Mapping access to care and identification of barriers for traumatic brain injury in a South African township.

RATIONALE: South Africa has a high traumatic injury burden resulting in a significant number of persons suffering from traumatic brain injury (TBI). TBI is a time-sensitive condition requiring a responsive and organized health system to minimize morbidity and mortality. This study outlined the barriers to accessing TBI care in a South African township. METHODS: This was a multimethod study. A facility survey was carried out on health facilities offering trauma care in Khayelitsha township, Cape Town, South Africa. Perceived barriers to accessing TBI care were explored using qualitative interviews and focus group discussions. The four-delay framework that describes delays in four phases was used: seeking, reaching, receiving, and remaining in care. We purposively recruited individuals with a history of TBI (n = 6) and 15 healthcare professionals working with persons with TBI (seven individuals representing each of the five facilities, the heads of neurosurgery and emergency medical services and eight additional healthcare providers who participated in the focus group discussions). Quantitative data were analysed descriptively while qualitative data were analysed thematically, following inductive and deductive approaches. FINDINGS: Five healthcare facilities (three community health centres, one district hospital and one tertiary hospital) were surveyed. We conducted 13 individual interviews (six with persons with TBI history, seven with healthcare providers from each of the five facilities, neurosurgery department and emergency medical service heads and two focus group discussions involving eight additional healthcare providers. Participants mentioned that alcohol abuse and high neighbourhood crime could lead to delays in seeking and reaching care. The most significant barriers reported were related to receiving definitive care, mostly due to a lack of diagnostic imaging at community health centres and the district hospital, delays in interfacility transfers due to ambulance delays and human and infrastructural limitations. A barrier to remaining in care was the lack of clear communication between persons with TBI and health facilities regarding follow-up care. CONCLUSION: Our study revealed that various individual-level, community and health system factors impacted TBI care. Efforts to improve TBI care and reduce injury-related morbidity and mortality must put in place more community-level security measures, institute alcohol regulatory policies, improve access to diagnostics and invest in hospital infrastructures.

Procedure competence versus number performed: a survey of graduate emergency medicine specialists in a developing nation.

BACKGROUND: Emergency medicine (EM) training programmes are being conducted around the world but no study has assessed the procedural competence of developing nations' EM trainees. OBJECTIVES: To quantify the number of core procedures and resuscitations performed and describe the perceived procedural competency of graduates of Africa's first EM registrarship at the University of Cape Town/Stellenbosch University (UCT/SUN) in Cape Town, South Africa. METHODS: All 30 graduates from the first four classes in the UCT/SUN EM programme (2007-10) were asked to complete a written, self-administered survey on the number of procedures needed for competency, the number of procedures performed during registrarship and the perceived competence in each procedure ranked on a five-point Likert scale. The procedures selected were the 10 core procedures and four types of resuscitations as defined by the US-based Residency Review Committee. Results were compiled and analysed using descriptive statistics. RESULTS: Twenty-seven (90%) completed surveys. For most core procedures and all resuscitations, the number of procedures reported by respondents far exceeded the Residency Review Committee minimum. The three procedures not meeting the minimum were internal cardiac pacing, cricothyrotomy and periocardiocentesis. Respondents reported perceived competence in most procedures and all resuscitations. CONCLUSIONS: EM trainees in a South Africa registrarship report a high number of procedures performed for most procedures and all resuscitations. As medical education moves to the era of direct observation and other methods of assessment, more studies are needed to define and ensure procedural competence in trainees of nascent EM programmes.

Advanced life support courses in Africa: Certification, availability and perceptions.

BACKGROUND: Advanced life support (ALS) short training courses are in demand across Africa, though overwhelmingly designed and priced for non-African contexts. The continental expansion of emergency care is driving wider penetration of these courses, but their relevance and accessibility is not known. We surveyed clinicians within emergency settings to describe ALS courses' prevalence and perceived value in Africa. METHODS: We conducted a cross-sectional quantitative analysis of 235 clinicians' responses to the African Federation for Emergency Medicine's online needs assessment for an open-access ALS course in Africa. Participants responded to multiple-choice and open answer questions assessing demographics, ALS course certification and availability, perceptions of ALS courses, and barriers and facilitators to undertaking such courses. RESULTS: 235 clinicians working in 23 African nations responded. Most clinicians reported ALS course completion within the past three years (73%) and in-country access to ALS courses (76%). Most believed the content adequately met their region's needs (60%). Price and course availability were the most common barriers to taking an ALS course. The most common courses were cardiac and paediatric-focused, and the most common reasons to take a course included general career development, personal interest, and departmental requirements. CONCLUSION: One-quarter of emergency care clinicians lack access to ALS courses in twenty-three African nations. Most clinicians believe that ALS courses have value in their clinical settings and meet the needs of their region. Our findings illustrate the need for an affordable, widely available ALS course tailored to lower-resource African settings that could reach rural and peri-urban clinicians.

Perceptions of graduates from Africa's first emergency medicine training program at the University of Cape Town/Stellenbosch University.

OBJECTIVE: Africa's first postgraduate training program in emergency medicine (EM) was established at the University of Cape Town/Stellenbosch University (UCT/SUN) in 2004. This study of the UCT/SUN EM program investigated the backgrounds, perceptions, and experiences of its graduates. METHODS: This was a cross-sectional descriptive study. The study population was the 30 graduates from the first four classes in the UCT/SUN EM program (2007-2010). We employed a scripted interview with a combination of closed and open-ended questions. Data were analyzed using the thematic method of qualitative analysis. RESULTS: Twenty-seven (90%) graduates were interviewed. Initial career goals were primarily (78%) to practice EM in a nonacademic clinical capacity. At the time of the interview, 52% held academic positions, 15% had nonacademic clinical positions, and 33% had temporary positions and were looking for other posts. The three most commonly cited strengths of their program were diversity of clinical rotations (85%), autonomy and procedural experience (63%), and importance of being pioneers within Africa (52%). The three most commonly cited weaknesses were lack of bedside teaching in the ED (96%), lack of career options after graduation (74%), and lack of preparation for academic careers (70%). CONCLUSIONS: The lessons identified from structured interviews with graduates from Africa's first EM training include the importance of strong clinical training, difficulty of ensuring bedside teaching in a new program, the necessity of ensuring postgraduation positions, and the need for academic training. These findings may be useful for other developing countries looking to start EM training programs.

Africa's first emergency medicine training program at the University of Cape Town/Stellenbosch University: history, progress, and lessons learned.

Africa's first residency training program in emergency medicine (EM) was established at the University of Cape Town (UCT)/Stellenbosch University (SUN) in 2004. There have since been four classes for a total of 29 graduates from this program who are practicing, teaching, and leading EM. This article describes the structure of the program and discusses the history and major drivers behind its founding. We report major changes, cite ongoing challenges, and discuss lessons learned from the program's first 7 years that may help advise other nascent training programs in developing countries.