The Effect of Prehospital Clinical Trial-Related Procedures on Scene Interval, Cognitive Load, and Error: A Randomized Simulation Study.

INTRODUCTION: Globally, very few settings have undertaken prehospital randomized controlled trials. Given this lack of experience, there is a risk that such trials in these settings may result in protocol deviations, increased prehospital intervals, and increased cognitive load, leading to error. Ultimately, this may affect patient safety and mortality. The aim of this study was to assess the effect of trial-related procedures on simulated scene interval, self-reported cognitive load, medical errors, and time to action. METHODS: This was a prospective simulation study. Using a cross-over design, ten teams of prehospital clinicians were allocated to three separate simulation arms in a random order. Simulations were: (1) Eligibility assessment and administration of freeze-dried plasma (FDP) and a hemoglobin-based oxygen carrier (HBOC), (2) Eligibility assessment and administration of HBOC, (3) Eligibility assessment and standard care. All simulations also required clinical management of hemorrhagic shock. Simulated scene interval, error rates, cognitive load (measured by NASA Task Load Index), and competency in clinical care (assessed using the Simulation Assessment Tool Limiting Assessment Bias (SATLAB)) were measured. Mean differences between simulations with and without trial-related procedures were sought using one-way ANOVA or Kruskal-Wallis test. A p-value of <0.05 within the 95% confidence interval was considered significant. RESULTS: Thirty simulations were undertaken, representing our powered sample size. The mean scene intervals were 00:16:56 for Simulation 1 (FDP and HBOC), 00:17:22 for Simulation 2 (HBOC only), and 00:14:24 for Simulation 3 (standard care). Scene interval did not differ between the groups (p = 0.27). There were also no significant differences in error rates (p = 0.28) or cognitive load (p = 0.67) between the simulation groups. There was no correlation between cognitive load and error rates (r = 0.15, p = 0.42). Competency was achieved in all the assessment criteria for all simulation groups. CONCLUSION: In a simulated environment, eligibility screening, performance of trial-related procedures, and clinical management of patients with hemorrhagic shock can be completed competently by prehospital advanced life support clinicians without delaying transport or emergency care. Future prehospital clinical trials may use a similar approach to help ensure graded and cautious implementation of clinical trial procedures into prehospital emergency care systems.

Routine investigations for patients with mental and behavioural disturbances.

Background: The process of medical clearance aims to exclude a general medical condition as an underlying cause for mental and behavioural disorders and involves routine screening with special investigations. Current evidence, however, suggests that clinician gestalt should guide the need for special investigations and that there is no benefit to routine screening. Aim: This study aimed to determine the effectiveness of and adherence to the Western Cape (WC) provincial guidelines for routine investigations of adult patients with behavioural disturbances. Setting: This study was conducted at Mitchells Plain Hospital in Cape Town, South Africa. Methods: This descriptive study was conducted at Mitchells Plain Hospital in Cape Town, South Africa. Data were collected from existing electronic registries over a 6-month period. Adult mental healthcare users were risk stratified into the probability of having a general medical condition and the results of their special investigations were described against their outcome. Results: Of the 688 patients included in this study, 66% had abnormal vital signs and of the 312 patients who received special investigations, 56% were abnormal, including 18% who were clinically significantly abnormal. Abnormal special investigations changed the clinical outcome for 3 (<1%) patients. Adherence to the guidelines was reasonable (82%) but non-adherence resulted in unnecessary investigations. Conclusion: The results of this study support the existing evidence that clinical assessment and clinician gestalt should guide the need for special investigations and that there is no benefit to routine screening in the emergency centre (EC). The results also demonstrate that non-adherence rarely changed patient outcomes. Contribution: This study provides information on the value of routine screening investigations in ECs.

The value of shock index, modified shock index and age shock index to predict mortality and hospitalisation in a district level emergency centre.

Introduction: Triage is the most important step in patients' journey through an Emergency Centre (EC) and directly impacts time to critical actions. Triage tools, like the South African Triage Scale, are however not designed to predict patient outcomes. The shock index (SI), modified shock index (MSI) and age shock index (ASI) are clinical markers derived from vital signs and correlate with tissue perfusion in critically ill patients. This study aimed to assess the value of SI, MSI and ASI to predict mortality and the need for hospitalisation in all adult patients presenting to a district level emergency centre in South Africa. Methods: This diagnostic study was performed as a retrospective observational study, using data from an existing electronic registry at a district level hospital emergency centre over a period of 24 months. All adult patients who presented to Mitchells Plain Hospital were eligible for inclusion. Sensitivity, specificity and likelihood ratios were calculated for each variable as a predictor of mortality and hospitalisation with pre-determined thresholds. Results: During the study period of 24 months, a total of 61 329 patients ≥ 18 years old presented to the EC with 60 599 included in the final sample. A red SATS triage category (+LR = 7.2) and SI ≥1.3 (+LR = 4.9) were the only two predictors with any significant clinical value. The same two markers performed well for both patients with and without trauma and specifically for patients who died while under the care of the emergency centre. Discussion: The study demonstrated that patients with a SI≥1.3 at triage have a significantly higher likelihood to die or require hospitalisation, whether the presenting complaint is trauma related or not, especially to predict mortality while under the care of the EC. Incorporating this marker as a triage alert could expedite the identification of patients requiring time critical interventions and improve patient throughput in the emergency centre.

Temporal changes in trauma according to alcohol sale restrictions during the South African national COVID-19 lockdown.

INTRODUCTION: The South African government enforced various alcohol sale restrictions during the COVID-19 lockdown in order to reduce hospital admissions related to alcohol-associated injuries. A cross-sectional study was performed to describe the temporal changes in trauma according to alcohol sale restrictions during the South African national COVID-19 lockdown. METHODS: Data from all trauma-related patients presenting to the emergency centre of Mitchells Plain Hospital from 01/03/2020 till 29/9/2020 and corresponding periods during 2019 were exported from an existing database. The relationship between variables was determined with the χ2-test, Fisher's exact test, independent samples median test or t-test. A sub-analysis compared similar 2020 lockdown levels when a second alcohol ban were instituted while most business were allowed to operate (level 3b - alcohol banned versus level 3 - alcohol restricted). RESULTS: Total number of trauma presentations were 539 (14.6%) less in 2020 (n = 3160) than in 2019 (n = 3699); the mean number decreased by 2.5 per day (95% CI -2.9 to -2.1). Lockdown levels with an alcohol ban had on average 4.8 less patients per day than corresponding periods in 2019 (p < 0.001). No significant difference was observed in lockdown levels with alcohol sale restrictions (mean difference per day -0.4, p = 0.195). Trauma presentations increased significantly (mean difference per day 7.0 (95% CI 6.5 to 7.5)) from 2020 lockdown levels with alcohol sales ban (mean per day 11.4) to 2020 lockdown levels with alcohol sale restrictions (mean per day 18.4). Significantly less patients (mean -3.2 (95% CI -3.9 to -2.5)) presented during 2020 lockdown level 3b (alcohol sales banned, mean 13.9) compared to level 3 (alcohol sales restricted, mean 17.1). CONCLUSION: Temporal changes in trauma were observed according to alcohol sale restrictions during South Africa's COVID-19 lockdown periods. Significantly less trauma cases presented during periods with an alcohol ban compared to periods where alcohol sales were only restricted.