Background: Emergency centres in South Africa are among the busiest in the world and serve as entry points for hospital care for most of the population. The South African Triage Scale (SATS) is a ...validated tool introduced nationally in 2006 and intended to increase the efficiency of emergency centres through a process of prioritisation of the severely ill patient. The objective of this study was to evaluate the use of the SATS in a busy urban district hospital in Durban, South Africa.
Methods: A chart review of triaged patients was performed. The hospital uses a one-page SATS sheet and manages both medical and surgical patients. The triage history, physiological parameters, application of discriminator lists, final triage code and outcome was audited and compared with findings from the patients' clinical records.
Results: The mean triage early warning score was 1.50 (95% CI 1-2) and average time to treatment was 59 min (95% CI 51-67). Essential bedside investigations were missing on some very ill patients, there was poor documentation in many fields and confirmed time to treatment was within recommended timescales for only 48% of patients. Use of the discriminator list resulted in over-triage of 66.7% and an under-triage of 14%. Some 76% of patients were discharged from the emergency centre, 15% were admitted and 5.5% were transferred out.
Conclusion: Nurse-led triage has been successfully implemented at the emergency centre of this hospital using SATS but some notable gaps were identified.
Hypothermia is common in emergency general surgical patients. It is known to be associated with major complications in multiple organ systems. It is also easily preventable with the use of safe and ...cost-effective equipment. However, by observation, it appears that this equipment is used too infrequently thus resulting in unnecessary harm to patients.
This descriptive, observational, cross-sectional study was conducted in two arms to evaluate both emergency centres and operating theatres in the major state hospitals in Durban. It was conducted as an audit as well as a questionnaire-based study, to ascertain the availability of equipment used to prevent hypothermia and also how appropriately the equipment was being used.
There was good availability of equipment in both the operating theatres and the emergency centres. However it was being used very poorly, particularly in emergency centres (41% of responses deemed not beneficial to patients versus 29% from operating theatres; 39% of answers beneficial versus 54% from operating theatres). Institutions with hypothermia-prevention protocols scored significantly better than those without a protocol (59% versus 25% beneficial; p=0.01).
In the field of hypothermia prevention, there was sufficient equipment to result in optimal patient care. However there appears to be a lack of knowledge amongst health care providers, resulting in suboptimal use of this equipment. Protocolised management may provide a solution to this problem and improve patient outcomes.
Popular demand for high quality care has increased in recent years. This is also the case for medical services and support at all times of the day and night is nowadays required. During the last ten ...years, there has been a marked increase in the demands on hospital emergency hospitals, particularly in the Western industrialized countries. The present retrospective study investigates how the demands on a large Swiss university centre have changed over a period of 10 years. Patient numbers are differentiated by age, gender, nationality, weekday and mode of referral. A retrospective analysis was performed of the data of the patients admitted to the Emergency Centre of Bern University Medical Hospital (Inselspital) during the ten-year period from 2004 up to and including 2013 and who were treated as emergencies. A total of 264,272 patients were included in the study. It was shown that there was an uninterrupted annual increase from 23,555 patients in 2004 to 34,918 patients in 2013 (+48%). Most patients came to the Emergency Centre on Mondays, followed by Fridays. Because of the marked increase in life expectancy and the resulting demographic changes, there has been a marked increase in the number of older patients coming to the Emergency Centre for acute medical care. It was found that there were disproportionately high numbers of patients aged 20 to 49 years who were not Swiss citizens. In contrast, most patients over 60 were Swiss. In the coming years, emergency centres will have to adapt to the continued increase in patient numbers. This trend will continue, so that it is essential to consider the sociodemographic structure of a region when planning the availability of emergency medical care.
The aim of this study was to determine the prevalence, aetiologies and outcome of neurological disorders at the emergency centre (EC) of the Douala General Hospital (DGH).
A cross-sectional study was ...carried out from 1st January to 30th April 2014, at the EC of the DGH, in Cameroon. We included all patients above 15years of age who presented with isolated or associated neurological complaints. Data collected for each patient were: socio-demographic, clinical and laboratory characteristics, time lapse before management and the prognosis. Patients with no definitive diagnosis made in the EC, had their files reviewed on the wards by the investigators for the final diagnosis and/or aetiology.
Of 1844 patients who were consulted in the EC over the study period, 502 of them presented with neurological disorders (27.2%). The mean age was 44.4±17.8years with 53.6% males. The common symptoms were headache (47.8%), loss of consciousness (19.5%), lumbar pain (11%), hemiparesis (8.4%), and seizure (7%). Non-traumatic neurological disorders were common (86.1%). The common aetiologies were malaria (16.9%), stroke (13.5%), primary headaches (13.1%), head injury (12.9%) and metabolic encephalopathy (12.4%). Mean time lapse to be consulted by a general practitioner was 23.1±20.7min and 2.1±1.3h for neurologist’s consultation. The time lapse to receive initial medical care was 26.3±30.6min. The mean duration to have an imaging result was 1.3±0.9h and 3.1±1.7h for laboratory tests. The in-hospital mortality rate of neurological disorders was 15.1%.
Neurological disorders are common in the emergency centre of the DGH. Aetiologies are diverse and in-hospital mortality is high. This highlights the need to organize neurologist calls at the EC and/or to improve the human resources capacity through regular training and evaluation.
L’objectif de cette étude était de déterminer la prévalence, les étiologies et l’évolution des troubles neurologiques au centre des urgences (CU) de l’Hôpital Général de Douala (HGD).
Une étude transversale a été réalisée du 1er janvier au 30 avril 2014 au CU de l’HGD, au Cameroun. Nous avons inclus tous les patients âgés de plus de 15 ans se présentant aux urgences en se plaignant de troubles neurologiques isolés ou associés. Les données recueillies sur chaque patient étaient les suivantes : sociodémographiques, cliniques et résultats des tests en laboratoire, temps écoulé avant la prise en charge et le diagnostic. Les dossiers des patients pour lesquels aucun diagnostic définitif n’était réalisé au CU ont été examinés par les enquêteurs dans les services vers lesquels ils avaient été envoyés afin d’obtenir le diagnostic définitif et/ou l’étiologie.
Sur les 1 844 patients qui avaient consulté au CU au cours de la période d’étude, 502 présentaient des troubles neurologiques (27,2 %). L’âge moyen était de 44,4±17,8 ans, 53,6 % étant des hommes. Les symptômes courants étaient les maux de tête (47,8 %), la perte de connaissance (19,5 %), les douleurs lombaires (11 %), l’hémiparésie (8,4 %) et les attaques (7 %). Les troubles neurologiques non traumatiques étaient courants (86,1 %). Les étiologies courantes étaient le paludisme (16,9 %), les accidents vasculaires cérébraux (13,5 %), les céphalées primitives (13,1 %), les traumatismes crâniens (12,9 %) et les encéphalopathies métaboliques (12,4 %). Le temps d’attente moyen avant d’être examiné par un médecin généraliste était de 23,1±20,7min et de 2,1±1,3 heures avant d’être examiné par un neurologue. La durée moyenne pour bénéficier d’une prise en charge médicale initiale était de 26,3±30,6min. La durée moyenne pour obtenir un résultat d’examen radiographique était de 1,3±0,9 heures et de 3,1±1,7 heures pour obtenir des résultats d’examens du laboratoire. Le taux de mortalité hospitalière associé aux troubles neurologique s’élevait à 15,1 %.
Les troubles neurologiques sont courants au Centre des urgences de l’HGD. Les étiologies sont variées et le taux de mortalité hospitalière est élevé. Cela souligne la nécessité de mettre en place un neurologue de garde au CU et/ou d’améliorer la capacité en termes de ressources humaines par une formation et une évaluation régulières.
Emergency Centres (ECs) have a prominent trauma burden requiring effective pain management. This study aimed to review analgesia-prescribing habits in minor trauma, reviewing the patient demographics ...and diagnoses, analgesia-prescribing habits of health care professionals (HCPs) managing these cases, and differences in prescribing noted by patients' age group, gender and triage code.
A prospective, cross-sectional, descriptive study was conducted in a regional EC in KwaZulu-Natal. HCPs managing minor trauma patients completed a closed-ended questionnaire which indicated the patients' demographics, diagnosis and analgesia prescribed.
The study comprised of 314 cases of which the demographic most represented were male patients aged between 20-30 years with soft tissue injuries. Simple analgesics and weak opioids (paracetamol, ibuprofen and tramadol) accounted for 87.9% of prescriptions. Referral clinics prescribed less analgesics than that provided in the EC. There were mostly no significant differences in prescription habits by patients' age group, gender and triage code.
Presenting complaints in our study were varied and likely to result in mild to moderate pain. Only a minority of patients received analgesics at initial contact. Standardised protocols providing treatment guidance for nurse-initiated pain management at initial contact is thus important. There were no significant differences in analgesics prescribed for adults and the elderly, which is worrisome given the potential negative side effects of analgesics in the elderly. Similar concerns in our paediatric population were not noted. Ensuring adequate analgesia with cognisance for safety at the extremes of age is of paramount importance.
The Collaborative Emergency Centre (CEC) model of care was implemented in Nova Scotia without an identifiable, directly comparable precedent. It features interprofessional teams working towards the ...goal of providing improved access to primary health care, and appropriate access to 24/7 emergency care. One important component of CEC functioning is overnight staffing by a paramedic and registered nurse (RN) team consulting with an off-site physician. Our objective was to ascertain the attitudes, feelings and experiences of paramedics working within Nova Scotia’s CECs.
We conducted a qualitative study informed by the principles of grounded theory. Semi-structured telephone interviews were conducted with paramedics with experience working in a CEC. Analysis involved an inductive grounded approach using constant comparative analysis. Data collection and analysis continued until thematic saturation was reached.
Fourteen paramedics participated in the study. The majority were male (n=10, 71%) with a mean age of 44 years and mean paramedic experience of 14 years. Four major themes were identified: 1) interprofessional relationships, 2) leadership support, 3) value to community and 4) paramedic identity.
Paramedics report largely positive interprofessional relationships in Nova Scotia’s CECs. They expressed enjoyment working in these centres and believe this work aligns with their professional identity. High levels of patient and community satisfaction were reported. Paramedics believe future expansion of the model would benefit from development of continuing education and improved communication between leadership and front-line workers.
This article describes and analyzes the decision‐making process related to the establishment of Norway's National Police Emergency Response Center (NPERC). Following the July 22, 2011 terrorist ...attacks, Norway's Inquiry Commission recommended the establishment of a NPERC at one physical site. The goal was to enhance governance capacity and contribute to crisis mitigation, prevention, preparedness, and operational crisis management. Although the main actors claimed that such a center was urgently needed, it took several years for the government to reach a final decision. The main puzzle is, why did it take so long? To answer this question, we use a structural‐instrumental perspective and a garbage‐can approach, while also focusing on the issues of shifting attention and agenda‐setting. We conclude that the decision‐making process was marked by a lack of rational calculation but also influenced by external shocks, focusing events, and windows of opportunities. This led to changing expectations, shifts in attention and opportunities for new agenda‐setting. Hence, the choices made throughout the decision‐making process can be seen as the linkage of a specific policy stream, a political stream, and a problem stream. Our main conclusion is that the sense of urgency created by the terrorist attacks led to a delay in the decision‐making process.
摘要
本文描述并分析了有关建立挪威国家警察应急响应中心的决策过程。自2011年7月22日恐怖袭击后，挪威调查委员会推荐选址建立挪威国家警察应急响应中心。此举目的是提高治理能力，并促进危机缓解、预防、预备和操作性危机管理。尽管主要行动者声称迫切需要此类响应中心，但政府花费了几年时间才达成最终决定。主要的困惑在于，为何花费了这么长的时间？为回答此问题，本文使用结构性和工具性视角，以及一项垃圾桶模型，同时聚焦于注意力转变和议程设置等议题。结论认为，决策过程的标志是缺少理性计算，同时受到外部冲击、焦点事件和机会之窗的影响。这导致了预期的不断变化、注意力的转变，同时为新的议程设置提供了机会。因此，决策过程中做出的决定可被视为特定政策流、政治流和问题流之间的联系。本文的主要结论是，恐怖袭击产生的紧迫感导致了决策过程中的拖延。
Resumen
Este artículo describe y analiza el proceso de toma de decisiones relacionado con el establecimiento de un centro de emergencias de la policía nacional de Noruega. Después de los atentados terroristas del 22 de Julio de 2011, la comisión de investigaciones de Noruega recomendó la fundación de un centro nacional de respuesta a emergencias de la policía en un lugar físico. El objetivo era mejorar la capacidad de gobernanza y contribuir a la mitigación, preparación y disposición a crisis y gestión operacional de las crisis. A pesar de que los actores principales argumentaban que un centro así se necesitaba con urgencia, pasaron varios años antes que el gobierno llegara a una decisión final. El acertijo principal es: ¿Por qué tomó tanto tiempo? Para responder a esta pregunta, utilizamos una perspectiva estructural‐instrumental y una aproximación de bote de basura, mientras al mismo tiempo nos enfocamos en los problemas de los cambios de atención y el arreglo de itinerarios. Concluimos que el proceso de toma de decisiones estaba marcado por una falta de cálculo racional pero también estaba influenciada por choques externos, eventos de enfoque y ventanas de oportunidad. Esto llevó a que las expectativas y atención cambiaran, y a que hubiera oportunidades para establecer una nueva agenda. Por ende, las decisiones que se tomaron a lo largo del proceso pueden ser vistas como un vínculo de una corriente política específica y una corriente de problemas. Nuestra conclusión principal es que el sentido de urgencia creado por los atentados terroristas llevó a una demora en el proceso de toma de decisiones.
Objective: To estimate the validity of triage ratings by South African nurses and doctors with training and practical experience using the South African Triage Scale. Methods: Five emergency ...physicians and 10 enrolled nursing assistants, who had been trained in the use of the South African Triage Scale, were selected via convenience sampling to retrospectively triage adult emergency centre vignettes. Participants independently assigned triage ratings to 100 written vignettes unaware of the ratings given by others. Triage ratings were compared with ratings of two experts from the South African Triage Group. Standard validity indicators including sensitivity, specificity, positive predictive value and negative predictive value were used to estimate the validity for the combined group of emergency physicians and enrolled nursing assistants. Associated percentages for over-/under-triage were used to further assess validity within the South African context and over-/under-prediction to further assess practical application of the South African Triage Scale. Results: On average over all acuity levels, sensitivity was 75%, specificity 91%, under-triage occurred 10% and over-triage 15% of the time. The positive predictive value was 74% and negative predictive value 91%. Conclusion: The results of this study fall within the accepted range of over-/under-triage and indicate that the South African Triage Scale is valid when used by emergency physicians and nurses to triage emergency centre vignettes under South African conditions. Further research into appropriate reference ranges for extent of over-/under-triage and over-/under-prediction within each acuity level is recommended.
Procedural sedation and analgesia (PSA) is a vital skill for physicians working in an emergency centre (EC). For doctors working in the African setting, dealing with high patient loads and limited ...theatre availability, knowledge and proficiency in PSA is a highly valuable and necessary skill. The aim of this study was to audit the practice of PSA in the EC of Steve Biko Academic Hospital.
This was a cross-sectional descriptive audit. Procedures conducted under PSA were identified. An audit of clinical notes and interviews with staff was conducted. Data were analysed using the STAT 12 package. The results were presented as adherence statistics with reference to the PSA guidelines of the Emergency Medicine Society of South Africa (EMSSA).
This audit indicated that documentation of informed consent prior to PSA was poor in this hospital’s EC. No evidence of informed consent was found in any audited cases. Adherence to the other aspects of PSA was also fairly average (below 50% in most). The mean adherence scores for these components were as follows: pre-procedure preparation and equipment check 46.19% (95% CI 36.62–55.76), documented patient pre-evaluation 50.99% (95% CI 46.78–55.18), monitoring during procedure 39.22% (95% CI 34.68–43.75), post procedure monitoring 37.99% (95% CI 32.78–43.20), and overall documentation of procedure 40.69% (95% CI 37.85–43.52). Analysis of adherence to the guidelines between different ranks of doctors demonstrated that the registrars in EM were, in general, more compliant.
This audit identified documentation of informed consent as a major shortcoming in the practice of PSA in this EC. There is also room for improvement in most of the other aspects that were assessed. As part of the clinical audit cycle, the results of this study will be used to initiate changes to increase adherence to the guidelines.
La sédation et l’analgésie d’intervention (SAI) est une compétence vitale chez les médecins travaillant en centre des urgences (CU). Pour les médecins travaillant en Afrique, gérant un grand nombre de patients et une disponibilité limitée des salles d’opération, la connaissance et la familiarisation avec la SAI est une compétence extrêmement précieuse et nécessaire. L’objectif de cette étude était d’auditer la pratique de la SAI au sein du CU de l’hôpital universitaire Steve Biko.
Il s’agissait d’un audit descriptif transversal. Les procédures effectuées dans le cadre de la SAI ont été identifiées. Un audit des notes cliniques et des entretiens avec les membres du personnel ont été réalisés. Les données ont été utilisées en utilisant le logiciel STAT 12. Les résultats ont été présentés sous forme de statistiques de respect, en référence aux directives sur la SAI de la Société sud-africaine de médecine urgentiste (Emergency Medicine Society of South Africa (EMSSA).
Cet audit a indiqué que la documentation du consentement éclairé avant la SAI était de mauvaise qualité dans le CU de cet hôpital. Aucune preuve de consentement éclairé n’a été trouvée dans aucun des cas audités. Le respect des autres aspects de la SAI était également relativement médiocre (inférieure à 50% dans la plupart des cas). Les notes de respect moyennes pour ces composantes étaient telles suit: préparation et vérification du matériel avant la procédure, 46,19% (IC à 95% 36,62–55,76), examen préliminaire documenté du patient, 50,99% (IC à 95% 46,78–55,18), suivi pendant l’intervention, 39,22% (IC à 95% 34,68–43,75), suivi suite à l’intervention, 37,99% (IC à 95% 32,78–43,20), et documentation globale de l’intervention, 40,69% (IC à 95% 37,85–43,52). L’analyse du respect des directives entre différents niveaux de médecins a montré que les registres en MU étaient généralement plus en conformité.
Cet audit a identifié le consentement éclairé comme une lacune majeure de la pratique de la SAI dans ce CU. La plupart des autres aspects évalués peuvent également être améliorés. Dans le cadre de ce cycle d’audits cliniques, les résultats de cet étude seront utilisés afin d’initier des changements visant à augmenter le respect des directives.
The COVID-19 global pandemic forced healthcare facilities to put special isolation measures in place to limit nosocomial transmission. Cohorting is such a measure and refers to placing infected ...patients (or under investigation) together in a designated area. This report describes the physical reorganisation of the emergency centre at Khayelitsha Hospital, a district level hospital in Cape Town, South Africa in preparation to the COVID-19 pandemic. The preparation included the identification of a person under investigation (PUI) room, converting short stay wards into COVID-19 isolation areas, and relocating the paediatric section to an area outside the emergency centre. Finally, we had to divide the emergency centre into a respiratory and non-respiratory side by utilising part of the hospital's main reception. We are positive that the preparation and reorganization of the emergency centre will limit nosocomial transmission during the expected COVID-19 surge. Our experience in adapting to COVID-19 may have useful implications for ECs throughout South Africa and in low-and-middle income countries that are preparing for this pandemic.
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