A strategy to implement and support pre-hospital emergency medical systems in developing, resource-constrained areas of South Africa

doi:10.1016/j.injury.2012.08.015

Injury

Volume 45, Issue 1, January 2014, Pages 31-38

https://doi.org/10.1016/j.injury.2012.08.015 Get rights and content

Abstract

Resource-constrained countries are in extreme need of pre-hospital emergency care systems. However, current popular strategies to provide pre-hospital emergency care are inappropriate for and beyond the means of a resource-constrained country, and so new ones are needed—ones that can both function in an under-developed area's particular context and be done with the area's limited resources. In this study, we used a two-location pilot and consensus approach to develop a strategy to implement and support pre-hospital emergency care in one such developing, resource-constrained area: the Western Cape province of South Africa. Local community members are trained to be emergency first aid responders who can provide immediate, on-scene care until a Transporter can take the patient to the hospital. Management of the system is done through local Community Based Organizations, which can adapt the model to their communities as needed to ensure local appropriateness and feasibility. Within a community, the system is implemented in a graduated manner based on available resources, and is designed to not rely on the whole system being implemented first to provide partial function. The University of Cape Town's Division of Emergency Medicine and the Western Cape's provincial METRO EMS intend to follow this model, along with sharing it with other South African provinces.

Introduction

Over 90% of traumatic deaths worldwide occur in resource-constrained countries,¹ with mortality rates expected to increase as these nations further develop, urbanize, and industrialize.2, 3, 4, 5, 6, 7, 8, 9 In addition, an overwhelming proportion of these deaths occur before patients even reach the hospital.¹⁰ As a result, governments in resource-constrained countries have been attempting to establish and strengthen pre-hospital emergency medical systems that can provide patients with pre-hospital basic life support and transportation to higher care.7, 11, 12, 13, 14, 15, 16

Thus far, a popular strategy to establish pre-hospital emergency medical systems has been to implement an adapted version of a Western country's model, particularly the United States’.¹⁷ However, the Western world's top-down and centralized pre-hospital care models often greatly exceed a resource-constrained country's limited resources, and were not designed to function in a resource-constrained country's context anyway.¹⁷ Consequently, this strategy could delay the establishment of an adequate pre-hospital emergency medical system by distracting valuable, scarce resources towards a pre-hospital care system that may be inappropriate. Resource-constrained countries require new strategies of establishing and supporting new pre-hospital emergency medical systems—ones that are within their means.

South Africa, which currently has the highest proportional annual death rate in the world,¹⁸ is no exception to this problem. Within its population of 50 million people, South Africa is experiencing some of the highest rates of injury worldwide.¹⁹ Additionally, prevalent developing world diseases, such as HIV and tuberculosis, and increasing urbanization and adoption of Western lifestyles, which result in chronic conditions such as heart disease and cancer, are increasing medical emergency rates.²⁰ Many parts of the country still have inadequate or non-existent pre-hospital care,²¹ and are faced with emergency patient overloads, financially constrained public-sectors, and poor infrastructure such as a lack of communication technology, poor road networks, and qualified personnel.²¹

To begin to address this problem, in 2010 we designed and implemented an emergency first aid responder (EFAR) system prototype in Manenberg, one of South Africa's most crime violent townships.²² Community members were trained to become EFARs that provided first-responder care for emergency patients until (if necessary) an ambulance or other transportation method was available. We observed that the system was low-cost and able to deliver pre-hospital emergency care and transport for patients,²² and that EFARs were able to learn and retain their training.²³ Following the success of the EFAR system in Manenberg, the University of Cape Town's Division of Emergency Medicine (UCT EM) and the Western Cape's provincial emergency medical services (METRO EMS) are now attempting to expand the EFAR system throughout the Western Cape province, and there is growing interest for the EFAR system in other provinces of South Africa as well. However, because Manenberg's EFAR system was designed specifically for Manenberg, and because other resource-constrained areas of South Africa can range in terms of infrastructure, financial resources, and population needs, a more general and locally adaptable EFAR system model and implementation strategy was needed.

In this study, we aimed to use a two-location pilot and consensus approach to develop a pre-hospital care system and implementation strategy that was more appropriate for a range of conditions in South Africa. This model utilizes a core EFAR system model that can be locally adapted, along with an implementation strategy that could be done in a graduated fashion within an area's means. The UCT EM and METRO EMS intend to follow this model, and we present it, along with how we developed it, to help better establish more effective pre-hospital emergency care in under-developed parts of the world.

Section snippets

Methods: developing the model and strategy

To develop a generic model and implementation strategy, we first tested and compared versions of the EFAR system and implementation process at the original site, Manenberg, and at a new location, Lavender Hill, in order to first assess which parts of the Manenberg model were specific to that community and which could be universal. After developing a model scheme that was universal to both Manenberg and Lavender Hill, we then used a consensus approach to make the model more universal to other

The adaptable, core EFAR system model

Though they assumed various names and forms at each site, archetypical roles existed across the EFAR systems (see Fig. 1). There are two categories of roles: care delivery roles and management roles.

Discussion

Pre-hospital emergency care in a resource-constrained country such as South Africa faces three major obstacles: (1) limited access to acute care, (2) limited transportation to hospitals, and (3) inappropriateness of Western pre-hospital care models for resource-constrained areas. The EFAR system model addresses these issues in South Africa by utilizing and building upon the resources available in a resource-constrained area. Immediate emergency care is initiated and provided by community

Limitations and future research

Because individuals in South Africa designed the model, there are potential biases towards conditions in South Africa. We are unsure of how the model would work elsewhere. Additionally, though individuals familiar with a wide range of South African township conditions designed the model, the model has not been tested yet on all of these conditions. Finally, there are limited resources to quantify pre-hospital interventions’ affects on morbidity and mortality in any resource-constrained

Conclusion

The emergency first aid responder system and implementation strategy is designed to be a versatile pre-hospital emergency care model for South Africa's resource-constrained areas with emergency need, and shows great promise in making pre-hospital emergency care more accessible in under-developed areas of South Africa. It is also designed to be implemented in a graduated fashion based on resource availability. The University of Cape Town's Division of Emergency Medicine and the Western Cape's

Competing interests

The authors report no competing interests.

Acknowledgements

We gratefully thank the Manenberg Health Committee for their help in Manenberg, Mothers Unite for their help in Lavender Hill, and Systems Improvement At District Hospitals and Regional Training of Emergency Care (sidHARTe), the Ghana Health Services, and the participating experts and community members for their input and support. We also greatly appreciate Dr Cleeve Robertson, Dr Heike Geduld, Dr Shaheem de Vries and the rest of the Western Cape METRO EMS for their collaboration, enthusiasm

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The emergency first aid responder (EFAR) system was designed as a low-cost and adaptable community-based prehospital emergency care system, and was first published after conducting a study in the township of Manenberg, South Africa, in 2010. EFARs are laypersons who are trained to respond to emergencies in their communities, and can provide support to the emergency medical services (EMS) by providing early clinical care, reporting back about the scene, and assisting with local scene management and logistics. Over the past ten years in South Africa, the Western Cape Government Health (WCGH) EMS and the Western Cape Government (WCG) College of Emergency Care have implemented the EFAR system in multiple communities and have trained over 10,000 community members across the Western Cape. This report is a ten-year update on what has happened since the EFAR system started, and to candidly show how the system has evolved, what has been learned, and what challenges remain so that others could look ahead and plan accordingly as they develop similar community-based first aid responder systems in resource-constrained areas. Core pillars to the EFAR system's success have included community involvement and adaptation, collaboration with the WCGH EMS and WCG College of Emergency Care, opportunities for community and EMS development, and emphasis on the sustainability of local EFAR systems. Multiple challenges also remain that others may likely face.
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Seventy eight paramedics responded, and most (91%) indicated they were likely to use capnography when the tool was available. The majority of training in capnography had been during their primary qualification (85%). Most participants indicated that they would like further training (91%). Use of capnography for confirmation of endotracheal tube placement and quality of compressions during cardiopulmonary resuscitation was well understood (correct in 94% and 84% respectively), while more complicated knowledge such as waveform changes during ventilation (66%) and the effect of hypovolaemia (48%) on capnography were lacking.
Paramedics report using waveform capnography extensively when it is available in the South African out-of-hospital environment. Although the knowledge around capnography and its usage was found to be good in most areas, more complicated scenarios exposed flaws in the knowledge of many paramedics and suggest the need for improved and ongoing training, as well as incorporation into curricula as the field develops across the continent.
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One may argue that the solution lies in more ambulances and personnel being dispatched to assist in accidents whereby there are multiple patients. However, South Africa and Africa as a whole remains resource constrained with regard to the number of ambulances and EMS resources per capita [14]. Patient extrication was a factor which all participants believed played a role in prolonging the on-scene time interval.
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Reports from several African nations indicate small-scale success with the initial development of both tiers of prehospital care systems. In Ghana, Madagascar, Uganda and South Africa, tier-one systems were piloted using taxi-drivers, police officers, local councilmen and community laypersons, as community-based first aid responders.17–20 These programs demonstrated strengths of local-appropriateness, practicality, sustainability, and cost-effectiveness.
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Les soins d’urgence sont délivrés dans le cadre d’un continuum. Le développement de systèmes de soins pré-hospitaliers d’urgence intégrés aux systèmes de soins d’urgence en milieu hospitalier peut constituer un moyen durable et efficace de réduire la morbidité et la mortalité importantes associées aux maladies aigues en Afrique. Malheureusement, le développement de ces systèmes pré-hospitaliers en Afrique a jusqu’à présent progressé lentement pour diverses raisons, notamment la crainte des répercussions financières, l’absence d’accord sur la structure et la fonction optimales du système et la quasi-absence de plaidoyer.
En novembre 2013, l’AfricanFederation for Emergency Medicine (AFEM) a convoqué une seconde réunion d’experts et de parties prenantes au Cap, en Afrique du Sud, dans l’objectif d’atteindre un consensus sur quelques déclarations de position, afin de faciliter le plaidoyer et de guider le développement des soins d’urgence en Afrique. L’objectif de cet article est de rendre compte des résultats et des déclarations de position qui émergent du processus de consensus du Groupe de travail de l’AFEM sur les soins d’urgence hors des centres hospitaliers en Afrique.
Le terme « Soins d’urgence hors des centres hospitaliers » a été accepté par consensus et défini par le Groupe de travail comme un terme générique pouvant être utilisé en Afrique en référence à la gamme complète des soins d’urgence fournis en dehors des établissements de soins de santé. Les composantes essentielles de ce système ont été définies, notamment les systèmes de prise en charge par le premier intervenant (premier niveau) et les systèmes pré-hospitaliers de soins et de services médicaux d’urgence (deuxième niveau). Le groupe de travail a produit un ensemble de directives et de recommandations préconisées par les experts afin de faciliter le plaidoyer et le développement de systèmes de soins d’urgence hors des centres hospitaliers dans les régions africaines sinistrées.
Le Groupe de travail sur les soins d’urgence hors des centres hospitaliers travaillera ensuite à la création d’une Boîte à outils en ligne. Celle-ci tiendra lieu de dispositif d’archivage des documents de référence permettant de guider la mise en œuvre et le développement des soins cliniques, de l’éducation, du transport, de l’accès public, de la politique et de la gouvernance.

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A strategy to implement and support pre-hospital emergency medical systems in developing, resource-constrained areas of South Africa

Abstract

Introduction

Section snippets

Methods: developing the model and strategy

The adaptable, core EFAR system model

Discussion

Limitations and future research

Conclusion

Competing interests

Acknowledgements

Annals of Emergency Medicine

Injury

Preventive Medicine

Journal of Emergency Medicine

Resuscitation

African Journal of Emergency Medicine

The global burden of disease: 2004 update

Small arms and criminality in Cameroon

Crime, violence, and development: trends, costs, and policy options in the Caribbean

United Nations office on drugs and crime Latin America and the Caribbean region of the World Bank

More slums equals more violence: reviewing armed violence and Urbanization in Africa

United Nations development programme: small arms survey