Emergency care in Africa

Dispatcher Triage Accuracy in the Western Cape Government Emergency Medical Services System, Cape Town, South Africa

INTRODUCTION

Triage - the sorting of patients according to urgency of need for clinical care - is an essential part of delivering effective and efficient emergency care. But when frequent over- or under-triaging occurs, finite time and resources are diverted away from those in greatest need of care and the entire Emergency Medical Services (EMS) system is strained. In resource-constrained settings, such as South Africa, poor triage in EMS only serves to compound other contextual challenges. This study examined the accuracy of dispatcher triage over a one-year period in the Western Cape Government (WCG) EMS system in South Africa.

METHODS

A retrospective analysis of existing dispatch and EMS data to assess the accuracy of dispatch-assigned priorities was conducted. The mismatch between dispatcher-assigned call priority and triage levels determined by EMS personnel was analyzed via over- and under-triage rates, sensitivity and specificity, and positive and negative predictive values (PPVs and NPVs, respectively).

RESULTS

A total of 185,166 records from December 2016 through November 2017 were analyzed. Across all dispatch complaints, the over-triage rate was 67.6% (95% CI, 66.34-68.76) and the under-triage rate was 16.2% (95% CI, 15.44-16.90). Dispatch triage sensitivity for all included records was 49.2% (95% CI, 48.10-50.38), specificity 71.9% (95% CI, 71.00-72.92), PPV 32.5% (95% CI, 30.02-34.88), and NPV 83.8% (95% CI, 81.93-85.73).

CONCLUSION

This study provides the first evaluation of dispatch triage accuracy in the WCG EMS system, identifying that the system is suffering from both under- and over-triage. Despite variance across dispatch complaints, both under- and over-triage remained higher than widely accepted norms, and all rates were significantly above acceptable target metrics described in similar studies. Results of this study will be used to motivate the development of more rigorous training programs and resources for WCG EMS dispatchers, including improved dispatch protocols for conditions suffering from high over- and under-triage.

The forgotten needs of mothers during neonatal transfers: A quest for greater sensitivity

Background

The transfer of critically ill neonates has escalated in developing countries. This calls for greater awareness of the needs of mothers who are often overlooked while clinical attention is prioritised in relation to the neonate. The objective of the study was to understand the emotional and clinical needs of mothers during the transfer process.

Methods

Using a qualitative research approach, the study sought the views of mothers who were involved in emergency transfers. In-depth interviews were held with seven mothers. In addition, data from interviews with seven neonatologists and data from focus group discussions with 35 advanced life paramedics, were included.

Results

What emerged was that both the clinical and emotional needs of mothers were overlooked during the transfer which resulted in acute distress. Moreover, the study found that paramedics lacked preparedness to deal with the psychological needs of mothers and often overlooked their physiological condition as well.

Conclusion

It is crucial that greater sensitivity towards both the clinical and emotional needs of mothers be prioritised during neonatal transfers.

A mixed methods investigation of emergency communications centre triage in the Government Emergency Medical Services System, Cape Town, South Africa

Introduction

In order to allocate resources in an effective manner, emergency medical services (EMS) systems use dispatch-based triaging to prioritise patients by acuity. Over-triage, wherein patients are assigned a higher priority level than necessary, can serve as a safety measure. However, it places strain on EMS systems, a problem believed to be experienced by South Africa's Western Cape Government EMS system, with almost half of its calls designated at the highest priority level.

To begin improving dispatch within WCG EMS, we aimed to describe the current system by identifying the most common conditions dispatched, and those most perceived to be suffering from over-triage.

Methods

A multi-methods approach was taken: First, a quantitative chart review was used to analyse all calls assigned a dispatch priority by WCG EMS between December 2016 and November 2017. These descriptive data then informed qualitative focus groups to further investigate emergency medical dispatch (EMD). Three focus groups were conducted, each with a convenience sample of staff from: WCG EMS staff, call takers/dispatchers, and call centre managers. Data were reviewed and coded, after which the lead researcher aggregated coded transcripts and conducted thematic content analysis.

Results

Seventy-nine condition categories were identified from 649,544 completed patient records for the study period. Non-specific pain accounted for the greatest proportion of dispatched complaints (16.88%), followed by assault with a weapon (10.00%) and respiratory complaints (9.71%).

Sixteen WCG EMS personnel took part in focus groups, highlighting challenges of the current EMD system, including time constraints, legal risks, communication, overuse of the system, and lack of training. Chest pain, collapsed/unresponsive patients, and vomiting and diarrhoea were frequently noted to be potentially over-triaged conditions. To improve this, participants suggested trainings, modifications to the electronic EMD system, additional protocols, and public education.

Conclusion

This study identified where over-triage is possibly occurring in the WCG EMS dispatch system, as well as potential solutions proposed by those working within the system.

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There are many types of effective emergency medical dispatch (EMD) established within high-income countries’ EMS systems.

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EMDs are often the first opportunity for the recognition of time-critical conditions.

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Effective EMDs can improve time-to-care and patient outcomes

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This study explored potential causes of, and solutions to, over-triage in the WCG EMS dispatch system.

Global health and emergency care: a resuscitation research agenda--part 1

At the 2013 Academic Emergency Medicine global health consensus conference, a breakout session on a resuscitation research agenda was held. Two articles focusing on cardiac arrest and trauma resuscitation are the result of that discussion. This article describes the burden of disease and outcomes, issues in resuscitation research, and global trends in resuscitation research funding priorities. Globally, cardiovascular disease and trauma cause a high burden of disease that receives a disproportionately smaller research investment. International resuscitation research faces unique ethical challenges. It needs reliable baseline statistics regarding quality of care and outcomes; data linkages between providers; reliable and comparable national databases; and an effective, efficient, and sustainable resuscitation research infrastructure to advance the field. Research in resuscitation in low- and middle-income countries is needed to understand the epidemiology, infrastructure and systems context, level of training needed, and potential for cost-effective care to improve outcomes. Research is needed on low-cost models of population-based research, ways to disseminate information to the developing world, and finding the most cost-effective strategies to improve outcomes.