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.

Guideline recommendations for antimicrobial stewardship education for clinical nursing practice in hospitals: A scoping review.

Background: Antimicrobial stewardship (AMS) is a proactive healthcare intervention to improve patient outcomes by optimising antimicrobial use. Although nursing involvement is a recognised necessity, bedside nurses may not yet possess competencies to fulfil this role. Objectives: To identify recommendations for AMS education for the bedside nurse in key global AMS guidelines. Methods: Scoping review methodology was used to systematically search published and 'grey' literature in PubMed, EBSCOhost, Google Scholar, government websites and websites of professional societies and organisations. Search dates were from 1990 to 2020. Inclusion criteria were English language AMS guidelines for hospitals. Results: Literature searches retrieved 1 824 articles, with 43 meeting the review inclusion criteria. Reference was made to AMS nursing education in 23 (53.4%) of the articles. Educational opportunities for nurses were recommended: inclusion of AMS concepts/content into undergraduate and postgraduate nursing curricula (n=12; 27.9%), in-hospital training (n=14; 32.5%) and continuing professional development (n=6; 13.9%). Recommendations for nursing education were as follows: role of AMS in preventing antimicrobial resistance (n=7; 16.2%), infection prevention and control (n=3; 6.9%), diagnostics in AMS (n=5; 11.6%), pharmacology (n=11; 25.5%) and collaboration (n=2; 4.6%). Identified nursing educational gaps were: nurses not recognising their role within AMS (n=5; 11.6%), inadequate nursing resources and expertise for dosing, pharmacokinetic/pharmacodynamic strategies and managing possible drug incompatibilities with extended/prolonged infusions (n=3; 6.9%), and inappropriate nurse disposal of antibiotic waste (n=1; 2.3%). Conclusion: Although recommendations for nursing education were found in many key AMS guidelines, few guidelines provided detailed descriptions of the nursing competencies that were required for this role. Contributions of the study: This study serves to compile and highlight previously little-known recommendations within key international antimicrobial stewardship (AMS) guidelines for the education of clinical nurses in their AMS role. It provides a summary of expected clinical nurse competencies. It adds to current discussion within the literature on how to improve and support this critical nursing role.

Alarms in the ICU: A study investigating how ICU nurses respond to clinical alarms for patient safety in a selected hospital in KwaZulu-Natal Province, South Africa.

Background: Advances in technology have facilitated the implementation of improved alarm management systems in the healthcare sector. There is a need to identify challenges encountered by intensive care unit (ICU) nurses with clinical alarm management systems in South Africa (SA) to ensure utilisation of these technological resources for patient safety. Objectives: To investigate how intensive care nurses respond to clinical alarms for patient safety in a selected hospital in KwaZulu-Natal Province, SA. Methods: A descriptive, non-experimental research design using the census sampling strategy was used to invite 120 nurses from four ICUs to complete an adapted, structured questionnaire. Descriptive statistics were used to analyse the data. Results: We had 91 respondents who completed the questionnaires (response rate of 75.8%). The majority of the respondents (85.7%) strongly knew the purpose of clinical alarms and 45.1% strongly felt confident about adjusting and monitoring the clinical alarms. More than half of the nurses (53.8 %) agreed to the existence of nuisance alarms that disrupted patient care (46.7%) and contributed to lack of responses (52.7%). While 76.9% strongly agreed with alarm sounds and displays to differentiate the priority of the alarms, 75.8% strongly agreed to the existence of proper documentation on setting alarms that are appropriate for each patient. The most frequent barriers were difficulty in setting alarms properly (51.6%) and lack of training on alarm systems (47.8%). Conclusion: The complexity in setting the alarms, limited training and existence of false alarms was evident. Alarm-specific training is required to keep intensive care nurses updated with changes in technology to ensure patient safety. Contributions of the study: The findings of this present study highlighted the importance of understanding the alarm management system within the ICU environment of the healthcare sector in SA. Technological improvements, specialised trainings and clear clinical policies for alarm management are essential to improve patient safety.

Guidelines for the hospital role of the clinical nurse in antimicrobial stewardship: A scoping review.

Background: Antimicrobial stewardship aims to optimise the use of antimicrobial medicines to preserve the efficacy of these medicines and to contain antimicrobial resistance where possible. Nurses constitute the largest group of healthcare workers; however, the role played by nurses within current antimicrobial stewardship strategies is largely unacknowledged despite nurses being at point-of-care at the hospital bedside. Objectives: To identify recommendations for the antimicrobial stewardship role of the bedside nurse in key global antimicrobial stewardship guidelines. Methods: Scoping review methodology was used to systematically search published and 'grey' literature in PubMed, EBSCOhost, Google Scholar, government websites, and websites of professional societies and organisations. Search dates were 1990 to 2020. Inclusion criteria were English language antimicrobial stewardship guidelines for hospitals. Screening was conducted in two stages for title and abstract and then full text relevancy and documented according to the PRISMA Extension for Scoping Reviews. Results: Of the 1 824 articles that were retrieved, only 43 met the inclusion criteria. Inclusion of the bedside nurse on the antimicrobial stewardship team occurred in 13.9% (n=6) of the papers. A role for the bedside nurse was recommended in antibiotic stewardship (32.5%; n=14), infection prevention and control (23.2%; n=10), and administration of antimicrobial medicines (20.9%; n=9) of reviewed documents. Other recommendations included the use of evidence-based antimicrobial stewardship (20.9%; n=9), collaboration with other healthcare staff (11.6%; n=5), facilitation of transition of care (18.6%; n=8), and nurse prescription of antibiotics (4.6%; n=2). Conclusion: This scoping review highlights a slow but incremental increase in recognition of the role of the bedside nurse within the operational hub of antimicrobial stewardship strategies. Contributions of the study: The present study was undertaken to fill the gap in the literature on clinical nurses' contribution in antimicrobial stewardship. The findings of the review largely demonstrate that multidisciplinary antimicrobial stewardship guidelines fail to view the bedside nurse as a contributor within antimicrobial stewardship strategies.

Families' perceptions of relational practice in the emergency department: A qualitative study.

PURPOSE: The purpose of this study was to describe families' perceptions of relational practice when interacting with health care professionals in emergency departments in the South African context. BACKGROUND: Relational practice is seen as an approach that amplifies the voices of families through creating meaningful connections with health care professionals. However, the voices of families maybe obliterated by factors in the clinical environment including the pressure to perform and timely patient flow. DESIGN: The study adopted a qualitative design. METHODS: Qualitative data were collected from six family members by means of semi-structured interviews and were analysed using qualitative content analysis. RESULTS: Four major categories emerged from family members' perceptions regarding relational practice when interacting with health care professionals in the emergency department, Disrupted worlds; Care is what you see and hear; Powerlessness; Feeling disconnected. CONCLUSIONS: Findings highlighted the need for improved relational practice between families and health care professionals in the emergency department. Pathways need to be created to involve families in decision-making and genuinely engage with them. There is a need to move away from the hierarchical "expert" emergency department culture towards one that seeks to include the voices of families in driving emergency department care.

Perceived barriers to the development of the antimicrobial stewardship role of the nurse in intensive care: Views of healthcare professionals.

Background: Antimicrobial stewardship has become an important initiative within intensive care units in the global fight against antimicrobial resistance. Support for nurses to participate in and actively direct antimicrobial stewardship interventions is growing however, there may be barriers that impede the development of this nursing role. Objectives: To explore the views of healthcare professionals regarding barriers to the antimicrobial stewardship role of the nurse in intensive care in a private hospital in KwaZulu-Natal, South Africa. Methods: Using a qualitative research approach, purposive sampling was used to identify fifteen participants from the disciplines of nursing, surgery, anaesthetics, internal medicine, microbiology, and pharmacy in a general intensive care unit. Content analysis was used to code data obtained from each individual interview. Results: The following categories and subcategories were derived: regarding barriers to the role of the nurse in antimicrobial stewardship: (i) lack of collaboration (subcategories: not participating in the antimicrobial stewardship programme, no feedback about antimicrobial resistance in the unit, and not part of decision-making); (ii) inadequate knowledge (subcategories: not understanding infection prevention and control, missing the link between laboratory results and start of treatment, and poor knowledge of antibiotics and their administration); and (iii) inexperienced nurses (subcategories: shortage of intensive care nurses, lack of experienced nurses, and inadequate nursing staff to provide in-service training). Conclusion: The nursing role within antimicrobial stewardship was negatively affected by both staffing and collaborative difficulties, which impacted on the implementation of antimicrobial stewardship within the unit. Contributions of the study: Nurses are not well-integrated into antimicrobial stewardship. Insufficient training and education on aspects of antimicrobial stewardship are available to nurses.

Compliance with the Surviving Sepsis Campaign guidelines for early resuscitation does not translate into improved outcomes in patients with surgical sepsis in South Africa.

INTRODUCTION: This project set out to audit our compliance with the 3-hour bundles of care for surgical sepsis and to interrogate how compliance or non-compliance impacts on the outcome of surgical sepsis in our institution. METHODS: All emergency surgical patients over the age of fifteen years were reviewed. All patients who fulfilled the ACCP/SCCM criteria for sepsis or septic shock, with a documented surgical source of infection, were identified for review. RESULTS: A total of 677 septic patients with a documented surgical source of sepsis were included. Of the 677 patients, 53% (360/677) had intra-abdominal sepsis, 17% (116/677) had diabetic-related limb sepsis and the remaining 30% (201) had soft tissue infections. A total of 585 operative procedures were performed. Compliance with all components of the 3-hour bundle metrics was achieved in 379/677 patients (56%), and not achieved in 298/677 patients (44%). The only significant difference between the compliant and the non-compliant groups was respiratory rate greater than 22 breaths/minute (131 vs 71, p = 0.002) in the compliant cohort. Amongst the compliant cohort 77/379 patients (20%) required admission to ICU, whilst 41/298 patients (14%) in the non-compliant cohort required admission to ICU. This difference was statistically different (p = 0.026). There was no difference in the median length of hospital stay (6 days) between the two groups. Fifty-five patients in the compliant cohort died (15%), whilst 31 (10%) of the patients in the non-compliant cohort died. This difference was not statistically different (p = 0.111). CONCLUSION: Compliance with the SCC 3-hour bundle did not seem to improve mortality outcomes in our setting. This observation cannot be adequately explained with our current data and further work looking at management of surgical sepsis in our setting is required. Time to surgical source control is probably the single most important determinant of outcome in patients with surgical sepsis and other aspects of the care bundle are of secondary importance.

An analysis of adverse events and human error associated with the imaging of patients at a major trauma centre in South Africa.

BACKGROUND: There is growing realisation that human error contributes significantly to morbidity and mortality in modern healthcare. A number of taxonomies and classification systems have been developed in an attempt to categorise errors and quantify their impact. OBJECTIVES: To record and identify adverse events and errors as they impacted on acute trauma patients undergoing a computed tomography (CT) scan, and then quantify the effect this had on the individual patients. It is hoped that these data will provide evidence to develop error prevention programmes designed to reduce the incidence of human error. METHODS: The trauma database was interrogated for the period December 2012 - April 2017. All patients aged >18 years who underwent a CT scan for blunt trauma were included. All recorded morbidity for these patients was reviewed. RESULTS: During the period under review, a total of 1 566 patients required a CT scan at our institution following blunt trauma. Of these, 192 (12.3%, 134 male and 58 female) experienced an error related to the process of undergoing a CT scan. Of 755 patients who underwent a CT scan with intravenous contrast, detailed results were available for 312, and of these 46 (14.7%) had an acute deterioration in renal function. According to Chang's taxonomy, physical harm occurred as follows: grade I n=6, grade II n=62, grade III n=45, grade IV n=11, grade V n=27, grade VI n=21, grade VII n=15, grade VIII n=3 and grade IX n=2. Adverse events were performing an unnecessary scan (n=24), omitting an indicated scan (n=23), performing the scan incorrectly (n=8), scanning the wrong body part (n=7), equipment failure (n=18), omitting treatment following the scan (n=6), incorrect interpretation of the scan (n=65), deterioration during the scan (n=6) and others (n=35). The setting for the error was the ward (n=19), the radiology suite (n=126), the emergency department (n=45) and the operating theatre (n=2). The staff responsible for the adverse events were medical (n=155), nursing (n=4) and radiology staff (n=15). There were 67 errors of commission and 125 errors of omission. The primary cause was a planning problem in 78 cases and an execution problem in 114. CONCLUSIONS: Errors and adverse events related to obtaining a CT scan following blunt polytrauma are not uncommon and may impact significantly on the patient. Communication is essential to eliminate errors related to performing the wrong type of scan. The commonest errors relate to misinterpretation of the scan.

Are nursing infusion practices delivering full-dose antimicrobial treatment?

Antimicrobial stewardship (AMS) has developed over the past decade as a critical tool to promote the appropriate use of antimicrobials in order to contain antimicrobial resistance (AMR) and conserve antimicrobial medicines. Current literature supports the role of the nurse in AMR, with a strong focus on the responsibilities of the nurse in infection prevention and control (IPC), both in the formal role of the IPC nurse specialist, and the more general IPC role of the bedside nurse. There is also growing support for the collaborative role of the nurse in the multidisciplinary AMS team. There is, however, very little literature examining the clinical practice role of the nurse in AMS. In this discussion, we contend that nursing practice may unknowingly contribute to AMR owing to varying methods of administration of intermittent intravenous infusions, resulting in under-dosing of antimicrobial medicines.

Civilian cerebral gunshot wounds in rural South African patients are associated with significantly higher mortality rates than in urban patients.

INTRODUCTION: This study focuses on a specific and often dramatic injury, namely gunshot wounds (GSW) of the head in order to determine whether there is a discrepancy in outcome between patients who sustain their injury in a rural setting and those who sustain it in an urban setting. MATERIALS AND METHODS: This study involves a retrospective review of our prospectively maintained regional electronic trauma registry. All patients who sustained a cerebral GSW from January 2010 to December 2014 were reviewed. RESULTS: During the 5-year study period, a total of 102 patients sustained an isolated cerebral GSW. Ninety-two per cent (94/102) were male and the mean age was 29 years. Ninety-four per cent (94/102) of injuries were related to interpersonal violence. Of the 102 patients in the study, 54% (55/102) were urban and were transported directly to our trauma centre. The remaining 46% (47/102) were rural and were transported to a rural district hospital prior to being referred to our trauma centre. The time of injury was available in 60% (61/102) of patients. The mean time from injury to arrival for all patients was 11 h (SD 7). The mean time from injury to arrival was significantly shorter for urban versus rural, 6 h (SD 5) and 15 h (SD 5), respectively (p < 0.001). The median admission GCS score was significantly lower in rural compared to urban patients (p = 0.022). The need for neurosurgery, need for ICU admission or length of hospital stay was not significantly different between rural and urban patients. Rural patients have a fourfold higher mortality compared with urban patients (36 vs 9%, p = 0.001). Amongst survivors, there was no significant difference in median length of hospital stay or mean discharge GCS. CONCLUSIONS: Cerebral GSWs are highly lethal injuries associated with significant mortality. Rural patients have a significantly longer transfer time, lower GCS on arrival and higher mortality than urban patients. Efforts should be directed at improving the pre-hospital EMS system in order to reduce delay to definitive care so that patient outcome can be optimised.

Developing a theory of family care during critical illness.

Background: The critical illness of a loved one can negatively affect all family members (FMs), leading to the interruption of family functioning and integrity. Hospitalisation is a stressful, unplanned event for both the patient and FMs and is associated with psychological disturbances, emotional distress and altered family roles and functioning. Objectives: To develop a theory of family care in critical care units (CCUs) for the South African setting. Methods: Grounded theory, based on Strauss and Corbin's school of thought, was used. Audio-recorded in-depth interviews were conducted with 32 participants (9 FMs, 17 critical care nurses and 6 doctors) at a private hospital (3 CCUs) and a state hospital (10 CCUs). Data analysis involved open, axial and selective coding. Results: The theory of family care during critical illness was identified. The core concept of the theory is empowerment, informed by the underlying constructs of information sharing, proximity, garnering resources, and cultural and religious cooperation. Conclusion: The concepts of this theory can equip healthcare professionals in CCUs to provide appropriate family care for meeting the needs of patients' FMs and, in so doing, contribute to families having a more manageable critical care experience during the illness of their loved one. Contributions of the study: This study adds to the limited body of knowledge regarding family care within the South African context. The study provides a theory to promote therapeutic partnerships between health care professionals, patients and FMs that will provide support for both the patient and FMs.It is further anticipated that the findings of the study will contribute not only to nurses' critical care curriculum, which currently includes very limited family support content, but also be helpful to doctors working in intensive care units.

A selective non-operative approach to thoracic stab wounds is safe and cost effective - a South African experience.

INTRODUCTION: Penetrating thoracic trauma is common and costly. Injuries are frequently and selectively amenable to non-operative management. Our selective approach to penetrating thoracic trauma is reviewed and the effectiveness of our clinical algorithms confirmed. Additionally, a basic cost analysis was undertaken to evaluate the financial impact of a selective nonoperative management approach to penetrating thoracic trauma. MATERIALS AND METHODS: The Pietermaritzburg Metropolitan Trauma Services electronic regional trauma registry hybrid electronic medical records were reviewed, highlighted all penetrating thoracic traumas. A micro-cost analysis estimated expenses for active observation, tube thoracostomy for isolated pneumothorax greater than 2 cm and tube thoracostomy for haemothorax. Routine thoracic computed tomography does not form part of these algorithms. RESULTS: Isolated thoracic stab wounds occurred in 589 patients. Eighty per cent (472 cases) were successfully managed nonoperatively. Micro-costing shows that active observation costs 4,370 ZAR (£270), tube thoracostomy for isolated pneumothorax costs 6,630 ZAR (£400) and tube thoracostomy for haemothorax costs 21,850 ZAR (£1,310). DISCUSSION: Penetrating thoracic trauma places a striking financial burden on our limited resources. Diligent and serial clinical assessments, alongside basic radiology and stringent management criteria, can accurately stratify patients to correct clinical algorithms. CONCLUSION: Selective nonoperative management for penetrating thoracic trauma is safe and effective. Routine thoracic computed tomography is unnecessary in all patients with isolated thoracic stab wounds, which can be reserved for a select group who are identifiable clinically. Routine thoracic computed tomography would not be financially prudent across Pietermaritzburg Metropolitan Trauma Services. Government action is required to reduce the overall incidence of such trauma to save resources and patients.

A raised serum lactate level is an independent predictor of in-hospital mortality in patients with isolated cerebral gunshot wounds.

BACKGROUND: Cerebral gunshot wounds (CGSWs) represent a highly lethal form of traumatic brain injury, and triaging these patients is difficult. The prognostic significance of the serum lactate level in the setting of CGSWs is largely unknown. OBJECTIVES: To examine the relationship between elevated serum lactate levels and mortality in patients with isolated CGSWs. METHODS: A retrospective review of the regional trauma registry was undertaken at the Pietermaritzburg Metropolitan Trauma Service, South Africa, over a 5-year period from 1 January 2010 to 31 December 2014. All patients with an isolated CGSW were included. RESULTS: A total of 102 patients with isolated CGSWs were identified. Of these, 92.2% (94/102) were male. The mean age (standard deviation) was 29 (8) years, and the in-hospital mortality rate was 21.6% (22/102). The mean serum lactate level was significantly higher among non-survivors than among survivors (6.1 mmol/L v. 1.3 mmol/L; p<0.001). Lactate levels among non-survivors were <2 mmol/L in 4.5%, 2 - 3.99 mmol/L in 9.1%, 4 - 5.99 mmol/L in 36.4% and ≥6 mmol/L in 50.0%. The odds ratio for mortality with a lactate level of 4 - 5.99 mmol/L was 67 (95% confidence interval (CI) 1.7 - 2 674.2), while for a lactate level of ≥6 mmol/L it was 1 787 (95% CI 9.0 - 354 116.1). The serum lactate level accurately predicted mortality even after adjustment for other variables. Based on a receiver operating curve analysis, an optimal cut-off of 3.3 mmol/L for serum lactate as a predictor for mortality was identified (area under the curve = 0.957). CONCLUSIONS: CGSWs are associated with significant mortality, and a raised serum lactate level appears to be an independent predictor of in-hospital mortality. It is a potentially useful adjunct in the resuscitation room for identifying patients with a very poor prognosis.

Validation of the Simplified Motor Score in patients with traumatic brain injury at a major trauma centre in South Africa.

BACKGROUND: This study used data from a large prospectively entered database to assess the efficacy of the motor score (M score) component of the Glasgow Coma Scale (GCS) and the Simplified Motor Score (SMS) in predicting overall outcome in patients with traumatic brain injury (TBI). OBJECTIVE: To safely and reliably simplify the scoring system used to assess level of consciousness of trauma patients in the acute setting. METHODS: A retrospective observational review of the Pietermaritzburg Metropolitan Trauma Service hybrid electronic medical registry database was performed during the period January 2013 - December 2015. Patients were classified into three groups using their GCS as an injury severity score. These were mild TBI (GCS 13 - 15), moderate TBI (GCS 9 - 12) and severe TBI (GCS <9). The Glasgow M score was specifically evaluated to determine the relationship between the individual motor component and patient outcome. RESULTS: GCS scores and M scores were analysed in a total of 830 patients. There was a decline in survival rate when the M score on admission was ≤4. The decline was more significant when the M score was ≤3. Survival rates were 26.8% (11/41) for patients with an M score of 1, 63.6% (14/22) for those with a score of 2, 56.5% (13/23) for those with a score of 3, 80.0% (20/25) for those with a score of 4, and 95.5% (121/128) for those with a score of 5. Of 591 patients with an M score of 6, 580 (98.1%) survived. Mortality rose dramatically with declining SMS. This was highly significant. When the M score was plotted against mortality in 830 patients, there was a correct prediction in 769 cases (accuracy 92.7%, sensitivity 67.6%, specificity 95%). The area under the receiver operating characteristic (ROC) curve was 0.9037, with a standard deviation (area) of 0.0227. When comparing the SMS against mortality, the accuracy was 77.1%, the sensitivity 84.5% and the specificity 76.4%. The fitted ROC area was 0.891 and the empirical ROC area 0.86. CONCLUSION: The M score component of the GCS and the SMS accurately predict outcome in patients with TBI. In cases where the full GCS is difficult to assess, the M score and SMS can be used safely as a triage tool.

Quantifying the funding gap for management of traumatic brain injury at a major trauma centre in South Africa.

BACKGROUND: Trauma is an eminently preventable disease. However, prevention programs divert resources away from other priorities. Costing trauma related diseases helps policy makers to make decisions on re-source allocation. We used data from a prospective digital trauma registry to cost Traumatic Brain Injury (TBI) at our institution over a two-year period and to estimate the funding gap that exists in the care of TBI. METHOD: All patients who were admitted to the Pietermaritzburg Metropolitan Trauma Service (PMTS) with TBI were identified from the Hybrid Electronic Medical Registry (HMER). A micro-costing model was utilised to generate costs for TBI. Costs were generated for two scenarios in which all moderate and severe TBI were admitted to ICU. The actual cost was then sub-tracted from the scenario costs to establish the funding gap. RESULTS: During the period January 2012 to December 2014, a total of 3 301 patients were treated for TBI in PMB. The mean age was 30 years (SD 50). There were 2 632 (80%) males and 564 (20%) females. The racial breakdown was overwhelmingly African (96%), followed by Asian (2%), Caucasian (1%) and mixed race (1%). There were 2 540 mild (GCS 13-15), 326 moderate (9-12), and 329 severe (GCS ≤8) TBI admissions during the period under review. A total of 139 patients died (4.2%). A total of 242 (7.3%) patients were admitted to ICU. Of these 137 (57%) had a GCS of 9 or less. A total of 2 383 CT scans were performed. The total cost of TBI over the two-year period was ZAR 62 million. If all 326 patients with moderate TBI had been admitted to ICU there would have been a further 281 ICU admissions. This was labelled Scenario 1. If all patients with severe as well as moderate TBI had been admitted there would have been a further 500 ICU admissions. This was labelled Scenario 2. Based on Scenario 1 and Scenario 2 the total cost would have been ZAR 73 272 250 and ZAR 82 032 250 respectively. The funding gaps for Scenario 1 and Scenario 2 were ZAR 11 240 000 and ZAR 20 000 000 respectively. CONCLUSION: There is a significant burden of TBI managed by the PMTS. The cost of managing TBI each year is in the order of sixty million ZAR. A significant funding gap exists in our environment. This data does not include any data on the broader social costs of TBI. Investing in programs to reduce and prevent TBI is justified by the potential for significant savings.

Defining the need for surgical intervention following a snakebite still relies heavily on clinical assessment: The experience in Pietermaritzburg, South Africa.

BACKGROUND: This audit of snakebites was undertaken to document our experience with snakebite in the western part of KwaZulu-Natal (KZN) Province, South Africa (SA). OBJECTIVE: To document our experience with snakebite in the western part of KZN, and to interrogate the data on patients who required some form of surgical intervention. METHODS: A retrospective study was undertaken at the Pietermaritzburg Metropolitan Trauma Service, Pietermaritzburg, SA. The Hybrid Electronic Medical Registry was reviewed for the 5-year period January 2012 - December 2016. All patients admitted to the service for management of snakebite were included. RESULTS: The offending snake is rarely identified, and the syndromic approach is now the mainstay of management. Most envenomations seen during the study period were cytotoxic, presenting with painful progressive swelling (PPS). We did not see any purely neurotoxic or haemotoxic envenomations. Antivenom is required for a subset of patients. The indications are essentially PPS that increases by >15 cm over an hour, PPS up to the elbow or knee after 4 hours, PPS of the whole limb after 8 hours, threatened airway, shortness of breath, associated clotting abnormalities and compartment syndrome. If no symptoms have manifested within 1 hour of a snakebite, clinically significant envenomation is unlikely to have occurred. Antivenom is associated with a high rate of anaphylaxis and should only be administered when absolutely indicated, preferably in a high-care setting under continuous monitoring. The need for surgery is less well defined. Urgent surgery is indicated for compartment syndrome of the limb, which is a potentially life- and limb-threatening condition. Its diagnosis is usually made clinically, but this is difficult in snakebites. Morbidity and cost increase dramatically once fasciotomy is required, as evidenced by much longer hospital stay. There is frequently a degree of cross-over between cytotoxicity and haemotoxicity in envenomations that require fasciotomy, which means that fasciotomy may result in catastrophic bleeding and should be preceded by the administration of antivenom, especially in patients with a low platelet count or a high international normalised ratio. Physiological and biochemical markers are unhelpful in assessing the need for fasciotomy. Objective methods include measurement of compartment pressures and ultrasound. CONCLUSION: The syndromic management of snakebite is effective and safe. There is a high incidence of anaphylactic reactions to antivenom, and its administration must be closely supervised. In our area we overwhelmingly see cytotoxic snakebites with PPS. Surgery is often needed, and we need to refine our algorithms in terms of deciding on surgery.

The spectrum and outcome of paediatric traumatic brain injury in KwaZulu-Natal Province, South Africa has not changed over the last two decades.

OBJECTIVES: This retrospective review of a prospectively entered and maintained hybrid electronic trauma registry was intended to develop a comprehensive overview of traumatic brain injury (TBI) in children and adolescents and to compare it with previous audits from our local environment and from other developing world centres. All TBI patients admitted to hospital were included in this study. We reviewed the age, gender, outcomes, radiological findings and treatment of the patients. METHODS: All patients aged ≤18 years old who were admitted by the Pietermaritzburg Metropolitan Trauma Service (PMTS) with TBI between December 2012 and December 2016 were included in this audit. RESULTS: During the 4-year period under review, a total of 563 children and adolescents were treated for TBI by the PMTS.  The median age was 6.4 years and 29% (n=165) were females. The mechanism of TBI was blunt trauma in 96% (n=544) of cases, with 4% (n=19) suffering penetrating trauma. The penetrating mechanisms included impalement by a cow horn and miscellaneous injuries due to saws, axes, barbed wire, spades, stones and knives. The blunt mechanisms included falls (n=102), assaults (n=108), collapse of a building (n=28), bicycle-related injury (n=14), falling off a moving vehicle (n=280), motor vehicle accident (MVA; n=59), pedestrian vehicle accident (PVA; n=183) and animal-related injuries (n=8). There were 454 (80%) mild, 67 (12%) moderate and 42 (7%) severe cases of TBI. A total of 48 patients were admitted to the intensive care unit and 23 were admitted to the high care unit. Nine patients died.  All the deaths were in the MVA and PVA group. The spectrum of TBI as diagnosed on computed tomography scans was nonspecific cerebral contusion (n=92), depressed skull fracture (n=70), sub-arachnoid haemorrhage (n=60), extradural haemorrhage (n=41), intracerebral haemorrhage (n=19), free air (n=19), subdural haemorrhage (n=13), intraventricular haemorrhage (n=9). A total of 62 (11%) patients required surgery. CONCLUSION: There is a significant burden of paediatric TBI in Pietermaritzburg. The majority of TBI was related to blunt trauma and assaults were very common.  Although the short-term outcomes are good, the long-term consequences are poorly understood. Injury prevention programmes are needed to help reduce this burden of disease and a nationwide trauma registry is long overdue.

Defining predictors of mortality in pediatric trauma patients.

BACKGROUND: The aim of this study was to describe our cohort of pediatric trauma patients and to analyze their physiological data. The intention was to highlight the difficulty in using systolic blood pressure (SBP) readings in this population and to investigate the role of base excess (BE) in predicting clinical outcomes in pediatric trauma patien. METHOD: The Pietermaritzburg Metropolitan Trauma Service (PMTS) maintains a prospective digital trauma registry, and all pediatric trauma patients admitted to the service for the period January 2012 - July 2016 were included. RESULTS: Out of an original dataset of 1239 pediatric trauma patients admitted to the emergency departments of the PMTS, 26 elective patients and 216 patients with missing SBP were excluded to leave a sample size of 997 patients. The majority of the sample was male accounting for 669 patients (67.2 %) with 327 females (32.8%) and 1 (0.1%) missing data. The mean age (SD) was 7.7 years (3.9) and the median age (IQR) was 8 years (5 - 11). There were 58 children < 2 years of age, 177 between the age of 2 to < 5 years of age, 402 between 5 to < 10 years of age and 360 between 10 and < 15 years of age. The predominant mechanism of injury was blunt trauma (78.4% or 782/997). Penetrating trauma accounted for 11.0% of cases (110/997). The mean systolic BP (SD) across the whole cohort was 110.1 mm Hg (16.9) and the median systolic BP (IQR) was 110 mm Hg (100-119). Mortality rate remains low and then precipitously increases below a SBP of 93 mm Hg in children older than 2 and below 89 mm Hg in children younger than 2. This suggests that a SBP of 93 mm Hg or less in children older than 2 and 89 mm Hg or less in children under 2 years is clinically significant. Similarly, as BE decreased, the mortality risk also increased prominently. CONCLUSION: This study has used a previously described methodology based on large developed world trauma databases and confirms the current thinking that SBP is a late marker and thus not useful in the pediatric population and a better system/ approach is needed. The use of BE in conjunction with SBP may be a more useful means of identifying shock.

The effect of systematic factors on the outcome of trauma laparotomy at a major trauma centre in South Africa.

Introduction The aim of this study was to examine and interrogate outcomes in trauma laparotomy in a South African trauma centre to determine whether systematic factors were associated with any discrepancies in outcome. Methods This was a retrospective review of a prospectively entered trauma registry undertaken at the Pietermaritzburg Metropolitan Trauma Service, Pietermaritzburg, South Africa. The service has developed a hybrid electronic medical record system (HEMR) where clinical data were captured in real time, which were incorporated this into a database. Results During the period from December 2012 to July 2016, 562 patients underwent emergency laparotomy for trauma and the time and date of surgery was recorded in the HEMR. The mean age of all patients was 29.5 years. There were 256 operations during the weekend or over a public holiday, with a mortality of 8% (n = 21) compared with 306 during the week (mortality of 10%, n = 31). This difference was not statistically significant (P = 0.237). A total of 327 operations were performed at night (18:00 - 08:00) and 235 operations were performed during the day (08:00-18:00 Hours). This was a significant difference in mortality (10% (33) vs 7 % (16), P=0.013) These differences persisted if weekends and public holidays were separated out from normal working days. A total of 188 operations were performed on a week night, with a mortality of 11% (n = 20) and 121 operations were performed during a week day, with a mortality of 8% (n = 10). There were 139 operations on a weekend or public holiday night, with a mortality of 9% (n = 13). A total of 114 operations were performed on a weekend or public holiday day with a mortality of 7% (n = 8). A total of 208 procedures were performed with an consultant present. Of these, 32 patients (15%) died. A total of 368 procedures were performed without a consultant present and 8 (2%) died. Conclusions This study demonstrated a discrepancy in outcome for trauma laparotomy, depending on whether the operation was performed at night or during the day. The reasons for this are unclear, although the lack of consultant presence at night in comparison to during the day appears to be implicated.