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BackgroundHypoglycaemia commonly occurs in patients diagnosed with diabetes mellitus (DM) and dementia. The impact of dementia on hypoglycaemic events is controversial. Thus, we evaluated whether dementia increases the risk of hypoglycaemic events in older patients diagnosed with DM.DesignA retrospective cohort study.SettingWe used the IQVIA Medical Research Data (IMRD-UK) database (formerly known as the THIN database).ParticipantsAll patients aged ≥55 years and diagnosed with DM who were prescribed at least two prescriptions of antidiabetic medication between 2000 and 2017. Two groups of patients, dementia and non-dementia group, were propensity-score (PS) matched at 1:2. The risk of hypoglycaemia was assessed through a Cox regression analysis.Main outcome and measuresHypoglycaemic events were determined during the follow-up period by Read codes.ResultsFrom the database, 133,664 diabetic patients were identified, with a mean follow-up of 6.11 years. During the study period, 7,762 diabetic patients diagnosed with dementia were matched with 12,944 diabetic patients who had not been diagnosed with dementia. The PS-matched Cox regression analysis showed that patients diagnosed with dementia were at a 2-fold increased risk for hypoglycaemic events compared with those not diagnosed with dementia (hazard ratio [HR], 2.00; 95% CI, 1.63–2.66). A similar result was shown for a multivariable analysis using all patient data (adjusted HR, 2.25; 95% CI, 2.22–2.32).ConclusionOur findings suggest that diabetic patients with a diagnosis of dementia have a statistically significant higher risk of experiencing hypoglycaemia.

Abstract Background To manage the risk factors and to improve clinical outcomes, patients with stroke commonly receive multiple cardiovascular medications. However, there is a lack of evidence on the optimum combination of medication therapy in the primary care setting after ischemic stroke. Therefore, this study aimed to investigate the effect of multiple cardiovascular medications on long-term survival after an incident stroke event (ischemic stroke or transient ischemic attack (TIA)). Methods This study consisted of 52,619 patients aged 45 and above with an incident stroke event between 2007 and 2016 in The Health Improvement Network database. We estimated the risk of all-cause mortality in patients with multiple cardiovascular medications versus monotherapy using a marginal structural model. Results During an average follow-up of 3.6 years, there were 9230 deaths (7635 in multiple cardiovascular medication groups and 1595 in the monotherapy group). Compared with patients prescribed monotherapy only, the HRs of mortality were 0.82 (95% CI 0.75–0.89) for two medications, 0.65 (0.59–0.70) for three medications, 0.61 (0.56–0.67) for four medications, 0.60 (0.54–0.66) for five medications and 0.66 (0.59–0.74) for ≥ six medications. Patients with any four classes of antiplatelet agents (APAs), lipid-regulating medications (LRMs), angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs), beta-blockers, diuretics and calcium channel blockers (CCBs) had the lowest risk of mortality (HR 0.51, 95% CI 0.46–0.57) versus any one class. The combination containing APAs, LRMs, ACEIs/ARBs and CCBs was associated with a 61% (95% CI 53–68%) lower risk of mortality compared with APAs alone. Conclusion Our results suggested that combination therapy of four or five cardiovascular medications may be optimal to improve long-term survival after incident ischemic stroke or TIA. APAs, LRMs, ACEIs/ARBs and CCBs were the optimal constituents of combination therapy in the present study.

OBJECTIVES: To describe the demographics, referral mechanism and outcome of the emergency consultation in patients presenting to a secondary hospital emergency centre (EC). DESIGN: An observational study of patients presenting to an EC in a 1-month period from 19 November to 20 December 2007. SETTING: New Somerset Hospital, Cape Town, South Africa. SUBJECTS: All patients presenting alive to the EC during the study period who were seen by an EC doctor. OUTCOME MEASURES: A data collection form was completed by EC doctors at the time of the initial EC consultation documenting patient demographics, time and delay periods, South African Triage Score (SATS), initial diagnosis, transport and referral mechanisms and outcome of EC consultation. RESULTS: Data on 2646 patient presentations were described with a mix of SATS acuity levels (green: routine care; yellow: urgent; orange: very urgent; red: immediate), with more than one-third of presentations scoring an orange or red SATS. Most patients presented in the daytime, with an increase in more ill patients (higher SATS) later in the day and at night. The peak age group was 20-40 years, with 39% resident in informal settlements within 15 km of the hospital. The initial diagnosis was trauma in 26% of presentations, with a wide spread of other presentations. Patients were transported by ambulance to the EC in 39% of presentations, 41% were self-referred and 41% were referred by a primary health care practitioner. Fifty-three percent of presentations were either admitted to hospital or kept in the EC for further investigations, and the remainder were discharged from the EC. CONCLUSIONS: Clear trends are seen for patient demographics and temporal attendance patterns which are important for resource allocation and planning. Many low-acuity patients, largely non-referred, are being seen in the EC and should be managed by primary health care level staff outside the EC. [ABSTRACT FROM AUTHOR]

Motor vehicle crashes are a leading cause of morbidity and mortality in the United Kingdom. Airbags drastically reduce both morbidity and mortality from crashes, but with the increased use of airbags there has been a corresponding increase in the number of injuries attributable to these devices. This review discusses the history and mechanism of action of airbags, along with the spectrum of injuries seen as a result of their deployment, and future advances that may be of benefit in increasing motor vehicle safety. [ABSTRACT FROM AUTHOR]

Objectives: Providing care for injured children is challenging in resource-poor settings. While checklists can assess local capacities and guide the setting of priorities for improvement, key insights can be gained from consultation with locally practising clinicians. This study aimed to highlight barriers to and facilitators of the delivery of paediatric injury care experienced by clinicians from hospitals at different levels of care in Maputo, Mozambique., Design: We conducted semistructured individual qualitative interviews with clinical staff at four hospitals. Data were analysed using inductive content analysis., Setting: The study was conducted in four hospitals, each representing a specific level of care in Maputo, Mozambique., Participants: We recruited clinicians (doctors, nurses and technicians) involved in paediatric injury care to be interviewed on-site (we target around 10 clinicians per hospital)., Results: From the 40 interviews conducted, four categories of barriers emerged: (1) prehospital care constraints, (2) shortage of child-appropriate resources, (3) inappropriate infrastructure for paediatric emergency care and (4) limited qualified staff available. By contrast, one category of facilitators stood out, namely that of cross-boundaries support and mentorship, between professionals and institutions., Conclusion: From clinicians' perspective, barriers to paediatric injury care are often similar across hospitals and professional groups, and they include the prehospital setting. Resource and infrastructure challenges were emphasized, as expected, and clinicians expressed a clear desire for knowledge and competence sharing., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Background: Out-of-hospital cardiac arrest (OHCA) is a prevalent condition with high mortality and poor outcomes even in settings where extensive emergency care resources are available. Interventions to address OHCA have had limited success, with survival rates below 10% in national samples of high-income countries. In resource-limited settings, where scarcity requires careful priority setting, more data is needed to determine the optimal allocation of resources., Objective: To establish the cost-effectiveness of OHCA care and assess the affordability of interventions across income settings., Methods: The authors conducted a systematic review of economic evaluations on interventions to address OHCA. Six databases (PubMed, EMBASE, Global Health, Cochrane, Global Index Medicus, and Tuft's Cost-Effectiveness Registry) were searched in September 2023. Included studies were (1) economic evaluations (beyond a simple costing exercise); and (2) assessed an intervention in the chain of survival for OHCA. Article quality was assessed using the CHEERs checklist and data summarised. Findings were reported by major themes identified by the reviewers. Based upon the results of the cost-effectiveness analyses we then conduct an analysis for the progressive realization of the OHCA chain of survival from the perspective of decision-makers facing resource constraints., Results: Four hundred and sixty-eight unique articles were screened, and 46 articles were included for final data abstraction. Studies predominantly used a healthcare sector perspective, modeled for all patients experiencing non-traumatic cardiac OHCA, were based in the US, and presented results in US Dollars. No studies reported results or used model inputs from low-income settings. Progressive realization of the chain of survival could likely begin with investments in termination of resuscitation protocols, professional prehospital defibrillator use, and CPR training followed by the distribution of AEDs in high-density public locations. Finally, other interventions such as indiscriminate defibrillator placement or adrenaline use, would be the lowest priority for early investment., Conclusion: Our review found no high-quality evidence on the cost-effectiveness of treating OHCA in low-resource settings. Existing evidence can be utilized to develop a roadmap for the development of a cost-effective approach to OHCA care, however further economic evaluations using context-specific data are crucial to accurately inform prioritization of scarce resources within emergency care in these settings., (© 2024. The Author(s).)

Objective: This study examined the trade-offs low-resource setting community members were willing to make in regard to out-of-hospital cardiac arrest care using a discrete choice experiment survey., Methods: We administered a discrete choice experiment survey to a sample of community members 18 years or older across South Africa between April and May 2022. Participants were presented with 18 paired choice tasks comprised of 5 attributes (distance to closest adequate facility, provider of care, response time, chances of survival, and transport cost) and a range of 3 to 5 levels. We used mixed logit models to evaluate respondents' preferences for selected attributes., Results: Analyses were based on 2228 responses and 40 104 choice tasks. Patients valued care with the shortest response time, delivered by the highest qualified individuals, which placed them within the shortest distance of an adequate facility, gave them the highest chance of survival, and costed the least. In addition, patients preferred care delivered by their family members over care delivered by the lay public. The highest mean willingness-to-pay for increased survival is 11 699 South African rand (ZAR), followed by distance to health facility (8108 ZAR), and response time (5678 ZAR), and the lowest for increasing specialization of provider (1287 ZAR)., Conclusions: In low-resource settings, it may align with patients' preference to include targeted resuscitation training for family members of individuals with high-risk for cardiac arrest as a part of out-of-hospital cardiac arrest intervention strategies., Competing Interests: Author Disclosures Author disclosure forms can be accessed below in the Supplemental Material section., (Copyright © 2024 International Society for Health Economics and Outcomes Research. Published by Elsevier Inc. All rights reserved.)

Background: Out-of-hospital cardiac arrest (OHCA) is a prevalent condition with high mortality and poor outcomes even in settings where extensive emergency care resources are available. Interventions to address OHCA have had limited success, with survival rates below 10% in national samples of high-income countries. In resource-limited settings, where scarcity requires careful priority setting, more data is needed to determine the optimal allocation of resources., Objective: To establish the cost-effectiveness of OHCA care and assess the affordability of interventions across income settings., Methods: The authors conducted a systematic review of economic evaluations on interventions to address OHCA. Included studies were (1) economic evaluations (beyond a simple costing exercise); and (2) assessed an intervention in the chain of survival for OHCA. Article quality was assessed using the CHEERs checklist and data summarised. Findings were reported by major themes identified by the reviewers. Based upon the results of the cost-effectiveness analyses we then conduct an analysis for the progressive realization of the OHCA chain of survival from the perspective of decision-makers facing resource constraints., Results: 468 unique articles were screened, and 46 articles were included for final data abstraction. Studies predominantly used a healthcare sector perspective, modeled for all patients experiencing non-traumatic cardiac OHCA, were based in the US, and presented results in US Dollars. No studies reported results or used model inputs from low-income settings. Progressive realization of the chain of survival could likely begin with investments in TOR protocols, professional prehospital defibrillator use, and CPR training followed by distribution of AEDs in high-density public locations. Finally, other interventions such as indiscriminate defibrillator placement or adrenaline use, would be the lowest priority for early investment., Conclusion: Our review found no high-quality evidence on the cost-effectiveness of treating OHCA in low-resource settings. Existing evidence can be utilized to develop a roadmap for the development of a cost-effective approach to OHCA care, however further economic evaluations using context-specific data are crucial to accurately inform prioritization of scarce resources within emergency care in these settings., Competing Interests: Competing interests: The authors declare that they have no competing interests

Objectives: The present study aimed to establish appropriate quality standards for emergency departments (EDQS) in Palestine., Methods: The study comprised four phases. First, a comprehensive literature review was conducted to develop a framework for assessing healthcare services in EDs. Second, the initial set of EDQS was developed based on the review findings. Third, local experts provided feedback on the EDQS, suggesting additional standards, and giving recommendations. This feedback was analysed to create a preliminary set of EDQS. Finally, an expanded group of local emergency care experts evaluated the preliminary set, providing feedback on content and structure to contribute to the final set of EDQS., Findings: We identified quality domains in EDs and categorised them into clinical and administrative pathways. The clinical pathway comprises 39 standards across 7 subdomains: triage, treatment, transportation, medication safety, patient flow and medical diagnostic services. Expert consensus was achieved on 87.5% of these standards. The administrative domain includes 64 consensus-based standards across 9 subdomains: documentation, information management systems, access-location, design, leadership, management, workforce staffing, training, equipment, supplies, capacity-resuscitation rooms, resources for a safe working environment, performance indicators and patient safety-infection prevention and control programmes., Conclusion: This study employed a rigorous approach to identify QS for EDs in Palestine. The multiphase consensus process ensured the appropriateness of the developed EDQS. Inclusion of diverse perspectives enriched the content. Future studies will validate and refine the standards based on feedback. The EDQS has potential to enhance emergency care in Palestine and serve as a model for other regions facing similar challenges., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Prehospital transfusion can be life-saving when transport is delayed but conventional plasma, red cells, and whole blood are often unavailable out of hospital. Shelf-stable products are needed as a temporary bridge to in-hospital transfusion. Bioplasma FDP (freeze-dried plasma) and Hemopure (hemoglobin-based oxygen carrier; HBOC) are products with potential for prehospital use. In vivo use of these products together has not been reported. This study assessed the safety of intravenous administration of HBOC+FDP, relative to normal saline (NS), in rhesus macaques (RM)., Methods: After 30% blood volume removal and 30 minutes in shock, animals were resuscitated with either NS or two units (RM size adjusted) each of HBOC+FDP during 60 minutes. Sequential blood samples were collected. After neurological assessment, animals were killed at 24 hours and tissues collected for histopathology., Results: Due to a shortage of RM during the COVID-19 pandemic, the study was stopped after nine animals (HBOC+FDP, seven; NS, two). All animals displayed physiologic and tissue changes consistent with hemorrhagic shock and recovered normally. There was no pattern of cardiovascular, blood gas, metabolic, coagulation, histologic, or neurological changes suggestive of risk associated with HBOC+FDP., Conclusion: There was no evidence of harm associated with the combined use of Hemopure and Bioplasma FDP. No differences were noted between groups in safety-related cardiovascular, pulmonary, renal or other organ or metabolic parameters. Hemostasis and thrombosis-related parameters were consistent with expected responses to hemorrhagic shock and did not differ between groups. All animals survived normally with intact neurological function., Level of Evidence: Not applicable., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Globally, very few settings have undertaken prehospital randomized controlled trials. Given this lack of experience, there is a risk that such trials in these settings may result in protocol deviations, increased prehospital intervals, and increased cognitive load, leading to error. Ultimately, this may affect patient safety and mortality. The aim of this study was to assess the effect of trial-related procedures on simulated scene interval, self-reported cognitive load, medical errors, and time to action., Methods: This was a prospective simulation study. Using a cross-over design, ten teams of prehospital clinicians were allocated to three separate simulation arms in a random order. Simulations were: (1) Eligibility assessment and administration of freeze-dried plasma (FDP) and a hemoglobin-based oxygen carrier (HBOC), (2) Eligibility assessment and administration of HBOC, (3) Eligibility assessment and standard care. All simulations also required clinical management of hemorrhagic shock. Simulated scene interval, error rates, cognitive load (measured by NASA Task Load Index), and competency in clinical care (assessed using the Simulation Assessment Tool Limiting Assessment Bias (SATLAB)) were measured. Mean differences between simulations with and without trial-related procedures were sought using one-way ANOVA or Kruskal-Wallis test. A p-value of <0.05 within the 95% confidence interval was considered significant., Results: Thirty simulations were undertaken, representing our powered sample size. The mean scene intervals were 00:16:56 for Simulation 1 (FDP and HBOC), 00:17:22 for Simulation 2 (HBOC only), and 00:14:24 for Simulation 3 (standard care). Scene interval did not differ between the groups ( p  = 0.27). There were also no significant differences in error rates ( p  = 0.28) or cognitive load ( p  = 0.67) between the simulation groups. There was no correlation between cognitive load and error rates ( r  = 0.15, p  = 0.42). Competency was achieved in all the assessment criteria for all simulation groups., Conclusion: In a simulated environment, eligibility screening, performance of trial-related procedures, and clinical management of patients with hemorrhagic shock can be completed competently by prehospital advanced life support clinicians without delaying transport or emergency care. Future prehospital clinical trials may use a similar approach to help ensure graded and cautious implementation of clinical trial procedures into prehospital emergency care systems.

Introduction: Emergency medical service (EMS) resources are limited and should be reserved for incidents of appropriate acuity. Over-triage in dispatching of EMS resources is a global problem. Analysing patients that are not transported to hospital is valuable in contributing to decision-making models/algorithms to better inform dispatching of resources. The aim is to determine variables associated with patients receiving an emergency response but result in non-conveyance to hospital., Methods: A retrospective cross-sectional study was performed on data for the period October 2018 to September 2019. EMS records were reviewed for instances where a patient received an emergency response but the patient was not transported to hospital. Data were subjected to univariate and multivariate regression analysis to determine variables predictive of non-transport to hospital., Results: A total of 245 954 responses were analysed, 240 730 (97.88 %) were patients that were transported to hospital and 5 224 (2.12 %) were not transported. Of all patients that received an emergency response, 203 450 (82.72 %) patients did not receive any medical interventions. Notable variables predictive of non-transport were green (OR 4.33 (95 % CI: 3.55-5.28; p<0.01)) and yellow on-scene (OR 1.95 (95 % CI: 1.60-2.37; p<0.01).Incident types most predictive of non-transport were electrocutions (OR 4.55 (95 % CI: 1.36-15.23; p=0.014)), diabetes (OR 2.978 (95 % CI: 2.10-3.68; p<0.01)), motor vehicle accidents (OR 1.92 (95 % CI: 1.51-2.43; p<0.01)), and unresponsive patients (OR 1.98 (95 % CI: 1.54-2.55; p<0.01)). The highest treatment predictors for non-transport of patients were nebulisation (OR 1.45 (95 % CI: 1.21-1.74; p<0.01)) and the administration of glucose (OR 4.47 (95 % CI: 3.11-6.41; p<0.01))., Conclusion: This study provided factors that predict ambulance non-conveyance to hospital. The prediction of patients not transported to hospital may aid in the development of dispatch algorithms that reduce over-triage of patients, on-scene discharge protocols, and treat and refer guidelines in EMS., Competing Interests: At the time of peer review, Dr Willem Stassen and Prof Lee Wallis were editors of the African Journal of Emergency Medicine. Both Dr Stassen and Prof Wallis were not involved in the editorial workflow for this manuscript. The African Journal of Emergency Medicine applies a double blinded process for all manuscript peer reviews. The authors declared no further conflict of interest., (© 2023 The Authors. Published by Elsevier B.V. on behalf of African Federation for Emergency Medicine.)

Introduction: Prehospital care in many low- and middle-income countries is underdeveloped and needs strengthening for improved outcomes. Where formal prehospital care systems are under development, integration of a layperson first responder programme may help improve access for those in need. The World Health Organization recently developed the Community First Aid Responder (CFAR) learning program in support of this system, providing that it may require adaptation to be contextually suitable and sustainably implemented at country level. This study assesses a pilot WHO CFAR course in Kinshasa, Democratic Republic of Congo, to inform future rollouts and related research., Methods: We conducted a 3-day in-person pilot CFAR training with 42 purposively selected community health workers. Data collection involved quantitative and qualitative phases. The first consisted of structured pre- and post-training surveys, and a course evaluation by participants. The second consisted of two focus group discussions involving purposively selected community health workers in one group, and a convenience sample of course instructors and organisers in the other. Perceptions regarding course content, perceived knowledge acquisition and self-confidence gain were analysed using descriptive statistics for the quantitative data and content analysis for qualitative data., Results: Course participants were predominantly male (76.3 %) with a median age of 42 years and most (80.5 %) had no prior first aid training. Most were satisfied that the learning objectives were reached, the logistics were adequate, and that the content and teaching language were appropriately tailored to local context. The majority (94.7 %) found the 3-day duration insufficient. There was a significant self-confidence gain regarding first aid skills (average 17.9 % in pre- to 95.3 % in post-training, p  < 0.001). Favourable opinions on the course structure, content, logistics and teaching methods were noted., Conclusion: A CFAR course pilot was successfully conducted in Kinshasa. The course is appropriate for context and well received by participants. It can form a key component of developing prehospital care systems in resource-constrained settings., Competing Interests: The authors declared no conflicts of interest., (© 2023 The Authors. Published by Elsevier B.V. on behalf of African Federation for Emergency Medicine.)

Background: Tools proposed to triage ED acuity in suspected COVID-19 were derived and validated in higher income settings during early waves of the pandemic. We estimated the accuracy of seven risk-stratification tools recommended to predict severe illness in the Western Cape, South Africa., Methods: An observational cohort study using routinely collected data from EDs across the Western Cape, from 27 August 2020 to 11 March 2022, was conducted to assess the performance of the PRIEST (Pandemic Respiratory Infection Emergency System Triage) tool, NEWS2 (National Early Warning Score, version 2), TEWS (Triage Early Warning Score), the WHO algorithm, CRB-65, Quick COVID-19 Severity Index and PMEWS (Pandemic Medical Early Warning Score) in suspected COVID-19. The primary outcome was intubation or non-invasive ventilation, death or intensive care unit admission at 30 days., Results: Of the 446 084 patients, 15 397 (3.45%, 95% CI 34% to 35.1%) experienced the primary outcome. Clinical decision-making for inpatient admission achieved a sensitivity of 0.77 (95% CI 0.76 to 0.78), specificity of 0.88 (95% CI 0.87 to 0.88) and the negative predictive value (NPV) of 0.99 (95% CI 0.99 to 0.99). NEWS2, PMEWS and PRIEST scores achieved good estimated discrimination (C-statistic 0.79 to 0.82) and identified patients at risk of adverse outcomes at recommended cut-offs with moderate sensitivity (>0.8) and specificity ranging from 0.41 to 0.64. Use of the tools at recommended thresholds would have more than doubled admissions, with only a 0.01% reduction in false negative triage., Conclusion: No risk score outperformed existing clinical decision-making in determining the need for inpatient admission based on prediction of the primary outcome in this setting. Use of the PRIEST score at a threshold of one point higher than the previously recommended best approximated existing clinical accuracy., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Background: To limit virus spread during the COVID pandemic, extensive measures were implemented around the world. In South Africa, these restrictions included alcohol and movement restrictions, factors previously linked to injury burden in the country. Consequently, reports from many countries, including South Africa, have shown a reduction in trauma presentations related to these restrictions. However, only few studies and none from Africa focus on the impact of the pandemic restrictions on the Emergency Medical System (EMS)., Methods: We present a retrospective, observational longitudinal study including data from all ambulance transports of physical trauma cases collected during the period 2019-01-01 and 2021-02-28 from the Western Cape Government EMS in the Western Cape Province, South Africa (87,167 cases). Within this timeframe, the 35-days strictest lockdown level period was compared to a 35-days period prior to the lockdown and to the same 35-days period in 2019. Injury characteristics (intent, mechanism, and severity) and time were studied in detail. Ambulance transport volumes as well as ambulance response and on-scene time before and during the pandemic were compared. Significance between indicated periods was determined using Chi-square test., Results: During the strictest lockdown period, presentations of trauma cases declined by > 50%. Ambulance transport volumes decreased for all injury mechanisms and proportions changed. The share of assaults and traffic injuries decreased by 6% and 8%, respectively, while accidental injuries increased by 5%. The proportion of self-inflicted injuries increased by 5%. Studies of injury time showed an increased share of injuries during day shift and a reduction of total injury volume during the weekend during the lockdown. Median response- and on-scene time remained stable in the time-periods studied., Conclusion: This is one of the first reports on the influence of COVID-19 related restrictions on EMS, and the first in South Africa. We report a decline in trauma related ambulance transport volumes in the Western Cape Province as well as changes in injury patterns, largely corresponding to previous findings from hospital settings in South Africa. The unchanged response and on-scene times indicate a well-functioning EMS despite pandemic challenges. More studies are needed, especially disaggregating the different restrictions., (© 2023. The Author(s).)

Background: Emergency Departments serve as a main entry point for patients into hospitals, and the team, the core of which is formed by doctors and nurses needs to make sense of and respond to the constant flux of information. This requires sense-making, communication, and collaborative operational decision-making. The study's main aim was to explore how collective, interprofessional sense-making occurs in the emergency department. Collective sense-making is deemed a precursor for adaptive capability, which, in turn, promotes coping in a dynamically changing environment., Method: Doctors and nurses working in five large state emergency departments in Cape Town, South Africa, were invited to participate. Using the SenseMaker® tool, a total of 84 stories were captured over eight weeks between June and August 2018. Doctors and nurses were equally represented. Once participants shared their stories, they self-analysed these stories within a specially designed framework. The stories and self-codified data were analysed separately. Each self-codified data point was plotted in R-studio and inspected for patterns, after which the patterns were further explored. The stories were analysed using content analysis. The SenseMaker® software allows switching between quantitative (signifier) and qualitative (descriptive story) data during interpretation, enabling more deeply nuanced analyses., Results: The results focused on four aspects of sense-making, namely views on the availability of information, the consequences of decisions (actions), assumptions regarding appropriate action, and preferred communication methods. There was a noticeable difference in what doctors and nurses felt would constitute appropriate action. The nurses were more likely to act according to rules and policies, whereas the doctors were more likely to act according to the situation. More than half of the doctors indicated that they found it best to communicate informally, whereas the nurses indicated that formal communication worked best for them., Conclusion: This study was the first to explore the ED's interprofessional team's adaptive capability to respond to situations from a sense-making perspective. We found an operational disconnect between doctors and nurses caused by asymmetric information, disjointed decision-making approaches, differences in habitual communication styles, and a lack of shared feedback loops. By cultivating their varied sense-making experiences into one integrated operational foundation with stronger feedback loops, interprofessional teams' adaptive capability and operational effectiveness in Cape Town EDs can be improved., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Cunningham et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Low- and middle-income countries bear a disproportionate amount of the global burden of disease from emergency conditions. To improve the provision of emergency care in low-resource settings, a multifaceted World Health Organization (WHO) intervention introduced a toolkit including Basic Emergency Care training, resuscitation area guidelines, a trauma registry, a trauma checklist, and triage tool in two public hospital sites in Uganda. While introduction of the toolkit revealed a large reduction in the case fatality rate of patients, little is known about the cost-effectiveness and affordability. We analysed the cost-effectiveness of the toolkit and conducted a budget analysis to estimate the impact of scale up to all regional referral hospitals for the national level., Methods: A decision tree model was constructed to assess pre- and post-intervention groups from a societal perspective. Data regarding mortality were drawn from WHO quality improvement reports captured at two public hospitals in Uganda from 2016-2017. Cost data were drawn from project budgets and included direct costs of the implementation of the intervention, and direct costs of clinical care for patients with disability. Development costs were not included. Parameter uncertainty was assessed using both deterministic and probabilistic sensitivity analyses. Our model estimated the incremental cost-effectiveness of implementing the WHO emergency care toolkit measuring all costs and outcomes as disability-adjusted life-years (DALYs) over a lifetime, discounting both costs and outcomes at 3.5%., Results: Implementation of the WHO Toolkit averted 1,498 DALYs when compared to standard care over a one-year time horizon. The initial investment of $5,873 saved 34 lives (637 life years) and avoided $1,670,689 in downstream societal costs, resulted in a negative incremental cost-effectiveness ratio, dominating the comparator scenario of no intervention. This would increase to saving 884 lives and 25,236 DALYs annually with national scale up. If scaled to a national level the total intervention cost over period of five years would be $4,562,588 or a 0.09% increase of the total health budget for Uganda. The economic gains are estimated to be $29,880,949 USD, the equivalent of a 655% return on investment. The model was most sensitive to average annual cash income, discount rate and frequency survivor is a road-traffic incident survivor, but was robust for all other parameters., Conclusion: Improving emergency care using the WHO Toolkit produces a cost-savings in a low-resource setting such as Uganda. In alignment with the growing body of literature highlighting the value of systematizing emergency care, our findings suggest the toolkit could be an efficient approach to strengthening emergency care systems., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests:TR is a paid employee of the World Health Organization. This does not alter our adherence to PLOS ONE policies on sharing data and materials. The authors declare no further conflict of interest., (Copyright: © 2022 Werner et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Deaths due to injuries exceed 4.4 million annually, with over 90% occurring in low-and middle-income countries. A key contributor to high trauma mortality is prolonged trauma-to-treatment time. Earlier receipt of medical care following an injury is critical to better patient outcomes. Trauma epidemiological studies can identify gaps and opportunities to help strengthen emergency care systems globally, especially in lower income countries, and among military personnel wounded in combat. This paper describes the methodology of the "Epidemiology and Outcomes of Prolonged Trauma Care (EpiC)" study, which aims to investigate how the delivery of resuscitative interventions and their timeliness impacts the morbidity and mortality outcomes of patients with critical injuries in South Africa., Methods: The EpiC study is a prospective, multicenter cohort study that will be implemented over a 6-year period in the Western Cape, South Africa. Data collected will link pre- and in-hospital care with mortuary reports through standardized clinical chart abstraction and will provide longitudinal documentation of the patient's clinical course after injury. The study will enroll an anticipated sample of 14,400 injured adults. Survival and regression analysis will be used to assess the effects of critical early resuscitative interventions (airway, breathing, circulatory, and neurologic) and trauma-to-treatment time on the primary 7-day mortality outcome and secondary mortality (24-h, 30-day) and morbidity outcomes (need for operative interventions, secondary infections, and organ failure)., Discussion: This study is the first effort in the Western Cape of South Africa to build a standardized, high-quality, multicenter epidemiologic trauma dataset that links pre- and in-hospital care with mortuary data. In high-income countries and the U.S. military, the introduction of trauma databases and registries has led to interventions that significantly reduce post-injury death and disability. The EpiC study will describe epidemiology trends over time, and it will enable assessments of how trauma care and system processes directly impact trauma outcomes to ultimately improve the overall emergency care system., Trial Registration: Not applicable as this study is not a clinical trial., (© 2022. The Author(s).)

Objective: To explore patient's experience of entrapment and subsequent extrication following a motor vehicle collision and identify their priorities in optimising this experience., Design: Semistructured interviews exploring the experience of entrapment and extrication conducted at least 6 weeks following the event. Thematic analysis of interviews., Setting: Single air ambulance and spinal cord injury charity in the UK., Participants: 10 patients were recruited and consented; six air ambulance patients and two spinal cord injury charity patients attended the interview. 2 air ambulance patients declined to participate following consent due to the perceived potential for psychological sequelae., Results: The main theme across all participants was that of the importance of communication; successful communication to the trapped patient resulted in a sense of well-being and where communication failures occurred this led to distress. The data generated three key subthemes: 'on-scene communication', 'physical needs' and 'emotional needs'. Specific practices were identified that were of use to patients during entrapment and extrication., Conclusions: Extrication experience was improved by positive communication, companionship, explanations and planned postincident follow-up. Extrication experience was negatively affected by failures in communication, loss of autonomy, unmanaged pain, delayed communication with remote family and onlooker use of social media. Recommendations which will support a positive patient-centred extrication experience are the presence of an 'extrication buddy', the use of clear and accessible language, appropriate reassurance in relation to co-occupants, a supportive approach to communication with family and friends, the minimisation of onlooker photo/videography and the provision of planned (non-clinical) follow-up., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Civilian and military populations alike are increasingly faced with undesirable situations in which prehospital and definitive care times will be delayed. The Western Cape of South Africa has some similarities in capabilities, injury profiles, resource limitations, and system configuration to US military prolonged casualty care (PCC) settings. This study provides an initial description of civilians in the Western Cape who experience PCC and compares the PCC and non-PCC populations., Methods: We conducted a 6-month analysis of an ongoing, prospective, large-scale epidemiologic study of prolonged trauma care in the Western Cape (Epidemiology and Outcomes of Prolonged Trauma Care [EpiC]). We define PCC as ≥10 hours from injury to arrival at definitive care. We describe patient characteristics, critical interventions, key times, and outcomes as they may relate to military PCC and compare these using χ 2 and Wilcoxon tests. We estimated the associations between PCC status and the primary and secondary outcomes using logistic regression models., Results: Of 995 patients, 146 experienced PCC. The PCC group, compared with non-PCC, were more critically injured (66% vs. 51%), received more critical interventions (36% vs. 29%), and had a greater proportionate mortality (5% vs. 3%), longer hospital stays (3 vs. 1 day), and higher Sequential Organ Failure Assessment scores (5 vs. 3). The odds of 7-day mortality and a Sequential Organ Failure Assessment score of ≥5 were 1.6 (odds ratio, 1.59; 95% confidence interval, 0.68-3.74) and 3.6 (odds ratio, 3.69; 95% confidence interval, 2.11-6.42) times higher, respectively, in PCC versus non-PCC patients., Conclusion: The EpiC study enrolled critically injured patients with PCC who received resuscitative interventions. Prolonged casualty care patients had worse outcomes than non-PCC. The EpiC study will be a useful platform to provide ongoing data for PCC relevant analyses, for future PCC-focused interventional studies, and to develop PCC protocols and algorithms. Findings will be relevant to the Western Cape, South Africa, other LMICs, and military populations experiencing prolonged care., Level of Evidence: Therapeutic/care management; Level IV., (Copyright © 2022 Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a “work of the United States Government” for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government.)

Grinding stones and ground stone implements are important technological innovations in later human evolution, allowing the exploitation and use of new plant foods, novel tools (e.g., bone points and edge ground axes) and ground pigments. Excavations at the site of Madjedbebe recovered Australia's (if not one of the world's) largest and longest records of Pleistocene grinding stones, which span the past 65 thousand years (ka). Microscopic and chemical analyses show that the Madjedbebe grinding stone assemblage displays the earliest known evidence for seed grinding and intensive plant use, the earliest known production and use of edge-ground stone hatchets (aka axes), and the earliest intensive use of ground ochre pigments in Sahul (the Pleistocene landmass of Australia and New Guinea). The Madjedbebe grinding stone assemblage reveals economic, technological and symbolic innovations exemplary of the phenotypic plasticity of Homo sapiens dispersing out of Africa and into Sahul., (© 2022. Crown.)

Introduction: The Ministry of Health - Uganda implemented the World Health Organization's Basic Emergency Care course (BEC) to improve formal emergency care training and address its high burden of acute illness and injury. The BEC is an open-access, in-person, short course that provides comprehensive basic emergency training in low-resource settings. A free, open-access series of pre-course online cases available as downloadable offline files were developed to improve knowledge acquisition and retention. We evaluated BEC participants' knowledge and self-efficacy in emergency care provision with and without these cases and their perceptions of the cases., Methods: Multiple Choice Questions (MCQs) and Likert-scale surveys assessed 137 providers' knowledge and self-efficacy in emergency care provision, respectively, and focus group discussions explored 74 providers' perceptions of the BEC course with cases in Kampala in this prospective, controlled study. Data was collected pre-BEC, post-BEC and six-months post-BEC. We used liability analysis and Cronbach alpha coefficients to establish intercorrelation between categorised Likert-scale items. We used mixed model analysis of variance to interpret Likert-scale and MCQ data and thematic content analysis to explore focus group discussions., Results: Participants gained and maintained significant increases in MCQ averages (15%) and Likert-scale scores over time (p < 0.001). The intervention group scored significantly higher on the pre-test MCQ than controls (p = 0.004) and insignificantly higher at all other times (p > 0.05). Nurses experienced more significant initial gains and long-term decays in MCQ and self-efficacy than doctors (p = 0.009, p < 0.05). Providers found the cases most useful pre-BEC to preview course content but did not revisit them post-course. Technological difficulties and internet costs limited case usage., Conclusion: Basic emergency care courses for low-resource settings can increase frontline providers' long-term knowledge and self-efficacy in emergency care. Nurses experienced greater initial gains and long-term losses in knowledge than doctors. Online adjuncts may enhance health professional education in low-to-middle income countries., Competing Interests: Prof Wallis is an editor of the African Journal for Emergency Medicine and Dr. Friedman is a copy editor. Neither participated in this manuscript's editorial process. The journal applies a double blinded process for all manuscript peer review. The authors declared no further conflicts of interest., (© 2022 The Authors. Published by Elsevier B.V. on behalf of African Federation for Emergency Medicine.)

Background: Accurate triage of the undifferentiated patient is a critical task in prehospital emergency care. However, there is a paucity of literature synthesizing currently available prehospital triage tools. This scoping review aims to identify published tools used for prehospital triage globally and describe their performance characteristics., Methods: A comprehensive search was performed of primary literature in English-language journals from 2009 to 2019. Papers included focused on emergency medical services (EMS) triage of single patients. Two blinded reviewers and a third adjudicator performed independent title and abstract screening and subsequent full-text reviews., Results: Of 1521 unique articles, 55 (3.6%) were included in the final synthesis. The majority of prehospital triage tools focused on stroke (n = 19; 35%), trauma (19; 35%), and general undifferentiated patients (15; 27%). All studies were performed in high income countries, with the majority in North America (23, 42%) and Europe (22, 40%). 4 (7%) articles focused on the pediatric population. General triage tools aggregate prehospital vital signs, mental status assessments, history, exam, and anticipated resource need, to categorize patients by level of acuity. Studies assessed the tools' ability to accurately predict emergency department triage assignment, hospitalization and short-term mortality. Stroke triage tools promote rapid identification of patients with acute large vessel occlusion ischemic stroke to trigger timely transport to diagnostically- and therapeutically-capable hospitals. Studies evaluated tools' diagnostic performance, impact on tissue plasminogen activator administration rates, and correlation with in-hospital stroke scales. Trauma triage tools identify patients that require immediate transport to trauma centers with emergency surgery capability. Studies evaluated tools' prediction of trauma center need, under-triage and over-triage rates for major trauma, and survival to discharge., Conclusions: The published literature on prehospital triage tools predominantly derive from high-income health systems and mostly focus on adult stroke and trauma populations. Most studies sought to further simplify existing triage tools without sacrificing triage accuracy, or assessed the predictive capability of the triage tool. There was no clear 'gold-standard' singular prehospital triage tool for acute undifferentiated patients., Trial Registration: Not applicable., (© 2022. The Author(s).)

Introduction: Out-of-hospital cardiac arrest (OHCA) is well studied in high-income countries, and research has encouraged the implementation of policy to increase survival rates. On the other hand, comprehensive research on OHCA in Africa is sparse, despite the higher incidence of risk factors. In this vein, structural barriers to OHCA care in Africa must be fully recognised and understood before similar improvements in outcome may be made. The aim of this study was to describe and summarise the body of literature related to OHCA in Africa., Methods and Analysis: Using an a priori developed search strategy, electronic searches were performed in Medline via Pubmed, Web of Science, Scopus and Google Scholar databases to identify articles published in English between 2000 and 2020 relevant to OHCA in Africa. Titles, abstract and full text were reviewed by two reviewers, with discrepancies handled by an independent reviewer. A summary of the main themes contained in the literature was developed using descriptive analysis on eligible articles., Results: A total of 1200 articles were identified. In the screening process, 785 articles were excluded based on title, and a further 127 were excluded following abstract review. During full-text review to determine eligibility, 80 articles were excluded and one was added following references review. A total of 19 articles met the inclusion criteria. During analysis, the following three themes were found: epidemiology and underlying causes for OHCA, first aid training and bystander action, and Emergency Medical Services (EMS) resuscitation and training., Conclusions: In order to begin addressing OHCA in Africa, representative research with standardised reporting that complies to data standards is required to understand the full, context-specific picture. Policies and research may then target underlying conditions, improvements in bystander and EMS training, and system improvements that are contextually relevant and ultimately result in better outcomes for OHCA victims., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Patients experiencing traumatic shock are at a higher risk for death and complications. We previously designed a bundle of emergency medical services traumatic shock care ("EMS-TruShoC") for prehospital providers in resource-limited settings. We assess how EMS-TruShoC changes clinical outcomes of critically injured prehospital patients., Methods: This is a quasi-experimental educational implementation of a simplified bundle of care using a pre-post design with a control group. The intervention was delivered to EMS providers in Western Cape, South Africa. Delta shock index (heart rate divided by systolic blood pressure, reported as change from the scene to facility arrival) from the 13 months preceding intervention were compared to the 13 months post-implementation. A difference-in-differences analysis examined the difference in mean shock index change between the groups., Results: Data were collected from 198 providers who treated 770 severe trauma patients. The patient groups had similar demographic and clinical characteristics at baseline. Over all time-points, both groups had an increase in mean delta shock index (worsening shock), with the largest difference occurring 4-months post-implementation (0.047 change in control arm, 0.004 change in intervention arm; -0.043 difference-in-differences, P  = 0.27). In pre-specified subgroup analyses, there was a statistically significant improvement in delta shock index in the intervention arm in patients with penetrating trauma cared for by basic providers immediately post-implementation (-0.372 difference-in-differences, P  = 0.02)., Discussion: Overall, there was no significant difference in delta shock index between the EMS-TruShoC intervention versus control groups. However, significant improvement in shock index in one subgroup suggests the intervention may be more likely to benefit penetrating trauma patients and basic providers., Competing Interests: Opinions, interpretations, conclusions, and recommendations are those of the authors and are not necessarily endorsed by, or the official opinions of, the NIH, the U.S. Department of Defense, the Western Cape Government Department of Health, or the University of Colorado., (© 2021 The Authors.)

Background and Aims: Improving the quality of pre-hospital traumatic shock care, especially in low- and middle-income countries, is particularly relevant to reducing the large global burden of disease from injury. What clinical interventions represent high-quality care is an actively evolving field and often dependent on the specific injury pattern. A key component of improving the quality of care is having a consistent way to assess and measure the quality of shock care in the pre-hospital setting. The objective of this study was to develop and validate a chart abstraction instrument to measure the quality of trauma care in a resource-limited, pre-hospital emergency care setting., Methods: Traumatic shock was selected as the tracer condition. The pre-hospital quality of traumatic shock care (QTSC) instrument was developed and validated in three phases. A content development phase utilized a rapid literature review and expert consensus to yield the contents of the draft instrument. In the instrument validation phase, the QTSC instrument was created and underwent end user and content validation. A pilot-testing phase collected user feedback and performance characteristics to iteratively refine draft versions into a final instrument. Accuracy and inter- and intra-rater agreement were calculated., Results: The final QTSC instrument contains 10 domains of quality, each with specific criteria that determine how the domain is measured and the level of quality of care rendered. The instrument is over 90% accurate and has good inter- and intra-rater reliability when used by trained pre-hospital provider users in South Africa. Pre-hospital provider user feedback indicates the tool is easy to learn and quick to use., Conclusion: We created and validated a novel chart abstraction instrument that can reliably and accurately measure the quality of pre-hospital traumatic shock care. We provide a systematic methodology for developing and validating a quality of care tool for resource-limited care settings., Competing Interests: The authors declare that there is no conflict of interest., (© 2021 The Authors. Health Science Reports published by Wiley Periodicals LLC.)

Objectives: Purposefully designed and validated screening, triage, and severity scoring tools are needed to reduce mortality of COVID-19 in low-resource settings (LRS). This review aimed to identify currently proposed and/or implemented methods of screening, triaging, and severity scoring of patients with suspected COVID-19 on initial presentation to the healthcare system and to evaluate the utility of these tools in LRS., Design: A scoping review was conducted to identify studies describing acute screening, triage, and severity scoring of patients with suspected COVID-19 published between 12 December 2019 and 1 April 2021. Extracted information included clinical features, use of laboratory and imaging studies, and relevant tool validation data., Participant: The initial search strategy yielded 15 232 articles; 124 met inclusion criteria., Results: Most studies were from China (n=41, 33.1%) or the United States (n=23, 18.5%). In total, 57 screening, 23 triage, and 54 severity scoring tools were described. A total of 51 tools-31 screening, 5 triage, and 15 severity scoring-were identified as feasible for use in LRS. A total of 37 studies provided validation data: 4 prospective and 33 retrospective, with none from low-income and lower middle-income countries., Conclusions: This study identified a number of screening, triage, and severity scoring tools implemented and proposed for patients with suspected COVID-19. No tools were specifically designed and validated in LRS. Tools specific to resource limited contexts is crucial to reducing mortality in the current pandemic., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Globally, critical illness results in millions of deaths every year. Although many of these deaths are potentially preventable, the basic, life-saving care of critically ill patients are often overlooked in health systems. Essential Emergency and Critical Care (EECC) has been devised as the care that should be provided to all critically ill patients in all hospitals in the world. EECC includes the effective care of low cost and low complexity for the identification and treatment of critically ill patients across all medical specialties. This study aimed to specify the content of EECC and additionally, given the surge of critical illness in the ongoing pandemic, the essential diagnosis-specific care for critically ill patients with COVID-19., Methods: In a Delphi process, consensus (>90% agreement) was sought from a diverse panel of global clinical experts. The panel iteratively rated proposed treatments and actions based on previous guidelines and the WHO/ICRC's Basic Emergency Care. The output from the Delphi was adapted iteratively with specialist reviewers into a coherent and feasible package of clinical processes plus a list of hospital readiness requirements., Results: The 269 experts in the Delphi panel had clinical experience in different acute medical specialties from 59 countries and from all resource settings. The agreed EECC package contains 40 clinical processes and 67 requirements, plus additions specific for COVID-19., Conclusion: The study has specified the content of care that should be provided to all critically ill patients. Implementing EECC could be an effective strategy for policy makers to reduce preventable deaths worldwide., Competing Interests: Competing interests: JCM declares personal fees from Gilead Pharmaceuticals, support for meetings from Sphingotec, participation in advisory boards for AKPA Pharma and AM Pharma, and the position of Associate Editor at Critical Care Medicine, all outside the submitted work. JR declares grants from Wellcome Trust, NIHR, and the position of Vice Chair of the Adult and Child Lung Health Section of the Union (unpaid). TB declares personal fees from UNICEF, the World Bank, USAID and the Wellcome Trust, all outside the submitted work. The other coauthors declare no conflicts of interest. Among the EECC Collaborators, AA declares the positions of Vice-Chair of the Rural Doctors of Southern Africa (RuDASA) and of the editorial board of South African Family Practice journal (both unpaid). AL declares personal fees from JHIPIEGO and the position of Vice-Chair of the International Federation of Emergency Medicine (IFEM) Critical Care subgroup (both unpaid). AREA declares the positions of Immediate Past President of the Moroccan Society of Anaesthesiology and Intensive Care (SMAR), of Vice-President of the Moroccan Society of Medical Simulation (Morocco Sim), of the African Regional Section World Federation of Societies of Anaesthesiologists (WFSA) Board and of the WFSA Safety and Quality of Practice Committee (all unpaid). BV declares speaking fees from Baxter and grants from NHMRC, MRFF and Baxter—all outside the submitted work. FB declares personal fees from Gradian Health, honoraria from Smile Train, and the position of member of the scientific committee of WFSA. JAM declares personal fees from the Swiss Institute of Tropical Medicine and Public Health outside the submitted work. MM declares the position as Chair of the European Society of Intensive Care Medicine (ESICM) Global Intensive Care Working Group. MSL declares grants from USAID Star outside the submitted work. PS declares payments from Drageer outside the submitted work. RPVH declares the position of the Scientific Advisory Board for Fresenius-Kabi South Africa 2019. The other EECC Collaborators declare no conflicts of interest., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Objectives: While prospective epidemiological data for out-of-hospital cardiac arrest (OHCA) exists in many high-income settings, there is a dearth of such data for the African continent. The aim of this study was to describe OHCA in the Cape Town metropole, South Africa., Design: Observational study with a retrospective descriptive design., Setting: Cape Town metropole, Western Cape province, South Africa., Participants: All patients with OHCA for the period 1 January 2018-31 December 2018 were extracted from public and private emergency medical services (EMS) and described., Outcome Measures: Description of patients with OHCA in terms of demographics, treatment and short-term outcome., Results: A total of 929 patients with OHCA received an EMS response in the Cape Town metropole, corresponding to an annual prevalence of 23.2 per 100 000 persons. Most patients were adult (n=885; 96.5%) and male (n=526; 56.6%) with a median (IQR) age of 63 (26) years. The majority of cardiac arrests occurred in private residences (n=740; 79.7%) and presented with asystole (n=322; 34.6%). EMS resuscitation was only attempted in 7.4% (n=69) of cases and return of spontaneous circulation (ROSC) occurred in 1.3% (n=13) of cases. Almost all patients (n=909; 97.8%) were declared dead on the scene., Conclusion: To our knowledge, this was the largest study investigating OHCA ever undertaken in Africa. We found that while the incidence of OHCA in Cape Town was similar to the literature, resuscitation is attempted in very few patients and ROSC-rates are negligible. This may be as a consequence of protracted response times, poor patient prognosis or an underdeveloped and under-resourced Chain of Survival in low- to middle-income countries, like South Africa. The development of contextual guidelines given resources and disease burden is essential., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Emergency Medical Services (EMS) are designed to respond to and manage patients experiencing life-threatening emergencies; however, not all emergency calls are necessarily emergent and of high acuity. Emergency responses to low-acuity patients affect not only EMS, but other areas of the health care system. However, definitions of low-acuity calls are vague and subjective; therefore, it was necessary to provide a clear description of the low-acuity patient in EMS., Aim: The goal of this study was to develop descriptors for "low-acuity EMS patients" through expert consensus within the EMS environment., Methods: A Modified Delphi survey was used to develop call-out categories and descriptors of low acuity through expert opinion of practitioners within EMS. Purposive, snowball sampling was used to recruit 60 participants, of which 29 completed all three rounds. An online survey tool was used and offered both binary and free-text options to participants. Consensus of 75% was accepted on the binary options while free text offered further proposals for consideration during the survey., Results: On completion of round two, consensus was obtained on 45% (70/155) of the descriptors, and a further 30% (46/155) consensus was obtained in round three. Experts felt that respiratory distress, unconsciousness, chest pain, and severe hemorrhage cannot be considered low acuity. For other emergency response categories, specific descriptors were offered to denote a case as low acuity., Conclusion: Descriptors of low acuity in EMS are provided in both medical and trauma cases. These descriptors may not only assist in the reduction of unnecessary response and transport of patients, but also assist in identifying the most appropriate response of EMS resources to call-outs. Further development and validation are required of these descriptors in order to improve accuracy and effectiveness within the EMS dispatch environment.

Digital technologies continue to penetrate the South African (SA) healthcare sector at an increasing rate. Clinician-to-clinician diagnostic and management assistance through mHealth is expanding rapidly, reducing professional isolation and unnecessary referrals, and promoting better patient outcomes and more equitable healthcare systems. However, the widespread uptake of mHealth use raises ethical concerns around patient autonomy and safety, and guidance for healthcare workers around the ethical use of mHealth is needed. This article presents the results of a multi-stakeholder workshop at which the 'dos and don'ts' pertaining to mHealth ethics in the SA context were formulated and aligned to seven basic recommendations derived from the literature and previous multi-stakeholder, multi-country meetings.

Background: In many low- and middle-income countries, where vaccinations will be delayed and healthcare systems are underdeveloped, the COVID-19 pandemic will continue for the foreseeable future. Mortality scales can aid frontline providers in low-resource settings (LRS) in identifying those at greatest risk of death so that limited resources can be directed towards those in greatest need and unnecessary loss of life is prevented. While many prognostication tools have been developed for, or applied to, COVID-19 patients, no tools to date have been purpose-designed for, and validated in, LRS., Objectives: This study aimed to develop a pragmatic tool to assist LRS frontline providers in evaluating in-hospital mortality risk using only easy-to-obtain demographic and clinical inputs., Methods: Machine learning was used on data from a retrospective cohort of Sudanese COVID-19 patients at two government referral hospitals to derive contextually appropriate mortality indices for COVID-19, which were then assessed by C-indices., Findings: Data from 467 patients were used to derive two versions of the AFEM COVID-19 Mortality Scale (AFEM-CMS), which evaluates in-hospital mortality risk using demographic and clinical inputs that are readily obtainable in hospital receiving areas. Both versions of the tool include age, sex, number of comorbidities, Glasgow Coma Scale, respiratory rate, and systolic blood pressure; in settings with pulse oximetry, oxygen saturation is included and in settings without access, heart rate is included. The AFEM-CMS showed good discrimination: the model including pulse oximetry had a C-statistic of 0.775 (95% CI: 0.737-0.813) and the model excluding it had a C-statistic of 0.719 (95% CI: 0.678-0.760)., Conclusions: In the face of an enduring pandemic in many LRS, the AFEM-CMS serves as a practical solution to aid frontline providers in effectively allocating healthcare resources. The tool's generalisability is likely narrow outside of similar extremely LRS settings, and further validation studies are essential prior to broader use., Competing Interests: The authors have no competing interests to declare., (Copyright: © 2021 The Author(s).)