compared with the 2020 prelockdown period (n=1342). The proportion of under 1 year olds increased by 10.4% (p<0.001), with a 7.4% increase in self-referrals (p<0.001) and a 6.9% reduction in referrals from clinics (p<0.001). Proportionally more children were referred to inpatient disciplines (5.6%, p=0.001) and to a higher level of care (3.9%, p=0.004). Significant reductions occurred in respiratory diseases (66.9%, p<0.001), injuries (36.1%, p<0.001) and infectious diseases (34.1%, p<0.001). All process times were significantly different between the various study periods. CONCLUSION: Significantly less children presented to the emergency centre since the implementation of the COVID-19 lockdown, with marked reductions in respiratory and infectious-related diseases and in injuries.

Evaluating trauma scoring systems for patients presenting with gunshot injuries to a district-level urban public hospital in Cape Town, South Africa.

INTRODUCTION: Trauma scoring systems are widely used in emergency settings to guide clinical decisions and to predict mortality. It remains unclear which system is most suitable to use for patients with gunshot injuries at district-level hospitals. This study compares the Triage Early Warning Score (TEWS), Injury Severity Score (ISS), Trauma and Injury Severity Score (TRISS), Kampala Trauma Score (KTS) and Revised Trauma Score (RTS) as predictors of mortality among patients with gunshot injuries at a district-level urban public hospital in Cape Town, South Africa. METHODS: Gunshot-related patients admitted to the resuscitation area of Khayelitsha Hospital between 1 January 2016 and 31 December 2017 were retrospectively analysed. Receiver Operating Characteristic (ROC) analysis were used to determine the accuracy of each score to predict all-cause in-hospital mortality. The odds ratio (with 95% confidence intervals) was used as a measure of association. RESULTS: In total, 331 patients were included in analysing the different scores (abstracted from database n = 431, excluded: missing files n = 16, non gunshot injury n = 10, <14 years n = 1, information incomplete to calculate scores n = 73). The mortality rate was 6% (n = 20). The TRISS and KTS had the highest area under the ROC curve (AUC), 0.90 (95% CI 0.83-0.96) and 0.86 (95% CI 0.79-0.94), respectively. The KTS had the highest sensitivity (90%, 95% CI 68-99%), while the TEWS and RTS had the highest specificity (91%, 95% CI 87-94% each). CONCLUSIONS: None of the different scoring systems performed better in predicting mortality in this high-trauma burden area. The results are limited by the low number of recorded deaths and further studies are needed.

Evaluating trauma scoring systems for patients presenting with gunshot injuries to a district-level urban public hospital in Cape Town, South Africa

Introduction : Trauma scoring systems are widely used in emergency settings to guide clinical decisions and to predict mortality. It remains unclear which system is most suitable to use for patients with gunshot injuries at district-level hospitals. This study compares the Triage Early Warning Score (TEWS), Injury Severity Score (ISS), Trauma and Injury Severity Score (TRISS), Kampala Trauma Score (KTS) and Revised Trauma Score (RTS) as predictors of mortality among patients with gunshot injuries at a district-level urban public hospital in Cape Town, South Africa. Methods : Gunshot-related patients admitted to the resuscitation area of Khayelitsha Hospital between 1 January 2016 and 31 December 2017 were retrospectively analysed. Receiver Operating Characteristic (ROC) analysis were used to determine the accuracy of each score to predict all-cause in-hospital mortality. The odds ratio (with 95% confidence intervals) was used as a measure of association.Results : In total, 331 patients were included in analysing the different scores (abstracted from database n = 431, excluded: missing files n = 16, non gunshot injury n = 10, <14 years n = 1, information incomplete to calculate scores n = 73). The mortality rate was 6% (n = 20). The TRISS and KTS had the highest area under the ROC curve (AUC), 0.90 (95% CI 0.83-0.96) and 0.86 (95% CI 0.79­0.94), respectively. The KTS had the highest sensitivity (90%, 95% CI 68-99%), while the TEWS and RTS had the highest specificity (91%, 95% CI 87­94% each). Conclusions : None of the different scoring systems performed better in predicting mortality in this high-trauma burden area. The results are limited by the low number of recorded deaths and further studies are needed

The epidemiology of operations performed by the National Sea Rescue Institute of South Africa over a 5-year period.

BACKGROUND: Injuries remain a major contributor of morbidity and mortality worldwide, with drowning accounting for 7% of all injury-related deaths with rates of between 4 and 8 per 100,000. The African region has death rates comparable to most low-income countries. Non-fatal drowning in Africa remains unquantified but it is estimated to be ten times higher than the fatal drowning rate. Timely search and rescue, initial resuscitation and rapid transportation to definitive care play a crucial role in preventing injury- related morbidity and mortality. The National Sea Rescue Institute (NSRI) of South Africa is a non-profit organisation responsible for ~97% of maritime search and rescue operations in South Africa (including inland navigable waters). The aim of the study was to describe the epidemiology of operations performed by the NSRI of South Africa over a 5-year period. MATERIALS AND METHODS: The NSRI operational database was analysed from 1 January 2010 to 31 December 2014. Summary statistics are presented. RESULTS: The NSRI launched 3281 operations over the study period. Marked seasonal variation were noticeable with peak periods in December and January, corresponding to the South African summer holiday season. Water-based operations (67.6%) were the most frequent operation performed. The NSRI assisted 3399 individuals of which 77% were male. The mean age of rescued persons was 42 years. Eight hundred and thirty-six (25%) individuals had non-fatal injuries or illnesses requiring medical assistance. Medical emergencies (35%), traumatic injuries (32.8%), and non-fatal drownings (23%) were the most common types of injury and illness. The majority of the 184 (18%) deaths recorded were due to drowning (75%). CONCLUSIONS: Injury and illness, specifically drowning utilise a large proportion of search and rescue services. The results suggest further preventative measures and public health strategies be implemented to minimise traumatic and medical incident severity and subsequent casualties at sea.

The epidemiology of major incidents in the Western Cape Province, South Africa.

BACKGROUND: Major incidents put pressure on any health system. There are currently no studies describing the epidemiology of major incidents in South Africa (SA). The lack of data makes planning for major incidents and exercising of major incident plans difficult. OBJECTIVE: To describe the epidemiology of major incidents in the Western Cape Province, SA. METHODS: A retrospective analysis of the Western Cape Major Incident database was conducted for the period 1 December 2008-30 June 2014. Variables collected related to patient demographics and incident details. Summary statistics were used to describe all variables. RESULTS: Seven hundred and seventy-seven major incidents were reviewed (median n=11 per month). Most major incidents occurred in the City of Cape Town (57.8%, n=449), but the Central Karoo district had the highest incidence (11.97/10 000 population). Transport-related incidents occurred most frequently (94.0%, n=730). Minibus taxis were involved in 312 major incidents (40.2%). There was no significant difference between times of day when incidents occurred. A total of 8,732 patients were injured (median n=8 per incident); ten incidents involved 50 or more victims. Most patients were adults (80.0%, n=6 986) and male (51.0%, n=4,455). Of 8,440 patients, 630 (7.5%) were severely injured. More than half of the patients sustained minor injuries (54.6%, n=4,605). CONCLUSION: Major incidents occurred more often than would have been expected compared with other countries, with road traffic crashes the biggest contributor. A national database will provide a better perspective of the burden of major incidents.