Case mix of patients managed in the resuscitation area of a district-level public hospital in Cape Town

A multi-parameter diagnostic clinical decision tree for the rapid diagnosis of tuberculosis in HIV-positive patients presenting to an emergency centre

Background: Early diagnosis is essential to reduce the morbidity and mortality of HIV-associated tuberculosis. We developed a multi-parameter clinical decision tree to facilitate rapid diagnosis of tuberculosis using point-of-care diagnostic tests in HIV-positive patients presenting to an emergency centre. Methods: A cross-sectional study was performed in a district hospital emergency centre in a high-HIV-prevalence community in South Africa. Consecutive HIV-positive adults with ≥1 WHO tuberculosis symptoms were enrolled over a 16-month period. Point-of-care ultrasound (PoCUS) and urine lateral flow lipoarabinomannan (LF-LAM) assay were done according to standardized protocols. Participants also received a chest X-ray. Reference standard was the detection of Mycobacterium tuberculosis using Xpert MTB/RIF or culture. Logistic regressions models were used to investigate the independent association between prevalent microbiologically confirmed tuberculosis and clinical and biological variables of interest. A decision tree model to predict tuberculosis was developed using the classification and regression tree algorithm. Results: There were 414 participants enrolled: 171 male, median age 36 years, median CD4 cell count 86 cells/mm3. Tuberculosis prevalence was 42% (n=172). Significant variables used to build the classification tree included ≥2 WHO symptoms, antiretroviral therapy use, LF-LAM, PoCUS independent features (pericardial effusion, ascites, intra-abdominal lymphadenopathy) and chest X-ray. LF-LAM was positioned after WHO symptoms (75% true positive rate, representing 17% of study population). Chest X-ray should be performed next if LF-LAM is negative. The presence of ≤1 PoCUS independent feature in those with ‘possible or unlikely tuberculosis’ on chest x-ray represented 47% of non-tuberculosis participants (true negative rate 83%). In a prediction tree which only included true point-of-care tests, a negative LF-LAM and the presence of ≤2 independent PoCUS features had a 71% true negative rate (representing 53% of sample). Conclusions: LF-LAM should be performed in all adults with suspected HIV-associated tuberculosis (regardless of CD4 cell count) presenting to the emergency centre.

The characteristics of geriatric patients managed within the resuscitation unit of a district-level emergency centre in Cape Town

Introduction

The world's population is aging and this trend is also seen in South Africa. This increase will invariably affect acute care services. The geriatric population attending emergency centres have not been described in the South African setting. The objective was to describe the characteristics of geriatric patients presenting to the resuscitation unit of a district-level hospital in Cape Town.

Methods

All patients (≥65 years) managed within the resuscitation unit of Khayelitsha Hospital over an 8-month period (01 January–30 August 2018) were retrospective analysed. Data were collected from the Khayelitsha Hospital Emergency Centre database and by means of a retrospective chart review. Summary statistics are presented of all variables.

Results

A total of 225 patients were analysed. The median age was 71.1 years, 148 (65.8%) were female and all were residing in their family home. The majority (n = 162, 72%) presented outside office hours, 124 (55.1%) arrived by ambulance, and 94 (41.8%) had presented to the emergency centre within the previous year. Only half the patients (n = 114, 50.7%) were triaged as very urgent or higher. Most patients (n = 169, 75.1%) were admitted by in-hospital services and the in-hospital mortality was 21.8% (n = 49). Diseases related to the circulatory system (n = 54, 24.0%) were the most frequent primary diagnosis and acute kidney injury were the most frequent secondary diagnosis (n = 101, 44.9%). The most common comorbidities were hypertension (n = 176, 78.2%) and diabetes (n = 110, 48.9%), and 99 (44%) had three or more comorbidities. Polypharmacy (≥5 medications) occurred in 100 (44.4%) patients with 114 (50.7%) using medications from three or more different classes. The prevalence of hypernatremia was 2.6% and for hyponatremia 54.4%.

Conclusion

Geriatric patients managed within the resuscitation unit of a district-level hospital had a high return rate, multiple comorbidities and a high prevalence of polypharmacy and hyponatraemia.

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The average life expectancy in Africa is increasing

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Geriatric patients often present with multiple co-morbidities and polypharmacy

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Geriatric-friendly processes should be considered to ensure that geriatric patients are appropriately triaged and managed in the acute care setting

Demographics and clinical characteristics of hospitalised patients under investigation for COVID-19 with an initial negative SARS-CoV-2 PCR test result

Background

The COVID-19 pandemic is placing abnormally high and ongoing demands on healthcare systems. Little is known about the full effect of the COVID-19 pandemic on diseases other than COVID-19 in the South African setting.

Objective

To describe a cohort of hospitalised patients under investigation for SARS-CoV-2 that initially tested negative.

Methods

Consecutive patients hospitalised at Khayelitsha Hospital from April to June 2020, whose initial polymerase chain reaction test for SARS-CoV-2 was negative were included. Patient demographics, clinical characteristics, ICD-10 (International Statistical Classification of Diseases and Related Health Problems 10th Revision) diagnosis, referral to tertiary level facilities and ICU, and all-cause in-hospital mortality were collected. The 90-day re-test rate was determined and comparisons were made using the χ²-test and the independent samples median test.

Results

Overall, 261 patients were included: median age 39.8 years, 55.6% female (n = 145). Frequent comorbidities included HIV (41.4%), hypertension (26.4%), and previous or current tuberculosis (24.1%). Nine (3.7%) patients were admitted to ICU and 38 (15.6%) patients died. Ninety-three patients (35.6%) were re-tested and 21 (22.6%) were positive for SARS-CoV-2. The top primary diagnoses related to respiratory diseases (n = 82, 33.6%), and infectious and parasitic diseases (n = 62, 25.4%). Thirty-five (14.3%) had a COVID-19 diagnostic code assigned (26 without microbiological confirmation) and 43 (16.5%) had tuberculosis. Older age (p = 0.001), chronic renal impairment (p = 0.03) and referral to higher level of care (all p < 0.001; ICU p = 0.03) were more frequent in those that died.

Conclusion

Patients with tuberculosis and other diseases are still presenting to emergency centres with symptoms that may be attributable to SARS-CoV-2 and requiring admission. Extreme vigilance will be necessary to diagnosis and treat tuberculosis and other diseases as we emerge from the COVID-19 pandemic.

The burden of diabetic emergencies on the resuscitation area of a district-level public hospital in Cape Town

INTRODUCTION

Diabetes and its complications continue to cause a daunting and growing concern on resource-limited environments. There is a paucity of data relating to the care of diabetic emergencies in the emergency centres of entry-level hospitals in Africa. The aim of this study was to describe the burden of diabetic emergencies presenting to the emergency centre of an urban district-level hospital in Cape Town, South Africa.

METHODS

The Khayelitsha Hospital Emergency Centre database was retrospectively analysed for patients presenting with a diabetic emergency within a 24-week randomly selected period. The database was supplemented by a retrospective chart review to include additional variables for participants with diabetic ketoacidosis (DKA), uncomplicated hyperglycaemia, severe hypoglycaemia and hyperosmolar hyperglycaemic state (HHS). Summary statistics are presented of all variables.

RESULTS

The prevalence of all diabetic emergencies was 8.1% (197/2424) (DKA n = 96, 48.7%; uncomplicated hyperglycaemia n = 45, 22.8%; severe hypoglycaemia n = 44, 22.3%; HHS n = 12, 6%). The median age was 48 years, with those presenting with DKA being substantially younger (36 years). A likely precipitant was identified in 175 (88%) patients; infection was the most common precipitant (n = 79, 40.1%). Acute kidney injury occurred in 80 (40.6%) cases. The median length of stay in the resuscitation area was 13 h (IQR 7.2-24) and 101 (51.3%) participants represented with a diabetic- related emergency within six months of the study period. The overall mortality rate was 5% (n = 10).

CONCLUSION

This study highlights the high burden of diabetic emergencies on the provision of acute care at a district-level hospital. The high prevalence of diabetic emergencies (8%) consisted of DKA (48.7%), uncomplicated hyperglycaemia (22.8%), severe hypoglycaemia (22.3%), and HHS (6%). The high infection rate (40%) and the high percentage of patients returning with a diabetic emergency (51%) could be indicative of the need for improved community-based diabetic programmes.

Trauma patients at the Helderberg District Hospital emergency centre, South Africa: A descriptive study

INTRODUCTION

Trauma is a substantial component of South Africa's burden of disease. District hospitals provide primary trauma care for a large proportion of this trauma burden, although most studies are in specialised or tertiary settings. The aim was to evaluate the profile of physical trauma patients attending the emergency centre at Helderberg District Hospital, Cape Town.

METHODS

An observational descriptive study was conducted between 1 January and 30 April 2019. Patients with trauma were identified from a register and systematically sampled to achieve a sample size of 377. Retrospective data from medical records was collected and analysed in the Statistical Package for Social Sciences.

RESULTS

Of the 14,873 patients attending the emergency centre 24.6% were trauma related and 381 folders were analysed. Of these patients 30.4% were female and 69.6% male with an average age of 27.8 years. Over 60% of patients used an ambulance to get to the hospital. Sundays were the busiest days with 23.9% of all cases. Intentional trauma accounted for 45.4% of cases and accidental injuries 49.1%. The commonest mechanisms were sharp injuries (27.6%), falls (22.0%) and blunt trauma (19.4%). Intentional trauma made up more than half of all trauma in males, was more prevalent than accidental trauma between 20 and 60 years and resulted in a higher proportion of admissions.

CONCLUSION

There were high levels of intentional trauma, especially involving young males over the weekend, mostly with sharp objects. This trauma burden resulted in high numbers of admissions and transfer to tertiary hospitals. Family physicians and other generalists need to be well trained in trauma resuscitation and stabilisation. District hospital need to be appropriately equipped and supplied to manage trauma. Further research is needed to identify underlying modifiable factors that can be addressed through community-orientated interventions.

Adult medical emergency unit presentations due to adverse drug reactions in a setting of high HIV prevalence

INTRODUCTION

South Africa has the world's largest antiretroviral treatment programme, which may contribute to the adverse drug reaction (ADR) burden. We aimed to determine the proportion of adult non-trauma emergency unit (EU) presentations attributable to ADRs and to characterise ADR-related EU presentations, stratified according to HIV status, to determine the contribution of drugs used in management of HIV and its complications to ADR-related EU presentations, and identify factors associated with ADR-related EU presentation.

METHODS

We conducted a retrospective folder review on a random 1.7% sample of presentations over a 12-month period in 2014/2015 to the EUs of two hospitals in Cape Town, South Africa. We identified potential ADRs with the help of a trigger tool. A multidisciplinary panel assessed potential ADRs for causality, severity, and preventability.

RESULTS

We included 1010 EU presentations and assessed 80/1010 (7.9%) as ADR-related, including 20/239 (8.4%) presentations among HIV-positive attendees. Among HIV-positive EU attendees with ADRs 17/20 (85%) were admitted, versus 22/60 (37%) of HIV-negative/unknown EU attendees. Only 5/21 (24%) ADRs in HIV-positive EU attendees were preventable, versus 24/63 (38%) in HIV-negative/unknown EU attendees. On multivariate analysis, only increasing drug count was associated with ADR-related EU presentation (adjusted odds ratio 1.10 per additional drug, 95% confidence interval 1.03 to 1.18), adjusted for age, sex, HIV status, comorbidity, and hospital.

CONCLUSIONS

ADRs caused a significant proportion of EU presentations, similar to findings from other resource-limited settings. The spectrum of ADR manifestations in our EUs reflects South Africa's colliding epidemics of infectious and non-communicable diseases. ADRs among HIV-positive EU attendees were more severe and less likely to be preventable.

The burden of HIV and tuberculosis on the resuscitation area of an urban district-level hospital in Cape Town

INTRODUCTION

Many patients present to emergency centres with HIV and tuberculosis related emergencies. Little is known about the influence of HIV and tuberculosis on the resuscitation areas of district-level hospitals. The primary objective was to determine the burden of non-trauma patients with HIV and/or tuberculosis presenting to the resuscitation area of Khayelitsha Hospital, Cape Town.

METHODS

A retrospective analysis was performed on a prospectively collected observational database. A randomly selected 12-week sample of data from the resuscitation area was used. Trauma and paediatric (<13 years) cases were excluded. Patient demographics, HIV and tuberculosis status, disease category, investigations and procedures undertaken, disposition and in-hospital mortality were assessed. HIV and tuberculosis status were determined by laboratory confirmation or from clinical records. Descriptive statistics are presented and comparisons were done using the χ2-test or independent t-test.

RESULTS

A total of 370 patients were included. HIV prevalence was 38.4% (n = 142; unknown n = 78, 21.1%), tuberculosis prevalence 13.5% (n = 50; unknown n = 233, 63%), and HIV/tuberculosis co-infection 10.8% (n = 40). HIV and tuberculosis were more likely in younger patients (both p < 0.01) and more females were HIV-positive (p < 0.01). Patients with tuberculosis spend 93 min longer in the resuscitation area than those without (p = 0.02). The acuity of patients did not differ by HIV or tuberculosis status.Infectious-related diseases and diseases of the digestive system occurred significantly more in the HIV-positive group, and endocrine-related diseases and diseases of the nervous system in HIV-negative patients.HIV-positive patients received more abdominal ultrasound examinations (p < 0.01), blood cultures (p < 0.01) and intravenous antibiotics (p < 0.01). In-hospital mortality was 17% and was not influenced by HIV status (p = 0.36) or tuberculosis status (p = 0.29).

CONCLUSION

This study highlights the burden of HIV and tuberculosis on the resuscitation area of a district level hospital. Neither HIV nor tuberculosis status were associated with in-hospital mortality.

Point-of-Care Ultrasound Predictors for the Diagnosis of Tuberculosis in HIV-Positive Patients Presenting to an Emergency Center

BACKGROUND

The performance of point-of-care ultrasound (PoCUS) to diagnose HIV-associated tuberculosis has not been evaluated in large prospective studies. We determined the diagnostic accuracy of individual PoCUS features, performed an external validation of the focused assessment with sonography for HIV/TB (FASH) protocol, and determined independent PoCUS predictors of HIV-associated tuberculosis appropriate for use by emergency center practitioners.

SETTING

A cross-sectional diagnostic study was performed at the emergency center of Khayelitsha Hospital (Cape Town, South Africa).

METHODS

HIV-positive adults with the suspicion of having tuberculosis were prospectively enrolled. PoCUS was performed according to a standardized protocol. Reference standard was the detection of Mycobacterium tuberculosis using Xpert MTB/RIF or culture.

RESULTS

We enrolled 414 participants: 243 female, median age 36 years, median CD4 cell count 86/mm, and 172 (42%) had tuberculosis. Sensitivity and specificity were ≥1 individual PoCUS feature [73% (95% CI: 65 to 79), 54% (95% CI: 47 to 60)], FASH protocol [71% (95% CI: 64 to 78), 57% (95% CI: 50 to 63)]. Independent PoCUS predictors identified were intra-abdominal lymphadenopathy of any size (aDOR 3.7 (95% CI: 2.0 to 6.7)], ascites [aDOR 3.0 (95% CI: 1.5 to 5.7)], and pericardial effusion of any size [aDOR 1.9 (95% CI: 1.2 to 3.0)]. The c-statistic for the derivation model was 0.680 (95% CI: 0.631 to 0.729), compared with 0.630 (95% CI: 0.576 to 0.684) of the FASH protocol. Two or more independent PoCUS predictors had 91% (95% CI: 86 to 94) specificity.

CONCLUSION

The presence of 2 or more independent PoCUS predictors (intra-abdominal lymphadenopathy, ascites, and pericardial effusion) had moderate discrimination for HIV-associated tuberculosis in patients presenting to the emergency center.

A multi-parameter diagnostic clinical decision tree for the rapid diagnosis of tuberculosis in HIV-positive patients presenting to an emergency centre

Background: Early diagnosis is essential to reduce the morbidity and mortality of HIV-associated tuberculosis. We developed a multi-parameter clinical decision tree to facilitate rapid diagnosis of tuberculosis using point-of-care diagnostic tests in HIV-positive patients presenting to an emergency centre. Methods: A cross-sectional study was performed in a district hospital emergency centre in a high-HIV-prevalence community in South Africa. Consecutive HIV-positive adults with ≥1 WHO tuberculosis symptoms were enrolled over a 16-month period. Point-of-care ultrasound (PoCUS) and urine lateral flow lipoarabinomannan (LF-LAM) assay were done according to standardized protocols. Participants also received a chest X-ray. Reference standard was the detection of Mycobacterium tuberculosis using Xpert MTB/RIF or culture. Logistic regressions models were used to investigate the independent association between prevalent microbiologically confirmed tuberculosis and clinical and biological variables of interest. A decision tree model to predict tuberculosis was developed using the classification and regression tree algorithm. Results: There were 414 participants enrolled: 171 male, median age 36 years, median CD4 cell count 86 cells/mm3. Tuberculosis prevalence was 42% (n=172). Significant variables used to build the classification tree included ≥2 WHO symptoms, antiretroviral therapy use, LF-LAM, PoCUS independent features (pericardial effusion, ascites, intra-abdominal lymphadenopathy) and chest X-ray. LF-LAM was positioned after WHO symptoms (75% true positive rate, representing 17% of study population). Chest X-ray should be performed next if LF-LAM is negative. The presence of ≤1 PoCUS independent feature in those with ‘possible or unlikely tuberculosis’ on chest x-ray represented 47% of non-tuberculosis participants (true negative rate 83%). In a prediction tree which only included true point-of-care tests, a negative LF-LAM and the presence of ≤2 independent PoCUS features had a 71% true negative rate (representing 53% of sample). Conclusions: LF-LAM should be performed in all adults with suspected HIV-associated tuberculosis (regardless of CD4 cell count) presenting to the emergency centre.

Brief Report: Real-World Performance and Interobserver Agreement of Urine Lipoarabinomannan in Diagnosing HIV-Associated Tuberculosis in an Emergency Center

BACKGROUND

The urine lipoarabinomannan (LAM) lateral flow assay is a point-of-care test to diagnose HIV-associated tuberculosis (TB). We assessed the performance of urine LAM in HIV-positive patients presenting to the emergency center and evaluated the interobserver agreement between emergency center physicians and laboratory technologists.

SETTING

A cross-sectional diagnostic study was performed at the emergency center of a district hospital in a high HIV-prevalence community in South Africa.

METHODS

Consecutive HIV-positive adults presenting with ≥1 WHO TB symptom were enrolled over a 16-month period. A urine LAM test was performed at point-of-care by an emergency physician and interpreted independently by 2 physicians. A second test was performed in the laboratory and interpreted independently by 2 laboratory technologists. The reference standard was a positive TB culture or Xpert MTB/RIF test on sputum or appropriate extrapulmonary samples. We compared diagnostic accuracy and reproducibility of urine LAM between point-of-care readers and laboratory readers.

RESULTS

One thousand three hundred eighty-eight samples (median, 3 samples/participant) were sent for TB microbiology tests in 411 participants; 170 had confirmed TB (41.4%). Point-of-care and laboratory-performed urine LAM had similar sensitivity (41.8% vs 42.0%, P = 1.0) and specificity (90.5% vs 87.5%, P = 0.23). Moderate agreement was found between point-of-care and laboratory testing (κ = 0.62), but there was strong agreement between point-of-care readers (κ = 0.95) and between laboratory readers (κ = 0.94). Positive percent agreement between point-of-care and laboratory readers was 68% and negative percent agreement 92%.

CONCLUSION

There is no diagnostic accuracy advantage in laboratory-performed versus point-of-care-performed urine LAM tests in emergency care centers in high-burden settings.

Evaluating trauma scoring systems for patients presenting with gunshot injuries to a district-level urban public hospital in Cape Town, South Africa

Introduction

Trauma scoring systems are widely used in emergency settings to guide clinical decisions and to predict mortality. It remains unclear which system is most suitable to use for patients with gunshot injuries at district-level hospitals. This study compares the Triage Early Warning Score (TEWS), Injury Severity Score (ISS), Trauma and Injury Severity Score (TRISS), Kampala Trauma Score (KTS) and Revised Trauma Score (RTS) as predictors of mortality among patients with gunshot injuries at a district-level urban public hospital in Cape Town, South Africa.

Methods

Gunshot-related patients admitted to the resuscitation area of Khayelitsha Hospital between 1 January 2016 and 31 December 2017 were retrospectively analysed. Receiver Operating Characteristic (ROC) analysis were used to determine the accuracy of each score to predict all-cause in-hospital mortality. The odds ratio (with 95% confidence intervals) was used as a measure of association.

Results

In total, 331 patients were included in analysing the different scores (abstracted from database n = 431, excluded: missing files n = 16, non gunshot injury n = 10, <14 years n = 1, information incomplete to calculate scores n = 73). The mortality rate was 6% (n = 20). The TRISS and KTS had the highest area under the ROC curve (AUC), 0.90 (95% CI 0.83-0.96) and 0.86 (95% CI 0.79–0.94), respectively. The KTS had the highest sensitivity (90%, 95% CI 68-99%), while the TEWS and RTS had the highest specificity (91%, 95% CI 87–94% each).

Conclusions

None of the different scoring systems performed better in predicting mortality in this high-trauma burden area. The results are limited by the low number of recorded deaths and further studies are needed.

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Gunshot injuries most often occurs in young males.

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Trauma scores can be used to prognosticate patients in order to allocate appropriate resources.

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Accuracy-related data of trauma scores in entry-level hospitals is limited.

The burden of trauma at a district hospital in the Western Cape Province of South Africa

BACKGROUND

Sub-Saharan Africa bears a disproportionate burden of mortality from trauma. District hospitals, although not trauma centres, play a critical role in the trauma care system by serving as frontline hospitals. However, the clinical characteristics of patients receiving trauma care in African district hospitals remains under-described and is a barrier to trauma care system development. We aim to describe the burden of trauma at district hospitals by analysing trauma patients at a prototypical district hospital emergency centre.

METHODS

An observational study was conducted in August, 2014 at Wesfleur Hospital, a district facility in the Western Cape Province of South Africa. Data were manually collected from a paper registry for all patients visiting the emergency centre. Patients with trauma were selected for further analysis.

RESULTS

Of 3299 total cases, 565 (17.1%) presented with trauma, of which 348 (61.6%) were male. Of the trauma patients, 256 (47.6%) were ages 18-34 and 298 (52.7%) presented on the weekend. Intentional injuries (assault, stab wounds, and gunshot wounds) represented 251 (44.4%) cases of trauma. There were 314 (55.6%) cases of injuries that were unintentional, including road traffic injuries. There were 144 (60%) intentionally injured patients that arrived overnight (7pm-7am). Patients with intentional injuries were three times more likely to be transferred (to higher levels of care) or admitted than patients with unintentional injuries.

CONCLUSION

This district hospital emergency centre, with a small complement of non-EM trained physicians and no trauma surgical services, cared for a high volume of trauma with over half presenting on weekends and overnight when personnel are limited. The high volume and rate of admission/ transfer of intentional injuries suggests the need for improving prehospital trauma triage and trauma referrals. The results suggest strengthening trauma care systems at and around this resource-limited district hospital in South Africa may help alleviate the high burden of post-trauma morbidity and mortality.

The burden of intentional self-poisoning on a district-level public Hospital in Cape Town, South Africa

INTRODUCTION

Intentional self-poisoning is a significant part of the toxicological burden experienced by emergency centres. The aim of this study was to describe all adults presenting with intentional self-poisoning over a six-month period to the resuscitation unit of Khayelitsha Hospital, Cape Town.

METHODS

Adult patients with a diagnosis of intentional self-poisoning between 1 November 2014 and 30 April 2015 were retrospectively analysed after eligible patients were obtained from the Khayelitsha Hospital Emergency Centre database. Missing data and variables not initially captured in the database were retrospectively collected by means of a chart review. Summary statistics were used to describe all variables.

RESULTS

A total of 192 patients were included in the analysis. The mean age was 27.3 years with the majority being female (n = 132, 68.8%). HIV-infection was a comorbidity in 39 (20.3%) patients, while 13 (6.8%) previously attempted suicide. Presentations per day of the week were almost equally distributed while most patients presented after conventional office hours (n = 152, 79.2%), were transported from home (n = 124, 64.6%) and arrived by ambulance (n = 126, 65.6%). Patients spend a median time of 3h37m in the resuscitation unit (interquartile range 1 h 45 m-7 h 00 m; maximum 65 h 49 m). Patient acuity on admission was mostly low according to both the Triage Early Warning Score (non-urgent n = 100, 52.1%) and the Poison Severity Score (minor severity n = 107, 55.7%). Pharmaceuticals were the most common type of toxin ingested (261/343, 76.1%), with paracetamol the most frequently ingested toxin (n = 48, 25.0%). Eleven patients (5.7%) were intubated, 27 (14.1%) received N-acetylcysteine, and 18 (9.4%) received benzodiazepines. Fourteen (7.3%) patients were transferred to a higher level of care and four deaths (2%) were reported.

DISCUSSION

Intentional self-poisoning patients place a significant burden on emergency centres. The high percentage of low-grade acuity patients managed in a high-acuity area is of concern and should be investigated further.

The association between hospital arrival time, transport method, prehospital time intervals, and in-hospital mortality in trauma patients presenting to Khayelitsha Hospital, Cape Town

INTRODUCTION

Trauma is a leading cause of unnatural death and disability in South Africa. The aim of the study was to determine whether method of transport, hospital arrival time or prehospital transport time intervals were associated with in-hospital mortality among trauma patients presenting to Khayelitsha Hospital, a district-level hospital on the outskirts of Cape Town, South Africa.

METHODS

The Khayelitsha Hospital Emergency Centre database was retrospectively analysed for trauma-related patients presenting to the resuscitation area between 1 November 2014 and 30 April 2015. Missing data and additional variables were collected by means of a chart review. Eligible patients' folders were scrutinised for hospital arrival time, transport time intervals, transport method and in-hospital mortality. Descriptive statistics were presented for all variables. Categorical data were analysed using the Fisher's Exact test and Chi-square, continuous data by logistic regression and the Mann Whitney test. A confidence interval of 95% was used to describe variance and a p-value of <0.05 was deemed significant.

RESULTS

The majority of patients were 19-44 year old males (n = 427, 80.3%) and penetrating trauma the most frequent mechanism of injury (n = 343, 64.5%). In total, 258 (48.5%) patients arrived with their own transport, 254 (47.7%) by ambulance and 20 (3.8%) by the police service. The arrival of trauma patients peaked during the weekend, and was especially noticeable between midnight and six a.m. In-hospital mortality (n = 18, 3.4%) was not significantly affected by transport method (p = 0.26), hospital arrival time (p = 0.22) or prehospital transport time intervals (all p-values >0.09).

DISCUSSION

Method of transport, hospital arrival time and prehospital transport time intervals did not have a substantially measurable effect on in-hospital mortality. More studies with larger samples are suggested due to the small event rate.

Estimated injury-associated blood loss versus availability of emergency blood products at a district-level public hospital in Cape Town, South Africa

INTRODUCTION

International guidance suggests that injury-associated haemorrhagic shock should be resuscitated using blood products. However, in low- and middle-income countries resuscitation emphasises the use of crystalloids - mainly due to poor access to blood products. This study aimed to estimate the amount of blood loss from serious injury in relation to available emergency blood products at a secondary-level, public Cape Town hospital.

METHODS

This retrospective, cross-sectional study included all injured patients cared for in the resuscitation area of Khayelitsha Hospital's emergency centre over a fourteen-week period. Injuries were coded using the Abbreviated Injury Scale, which was then used to estimate blood loss for each patient using an algorithm from the Trauma Audit Research Network. Descriptive statistics were used to describe blood volume lost and blood units required to replace losses greater than 15% circulating blood volume. Four units of emergency blood are stored in a dedicated blood fridge in the emergency centre. Platelets and fresh plasma are not available.

RESULTS

A total of 389 injury events were enrolled of which 93 were excluded due to absent clinic data. The mean age was 29 (±10) years. We estimated a median of one unit of blood requirement per week or weekend, up to a maximum of eight or six units, respectively. Most patients (n = 275, 94%) did not have sufficient injury to warrant transfusion. Overall, one person would require a transfusion for every 15 persons with a moderate to serious injury.

CONCLUSION

The volume of available emergency blood appears inadequate for injury care, and doesn't consider the need for other causes of acute haemorrhage (e.g. gastric, gynaecological, etc.). Furthermore, lack of other blood components (i.e. plasma and platelets) presents a challenge in this low-resourced setting. Further research is required to determine the appropriate management of injury-associated haemorrhage from a resource and budget perspective.