Peter Hodkinson

Validation of weight estimation by age and length based methods in the Western Cape, South Africa population

Objective To evaluate four paediatric weight estimation methods (APLS, Luscombe and Owens, Best Guess and Broselow tape) in order to determine which are accurate for weight estimation in South African children. Method From a database of 2832 children aged 1–10 years seen at Red Cross Hospital in Cape Town, measured weight was compared to estimated weights from all four methods. Results APLS formula and the Broselow Tape showed the best correlation with measured weight. Mean error was 3.3% for APLS (for 1–10-year olds) and 0.9% for Broselow tape (children <145 cm length and <35 kg). Both the Best Guess and Luscombe and Owens formulae tended to overestimate weight (15.4% and 12.4%, respectively). Conclusion The Broselow tape and APLS estimation methods are most accurate in estimating weight in the Western Cape paediatric population, even though they have a small tendency to underestimate weight. Clinicians need to bear in mind that none of the formulae are infallible and constant reassessment and clinical judgement should be used, as well as a measured weight as soon as possible in an emergency situation.

Emergency Medicine in the Developing World: A Delphi Study

OBJECTIVES Emergency medicine (EM) as a specialty has developed rapidly in the western world, but remains largely immature in developing nations. There is an urgent need for emergency services, but no clear guidelines are available on the priorities for establishing EM in the developing world. This study seeks to establish consensus on key areas of EM development in developing world settings, with respect to scope of EM, staffing needs, training requirements, and research priorities. METHODS A three-round Delphi study was conducted via e-mail. A panel was convened of 50 EM specialists or equivalent, with experience in or interest in EM in the developing world. In the first round, panelists provided free-text statements on scope, staffing, training, and research priorities for EM in the developing world. A five-point Likert scale was used to rate agreement with the statements in Rounds 2 and 3. Consensus statements are presented as a series of synopsis statements for each of the four major themes. RESULTS A total of 168 of 208 statements (81%) had reached consensus at the end of the study. Key areas in which consensus was reached included EM being a specialist-driven service, with substantial role for nonphysicians. International training courses should be adapted to local needs. EM research in developing countries should be clinically driven and focus on local issues of importance. CONCLUSIONS The scope and function of EM and relationships with other specialties are defined. Unambiguous principles are laid out for the development of the specialty in developing world environments. The next step required in this process is translation into practical guidelines for the development of EM in developing world settings where they may be used to drive policy, protocols, and research.

Pathways to care for critically ill or injured children: a cohort study from first presentation to healthcare services through to admission to intensive care or death

Purpose Critically ill or injured children require prompt identification, rapid referral and quality emergency management. We undertook a study to evaluate the care pathway of critically ill or injured children to identify preventable failures in the care provided. Methods A year-long cohort study of critically ill and injured children was performed in Cape Town, South Africa, from first presentation to healthcare services until paediatric intensive care unit (PICU) admission or emergency department death, using expert panel review of medical records and caregiver interview. Main outcomes were expert assessment of overall quality of care; avoidability of severity of illness and PICU admission or death and the identification of modifiable factors. Results The study enrolled 282 children, 252 emergency PICU admissions, and 30 deaths. Global quality of care was graded good in 10% of cases, with half having at least one major impact modifiable factor. Key modifiable factors related to access to care and identification of the critically ill, assessment of severity, inadequate resuscitation, and delays in decision making and referral. Children were transferred with median time from first presentation to PICU admission of 12.3 hours. There was potentially avoidable severity of illness in 185 (74%) of children, and death prior to PICU admission was avoidable in 17/30 (56.7%) of children. Conclusions The study presents a novel methodology, examining quality of care across an entire system, and highlighting the complexity of the pathway and the modifiable events amenable to interventions, that could reduce mortality and morbidity, and optimize utilization of scarce critical care resources; as well as demonstrating the importance of continuity and quality of care.

Identification of performance indicators for emergency centres in South Africa: results of a Delphi study

BackgroundEmergency medicine is a rapidly developing field in South Africa (SA) and other developing nations. There is a need to develop performance indicators that are relevant and easy to measure. This will allow identification of areas for improvement, create standards of care and allow inter-institutional comparisons to be made. There is evidence from the international literature that performance measures do lead to performance improvements.AimsTo develop a broad-based consensus document detailing quality measures for use in SA Emergency Centres (ECs).MethodsA three-round modified Delphi study was conducted over e-mail. A panel of experts representing the emergency medicine field in SA was formed. Participants were asked to provide potential performance indicators for use in SA, under subheaders of the various disciplines that are seen in emergency patients. These statements were collated and sent out to the panel for scoring on a 9-point Lickert scale. Statements that did not reach a predefined consensus were sent back to the panellist for reconsideration.ResultsConsensus was reached on 99 out of 153 (65%) of the performance indicators proposed. These were further refined, and a synopsis of the statements is presented, classified as to whether the statements were thought to be feasible or not in the current circumstances.ConclusionsA synopsis of the useful and feasible performance indicators is presented. The majority are structural and performance-based indicators appropriate to the development of the field in SA. Further refinement and research is needed to implement these indicators.

Strategies Used by Prehospital Providers to Overcome Language Barriers.

Abstract Objective: Language barriers are commonly encountered in the prehospital setting but there is a paucity of research on how prehospital providers address language discordance. We sought to identify the communication strategies, and the limitations of those strategies, used by emergency medical services (EMS) providers when confronted with language barriers in a variety of linguistic and cultural contexts. Methods: EMS providers were queried regarding communication strategies to overcome language barriers as part of an international, multi-site, sequential explanatory, qualitative-predominant, mixed methods study of prehospital language barriers. A survey of EMS telecommunicators was administered at dispatch centers in New Mexico (United States) and Western Cape (South Africa). Semi-structured qualitative interviews of EMS field providers were conducted at agencies who respond to calls from participating dispatch centers. Survey data included quantitative data on demographics and communication strategies used to overcome language barriers as well as qualitative free-text responses on the limitations of strategies. Interviews elicited narratives of encounters with language-discordant patients and the strategies used to communicate. Data from the surveys and interviews were integrated at the point of analysis. Results: 125 telecommunicators (overall response rate of 84.5%) and a purposive sample of 27 field providers participated in the study. The characteristics of participants varied between countries and between agencies, consistent with variations in participating agencies’ hiring and training practices. Telecommunicators identified 3rd-party telephonic interpreter services as the single most effective strategy when available, but also described time delays and frustration with interpreter communications that leads them to preferentially try other strategies. In the field, all providers reported using similar strategies, relying heavily on bystanders, multilingual coworkers, and non-verbal communication. Prehospital providers described significant limitations to these strategies, including time delays, breaches of patient confidentiality, and inaccurate interpretation. Participants suggested various resources to improve communication with language-discordant patients. Conclusions: Prehospital providers rely upon similar, informal strategies for overcoming language barriers across a variety of locations, provider types, and linguistic and cultural contexts.

Caregivers’ Experiences of Pathways to Care for Seriously Ill Children in Cape Town, South Africa: A Qualitative Investigation

Purpose Understanding caregivers’ experiences of care can identify barriers to timely and good quality care, and support the improvement of services. We aimed to explore caregivers’ experiences and perceptions of pathways to care, from first access through various levels of health service, for seriously ill and injured children in Cape Town, South Africa, in order to identify areas for improvement. Methods Semi-structured, qualitative interviews were conducted with primary caregivers of children who were admitted to paediatric intensive care or died in the health system prior to intensive care admission. Interviews explored caregivers’ experiences from when their child first became ill, through each level of health care to paediatric intensive care or death. A maximum variation sample of transcripts was purposively sampled from a larger cohort study based on demographic characteristics, child diagnosis, and outcome at 30 days; and analysed using the method of constant comparison. Results Of the 282 caregivers who were interviewed in the larger cohort study, 45 interviews were included in this qualitative analysis. Some caregivers employed ‘tactics’ to gain quicker access to care, including bypassing lower levels of care, and negotiating or demanding to see a healthcare professional ahead of other patients. It was sometimes unclear how to access emergency care within facilities; and non-medical personnel informally judged illness severity and helped or hindered quicker access. Caregivers commonly misconceived ambulances to be slow to arrive, and were concerned when ambulance transfers were seemingly not prioritised by illness severity. Communication was often good, but some caregivers experienced language difficulties and/or criticism. Conclusions Interventions to improve child health care could be based on: reorganising the reception of seriously ill children and making the emergency route within healthcare facilities clear; promoting caregivers’ use of ambulances and prioritising transfers according to illness severity; addressing language barriers, and emphasising the importance of effective communication to healthcare providers.

Prioritizing the Care of Critically Ill Children in South Africa: How Does SCREEN Perform Against Other Triage Tools?

Objective Childhood mortality remains unacceptably high. In low-resource settings, children with critical illness often present for care. Current triage strategies are time consuming and require trained health care workers. To address this limitation, our team developed a simple subjective tool, SCREEN (Sick Children Require Emergency Evaluation Now), which is easy to administer, to identify critically ill children. This article presents the development of the SCREEN program and evaluates its performance when compared with other commonly implemented triage tools in low-resource settings. Methods We measured the sensitivity and specificity of SCREEN, to identify critically ill children, compared with 4 other previously validated triage tools: the Integrated Management of Childhood Illnesses, the Pediatric Early Warning, the Pediatric South African Triage Scale, and the World Health Organization Emergency Triage Treatment Tool. Findings SCREEN has high sensitivity (100%–98.73%; P < 0.001) and specificity (64.41%–50.71%; P < 0.001) when compared with other validated triage tools. Conclusions The SCREEN tool may offer a simple and effective method to identify critically ill children in low-resource environments.

Lessons Learned From the Application of Mixed Methods to an International Study of Prehospital Language Barriers

Mixed methods research is increasingly common in emergency medical services, but methodological expertise among prehospital researchers has been found lacking. The purpose of this article is to describe unique challenges that the authors encountered in the application of mixed methods to a multisite, international study of prehospital language barriers. Lessons learned include the role of formative research in identifying cultural and organizational norms that affect researcher engagement with emergency medical service agencies, the necessity of developing approaches for member checking and assessing respondent validity, and the importance of promoting mixed methods as a rigorous methodology in international settings.

Defining and improving the role of emergency medical services in Cape Town, South Africa

Introduction Low and middle income countries bear a disproportionate burden of paediatric morbidity and mortality. South Africa, a middle income country, has unacceptably high mortality in children less than 5 years of age. Many factors that contribute to the child mortality rate are time sensitive and require efficient access to emergency care. Delays and barriers within the emergency medical services (EMS) system increase paediatric morbidity and mortality from time sensitive illnesses. Methods This study is a qualitative evaluation of the prehospital care system for paediatric patients in Cape Town, South Africa. A purposive sample of healthcare personnel within and interacting with the EMS system were interviewed. A structured interview form was used to gather data. All interviews were audio recorded and transcribed; two independent reviewers performed blinded content analysis of the transcribed script. Results 33 structured interviews were conducted over a 4 week period. Eight broad themes were identified during coding, including: access, communication, community education, equipment, infrastructure, staffing, training and triage. Subcategories were used to identify areas for targeted intervention. Overall agreement between the two independent coders was 93.36%, with a κ coefficient of 0.69. Conclusions The prehospital system is central to delivering time sensitive care for paediatric patients. In a single centre middle income setting, communication barriers between dispatch personnel and medical facilities/EMS personnel were deemed to be a high priority intervention in order to improve care delivery. Other areas for targeted interventions should include broadening the advanced life support provider base and introducing basic medical language in dispatch staff training.

South African pre-hospital guidelines: Report on progress and way forward

In a previous editorial the authors introduced the African Federation for Emergency Medicine (AFEM) pre-hospital clinical practice guideline (CPG) project initiated in 2015 on behalf of the Health Professions Council of South Africa Professional Board of Emergency Care (HPCSA PBEC). To date, aspects of the guideline development project were presented and discussed at the International Emergency Medicine Conference (ICEM) in early 2016 and the project has subsequently been completed and submitted to the HPCSA PBEC in June 2016 for review and eventually dissemination and implementation. The guideline represents the first evidence-based CPG for the emergency care profession in Africa. The guideline project aimed to review and update the existing protocols for emergency care providers and create an evidence-based CPG which: (i) provides an evidence base for emergency care practice contextualised to the South African setting (ii) is patient-centred, realistic and enhances the continuation of care throughout the emergency system (iii) is aligned to current local and international best practice and (iv) provide guidance to both current practitioners and those envisioned by the draft National Emergency Care Education and Training (NECET) policy. This CPG was developed under the direction of AFEM, collaborating with the Divisions of Emergency Medicine at the University of Cape Town (UCT) and Stellenbosch University (SU), together with the Department of Emergency Medical Sciences at Cape Peninsula University of Technology (CPUT) and the Centre for Evidence-based Health Care, Stellenbosch University. The guideline development project followed a systematic guideline development process with the input of a core guideline panel, methodological experts and an advisory board consisting of industry stakeholders and experts. The key principle, advocated in guideline development literature for low-tomiddle income countries, was not to create de novo clinical practice guidelines but to either adopt, adapt or contextualise current high quality CPGs or adapt evidence from existing systematic reviews as previously outlined. The development process involved setting key priority areas, comprehensively searching for existing pre-hospital relevant CPGs, screening over 5000 potentially-relevant CPGs, guideline critical appraisal (using the AGREE II tool), assessing and synthesising more than 270 included pre-hospital CPGs and incorporating industry and advisory board feedback. This culminated in a pre-hospital CPG with over 1000 recommendations for South African emergency care clinical practice aligned to local contextual factors and providers’ scope of practice. At this stage the AFEM CPGs is yet to be published pending internal review and industry wide stakeholder engagement by the PBEC. Despite the profession’s anticipation of receiving the updated guidelines (as the current protocols where last reviewed in 2006 and a few in 2009), patience is required while the challenge of digesting and eventually implementing these guidelines in practice takes place.