IntroductionTrauma 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.MethodsThe 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.ResultsThe 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).DiscussionMethod 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.

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IntroductionAt the core of the district health system is the emergency centre, for many the entry point into the healthcare system. Limited data is available on the patient population served by district-level emergency centres in South Africa. The objective of this study is to describe the case mix of adult patients managed in the resuscitation unit of a district-level hospital in the Western Cape.MethodsA six-month prospective observational study was conducted in the resuscitation unit of Khayelitsha Hospital. Data were collected by clinicians in the unit by means of a Smartphone application on their own devices. Variables collected included patient demographics, patient acuity, patient comorbidities, diagnosis made in the unit, interventions received, length of stay, and disposition. Summary statistics were used to describe all variables.ResultsA total of 2324 patient admissions were analysed. The mean age was 36.9 years with a male predominance (n = 1367, 58.8%). Most patients were triaged into high-acuity categories (n = 1626, 70%). HIV infection was the most common comorbidity (n = 530, 22.8%). Acute medical (n = 1181, 50.8%) and trauma-related patients (n = 928, 39.9%) dominated the cohort. The median length of stay was 195 min and 502 (21.6%) patients were transferred to higher levels of care. There were 74 (3.2%) deaths.ConclusionThis study yields novel epidemiological data of emergency care in a district-level emergency centre. It highlights the burden of trauma and acute medical emergencies at the district level and can be used as a foundation for further research to provide targeted and effective healthcare to all citizens.

BackgroundScreening, brief intervention, and referral to treatment (SBIRT) for risky substance use is infrequently included in routine healthcare in low-resourced settings. A SBIRT programme, adopted by the Western Cape provincial government within an alcohol harm reduction strategy, employed various implementation strategies executed by a diverse team to translate an evidence-based intervention into services at three demonstration sites before broader programme scale-up. This paper evaluates the implementation of this programme delivered by facility-based counsellors in South African emergency centres.MethodGuided by the Consolidated Framework for Implementation Research, this mixed methods study evaluated the feasibility, acceptability, appropriateness and adoption of this task-shared SBIRT programme. Quantitative data were extracted from routinely collected health information. Qualitative interviews were conducted with 40 stakeholders in the programme’s second year.ResultsIn the first year, 13 136 patients were screened and 4 847 (37%) patients met criteria for risky substance use. Of these patients, 83% received the intervention, indicating programme feasibility. The programme was adopted into routine services and found to be acceptable and appropriate, particularly by stakeholders familiar with the emergency environment. These stakeholders highlighted the burden of substance-related harm in emergency centres and favourable patient responses to SBIRT. However, some stakeholders expressed scepticism of the behaviour change approach and programme compatibility with emergency centre operations. Furthermore, adoption was both facilitated and hampered by a top-down directive from provincial leadership to implement SBIRT, while rapid implementation limited effective engagement with a diverse stakeholder group.ConclusionThis is one of the first studies to address SBIRT implementation in low-resourced settings. The results show that SBIRT implementation and adoption was largely successful, and provide valuable insights that should be considered prior to implementation scale-up. Recommendations include ensuring ongoing monitoring and evaluation, and early stakeholder engagement to improve implementation readiness and programme compatibility in the emergency setting.

Multisystem inflammatory syndrome in adult COVID-19 patientsTo the Editor: As we pass the peak of the COVID-19 epidemic in South Africa (SA), we want to remind healthcare workers to have heightened vigilance regarding a multisystem inflammatory syndrome reported in children and adolescents (MIS-c). [1][2][3] In Europe and North America (where this syndrome was initially reported), it is common practice for adolescents to be admitted to paediatric wards, [4][5][6] but in SA, those >13 years of age are conventionally admitted to adult wards. Since this life-threatening syndrome is mainly described in children, we are concerned that this seemingly rare condition may be missed by clinicians who treat adolescents and adults.At Tygerberg Hospital, Cape Town, SA, the first paediatric patient was diagnosed with MIS-c on 4 July 2020, and a number of cases followed thereafter. [7] The first three patients in the adult service, aged 15, 22 and 27 years, were diagnosed between 13 and 20 August 2020 (all presenting within a single week). All three met the World Health Organization (WHO) [8] and Centers for Disease Control and Prevention (CDC) [9] criteria for MIS-c, although prior COVID-19 infection could not be proven owing to unavailability of antibody tests. They presented with mucocutaneous involvement resembling a viral exanthem, cracked lips, sore throat, non-exudative conjunctivitis, oedema, abdominal pain, severe myocardial dysfunction resulting in shock, confusion, meningism and acute kidney injury. Despite having markedly raised inflammatory markers, no definite source of sepsis was found. They were treated with intravenous immunoglobulin (IVIG) and corticosteroids, with remarkable clinical, biochemical and echographic improvements.MIS-c cases are described to occur after the peak of the epidemic, and resemble both Kawasaki disease (familiar to paediatricians) and toxic shock, but are a distinct entity. [1,5] The condition is characterised by shock and/or other features of severe organ dysfunction with inflammation including severe abdominal pain, conjunctival injection, rash and notably renal and cardiac dysfunction. Laboratory features include raised inflammatory markers, abnormal coagulation profiles and markers of organ dysfunction. [2][3][4][5][6] The diagnosis is by exclusion of sepsis, toxic shock and autoimmune diseases. [7][8][9] The patients must have compatible clinical features, laboratory markers and evidence of prior COVID-19 diagnosis (as manifested by a current/prior positive SARS-CoV-2 diagnosis by polymerase chain reaction, or contact with a person who has COVID-19, or a positive antibody test). This currently poses a challenge in Africa as access to the COVID-19 antibody test is limited. [10] The WHO [8] definition includes patients up to 19 years of age and the CDC [9] includes patients up to 21 years of age. However, there have been reports of patients beyond their 20s who develop this syndrome, [11,12] and it may be more appropriate to use the term MIS after COVID-19 (MIS-C).Management is suppo...

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African countries are preparing to face the outbreak of COVID-19, which the World Health Organization declared a Global Public Health Emergency of International Concern on 31 January 2020 [1] and a pandemic 40 days later. [2] COVID-19 is caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). The virus, emerging in early December 2019 in Wuhan, Hubei Province, China, [3] has since spread explosively throughout the world. Most of Europe and the USA has been severely affected in recent weeks despite their relatively high income per capita and robust public healthcare systems. In contrast, African countries are poorly resourced, have a sizeable vulnerable population, and in recent years noticeably demonstrated vulnerability to epidemics. [4] Many South Africans of all ages have significant risk factors for severe COVID-19 outcomes. The pre-existing colliding epidemics of HIV infection and tuberculosis (TB), as well as the high prevalence of non-communicable diseases such as hypertension, diabetes and cardiovascular disease, place a large segment of the population at high risk. [5] This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

Background Screening, brief intervention and referral to treatment (SBIRT) programmes have resulted in generally positive outcomes in healthcare settings, particularly for problem alcohol use, yet implementation is hampered by barriers such as concerns regarding the burden on healthcare professionals. In low-resourced settings, task-sharing approaches can reduce this burden by using non-professional healthcare workers, yet data are scarce regarding the outcomes and acceptability to patients within a SBIRT service. This study aims to evaluate patient-reported outcomes, patient acceptability, perceived benefits and recommendations for improving a task-shared SBIRT service in South African emergency centres (ECs). Methods This mixed methods study incorporates quantitative substance use screening and patient satisfaction data collected routinely within the service at three hospitals, and qualitative semi-structured interviews with 18 EC patient beneficiaries of the programme exploring acceptability and perceived benefits of the programme, as well as recommendations to improve the service. Approximately three months after the acute EC visit, a sub-sample of patients were followed up telephonically to assess patient-reported satisfaction and substance use outcomes. Results Of the 4847 patients eligible for the brief intervention, 3707 patients (76%) used alcohol as their primary substance and 794 (16%) used cannabis. At follow-up (n = 273), significant reductions in substance use frequency and severity were noted and over 95% of patients were satisfied with the service. In the semi-structured interviews, participants identified the non-judgemental caring approach of the counsellors, and the screening and psychoeducation components of the intervention as being the most valuable, motivating them to decrease substance use and make other positive lifestyle changes. Study participants made recommendations to include group sessions, market the programme in communities and extend the programme’s reach to include a broader age group and a variety of settings. Conclusions This task-shared SBIRT service was found to be acceptable to patients, who reported several benefits of a single SBIRT contact session delivered during an acute EC visit. These findings add to the SBIRT literature by highlighting the role of non-professional healthcare workers in delivering a low-intensity SBIRT service feasible to implement in low-resourced settings.