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Introduction to out-of-hospital emergency systems in South Africa

710 384 Kirsten Kingma

Out-of-hospital Emergency System in South Africa

Craig and Minh recently did a great podcast discussing many of the above points: listen to it here on the PHARM

 

 

South Africa has a unique out-of-hospital healthcare system, it is by far one of the more developed when compared to neighbouring countries and many standards meet that of first world norms however we are by all means still a developing country and still have many steps to go. We rely on a two-tiered system of government and private medical facilities; this counts for both in and out of hospital systems. The large private organisations provide services are often comparable to first world standards whereas our government system, which is under far greater burden, excels in certain fields but also suffers from the excessive strain.

 

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Practitioners

  • Paramedics predominantly provide services out of hospital. Doctors and nurses working in the out-of-hospital environment are the exception.
  • Paramedics are trained at different levels
    • Basic Life Support (BLS): 5 week course equipping the provider in basic life sustaining measures (basic ventilation, CPR, how to recognise varying conditions and limited treatment (glucose, activated charcoal, oxygen, nitrous oxide). They are registered by the Health Professions Council of South Africa (HPCSA) in the supervised practice category and thus usually have an ILS or ALS practitioner working with them
    • Intermediate Life Support (ILS): This is a 6 month course (requires BLS and practical experience prior). The provider is equipped to manage any patient requiring basic life support, in addition they can place IV lines for fluid therapy as well as administer certain medications as indicated (aspirin, beta2 stimulants, ipratroprium bromide, dextrose, and BLS medications). They are registered as independent practitioners and can treat and make decisions at their own discretion.
    • Advanced Life Support (ALS): this can be done through continuation from the ILS qualification or via a program at a tertiary institution. In South Africa ALS practitioners are referred to as paramedics. All can give varying levels of Advanced Life Support medications and perform procedures however each is limited by a specific protocol. As an example an ECP is capable of RSI & fibrinolysis while the other qualifications are restricted in this field.
      • Critical Care Assistant (CCA): Course method consists of +- 11months as well as practical experience (in addition to having previous ILS qualification).
      • Emergency Care Technician in Emergency Medical Care (ECT) – 2 year full time at a University (this includes practical rotation during the course)
      • National Diploma in Emergency Medical Care (NDip) – 3 year full time at a University (this includes practical rotation during the course)
      • Bachelors in Emergency Medical Care (B.Tech/B.EMC) also known as ECP – 4 years full time at a University (this includes practical rotation during the course)

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Methods of transport

  • Road ambulance transport is the most common means of transport. While the standard of equipment on ambulances varies, the national department of health is making an effort to standardise minimum requirements for ambulances. In general ambulances are regular transport vehicles that are converted to accommodate a stretcher. Most ambulances have space for two patients on stretchers. In certain areas with a heavy burden of patients its is not uncommon for multiple patients to be transported simultaneously to a health care facility.
  • Aeromedical transport has a presence but is often heavily burdened and reserved primarily for transportation when distances are excessive for road transport. While there are cases where ambulances travel over 800km (Springbok to Cape Town) with patients, the aeromedical services reduce the incidence of these type of cases. The aeromedical services also provide a rescue service in the form of rotor-wing retrieval. Fixed wing services are also available in certain areas.

 

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Additional Services

  • Fire service: they have predominantly ILS trained practitioners at each station and roaming ALS practitioners. They do not transport patients however they often provide assistance at motor vehicle collisions as well as giving temporary care in medical rooms based at the fire station. They play a major role in rescue operations throughout the country.
  • Rescue services: these are a linked to the state ambulance service in the Western Cape, they provide support for motor vehicle extrication, structural collapses, wilderness rescues as well as others incidents which require specialised equipment and resources.
  • Volunteer organisations provide an important resource that supplements the full time services. These include organisations such as Wilderness Search and Rescue, Sea Rescue, volunteer ambulance services as well as others.

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Where the gaps hide

While we have a system that overall provides an essential service that is accessible to most, some of the biggest challenges include:

  • Interprovincial variation on equipment, personnel resources and standards
    • Response times to primary emergency calls can take over an hour till the 1st resources arrive on scene in rural regions
    • Inter-hospital transfers to a higher level of care can take hours to be processed even in urban areas (this includes critical patients)
  • Densely populated urban areas with good resources and under-resourced rural areas
  • Poor socioeconomic circumstances (lack of transportation, formal employment) putting additional strain on the road ambulance services (many individuals utilise ambulance transport for primary healthcare needs – not a problem unique to the developing world)

These restraints lead to a burdened service however provides an environment which encourages practitioners to work hard, find simple cost effective solutions for everyday problems.

Links to the various scope of practice policies

Summary table comparing different qualifications

BLS protocol

ILS protocol

ECT protocol

ALS protocol (primarily for NDip and CCA. Bachelors degree paramedics/ECPs have the added scope of RSI medications as well as thrombolytic drugs)

 

Links to tertiary universities offering paramedic degree programs

Cape Peninsula University of Technology

Durban University of Technology

University of Johannesburg

Nelson Mandela Metropolitan University – Port Elizabeth

Central University of Technology – Bloemfontein

The art of the EMS Handover

1367 618 Craig Wylie

 

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“Handover of care is one of the most perilous procedures in medicine, and when carried out improperly can be a major contributory factor to subsequent error and harm to patients.” – Professor Sir John Lilleyman, Medical Director, National Patient Safety Agency, UK

Scenario

A patient with blunt traumatic brain injury was intubated prehospital using Ketamine and Rocuronium, (thank you @ketaminh). The patient was placed on a ventilator, post-intubation analgesia and sedation was administered, ETCO2 was maintained at 38mmHg and the patient was transported to Ubuntu Hospital. On arrival at Ubuntu: the patient was verbally handed over to the registered nurse and emergency centre doctor and copies of EMS documentation taken to the reception area to ‘open a file’ (which is standard practice across many South African healthcare facilities).

The team jumped straight into patient care and paid very little attention to the handover given. About 20 minutes later I overheard them discussing that the patient was not a candidate for CT Scan or Neurosurgery intervention due to the GCS of 2T. I politely reminded them of the Rocuronium given 20 minutes prior.

The training, capability and scope of practice of South African out-of-hospital practitioners have increased dramatically over the last 10 years allowing practitioners to perform more complicated interventions, such as rapid sequence intubation (RSI) and thrombolysis. This does however bring a new safety concern to light. There is a vast amount of literature and discussion in Emergency Medicine & Patient Safety circles regarding the dangers of hand-over as a high risk arena. The majority of literature surrounds internal handover practices inside hospital with significantly less on EMS handover. Verbal handover is a skill that as EMS providers should become just as proficient with as they are with intravenous access. Experience alone does not by default give proficiency in this skill, which could arguably been viewed as an art rather than a skill. A novice paramedic may initially be mistaken in thinking that a good handover includes every detail of the entire patient care journey, when instead it is a brief summary of only important positives and negatives.

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Correct team members present:

Before starting your handover it is critical to ensure that you are, in fact, handing over to the correct person. I have, on more than one occasion, given my entire detailed handover to someone, only to discover 10 minutes later that this was a medical student or doctor from unrelated speciality.  Also ensure from the EMS team only one person is assigned to give verbal handover to keep messages clear. Classic example is a junior EMS staff member who is busy in the sluice room cleaning equipment before leaving, and doctor ‘popping in’ to confirm points that they forgot from handover, risk of incorrect information being conveyed.

“Healthcare professionals sometimes try to give verbal handovers at the same time as the team taking over the patient’s care are setting up vital life support and monitoring equipment. Unless both teams are able to concentrate on the handover of a sick patient, valuable information will be lost.” – Junior Doctors Committee, British Medical Association

Structured approach – DeMIST PAD

The Emergency Medicine Society of South Africa (@emmsaorgza) has recommended a standard approach using the pneumonic DeMIST, we would like to disseminate this tool further (with slight #badEM twist to DeMISTPAD).

Demographics Age, estimated weight (if paediatric), location of pick up, presence of accompanying family member, relevant chronic illnesses/allergies

Mechanism or insult that occurred.

Injuries – Use a Head—>Toe Approach

Signs & symptoms Vital signs.

Treatment provided for the patient. Consider using the ABCDE approach to listing this

Pending urgent interventions (EMS perspective)
Interventions that EMS recognise need to be done as a priority but no time in ambulance – e.g. IV line or ETT currently needs re-securing (strapping loose), another dose analgesia/sedation needed now,

Adverse events – eg. important to handover if airway was CL4, possible tooth aspiration during intubation, incorrect dosing,

Documentation
Needs to be left behind (& legible!) – this is not only critical from a medico-legal perspective but also for team members who arrive later in the patients care journey who were not present for verbal handover. A good example would be a neurosurgeon who would like to review the GCS on scene & presence of absence of a hemiplegia prior to intubation / sedation / paralysis. In patients not falling into ‘Red’ triage category, frequently the doctor who takes your verbal handover may not ultimately end up treating the patient as the patient gets triaged and joins the ‘queue’, so it is important to include all pertinent facts onto paperwork.

Two-Way-Traffic

Are you RECEIVING handovers from EMS?

Great advice from Natalie May summarised below (@_NMay) from @stemlyns – (read full article here for detail)

Sit Up = Pay attention, active listener, ask others to be quiet

Shut Up = Don’t interrupt

Sure Up = Once verbal handover complete – ask any remaining questions you have

Sum Up = Make your own verbal summary for EMS staff to ensure you understood correctly

Supplement = Make sure you go on later to read EMS notes.

  1. Troyer L, Brady W. Barriers to effective EMS to emergency department information transfer at patient handover: A systematic review. Am J Emerg Med [Internet]. Elsevier Inc.; 2020;38(7):1494–503. Available from: https://doi.org/10.1016/j.ajem.2020.04.036
  2. http://stemlynsblog.org/chinese-whispers-miscommunication-and-handover/
  3. Ashley Liebig at Resuscitate NYC17. St.Emlyn’s,” in St.Emlyn’s, January 20, 2017, https://www.stemlynsblog.org/ashley-liebig-at-resuscitate-nyc17-st-emlyns/
  4. Makkink AW, Stein COA, Bruijns SR, Gottschalk S. The variables perceived to be important during patient handover by South African prehospital care providers. African J Emerg Med [Internet]. Elsevier B.V.; 2019;9(2):87–90. Available from: https://doi.org/10.1016/j.afjem.2019.01.014