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.

An initiative to reduce psychiatric boarding in a Cape Town emergency department.

Background: Psychiatric boarding in Emergency Departments (ED) is a global challenge which results in long ED length of stays (LOS) with significant consequences on patient care and staff safety. Aim: This study investigated the impact of an initiative to reduce psychiatric boarding on LOS and readmission rate, as well as explored the relationship between boarding times and LOS. Setting: This study was conducted at Mitchells Plain Hospital, a large district-level hospital in Cape Town. Methods: This cross-sectional study collected data for 24 months, which included a 9-month period prior to the initiative and 16 months thereafter. Data were collected retrospectively from official electronic patient registries. The initiative comprised of inpatient hallway boarding as a full-capacity protocol with the accompanying capacitation of psychiatric wards to accommodate the additional burden. Results: The initiative was associated with a decrease of 95% (p < 0.001) in boarding time, 13% (p < 0.001) in ward LOS and 25% (p < 0.001) in hospital LOS. Ward LOS were found to be independent of ED boarding times. The readmission rate increased from 12% to 18% post intervention. Conclusion: The initiative resulted in a sustainable improvement in boarding times and LOSs. The observational nature of this study precludes concrete conclusions and further investigations into psychiatric inpatient hallway boarding are recommended. Contribution: Inpatient hallway boarding could be a feasible option to reduce the risk. Psychiatric boarding times in the ED are independent of ward LOS, rendering it devoid from any value from a lean and economic perspective.

A retrospective descriptive analysis of non-physician-performed prehospital endotracheal intubation practices and performance in South Africa.

INTRODUCTION: Prehospital advanced airway management, including endotracheal intubation (ETI), is one of the most commonly performed advanced life support skills. In South Africa, prehospital ETI is performed by non-physician prehospital providers. This practice has recently come under scrutiny due to lower first pass (FPS) and overall success rates, a high incidence of adverse events (AEs), and limited evidence regarding the impact of ETI on mortality. The aim of this study was to describe non-physician ETI in a South African national sample in terms of patient demographics, indications for intubation, means of intubation and success rates. A secondary aim was to determine what factors were predictive of first pass success. METHODS: This study was a retrospective chart review of prehospital ETIs performed by non-physician prehospital providers, between 01 January 2017 and 31 December 2017. Two national private Emergency Medical Services (EMS) and one provincial public EMS were sampled. Data were analysed descriptively and summarised. Logistic regression was performed to evaluate factors that affect the likelihood of FPS. RESULTS: A total of 926 cases were included. The majority of cases were adults (n = 781, 84.3%) and male (n = 553, 57.6%). The most common pathologies requiring emergency treatment were head injury, including traumatic brain injury (n = 328, 35.4%), followed by cardiac arrest (n = 204, 22.0%). The mean time on scene was 46 minutes (SD = 28.3). The most cited indication for intubation was decreased level of consciousness (n = 515, 55.6%), followed by cardiac arrest (n = 242, 26.9%) and ineffective ventilation (n = 96, 10.4%). Rapid sequence intubation (RSI, n = 344, 37.2%) was the most common approach. The FPS rate was 75.3%, with an overall success rate of 95.7%. Intubation failed in 33 (3.6%) patients. The need for ventilation was inversely associated with FPS (OR = 0.42, 95% CI: 0.20-0.88, p = 0.02); while deep sedation (OR = 0.56, 95% CI: 0.36-0.88, p = 0.13) and no drugs (OR = 0.47, 95% CI: 0.25-0.90, p = 0.02) compared to RSI was less likely to result in FPS. Increased scene time (OR = 0.99, 95% CI: 0.985-0.997, p < 0.01) was inversely associated FPS. CONCLUSION: This is one of the first and largest studies evaluating prehospital ETI in Africa. In this sample of ground-based EMS non-physician ETI, we found success rates similar to those reported in the literature. More research is needed to determine AE rates and the impact of ETI on patient outcome. There is an urgent need to standardise prehospital ETI reporting in South Africa to facilitate future research.

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.

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.

Emergency clinician output in a district hospital emergency centre: a cross-sectional analysis.

Introduction: Appropriate and efficient staffing is a cornerstone of emergency centre performance. There is however a paucity of literature describing clinician output in low- and middle-income countries with current staffing models based on anecdotal evidence. This study aimed to assess clinician output at a district level emergency centre, and how it varied depending on shift, clinician, and workload factors. Methods: We conducted a retrospective cross-sectional study using an existing electronic patient registry, to determine the patients consulted per hour (PPH) during each clinician shift and how this is affected by various clinician, shift, and workload factors. Data was collected over three non-contiguous randomly selected four-week cycles from Mitchells Plain Hospital's electronic patient registry. Associations between PPH and various factors were assessed using ANOVA with post-hoc adjustments where appropriate. The correlation between PPH and workload metrics was calculated with the Pearson's Rank correlation test. Statistical significance was defined as p<0.05. Results: A total of 1 289 clinician shifts were analysed with an overall PPH of 0.7. A significant association between PPH and shift type (p=0.021), clinician category (p<0.001) and cumulative shifts (p<0.001) were shown. There was a decline in clinician output during a shift and output was significantly decreased by the number of boarders in the emergency centre but increased with higher numbers of patients waiting at the start of the shift. Conclusion: This study describes a relatively low clinician output as compared to evidence from high-income countries and has highlighted several associations with various shift, clinician, and workload factors. The results from this study will form the basis of quality improvement interventions to improve patient throughput and will inform staff scheduling and surge planning strategies.

A descriptive analysis of the casemix presenting to a tertiary hospital emergency centre in East London, South Africa.

Introduction: Emergency centres are most often the point of entry to the healthcare system for patients presenting with emergencies. Even though emergency medicine has developed rapidly in certain regions of South Africa, it is yet to flourish in the Eastern Cape. A paucity of data exists with regards to the demographic and disease profile of patients presenting to Eastern Cape emergency centres. This study describes the casemix presenting to a tertiary hospital emergency centre in East London in the Eastern Cape. Methods: A retrospective descriptive study was conducted of all patients presenting to Frere Hospital emergency centre from 1st of August 2019 to 31st of October 2019. Data were manually collected from the emergency centre paper-based register for the study period and included: patient demographics, geographical location, triage category, presenting complaint, disposition, and process times. Descriptive statistics were used to describe all variables. Results: A total of 6 204 patients presented during the study period. The median age was 31 years, with a male predominance of 56%. Lower acuity triage categories (green and yellow) represented 67% of all cases. Trauma comprised 56% of all presentations, with assault being the most prevalent mechanism of injury in the adult population (n = 1 460, 48%). Sundays (18%) and Mondays (20%) had the highest patient caseload. The majority of patients were discharged home (n = 4 257, 69%) of which 79% had lower acuity triage categories. The majority of patients lived within a 20 km radius of Frere Hospital (n = 4 689, 77%). Conclusion: This descriptive study provides essential data that could guide further development of emergency care systems within the Eastern Cape. A high trauma burden, comprising predominantly of lower acuity presentations are described. Social and economic determinants of violence must be addressed and multisectoral interventions are required to reduce the high burden of trauma.

Access to acute stroke care: A retrospective descriptive analysis of stroke patients' journey to a district hospital.

Introduction: The burden of stroke in Africa has increased in the last two decades, with the population undergoing a rapid epidemiological transition, with a rise in the incidence of stroke risk factors together with the gradual aging of the population. Evidence-based guidelines for acute stroke care are often not feasible in resource challenged settings but even when resources are available, considerable delays to definitive care exists. This study aims to describe the factors that influence time from symptom onset to hospital arrival in patients that present to a district level hospital Emergency Centre with confirmed ischaemic strokes. Methods: A descriptive analysis was performed using a retrospective folder and database review. All adult patients with a confirmed ischaemic stroke, on Computed Tomography (CT) scan, presenting to Mitchells Plain Hospital Emergency Centre during the study period of 12 months (1st of January 2019 to 31st of December 2019), were eligible for inclusion. Data were collected from existing electronic patient databases and the time from onset of symptoms to hospital arrival was extracted from the clinical notes. Results: A total of 730 (2%) patients presented with a diagnosis of stroke, of which 381 (52%) were included (CT confirmed ischaemic strokes). Only 48 (13%) presented within 4.5 h of symptom onset and the median time from onset of symptoms to presentation to the hospital was 24 h (IQR 12-72 h). The majority of patients (31%) arrived via a primary public emergency medical service (EMS) call, while 29% presented directly to the hospital as self-referrals with private transport. Primary public EMS calls had the shortest call-to-hospital-arrival time (1 hour and 31 minutes), even though the median time from symptom onset to hospital arrival was still 16 h. Conclusion: The median time from symptom onset to hospital arrival for patients with stroke symptoms is much longer than what evidence-based guidelines suggest. The chain of survival for emergency stroke care is only as strong as its weakest link and the data from this study suggest that improvement campaigns should target stroke education and access to care.

Low prevalence of atrial fibrillation in ischaemic stroke: Underestimating a modifiable risk factor.

INTRODUCTION: Cerebrovascular disease remains one of the leading causes of morbidity and mortality globally. In South Africa, it was the fourth leading cause of death in 2016, responsible for 5.1% of all deaths - the leading cause of death in individuals 65 years and older. Atrial fibrillation accounts for 15% of all strokes and 25% are diagnosed when patients present with a stroke. We set out to determine the prevalence of atrial fibrillation in patients with confirmed ischaemic strokes in a district level hospital in the Western Cape, South Africa. METHODS: This descriptive study was conducted at Mitchells Plain Hospital in Cape Town and data was collected over a one-year period. Patients diagnosed with a stroke were identified from an electronic patient register and relevant radiology and clinical data were sourced retrospectively. The diagnosis of ischaemic stroke was confirmed by a CT scan report and ECGs were independently screened by two Emergency Physicians. Ethical approval was granted by the University of Cape Town Human Research Ethics Committee [790/2018]. RESULTS: The proportion of adult patients with a stroke diagnosis was 2%. Of the included cases, 80% had ischaemic strokes and 11% had haemorrhagic strokes. 11% of all patients with ischaemic strokes had atrial fibrillation, 67% of those presumed new. A total of 60 (15%) of all patients with ischaemic stroke were aged 45 years or younger. The inpatient mortality rate was statistically higher in patients who had atrial fibrillation (26% vs 7%, p < 0.001). CONCLUSION: With the increasing population life expectancy, and prevalence of cardiovascular disease the prevalence of atrial fibrillation and its complications will increase. Since the risk of stroke related to atrial fibrillation can be reduced significantly by oral anticoagulation, further studies should aim to explore barriers and challenges to effective screening.

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.

Cross-sectional study of paediatric case mix presenting to an emergency centre in Cape Town, South Africa, during COVID-19.

OBJECTIVE: To describe and compare the effect of level 5 lockdown measures on the workload and case mix of paediatric patients presenting to a district-level emergency centre in Cape Town, South Africa. METHODS: Paediatric patients (<13 years) presenting to Mitchells Plain Hospital were included. The level 5 lockdown period (27 March 2020-30 April 2020) was compared with similar 5-week periods immediately before (21 February 2020-26 March 2020) and after the lockdown (1 May 2020-4 June 2020), and to similar time periods during 2018 and 2019. Patient demographics, characteristics, International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) diagnosis, disposition and process times were collected from an electronic patient tracking and registration database. The χ2 test and the independent samples median test were used for comparisons. RESULTS: Emergency centre visits during the lockdown period (n=592) decreased by 58% compared with 2019 (n=1413) and by 56% compared with the 2020 prelockdown period (n=1342). The proportion of under 1 year olds increased by 10.4% (p<0.001), with a 7.4% increase in self-referrals (p<0.001) and a 6.9% reduction in referrals from clinics (p<0.001). Proportionally more children were referred to inpatient disciplines (5.6%, p=0.001) and to a higher level of care (3.9%, p=0.004). Significant reductions occurred in respiratory diseases (66.9%, p<0.001), injuries (36.1%, p<0.001) and infectious diseases (34.1%, p<0.001). All process times were significantly different between the various study periods. CONCLUSION: Significantly less children presented to the emergency centre since the implementation of the COVID-19 lockdown, with marked reductions in respiratory and infectious-related diseases and in injuries.

Access to acute care resources in various income settings to treat new-onset stroke: A survey of acute care providers.

INTRODUCTION: Stroke affects 15 million people annually and is responsible for 5 million deaths per annum globally. In contrast to the trend in low- and middle-income countries (LMICs), stroke mortality is on the decline in high-income countries (HICs). Even though the availability of resources varies considerably by geographic region and across LMICs and HICs, evidence suggests that material resources in LMICs to implement recommendations from international guidelines are largely unmet. This study describes and compares the availability of resources to treat new-onset stroke in countries based on the World Bank's gross national incomes, using recommendations of the American Heart Association and the American Stroke Association 2013 update. METHODS: A self-reported cross-sectional survey was conducted of delegates that attended the April 2016 International Conference on Emergency Medicine using the web-based e-Survey client, Survey Monkey Inc. The survey assessed both pre-hospital and in-hospital settings and was piloted before implementation. RESULTS: The survey was distributed and opened by 955 delegates and 382 (40%) responded. Respondents from LMICs reported significantly less access to a prehospital service (p < 0.001) or a national emergency number (p < 0.001). Access to specialist neurology services (p < 0.001) and radiology services (p < 0.001) were also significantly lower in LMICs. CONCLUSION: The striking finding from this study was that there was essentially very little difference between the responses between LMIC and HIC respondents with a few notable exceptions. The findings also propose a universal lack of adherence to the 2013 AHA/ASA stroke management guideline by both groups, in contrast to the good reported knowledge thereof. Carefully planned qualitative research is needed to identify the barriers to achieving the 2013 AHA/ACA recommendations.

Poor access to acute care resources to treat major trauma in low- and middle-income settings: A self-reported survey of acute care providers.

INTRODUCTION: Injury and violence are neglected global health concerns, despite being largely predictable and therefor preventable. We conducted a small study to indirectly describe and compare the perception of availability of resources to manage major trauma in high-income, and low- and middle-income countries using evidence-based guidance (as per the 2016 National Institute of Clinical Excellence guidelines), as self-reported by delegates attending the 2016 International Conference on Emergency Medicine held in South Africa. METHODS: A survey was distributed to delegates at the International Conference on Emergency Medicine 2016. The survey instrument captured responses from participants working in both pre- and in-hospital settings. Responses were grouped according to income group (either high-income, or low- and middle-income) based on the respondent's nationality (using the World Bank definition for income group). A Fisher's Exact test was conducted to compare responses between different income groups. RESULTS: The survey was distributed to 980 delegates, and 392 (40%) responded. A total of 206 (53%) respondents were from high-income countries and 186 (47%) were from low- to middle-income countries. Respondents described significantly less access to resources and services for low- and middle-income countries to adequately care for major trauma patients both pre- and in-hospital when compared to high-income countries. Shortages ranged from consumables to analgesia, imaging to specialist services, and pre-hospital to in-hospital care. CONCLUSION: Major trauma care requires a chain of successful, evidence-based events for outcomes to benefit. This small study suggests that many of the links of this chain are either missing or broken within low- and middle-income countries. These settings simply do not benefit from the currently available evidence-base in major trauma care. It is important that this evidence-base also be evaluated within low- and middle-income countries. The capacity of low- and middle-income country emergency care systems also needs better describing.

Injury severity in relation to seatbelt use in Cape Town, South Africa: a pilot study.

BACKGROUND: Injuries and deaths from road traffic collisions present an enormous challenge to the South African (SA) healthcare system. The use of restraining devices is an important preventive measure. OBJECTIVE: To determine the relationship between seatbelt use and injury severity in vehicle occupants involved in road traffic collisions in Cape Town, SA. METHODS: A prospective cohort design was used. Occupants of vehicles involved in road traffic collisions attended to by EMS METRO Rescue were included during the 3-month data collection period. Triage categories of prehospital patients were compared between restrained and unrestrained groups. Patients transferred to hospital were followed up and injury severity scores were calculated. Disposition from the emergency centre and follow-up after 1 week were also documented and compared. RESULTS: A total of 107 patients were included in the prehospital phase. The prevalence of seatbelt use was 25.2%. Unrestrained vehicle occupants were five times more likely to have a high triage score (odds ratio (OR) 5.4; 95% confidence interval (CI) 1.5 - 19.5). Fifty patients were transferred to study hospitals. Although seatbelt non-users were more likely to be admitted to hospital (p=0.002), they did not sustain more serious injuries (OR 0.44; 95% CI 0.02 - 8.8). CONCLUSION: The prevalence of seatbelt use in vehicle occupants involved in road traffic collisions was very low. The association between seatbelt non-use and injury severity calls for stricter enforcement of current seatbelt laws, together with the development and implementation of road safety interventions specifically focused on high-risk groups.