The value of electrocardiography in predicting inpatient mortality in patients with acute pulmonary embolism: A cross sectional analysis

Introduction

Pulmonary embolism (PE) is a significant global cause of mortality, ranking third after myocardial infarction and stroke. ECG findings may play a valuable role in the prognostication of patients with PE, with various ECG abnormalities proving to be reasonable predictors of haemodynamic decompensation, cardiogenic shock, and even mortality. This study aims to assess the value of electrocardiography in predicting inpatient mortality in patients with acute pulmonary embolism, as diagnosed with computed tomography pulmonary angiogram.

Method

This study was a cross sectional analysis based at Tygerberg Hospital, Cape Town, South Africa. Eligible patients were identified from all CT-PA performed between 1 January 2017 and 31 December 2019 (2 years). The ECGs were independently screened by two blinded emergency physicians for predetermined signs that are associated with right heart strain and higher pulmonary artery pressures, and these findings were analysed to in-hospital mortality.

Results

Of the included 81 patients, 61 (75 %) were female. Of the 41 (51 %) patients with submassive PE and 8 (10 %) with massive PE, 7 (17 %) and 3 (38 %) suffered inpatient mortality (p = 0.023) respectively. Univariate ECG analysis revealed that complete right bundle branch block (OR, 8.6; 95 % CI, 1.1 to 69.9; p = 0.044) and right axis deviation (OR, 5.6; 95 % CI, 1.4 to 22.4; p = 0.015) were significant predictors of inpatient mortality.

Conclusion

Early identification of patients with pulmonary embolism at higher risk of clinical deterioration and in-patient mortality remains a challenge. Even though no clinical finding or prediction tool in isolation can reliably predict outcomes in patients with pulmonary embolism, this study demonstrated two ECG findings at presentation that were associated with a higher likelihood of inpatient mortality. This single-centre observational study with a small sample precludes concrete conclusions and a large follow-up multi-centre study is advised.

Deeply jaundiced: Not so surgical after all

Leptospirosis is an under-recognised disease in sub-Saharan Africa and the diagnosis requires a high index of suspicion. This case report highlights the protean manifestations of leptospirosis. Leptospirosis should be considered in any patient presenting with fever and jaundice, especially when there has been a history of occupational or recreational exposure to water, soil or rodents.

Contribution

This case report describes a typical case of leptospirosis, which often presents as a diagnostic dilemma.

Cardiopulmonary resuscitation in low-resource settings: a statement by the International Liaison Committee on Resuscitation, supported by the AFEM, EUSEM, IFEM, and IFRC

Most recommendations on cardiopulmonary resuscitation were developed from the perspective of high-resource settings with the aim of applying them in these settings. These so-called international guidelines are often not applicable in low-resource settings. Organisations including the International Liaison Committee on Resuscitation (ILCOR) have not sufficiently addressed this problem. We formed a collaborative group of experts from various settings including low-income, middle-income, and high-income countries, and conducted a prospective, multiphase consensus process to formulate this ILCOR Task Force statement. We highlight the discrepancy between current cardiopulmonary resuscitation guidelines and their applicability in low-resource settings. Successful existing initiatives such as the Helping Babies Breathe programme and the WHO Emergency Care Systems Framework are acknowledged. The concept of the chainmail of survival as an adaptive approach towards a framework of resuscitation, the potential enablers of and barriers to this framework, and gaps in the knowledge are discussed, focusing on low-resource settings. Action points are proposed, which might be expanded into future recommendations and suggestions, addressing a large diversity of addressees from caregivers to stakeholders. This statement serves as a stepping-stone to developing a truly global approach to guide resuscitation care and science, including in health-care systems worldwide.

The Role of Cardiac Biomarkers in the Diagnosis of Hypertensive Emergency

There is a growing interest in the role of biomarkers in differentiating hypertensive emergency from hypertensive urgency. This study aimed to determine the diagnostic utility of lactate dehydrogenase (LDH), high-sensitivity cardiac troponin T (hscTnT), and N-terminal prohormone of brain-type natriuretic peptide (NT-proBNP) for identifying hypertensive emergency. A diagnosis of hypertensive emergency was made based on a systolic blood pressure of ≥180 mmHg and/or a diastolic blood pressure of ≥110 mmHg with acute hypertension-mediated organ damage. The predictive value of LDH, hscTnT, NT-proBNP, and models of these biomarkers for hypertensive emergency was determined using the area under the receiver operator characteristic curve (AUC). There were 66 patients (66.7% male) with a hypertensive emergency and 16 (31.3% male) with hypertensive urgency. LDH, NT-proBNP, and hscTnT were significantly higher in hypertensive emergency. Serum LDH > 190 U/L and high creatinine were associated with hypertensive emergency. LDH had an AUC ranging from 0.87 to 0.92 for the spectrum of hypertensive emergencies, while hscTnT had an AUC of 0.82 to 0.92, except for neurological emergencies, in which the AUC was 0.72. NT-proBNP was only useful in predicting acute pulmonary edema (AUC of 0.89). A model incorporating LDH with hscTnT had an AUC of 0.92 to 0.97 for the spectrum of hypertensive emergencies. LDH in isolation or combined with hscTnT correctly identified hypertensive emergency in patients presenting with hypertensive crisis. The routine assessment of these biomarkers has the potential to facilitate the timely identification of hypertensive emergencies, especially in patients with subtle and subclinical target organ injury.

Clinical Profile of Patients with Hypertensive Emergency Referred to a Tertiary Hospital in the Western Cape Province of South Africa

BACKGROUND

Despite advances in managing hypertension, hypertensive emergencies remain a common indication for emergency room visits. Our study aimed to determine the clinical profile of patients referred with hypertensive emergencies.

METHODS

We conducted an observational study involving patients aged ≥18 years referred with hypertensive crisis. A diagnosis of hypertensive emergencies was based on a systolic blood pressure (BP) ≥180 mmHg and/or a diastolic BP ≥110 mmHg, with acute hypertension-mediated organ damage (aHMOD). Patients without evidence of aHMOD were considered hypertensive urgencies. Hypertensive disorders of pregnancy and unconscious patients were excluded from the study.

RESULTS

Eighty-two patients were included, comprising 66 (80.5%) with hypertensive emergencies and 16 (19.5%) with hypertensive urgencies. The mean age of patients with hypertensive emergencies was 47.9 (13.2) years, and 66.7% were males. Age, systolic BP, and duration of hypertension were similar in the hypertensive crisis cohort. Most patients with hypertensive emergencies reported nonadherence to medication (78%) or presented de novo without a prior diagnosis of hypertension (36%). Cardiac aHMOD (acute pulmonary edema and myocardial infarction) occurred in 66%, while neurological emergencies (intracranial hemorrhage, ischemic stroke, and hypertensive encephalopathy) occurred in 33.3%. Lactate dehydrogenase (LDH) (P < 0.001), NT-proBNP (P=0.024), and cardiac troponin (P<0.001) were higher in hypertensive emergencies compared to urgencies. LDH did not differ in the subtypes of hypertensive emergencies.

CONCLUSION

Cardiovascular and neurological emergencies are the most common hypertensive emergencies. Most patients reported nonadherence to medication or presented de novo without a prior diagnosis of hypertension.

After-hour trauma-radiograph interpretation in the emergency centre of a District Hospital

Introduction

Plain radiographs remain a first-line trauma investigation. Most trauma radiographs worldwide are reported by junior doctors. This study assesses the accuracy of after-hour acute trauma radiograph reporting by emergency centre (EC) doctors in an African district hospital.

Methods

An institutional review board approved retrospective descriptive study over two consecutive weekends in February 2020. The radiologist report on the admission radiographs of adult trauma patients was compared with the initial EC interpretation. The accuracy, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for EC interpretation were calculated with 95% confidence intervals (95%CI). The association between reporting accuracy and anatomical region, mechanism of injury, time of investigation, and the number of abnormalities per radiograph was assessed.

Results

140 radiographs were included, of which 49 (35%) were abnormal. EC doctors recorded (95%CI) 77% (69-84%) accuracy, 38% (25-54%) sensitivity, 97% (91-99%) specificity, 86% (65-95%) PPV and 76% (71-80%) NPV. Performance was associated with the anatomical region (p=0.02), mechanism of injury (p=<0.01) time of day (p=0.04) and the number of abnormalities on the film (p=<0.01). The highest sensitivity was achieved in reports of the appendicular skeleton (42%) and in the setting of simple blunt trauma (62%). Overall accuracy was in line with the range (44%-99%) reported in the international literature.

Discussion

Accurate reporting of acute trauma radiographs is challenging. Key factors impact performance. Further training of junior doctors in this area of clinical practice is recommended. Future work should focus on assessing the impact of such training on reporting performance.

Assault-injured youth in the emergency centres of Khayelitsha, South Africa: A prospective study of recidivism and mortality

INTRODUCTION

Violence is a major cause of death worldwide among youth. The highest mortality rates from youth violence occur in low and middle-income countries (LMICs). We sought to identify risk factors for violent re-injury and emergency centre (EC) recidivism among assault-injured youth in South Africa.

METHODS

A prospective follow up study of assault injured youth and controls ages 14-24 presenting for emergency care was conducted in Khayelitsha, South Africa from 2016 to 2018. Sociodemographic and behavioral factors were assessed using a questionnaire administered during the index EC visit. The primary outcomes were return EC visit for violent injury or death within 15 months. We used multivariable logistic regression to compute adjusted odds ratios (OR) and 95% confidence intervals (CI) of associations between return EC visits and key demographic, social, and behavioral factors among assault-injured youth.

RESULTS

Our study sample included 320 assault-injured patients and 185 non-assault-injured controls. Of the assault-injured, 80% were male, and the mean age was 20.8 years. The assault-injured youth was more likely to have a return EC visit for violent injury (14%) compared to the control group (3%). The non-assault-injured group had a higher mortality rate (7% vs 3%). All deaths in the control group were due to end-stage HIV or TB-related complications. The strongest risk factors for return EC visit were prior criminal activity (OR = 2.3, 95% CI = 1.1-5.1), and current enrollment in school (OR = 2.1, 95% CI = 1.0-4.6). Although the assault-injured group reported high rates of binge drinking (73%) at the index visit, this was not found to be a risk factor for violence-related EC recidivism.

DISCUSSION

Our findings suggest that assault-injured youth in an LMIC setting are at high risk of EC recidivism and several sociodemographic and behavioral factors are associated with increased risk. These findings can inform targeted intervention programs.

The burden of diabetic emergencies on the resuscitation area of a district-level public hospital in Cape Town

INTRODUCTION

Diabetes and its complications continue to cause a daunting and growing concern on resource-limited environments. There is a paucity of data relating to the care of diabetic emergencies in the emergency centres of entry-level hospitals in Africa. The aim of this study was to describe the burden of diabetic emergencies presenting to the emergency centre of an urban district-level hospital in Cape Town, South Africa.

METHODS

The Khayelitsha Hospital Emergency Centre database was retrospectively analysed for patients presenting with a diabetic emergency within a 24-week randomly selected period. The database was supplemented by a retrospective chart review to include additional variables for participants with diabetic ketoacidosis (DKA), uncomplicated hyperglycaemia, severe hypoglycaemia and hyperosmolar hyperglycaemic state (HHS). Summary statistics are presented of all variables.

RESULTS

The prevalence of all diabetic emergencies was 8.1% (197/2424) (DKA n = 96, 48.7%; uncomplicated hyperglycaemia n = 45, 22.8%; severe hypoglycaemia n = 44, 22.3%; HHS n = 12, 6%). The median age was 48 years, with those presenting with DKA being substantially younger (36 years). A likely precipitant was identified in 175 (88%) patients; infection was the most common precipitant (n = 79, 40.1%). Acute kidney injury occurred in 80 (40.6%) cases. The median length of stay in the resuscitation area was 13 h (IQR 7.2-24) and 101 (51.3%) participants represented with a diabetic- related emergency within six months of the study period. The overall mortality rate was 5% (n = 10).

CONCLUSION

This study highlights the high burden of diabetic emergencies on the provision of acute care at a district-level hospital. The high prevalence of diabetic emergencies (8%) consisted of DKA (48.7%), uncomplicated hyperglycaemia (22.8%), severe hypoglycaemia (22.3%), and HHS (6%). The high infection rate (40%) and the high percentage of patients returning with a diabetic emergency (51%) could be indicative of the need for improved community-based diabetic programmes.

Multisystem inflammatory syndrome (MIS): a multicentre retrospective review of adults and adolescents in South Africa

OBJECTIVES

The aim of this study was to add to the descriptive data pertaining to the epidemiology, presentation, and clinical course of multisystem inflammatory syndrome (MIS) temporally associated with coronavirus disease 2019 in adults and adolescents from low- and middle-income countries.

METHODS

Patients presenting to the adult wards (14 years and older) of three academic hospitals in South Africa, who were diagnosed with MIS between August 1, 2020 and May 31, 2021, were reviewed retrospectively. The presentation, laboratory and radiographic findings, and clinical course are described.

RESULTS

Eleven cases of MIS were reported, four in adolescents (14-19 years) and seven in adults (≥19 years). Fever was universal. Gastrointestinal symptoms (90.9%), cardiorespiratory abnormalities (90.9%), and mucocutaneous findings (72.7%) were prominent. Echocardiography in 10/11 patients (90.9%) showed a median left ventricular ejection fraction of 26.3% (interquartile range 21.9-33.6%). All patients required high care admission and 72.7% required inotropic support. Glucocorticoids were initiated in all cases and 72.7% received intravenous immunoglobulin.

CONCLUSIONS

This constitutes the largest multicentre review of adults and adolescents with MIS in Africa. MIS may be overlooked in resource-limited settings, and heightened suspicion is needed in patients with multi-organ dysfunction, especially where repeated investigations for other aetiologies are negative.

Patient outcomes and experience of a task-shared screening and brief intervention service for problem substance use in South African emergency centres: a mixed methods study

Background

Screening, brief intervention and referral to treatment (SBIRT) programmes have resulted in generally positive outcomes in healthcare settings, particularly for problem alcohol use, yet implementation is hampered by barriers such as concerns regarding the burden on healthcare professionals. In low-resourced settings, task-sharing approaches can reduce this burden by using non-professional healthcare workers, yet data are scarce regarding the outcomes and acceptability to patients within a SBIRT service. This study aims to evaluate patient-reported outcomes, patient acceptability, perceived benefits and recommendations for improving a task-shared SBIRT service in South African emergency centres (ECs).

Methods

This mixed methods study incorporates quantitative substance use screening and patient satisfaction data collected routinely within the service at three hospitals, and qualitative semi-structured interviews with 18 EC patient beneficiaries of the programme exploring acceptability and perceived benefits of the programme, as well as recommendations to improve the service. Approximately three months after the acute EC visit, a sub-sample of patients were followed up telephonically to assess patient-reported satisfaction and substance use outcomes.

Results

Of the 4847 patients eligible for the brief intervention, 3707 patients (76%) used alcohol as their primary substance and 794 (16%) used cannabis. At follow-up (n = 273), significant reductions in substance use frequency and severity were noted and over 95% of patients were satisfied with the service. In the semi-structured interviews, participants identified the non-judgemental caring approach of the counsellors, and the screening and psychoeducation components of the intervention as being the most valuable, motivating them to decrease substance use and make other positive lifestyle changes. Study participants made recommendations to include group sessions, market the programme in communities and extend the programme’s reach to include a broader age group and a variety of settings.

Conclusions

This task-shared SBIRT service was found to be acceptable to patients, who reported several benefits of a single SBIRT contact session delivered during an acute EC visit. These findings add to the SBIRT literature by highlighting the role of non-professional healthcare workers in delivering a low-intensity SBIRT service feasible to implement in low-resourced settings.

How much time do doctors spend providing care to each child in the ED? A time and motion study

BACKGROUND

The total time per patient doctors spend providing care in emergency departments (EDs) has implications for the development of evidence-based ED staffing models. We sought to measure the total time taken by doctors to assess and manage individual paediatric patients presenting to two EDs in the Western Cape, South Africa and to compare these averages to the estimated benchmarks used regionally to calculate ED staffing allocations.

METHODS

We conducted a cross-sectional, observational study applying time and motion methodology, using convenience sampling. Data were collected over a 5-week period from 11 December 2015 to 18 January 2016 at Khayelitsha District Hospital Emergency Centre and Tygerberg Hospital Paediatric Emergency and Ambulatory Unit. We assessed total doctor time for each patient stratified by acuity level using the South African Triage Scale.

RESULTS

Care was observed for a total of 100 patients. Median age was 21 months (IQR 8-55). Median total doctor time per patient (95% CI) was 31 (22 to 38), 39 (31 to 63), 48 (32 to 63) and 96 (66 to 122) min for triage categories green, yellow, orange and red, respectively. Median timing was significantly higher than the estimated local benchmark for the lowest acuity 'green' triage category (31 min (22 to 38) vs 15 min; p=0.001) and the highest acuity 'red' category (96 min (66 to 122) vs 50 min; p=0.002).

CONCLUSION

Doctor time per patient increased with increasing acuity of triage category and exceeded estimated benchmarks for the highest and lowest acuities. The distinctive methodology can easily be extended to other settings and populations.

Adult medical emergency unit presentations due to adverse drug reactions in a setting of high HIV prevalence

INTRODUCTION

South Africa has the world's largest antiretroviral treatment programme, which may contribute to the adverse drug reaction (ADR) burden. We aimed to determine the proportion of adult non-trauma emergency unit (EU) presentations attributable to ADRs and to characterise ADR-related EU presentations, stratified according to HIV status, to determine the contribution of drugs used in management of HIV and its complications to ADR-related EU presentations, and identify factors associated with ADR-related EU presentation.

METHODS

We conducted a retrospective folder review on a random 1.7% sample of presentations over a 12-month period in 2014/2015 to the EUs of two hospitals in Cape Town, South Africa. We identified potential ADRs with the help of a trigger tool. A multidisciplinary panel assessed potential ADRs for causality, severity, and preventability.

RESULTS

We included 1010 EU presentations and assessed 80/1010 (7.9%) as ADR-related, including 20/239 (8.4%) presentations among HIV-positive attendees. Among HIV-positive EU attendees with ADRs 17/20 (85%) were admitted, versus 22/60 (37%) of HIV-negative/unknown EU attendees. Only 5/21 (24%) ADRs in HIV-positive EU attendees were preventable, versus 24/63 (38%) in HIV-negative/unknown EU attendees. On multivariate analysis, only increasing drug count was associated with ADR-related EU presentation (adjusted odds ratio 1.10 per additional drug, 95% confidence interval 1.03 to 1.18), adjusted for age, sex, HIV status, comorbidity, and hospital.

CONCLUSIONS

ADRs caused a significant proportion of EU presentations, similar to findings from other resource-limited settings. The spectrum of ADR manifestations in our EUs reflects South Africa's colliding epidemics of infectious and non-communicable diseases. ADRs among HIV-positive EU attendees were more severe and less likely to be preventable.

The burden of HIV and tuberculosis on the resuscitation area of an urban district-level hospital in Cape Town

INTRODUCTION

Many patients present to emergency centres with HIV and tuberculosis related emergencies. Little is known about the influence of HIV and tuberculosis on the resuscitation areas of district-level hospitals. The primary objective was to determine the burden of non-trauma patients with HIV and/or tuberculosis presenting to the resuscitation area of Khayelitsha Hospital, Cape Town.

METHODS

A retrospective analysis was performed on a prospectively collected observational database. A randomly selected 12-week sample of data from the resuscitation area was used. Trauma and paediatric (<13 years) cases were excluded. Patient demographics, HIV and tuberculosis status, disease category, investigations and procedures undertaken, disposition and in-hospital mortality were assessed. HIV and tuberculosis status were determined by laboratory confirmation or from clinical records. Descriptive statistics are presented and comparisons were done using the χ2-test or independent t-test.

RESULTS

A total of 370 patients were included. HIV prevalence was 38.4% (n = 142; unknown n = 78, 21.1%), tuberculosis prevalence 13.5% (n = 50; unknown n = 233, 63%), and HIV/tuberculosis co-infection 10.8% (n = 40). HIV and tuberculosis were more likely in younger patients (both p < 0.01) and more females were HIV-positive (p < 0.01). Patients with tuberculosis spend 93 min longer in the resuscitation area than those without (p = 0.02). The acuity of patients did not differ by HIV or tuberculosis status.Infectious-related diseases and diseases of the digestive system occurred significantly more in the HIV-positive group, and endocrine-related diseases and diseases of the nervous system in HIV-negative patients.HIV-positive patients received more abdominal ultrasound examinations (p < 0.01), blood cultures (p < 0.01) and intravenous antibiotics (p < 0.01). In-hospital mortality was 17% and was not influenced by HIV status (p = 0.36) or tuberculosis status (p = 0.29).

CONCLUSION

This study highlights the burden of HIV and tuberculosis on the resuscitation area of a district level hospital. Neither HIV nor tuberculosis status were associated with in-hospital mortality.

Assessment of documented adherence to critical actions in paediatric emergency care at a district-level public hospital in South Africa

Introduction

The provision of high-quality care is vital to improve child health and survival rates. A simple, practice-based tool was recently developed to evaluate the quality of paediatric emergency care in resource-limited settings in Africa. This study used the practice-based tool to describe the documented adherence to critical actions in paediatric emergency care at an urban district-level hospital in South Africa and assess its relation to clinical outcomes.

Methods

This study is a retrospective observational study covering a 19-month period (September 2017 to March 2019). Patients <13 years old, presenting to the emergency centre with one of six sentinel presentations (seizure, altered mental status, diarrhoea, fever, respiratory distress and polytrauma) were eligible for inclusion. In the patients' files, critical actions specific for each presentation were checked for completion. Post-hoc, a seventh group ‘multiple diagnoses’ was created for patients with more than one sentinel disease. The action completion rate was tested for association with clinical outcomes.

Results

In total, 388 patients were included (median age 1.1 years, IQR 0.3–3.6). The action completion rate varied from 63% (polytrauma) to 90% (respiratory distress). Participants with ≥75% action completion rate were younger (p < 0.001), presented with high acuity (p < 0.001), were more likely to be admitted (adjusted OR 2.2, 95%CI: 1.2–4.1), and had a hospital stay ≥4 days (adjusted OR 3.4, 95%CI: 1.5–7.9).

Conclusion

A high completion rate was associated with young age, a high patient acuity, hospital admission, length of hospital stay ≥4 days, and the specific sentinel presentation. Future research should determine whether or not documented care corresponds with the quality of delivered care and the predictive value regarding clinical outcome.

Emergency centre reorganization in preparation to the COVID-19 pandemic: A district hospital's dynamic adaptation response

The COVID-19 global pandemic forced healthcare facilities to put special isolation measures in place to limit nosocomial transmission. Cohorting is such a measure and refers to placing infected patients (or under investigation) together in a designated area. This report describes the physical reorganisation of the emergency centre at Khayelitsha Hospital, a district level hospital in Cape Town, South Africa in preparation to the COVID-19 pandemic. The preparation included the identification of a person under investigation (PUI) room, converting short stay wards into COVID-19 isolation areas, and relocating the paediatric section to an area outside the emergency centre. Finally, we had to divide the emergency centre into a respiratory and non-respiratory side by utilising part of the hospital’s main reception. We are positive that the preparation and reorganization of the emergency centre will limit nosocomial transmission during the expected COVID-19 surge. Our experience in adapting to COVID-19 may have useful implications for ECs throughout South Africa and in low-and-middle income countries that are preparing for this pandemic.

Clinical evolution, management and outcomes of patients with COVID-19 admitted at Tygerberg Hospital, Cape Town, South Africa: a research protocol

INTRODUCTION

The outbreak of the SARS-CoV-2 virus causing COVID-19, declared a global pandemic by the WHO, is a novel infection with a high rate of morbidity and mortality. In South Africa, 55 421 cases have been confirmed as of 10 June 2020, with most cases in the Western Cape Province. Coronavirus leaves us in a position of uncertainty regarding the best clinical approach to successfully manage the expected high number of severely ill patients with COVID-19. This presents a unique opportunity to gather data to inform best practices in clinical approach and public health interventions to control COVID-19 locally. Furthermore, this pandemic challenges our resolve due to the high burden of HIV and tuberculosis (TB) in our country as data are scarce. This study endeavours to determine the clinical presentation, severity and prognosis of patients with COVID-19 admitted to our hospital.

METHODS AND ANALYSIS

The study will use multiple approaches taking into account the evolving nature of the COVID-19 pandemic. Prospective observational design to describe specific patterns of risk predictors of poor outcomes among patients with severe COVID-19 admitted to Tygerberg Hospital. Data will be collected from medical records of patients with severe COVID-19 admitted at Tygerberg Hospital. Using the Cox proportional hazards model, we will investigate the association between the survival time of patients with COVID-19 in relation to one or more of the predictor variables including HIV and TB.

ETHICS AND DISSEMINATION

The research team obtained ethical approval from the Health Research Ethics Committee of the Faculty of Medicine and Health Sciences, Stellenbosch University and Research Committee of the Tygerberg Hospital. All procedures for the ethical conduct of scientific investigation will be adhered to by the research team. The findings will be disseminated in clinical seminars, scientific forums and conferences targeting clinical care providers and policy-makers.

Clinical teams' experiences of crowding in public emergency centres in Cape Town, South Africa

Introduction

Crowding is a significant challenge for emergency centres (ECs) globally. While South Africa is not alone in reckoning with high patient demand and insufficient resources to treat these patients; staff-to-patient ratios are generally lower than in the Global North. The study of crowding and its consequences for patient care is a key research priority for strengthening the quality and efficacy of emergency care in South Africa. The study set out to understand frontline staff's perspectives on crowding in Cape Town public ECs to learn how they cope in such high- pressure working conditions, determine what they see as the factors contributing to crowding, and obtain their recommendations for reform.

Methods

This research is a qualitative study from interviews and observations at five ECs in Cape Town, conducted in June and July 2017. In total 43 staff were interviewed individually or in pairs. The interviews included physicians of varying levels of experience (25), and registered or enrolled nurses (18). Data were analysed with the qualitative text-analysis software NVivo.

Results

Both doctors and nurses saw crowding as a consequence of three factors: 1) limited bed space in the EC, 2) insufficient health professionals to care for admitted patients, and 3) the presence of boarders. Systemic or organizational factors as well as human resource scarcity were determined to be the key reasons for crowding.

Discussion

With its high patient acuity and volume and its limited human and material resources, South Africa is an important case study for understanding how emergency care providers manage working in crowded conditions. The solutions to crowding recommended by interviewees were to expand the EC workforce and to add discharge lounges and examination tables.

A comparison of trauma scoring systems for injuries presenting to a district-level urban public hospital in Western Cape

BACKGROUND

Trauma is a major public health issue and has an extensive burden on the health system in South Africa. Many trauma scoring systems have been developed to estimate trauma severity and predict mortality. The prediction of mortality between different trauma scoring systems have not been compared at district-level health facilities in South Africa. The objective was to compare four trauma scoring systems (injury severity score (ISS), revised trauma score (RTS), Kampala trauma score (KTS), trauma and injury severity score (TRISS)) in predicting mortality in trauma-related patients presenting to a district-level hospital in Cape Town.

METHODS

A retrospective analysis of all trauma patients managed in the resuscitation unit of Khayelitsha Hospital during a six-month period. Logistic regression was done, and empirical cut-off points used to maximise sensitivity and specificity on receiver operating characteristic curves. The outcome was all-cause in-hospital mortality.

RESULTS

In total, 868 participants were analysed after 50 were excluded due to missing data. The mean (± SD) age was 28 ± 11 years, 726 (83.6%) were males, and penetrating injuries (n = 492, 56.6%) dominated. The mortality rate was 5.2% (n = 45). TRISS was the best mortality predictor (c-statistic 0.93, sensitivity 90%, specificity 87%). All scoring systems had overlapping confidence intervals.

CONCLUSION

TRISS, ISS, RTS and KTS performed equivocally in predicting mortality in trauma-related patients managed at a district-level facility. The appropriate scoring system should be the simplest one which can be practically implemented and will likely differ between facilities.

Ulnar Nerve Injury and Froment's Test: A Case Report

Traumatic, peripheral nerve injuries can be easily missed in the emergency department. The attending physician needs to maintain a high index of suspicion when reviewing patients with extremity injuries.

We present a case of a stable, 28-year-old male sustaining penetrating trauma to his right forearm with resultant, isolated ulnar nerve transection. Clinical findings and related anatomy are discussed pertaining to this patient's injury, with specific reference to Froment's test. This is a useful clinical adjunct when reviewing potential ulnar nerve injuries, demonstrating disruption of specific motor innervation to the thumb when such pathology exists. As a result, compensatory hyperflexion occurs with attempted thumb adduction, due to intact median nerve innervation of flexor pollicis longus. Early recognition of this pathology, whether isolated or concomitant, allows for early appropriate referral and improved patient outcomes.

Assault-injured youth in the emergency centres of Khayelitsha, South Africa: Baseline characteristics & opportunities for intervention

INTRODUCTION

Violence is a leading cause of death worldwide for youth age 15-29. A growing body of literature has described assault-injured youth in United States emergency centres, identifying risk factors for re-injury and mortality, and developing targeted interventions. Despite the fact that low- and middle-income countries are disproportionately affected by violence, little research on assault-injured youth exists in these settings.

METHODS

Survey and chart review of 14 to 24-year-old assault-injured patients and non-assault-injured controls to 24-hour emergency centres in Khayelitsha, South Africa over 15 weeks. Patient enrollment occurred 7pm Friday to 7am Monday. Multivariable logistic regression was used to estimate associations of behavioral and other factors with assault injury.

RESULTS

In total 513 patients were enrolled: 324 assault-injured patients and 189 controls (131 medical, 58 unintentional injuries). Overall 28% were female (n = 146) and 72% were male (n = 367). The mean age was 20.5 years. Assault-injured patients of both genders were more likely than controls to give a 30-day history of drinking any alcohol (OR 6.3) and binge drinking (OR 6.7). They were also more likely to report any physical fight (OR 4.4) or any physical fight requiring medical care in the past 6 months (OR 5.08), and lifetime history of arrest (OR 5.1) or conviction (OR 6.7). Drugs and/or alcohol were used by victims prior to 78% of the assaults. Significant differences were not detected between females (76%) and males (79%). Overall, 47% of assault-injured youth and 15% of controls reported a history of a fight requiring medical treatment in the past 6 months.

DISCUSSION

Violence is a chronic and recurring disease, suggesting opportunities for interventions during health care contacts. Our population of assault-injured youth demonstrated significant rates of alcohol use and binge drinking, as well as alcohol use prior to the assault. Future secondary violence prevention initiatives should consider targeting alcohol use and abuse.

The association between hospital arrival time, transport method, prehospital time intervals, and in-hospital mortality in trauma patients presenting to Khayelitsha Hospital, Cape Town

INTRODUCTION

Trauma is a leading cause of unnatural death and disability in South Africa. The aim of the study was to determine whether method of transport, hospital arrival time or prehospital transport time intervals were associated with in-hospital mortality among trauma patients presenting to Khayelitsha Hospital, a district-level hospital on the outskirts of Cape Town, South Africa.

METHODS

The Khayelitsha Hospital Emergency Centre database was retrospectively analysed for trauma-related patients presenting to the resuscitation area between 1 November 2014 and 30 April 2015. Missing data and additional variables were collected by means of a chart review. Eligible patients' folders were scrutinised for hospital arrival time, transport time intervals, transport method and in-hospital mortality. Descriptive statistics were presented for all variables. Categorical data were analysed using the Fisher's Exact test and Chi-square, continuous data by logistic regression and the Mann Whitney test. A confidence interval of 95% was used to describe variance and a p-value of <0.05 was deemed significant.

RESULTS

The majority of patients were 19-44 year old males (n = 427, 80.3%) and penetrating trauma the most frequent mechanism of injury (n = 343, 64.5%). In total, 258 (48.5%) patients arrived with their own transport, 254 (47.7%) by ambulance and 20 (3.8%) by the police service. The arrival of trauma patients peaked during the weekend, and was especially noticeable between midnight and six a.m. In-hospital mortality (n = 18, 3.4%) was not significantly affected by transport method (p = 0.26), hospital arrival time (p = 0.22) or prehospital transport time intervals (all p-values >0.09).

DISCUSSION

Method of transport, hospital arrival time and prehospital transport time intervals did not have a substantially measurable effect on in-hospital mortality. More studies with larger samples are suggested due to the small event rate.

Describing the categories of people that contribute to an Emergency Centre crowd at Khayelitsha hospital, Western Cape, South Africa

INTRODUCTION

Emergency Centre (EC) crowding has globally been recognised to adversely affect patients, staff and visitors. Anecdotally, local ECs are perceived to be fairly crowded, however, not much is known about the size of this crowd and what constitutes it. Although more reliable, resource restrictions render more detailed flow studies less achievable. This study describes the EC crowd at Khayelitsha hospital in Cape Town, South Africa as the number and different categories of people, at predefined times during the day over a four-week period.

METHODS

A prospective, cross-sectional design was used. Headcounts were made by predefined groups at 09h00, 14h00, and 21h00 every day for four weeks. Predefined groups included doctors, nurses, visitors, patients, and other allied health staff. Summary statistics were used to describe the data. Precision was described using the 95% confidence interval.

RESULTS

A total of 16,353 people were counted during the study period. On average, 6370 (39%) of the groups were staff, 5231 (32%) were patients and 4752 (29%) were visitors. Of the staff, 586 (3.6%) were EC doctors, 733 (4.4%) were non-EC doctors, 1488 (9%) were EC nurses, and 445 (3%) were non-EC nurses. Although patient numbers in the EC remained constant, visitors and non-EC staff varied significantly with visitors peaking in the afternoon and non-EC staff drastically reducing in the evening. The EC was consistently crowded - average occupancy: 130%.

CONCLUSION

Staff levels fluctuated predictably, reducing at night and over weekends, while patient levels remained constant. Non-EC doctors more than doubled during the day on week shifts, in significantly more numbers than EC doctors, suggesting that many of the patients in the EC were likely to be admissions boarding in the EC. Visitor numbers were substantial during visiting hours and further aggravated crowding. Resource-light studies involving flow are important to explore crowding in low- and middle income settings.

Poor adherence to Tranexamic acid guidelines for adult, injured patients presenting to a district, public, South African hospital

Introduction

In South Africa’s high injury prevalent setting, it is imperative that injury mortality is kept to a minimum. The CRASH-2 trial showed that Tranexamic acid (TXA) in severe injury reduces mortality. Implementation of this into injury protocols has been slow despite the evidence. The 2013 Western Cape Emergency Medicine Guidelines adopted the use of TXA. This study aims to describe compliance.

Methods

A retrospective study of TXA use in adult injury patients presenting to Khayelitsha Hospital was done. A sample of 301 patients was randomly selected from Khayelitsha’s resuscitation database and data were supplemented through chart review. The primary endpoint was compliance with local guidance: systolic blood pressure <90 or heart rate >110 or a significant risk of haemorrhage. Injury Severity Score (ISS) was used as a proxy for the latter. ISS >16 was interpreted as high risk of haemorrhage and ISS <8 as low risk. Linear regression and Fischer’s Exact test were used to explore assumptions.

Results

Overall compliance was 58% (172 of 295). For those without an indication, this was 96% (172 of 180). Of the 115 patients who had an indication, only eight (18%) received the first dose of TXA and none received a follow-up infusion. Compliance with the protocol was significantly better if an indication for TXA did not exist, compared to when one did (p < 0.001). Increased TXA use was associated only with ISS >15 (p < 0.001).

Discussion

TXA is not used in accordance with local guidelines. It was as likely not to be used when indicated than when not indicated. Reasons for this are multifactorial and likely include stock levels, lack of administration equipment, time to reach definitive care, poor documentation and hesitancy to use. Further investigation is needed to understand the barriers to administration.

Case mix of patients managed in the resuscitation area of a district-level public hospital in Cape Town

INTRODUCTION

At the core of the district health system is the emergency centre, for many the entry point into the healthcare system. Limited data is available on the patient population served by district-level emergency centres in South Africa. The objective of this study is to describe the case mix of adult patients managed in the resuscitation unit of a district-level hospital in the Western Cape.

METHODS

A six-month prospective observational study was conducted in the resuscitation unit of Khayelitsha Hospital. Data were collected by clinicians in the unit by means of a Smartphone application on their own devices. Variables collected included patient demographics, patient acuity, patient comorbidities, diagnosis made in the unit, interventions received, length of stay, and disposition. Summary statistics were used to describe all variables.

RESULTS

A total of 2324 patient admissions were analysed. The mean age was 36.9 years with a male predominance (n = 1367, 58.8%). Most patients were triaged into high-acuity categories (n = 1626, 70%). HIV infection was the most common comorbidity (n = 530, 22.8%). Acute medical (n = 1181, 50.8%) and trauma-related patients (n = 928, 39.9%) dominated the cohort. The median length of stay was 195 min and 502 (21.6%) patients were transferred to higher levels of care. There were 74 (3.2%) deaths.

CONCLUSION

This study yields novel epidemiological data of emergency care in a district-level emergency centre. It highlights the burden of trauma and acute medical emergencies at the district level and can be used as a foundation for further research to provide targeted and effective healthcare to all citizens.

The changing profile of Plasmodium falciparum malaria

Resurgence of malaria has been noted in the Rohtak district (Haryana, India) after the recent floods. The profile of 66 patients of P. falciparum infection who were admitted to our hospital over one month in October 1995 is reported. While only a minority of cases (< 15%) presented with an uncomplicated course, all others developed one or more complication(s), some of them very rare. The usual manifestations viz, cerebral malaria, black water fever and algid malaria seen in the past were observed in less than half the patients. The remaining presented with unusual complications like haemolytic anaemia (46.2%), severe anaemia (37.9%), thrombocytopaenia (18.2%), pancytopaenia (6%), adult respiratory distress syndrome (4.5%) often not seen in sporadic cases of falciparum malaria which occurred in the past in this district. Similarly all deaths (15.1%) were noted in patients with rarer manifestations and only one patient died of cerebral malaria. This study confirms the occurrence of severe and complicated falciparum malaria in this part of the country.