The Development of Consensus-Based Descriptors for Low-Acuity Emergency Medical Services Cases for the South African Setting

Prehospital hemorrhage management in low- and middle-income countries: A scoping review

INTRODUCTION

Low- and middle-income countries (LMICs) account for 90% of deaths due to injury, largely due to hemorrhage. The increased hemorrhage mortality burden in LMICs is exacerbated by absent or ineffective prehospital care. Hemorrhage management (HM) is an essential component of prehospital care in LMICs, yet current practices for prehospital HM and outcomes from first responder HM training have yet to be summarized.

METHODS

This review describes the current literature on prehospital HM and the impact of first responder HM training in LMICs. Articles published between January 2000 and January 2023 were identified using PMC, MEDLINE, and Scopus databases following PRISMA-ScR guidelines. Inclusion criteria spanned first responder training programs delivering prehospital care for HM. Relevant articles were assessed for quality using the Newcastle-Ottawa scale.

RESULTS

Of the initial 994 articles, 20 met inclusion criteria representing 16 countries. Studies included randomized control trials, cohort studies, case control studies, reviews, and epidemiological studies. Basic HM curricula were found in 15 studies and advanced HM curricula were found in six studies. Traumatic hemorrhage was indicated in 17 studies while obstetric hemorrhage was indicated in three studies. First responders indicated HM use in 55%-76% of encounters, the most frequent skill they reported using. Mean improvements in HM knowledge acquisition post-course ranged from 23 to 58 percentage points following training for pressure and elevation, gauze application, and tourniquet application.

CONCLUSIONS

Our study summarizes the current literature on prehospital HM in LMICs pertaining to epidemiology, interventions, and outcomes. HM resources should be a priority for further development.

The variables predictive of ambulance non-conveyance of patients in the Western Cape, South Africa

Introduction

Emergency medical service (EMS) resources are limited and should be reserved for incidents of appropriate acuity. Over-triage in dispatching of EMS resources is a global problem. Analysing patients that are not transported to hospital is valuable in contributing to decision-making models/algorithms to better inform dispatching of resources. The aim is to determine variables associated with patients receiving an emergency response but result in non-conveyance to hospital.

Methods

A retrospective cross-sectional study was performed on data for the period October 2018 to September 2019. EMS records were reviewed for instances where a patient received an emergency response but the patient was not transported to hospital. Data were subjected to univariate and multivariate regression analysis to determine variables predictive of non-transport to hospital.

Results

A total of 245 954 responses were analysed, 240 730 (97.88 %) were patients that were transported to hospital and 5 224 (2.12 %) were not transported. Of all patients that received an emergency response, 203 450 (82.72 %) patients did not receive any medical interventions. Notable variables predictive of non-transport were green (OR 4.33 (95 % CI: 3.55-5.28; p<0.01)) and yellow on-scene (OR 1.95 (95 % CI: 1.60-2.37; p<0.01).Incident types most predictive of non-transport were electrocutions (OR 4.55 (95 % CI: 1.36-15.23; p=0.014)), diabetes (OR 2.978 (95 % CI: 2.10-3.68; p<0.01)), motor vehicle accidents (OR 1.92 (95 % CI: 1.51-2.43; p<0.01)), and unresponsive patients (OR 1.98 (95 % CI: 1.54-2.55; p<0.01)). The highest treatment predictors for non-transport of patients were nebulisation (OR 1.45 (95 % CI: 1.21-1.74; p<0.01)) and the administration of glucose (OR 4.47 (95 % CI: 3.11-6.41; p<0.01)).

Conclusion

This study provided factors that predict ambulance non-conveyance to hospital. The prediction of patients not transported to hospital may aid in the development of dispatch algorithms that reduce over-triage of patients, on-scene discharge protocols, and treat and refer guidelines in EMS.

Outcomes of Emergency Trauma Patients After the Implementation of Web Application Operating Systems

PURPOSE

Trauma has significant impacts on the livelihoods and well-being of patients. Prompt emergency, medical, and nursing care is the key to reducing mortality rates. Digital platforms have become important for patient care. This research aimed to evaluate patient outcomes after implementing a novel web application operating system in trauma care.

METHODS

A descriptive comparative study was conducted on trauma patients. The patients were divided into two groups: those who used the developed application (n = 70) and those who did not (n = 70). The patients' characteristics, the time of the trauma team's arrival at the emergency department (ED) and the length of stay in the ED, and patients' outcomes were collected from electronic medical records and the application database. A statistical analysis was performed to evaluate this data. Sixty registered nurses who used the application completed the survey on the feasibility of the application.

RESULTS

The activated trauma intervals for the non-application-used group and the application-used group were 5.0 ± 1.1 and 3.1 ± 0.4 minutes, respectively (p = .010). The length of stay in the ED for the non-application-used group and the application-used group were 30.1 ± 5.1 and 18.3 ± 6.2 minutes, respectively. A high level of agreement confirms the feasibility of the application.

CONCLUSIONS

This application improves patient outcomes in terms of length of stay. This mobile application can improve the cooperation and communication and efficacy of the trauma care team.

A Qualitative Study of Rural and Remote Australian General Practitioners' Involvement in High-Acuity Patients

This study aimed to understand the experiences, barriers, and facilitators of rural general practitioners' involvement with high-acuity patients. Semi-structured interviews with rural general practitioners in South Australia who had experience delivering high-acuity care were audio-recorded, transcribed verbatim, and analyzed through content and thematic approaches incorporating Potter and Brough's capacity-building framework. Eighteen interviews were conducted. Barriers identified include the inability to avoid high-acuity work in rural and remote areas, pressure to handle complex presentations, lack of appropriate resources, lack of mental health support for clinicians, and impacts on social life. Enablers included a commitment to community, comradery in rural medicine, training, and experience. We concluded that general practitioners are a vital pillar of rural health service delivery and are inevitably involved in disaster and emergency response. While the involvement of rural general practitioners with high-acuity patients is complex, this study suggested that with the appropriate system, structure and role supports, rural general practitioners could be better empowered to manage high-acuity caseloads locally.

Implementation of the South African Triage Scale (SATS) in a New Ambulance System in Beira, Mozambique: A Retrospective Observational Study

In 2019, an urban ambulance system was deployed in the city of Beira, Mozambique to refer patients from peripheral health centres (HCs) to the only hospital of the city (Beira Central Hospital-HCB). Initially, the system worked following a first-in-first-out approach, thus leading to referrals not based on severity condition. With the aim of improving the process, the South African Triage Scale (SATS) has been subsequently introduced in three HCs. In this study, we assessed the impact of SATS implementation on the selection process and the accuracy of triage performed by nurses. We assessed 552 and 1608 referral charts from before and after SATS implementation, respectively, and we retrospectively calculated codes. We compared the expected referred patients' codes from the two phases, and nurse-assigned codes to the expected ones. The proportion of referred orange and red codes significantly increased (+12.2% and +12.9%) while the proportion of green and yellow codes decreased (-18.7% and -5.8%). The overall rates of accuracy, and under- and overtriage were 34.2%, 36.3%, and 29.5%, respectively. The implementation of SATS modified the pattern of referred patients and increased the number of severe cases receiving advanced medical care at HCB. While nurses' accuracy improved with the routine use of the protocol, the observed rates of incorrect triage suggest that further research is needed to identify factors affecting SATS application in this setting.

Improving ambulance dispatch triage to trauma: A scoping review using the framework of development and evaluation of clinical prediction rules

OBJECTIVE

Ambulance dispatch algorithms should function as clinical prediction rules, identifying high acuity patients for advanced life support, and low acuity patients for non-urgent transport. Systematic reviews of dispatch algorithms are rare and focus on study types specific to the final phases of rule development, such as impact studies, and may miss the complete value-added evidence chain. We sought to summarise the literature for studies seeking to improve dispatch in trauma by performing a scoping review according to standard frameworks for developing and evaluating clinical prediction rules.

METHODS

We performed a scoping review searching MEDLINE, EMBASE, CINAHL, the CENTRAL trials registry, and grey literature from January 2005 to October 2021. We included all study types investigating dispatch triage to injured patients in the English language. We reported the clinical prediction rule phase (derivation, validation, impact analysis, or user acceptance) and the performance and outcomes measured for high and low acuity trauma patients.

RESULTS

Of 2067 papers screened, we identified 12 low and 30 high acuity studies. Derivation studies were most common (52%) and rule-based computer-aided dispatch was the most frequently investigated (23 studies). Impact studies rarely reported a prior validation phase, and few validation studies had their impact investigated. Common outcome measures in each phase were infrequent (0 to 27%), making a comparison between protocols difficult. A series of papers for low acuity patients and another for pediatric trauma followed clinical prediction rule development. Some low acuity Medical Priority Dispatch System codes are associated with the infrequent requirement for advanced life support and clinician review of computer-aided dispatch may enhance dispatch triage accuracy in studies of helicopter emergency medical services.

CONCLUSIONS

Few derivation and validation studies were followed by an impact study, indicating important gaps in the value-added evidence chain. While impact studies suggest clinician oversight may enhance dispatch, the opportunity exists to standardize outcomes, identify trauma-specific low acuity codes, and develop intelligent dispatch systems.