ETD Collection
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Item A retrospective analysis of time delays in patients presenting with Cerebrovascular Accident (Stroke)(2017) Khalema, DitebohoRetrospective record review of time intervals regarding symptom onset, ED presentation and time to CT scan were recorded in patients who presented to the ED with signs and symptoms of stroke in 2014. RESULTS: There were 232 patient records included in the study. The average time to presentation to the ED was 33 hours with only 13.7% presenting within 3 hours. The earliest presentation was within 30 minutes of the onset of symptoms and the most delayed presentation was 3 months. Factors associated with early presentation were female sex, smoking and loss of consciousness. Known diabetic patients presented later than non-diabetic patients. Seventy-five percent of stroke patients had an ischaemic stroke and 25% were haemorrhagic. CONCLUSIONS: Due to delays in presentation, despite the availability of thrombolysis, patients are still not receiving thrombolytic treatment.Item Utilization of Emergency Point of Care Ultrasound in an Emergency Department in Johannesburg(2017) Stanton, Tamsyn B. B.Introduction Point-of-care ultrasound (PoCUS) is a widely utilized tool in Emergency Medicine (EM). The core PoCUS curriculum in South Africa (SA) does not currently include lung ultrasound or basic bedside echocardiography, although the burden of disease in a typical South African Emergency Department (ED) is skewed towards respiratory and cardiac pathologies. This study was undertaken to determine the profile of PoCUS examinations actually performed and potentially indicated in this ED, and whether current training in PoCUS is meeting the need in clinical practice. Methods This was a prospective observational audit of bedside PoCUS examinations actually performed, and potentially indicated, over a two-week period in the Helen Joseph Hospital ED in Johannesburg. Results The study included 372 patients. Ultrasound aided in the diagnosis and management of 107 (28,8%) of the patients. A total of 137 PoCUS investigations were performed. A total of 38,9% of the patients had positive ultrasound findings. The most frequently performed PoCUS applications were e-FAST (extended focused assessment by sonography in trauma) (32,8%), DVT assessment (13,9%) and procedural guidance (10,9%). A total of 758 PoCUS examinations were indicated in 307 (82,5%) of the patients. Overall, 18,1% of the potentially indicated PoCUS investigations were performed. The most frequently potentially indicated PoCUS applications were lung ultrasound (28,2%), basic cardiac (28%) and haemodynamic assessments (20,4%). Conclusions These findings reflect the high number of respiratory and cardiac cases seen in South African EDs. This highlights the consequent need for additional ultrasound skills to assist in the emergency management of such cases. Training of future South African EM specialist consultants should include both lung ultrasound and basic bedside echocardiography. It is time to update to the South African core PoCUS curriculum.Item Quality of Adult Chest Radiographs Using Slit Beam Radiography (LODOX) in the Trauma Setting(2014) Du Toit, Maria JohannaLODOX Statscan images the entire body in 13 seconds. There is no information available regarding quality assurance (QA) of this diagnostic imaging modality. We performed QA of the chest component of LODOX images at one Emergency Unit. AIM: To determine and score the prevalence and type of radiographic error of LODOX chest radiographs in the adult trauma setting. To develop a poster as visual aid to illustrate the advantages and disadvantages of the LODOX Stat scan and suggest methods to reduce errors that may influence the diagnostic quality of the image. METHOD: A retrospective descriptive study on one hundred LODOX studies in adults (> 18 years of age) over a period of six weeks was done. The open source OSIRIX software was used to view DICOM files and QA evaluations were performed by three observers, using a pre--‐drafted tick--‐sheet and scoring system. RESULTS: No perfect scores were achieved in our study with an average score of 3.79 out of a possible worst score of 10. The majority of points were scored due to positioning errors and poor planning such as un--‐removed clothing and other artefacts. Radiographic density, contrast and sharpness generally were of good quality contributing less to QA scores. CONCLUSION: Operator dependent errors were the most frequently encountered in LODOX chest images. These were acquired without a trained radiographer in a trauma setting which possess its own challenges. There appears to be a leniency with regards to the quality of the images in this setting. The majority of the images were considered diagnostic, but many of the errors encountered are correctible through proper radiographic principles and this should be targeted when training staff.Item Poisoning due to acetylcholinesterase inhibitors in the medical emergency unit, Chris Hani Baragwanath Academic Hospital, Soweto, South Africa(2017) Saffy, Patricia MarieIntroduction: Acetylcholinesterase Inhibitor (AChEI) poisoning is well described in chemical warfare and is commonly used for attempted suicide in many third world countries. Methods: This study serves to describe the demographic factors, temporal relationships and causes of acetylcholinesterase inhibitor overdose at a tertiary hospital emergency department in Gauteng, South Africa. Cross sectional chart review from the adult emergency unit overdose register was used to extract those patients with AChEI overdose and analysed for demographics, temporal relationships, presenting signs and blood results, treatment regimens and emergency department outcomes. Results: Of the 126 patients with AChEI overdose during this period over threequarters (77%) had taken AChEI for attempted suicide. AChEI were usually taken alone without being mixed with other toxins, medicines or poisons. Males (54.3%) were more likely to attempt AChEI overdose than females. Younger people were more likely to overdose on AChEI with the majority (43.7%) being between 20-29 years, 24.6% between 30-39 years and 17.4% between 14-19 years. The remainder were over 40 years. Miosis was the most common sign of poisoning exhibited by 74% of patients. Emergency treatment was supportive with urgent use of high doses of atropine in escalating doses. Oximes and benzodiazepines were not used in the initial urgent treatment. Most patients (69%) were admitted to a high care, nonventilated ward for observation and ongoing treatment but 19% of patients were severe enough to be ventilated and admitted into ICU. A small percentage, (12%) were sent to general wards. The mortality from AChEI poisoning in the unit was 2.4%. Conclusion: Typically, young healthy people were found to abuse AChEIs; the majority of which had suicidal intent. An average of 5 patients presented with AChEI poisoning per week. The mortality rate in the unit was very low.Item An exploration of the views of healthcare providers on family witnessed resuscitation in an emergency department of a private hospital in Gauteng(2018) Ambelal, Mayush NarendraBackground: There has been an international move towards allowing family member presence during the resuscitation of a relative for many years, but not in South Africa. This practice is discouraged in many hospitals locally. There is a lack of formal protocols on allowing family member presence during resuscitative efforts. Communication with the family is left to a doctor and often only occurs once the patient has demised. Aim: The aim of this study was to explore the views of the healthcare providers on the practice of family member presence during the resuscitation of their relative in an emergency department in a private hospital setting in Gauteng. The results were intended to inform policy for future reference on the practice of family member presence during the resuscitation of their relative in an emergency department. Design: This study was carried out at a level two private hospital with a busy emergency unit which receives complex trauma and medical cases. A qualitative, exploratory, descriptive and contextual design was used for this study. A total of twenty four (n=24) multidisciplinary healthcare providers at the selected study site were selected. The sample size was determined by saturation of information during data collection. Open ended questions in an interview were used and the data recorded using an audio recorder. Tesch’s method was used to analyse the data collected. Measures of trustworthiness were applied to ensure rigor of the findings in this study. Findings: This study revealed five themes with nine sub themes. The five themes included perceptions of emergency room staff, buy in towards family member presence, concerns from staff, family emotions as perceived by staff and balancing your act. Conclusion: The findings of this study show that there is no consensus between the different healthcare providers on family witnessed resuscitation. Key words: Family member presence, resuscitation, witnessed resuscitation, perceptions and healthcare providers.Item A review of chest trauma in the emergency departments at hospitals of a private hospital group in the KwaZulu-Natal from 01 January 2008 to 31 December 2010(2018) Pukana, Aime Musakay1. BACKGROUND AND SETTING The study is conducted in hospitals of a private hospital group in the KwaZulu-Natal province in South Africa. The increasing number of chest injuries in hospitals has led to increased interest in this field and has led me to conduct this study in the province. Data was collected from clinical records via the national data bank of the private hospital group. 2. AIM This thesis describes chest trauma in the Emergency departments of hospitals of a private hospital group in the KwaZulu-Natal province from 01 January 2008 to 31 December 2010. 3. METHODS It is a retrospective cohort study with a total sample size of 238 patients in different Emergency Departments, retrieved from clinical data bank of a private hospital group. 12 4. RESULTS - People between the age of 20 years and 40 years are more affected by chest trauma. - Chest trauma is more common in the Black population compared to other racial groups. - Male sex has the highest occurrence rate in comparison to female sex. - April and December have been shown to be a high risk period. - Most of the chest injuries cases happened during week days. - Motor vehicle accidents represent the major cause of chest injury in this study followed by physical assault. - Most patients who arrived in the ED had an Injury Severity Score that was ranging from mild to moderate. - The majority of cases have been associated with a good prognosis. - There was a mortality rate of 6.7%. 5. CONCLUSION Chest trauma represents a public health concern that needs to be addressed by the government in consultation/collaboration with the various stakeholders.Item A prospective pedometer study of doctors working in an Emergency department(2018) Beringer, Craig BrianObjective The positive impact of physical activity and exercise on health is well known; conversely a lack of physical activity has been clearly demonstrated to increase the risk of several non-communicable diseases. Individuals who walk 10 000 steps per day or more are likely to meet recommended physical activity guidelines. Very little is known about the physical activity levels of doctors at work, in particular those working in busy Emergency Departments (ED). Our primary objective was to determine how many steps per shift doctors working in a South African ED took. The secondary objectives were to assess what factors influenced the number of steps taken. Methods This was a prospective observational cohort study undertaken at Helen Joseph Hospital ED, Johannesburg, South Africa over a one-month period. The 32 participating doctors wore pedometers during their day shifts in the ED and the number of steps taken during their shifts were measured; as well as the number and triage category of patients seen; and whether chest compressions were performed. Results The median number of steps taken per shift was 6328 (Interquartile Range [IQR] 4646-8409). This was significantly less than the 10 000 recommended steps per day (p<0.0001). In only 11.7% (37/317) of shifts did the number of steps taken exceed the target of 10 000 steps. Factors which significantly increased the number of steps taken included shift duration and the performance of chest compressions. Each additional hour of shift led to a mean increase of 600 steps (95% CI: 548-772 steps). The mean number of steps for shift with chest compressions was 8308 (95% CI:7479- 9137) while the mean number of steps for shifts without chest compressions was 6503 (95% CI: 6121-6885). A low patient per hour rate was shown with an average rate, for all participants over the one month period of 0.9. Conclusions The results show that doctors working in the ED are not achieving the recommended number of daily steps while at work. Failing to meet the current physical activity guidelines can be explained by the overall low rate of patients seen per hour as well as the general layout of the ED. With little time outside of working hours for exercise and further physical activity, achieving the desired steps per day seems unlikely, which could potentially increase the risk of ill health and burnout.Item Patient profile of uninsured patients at a private emergency department(2018) Dippenaar (Forurie), NicoleBackground The aim of this study is to determine the patient profile of uninsured patients presenting to a private emergency department over a 3-month period. The study also looks at the time these patients spend in the private emergency department as well as reasons for delay in transfer when present. The study aims to assist the private emergency department in making financial and administrative plans for anticipated numbers of uninsured patients presenting to the unit in the future. Methods The study is a retrospective, cross-sectional study, reviewing patient data of uninsured patients presenting to a private emergency department in Tshwane over an allocated period from 01 September 2014 to 30 November 2014. The study population is any uninsured patient presenting to the private emergency department over the 3 month period and was identified by searching the existing patient register in the unit. The data collected includes age, gender, priority of the patients according to triage protocol, provisional diagnoses, outcome, time that a patient spends in the unit before transfer, admission or discharge and reasons for delay in transfer if experienced. The number of patients over the entire period as well as over each individual month was recorded and analysed. Results The total number of uninsured patient visits to the private ED over the 3-month period was 503 which included follow up visits. The total number of ED visits for insured and uninsured patients was 6505. Uninsured patients accounted for 7.7% of the total number of visits to the ED. There was a total of 427 uninsured patients (excluding follow up visits) seen in the private ED over the 3-month period. This is the study sample number. There were on average more patients seen over the weekend and the majority iv of all the uninsured patients were non-urgent cases. Seventy nine percent were discharged, 12% were transferred to a government facility, 7% were admitted to the private facility and 2% refused hospital treatment. There were 20 delays in transfer to government facilities identified. Conclusions The study provides insight into the patient profile and number of uninsured patients presenting to a private emergency department in South Africa over a 3-month period. This data can assist the emergency department in planning and managing these patients who often present a challenge to the physician due to delays when transferring the ill patients to government facilities.Item Audit of clinical records in paediatric head injuries(2017) Van Niekerk, Jacobus PetrusHead injuries are among the most common reasons children visit Emergency Departments (ED) worldwide (5). Head injuries seen in the ED can be categorized as minor, moderate or severe, as defined by the Glasgow Coma Scale (GCS) (3). Minor head injuries (MHI) are defined as a GCS of 13 to15 (6). The majority (>80%) of head injuries presenting in the ED, can be classified as MHI (5). When dealing with children who sustained a MHI, it is a challenge to determine whether there might be a potentially life threatening underlying injury to the brain (5,8,9). The introduction of CT scan greatly improved the evaluation and management of MHI. The advantages include high accuracy and it is relatively fast to determine potential life threatening intracranial pathology. Disadvantages include cost, as well as high radiation doses associated with CT scans (8). To help decide whether a CT scan would be useful/diagnostic, a number of international validated CT scan rules/guidelines were developed (14,26). Effort should be made to reduce the number of CT scans done in the ED. The aim of this study was to look at: • The population of children that presented to the private Emergency Department in the North of Pretoria with the history of minor blunt head injury over a 12-month period. • The management of children who presented with a minor blunt head injury in the Emergency Department studied. • Any evidence of an International recognized guideline used in the decision to perform a CT scan in the Emergency Department studied. • The incidence of positive CT scans that were done in the Emergency Department studied. vi • Which of the international validated guidelines are best suited for the children that present to the Emergency Department studied in terms of compliance. The study design was retrospective. The timeframe of data collected was 12 months. The sample size was 173 children. The results showed that the population demographics of the children as well as the etiology and management of the minor head injuries that presented in the unit studied was comparable to most internationally recognized studies, both in developed and developing countries. In the emergency department studied, there was no evidence found to prove that validated guidelines were used in the decision process to order a CT scan or not. We as emergency department doctors in South Africa need a cost effective, safe and sensitive guideline that is easy to incorporate in a private emergency department setting. We have to consider over investigation with the associated radiation risks of doing CT scans. We should also prevent under investigation and missing clinically significant intracranial pathology in minor head injuries. South Africa is a developing country and therefore financial constraints are a major factor in decision process of the management of all patients, including children with minor head injuries. Incorporating all data obtained and audited, as well as the international validated guidelines studied, it can be concluded that the PECARN Rule for minor head injuries would best be incorporated in the emergency department studied.Item Emergency department workplace violence(2016) Jaffal, AmerObjectives: The aim of the current research was to determine the perception and experience of different emergency department occupational groups regarding workplace violence in the past 12 months and to determine the effect that it had on them in two government hospitals in Johannesburg, South Africa. Materials and Methods: The current research was a cross sectional, retrospective qualitative survey. Results: Eighty-six surveys (43%) out of the distributed 200 questionnaires were returned. Five surveys were unfilled leaving 81 surveys (40.5%) that are included in the analysis. Psychological violence was experienced by 73 % (n=51) of the participants while physical violence was experienced by 34.2% (n=27). Patients were the perpetrators of 61% and 67.9% of psychological and physical violence against staff members, respectively. Friends and family members who accompanied patients in the emergency department accounted for 27.4% psychological violence while this same set of people caused 17.3% of physical violence. Ninety-one percent of the participants reported that they did not receive any training courses on how to handle workplace violence incidents. Medical staff (doctors and nurses) were found to be at an increased risk to psychological violence. Conclusions: Workplace violence was commonly experienced by ED staff members. Majority of the incidents were in the form of psychological violence; however, a considerable percentage of the participants experienced physical violent incidents. Most of the violent incidents experienced were perceived to be preventable by majority of participants. This research supports the need for practical training and education of the ED staff members, on how to prevent and deal with issues related to ED WPV.