Clinical quality and performance measurement in the prehospital emergency medical services in the low-to-middle income country setting

BACKGROUND
Measuring quality and safety in any healthcare setting however is highly contextual, and depends on the manner in which quality is defined or viewed within that setting. It is this contextual nature that has provoked significant debate and hindered efforts at developing formal standards or criteria for measuring quality and safety in healthcare, regardless of setting. Historically, performance within the Emergency Medical Services (EMS) delivering prehospital emergency care has been assessed primarily based on response times. While easy to measure and valued by the public, overall, response time targets are a poor predictor of quality of care and clinical outcomes.
AIM
The overall aim of the research was to develop a framework for clinical quality and performance-based assessment of prehospital emergency care for use in the South African EMS.
METHOD
The research was divided amongst four studies, with each study constituting one of the overall research objectives. Study I was a sequential explanatory mixed methods study with the aim of understanding the knowledge, attitudes and practices of clinical quality and performance assessment amongst South African EMS personnel. Part 1 consisted of a webbased cross-sectional survey, and Part 2 consisted of semi-structured telephonic interviews of select participants from Part 1 to explore the results of the survey. Descriptive statistics were carried out to summarise and present all survey items, and conventional content analysis employed to analyse the interview data. Study II utilised a three round modified Delphi study to identify, refine and review a list of appropriate quality indicators for potential use in the South African EMS setting. For Study III a novel quality indicator appraisal protocol was developed consisting of two categorical-based appraisal methods, combined with the qualitative analysis of their consensus application, and tested against the outcomes of Study II. Descriptive statistics were utilised to describe and summarize the categorical based appraisal data. Inter-rater reliability was calculated using percentage agreement and Gwet’s AC1. Correlation between the individual methods and the protocol was calculated using Spearman’s rank Correlation and z-test. Conventional content analysis was utilised to analyse the group discussions. Study IV utilised a multiple exploratory case study design to evaluate the current state of quality systems in the South African EMS. A formative assessment was conducted on the quality systems of four provincial EMS and one national private EMS, following which semi-structured interviews were conducted to further explore the results obtained from the formative assessment, supported by multiple
secondary data sources. Descriptive statistics were utilised to describe and summarize the formative assessment. Conventional content analysis was utilised to analyse the interview data and document analysis utilised to sort and analyse the supporting data
RESULTS
Despite relatively poor knowledge of organisational-specific quality systems, understanding of the core components and importance of quality systems was demonstrated. The role of these systems in the Low to Middle Income Country setting (LMICs) was supported by participants, where the importance of context, system transparency, reliability and validity were essential towards achieving ongoing success and utilisation. The role of leadership and communication towards the effective facilitation of such a system was equally identified. Participating services generally scored higher for structure and planning. Measurement and improvement were found to be more dependent on utilisation and perceived mandate. There was a relatively strong focus on clinical quality assessment within the private service, whereas in the provincial systems, measures were exclusively restricted to call times with little focus on clinical care. Staff engagement and programme evaluation were generally among the lowest scores. A multitude of contextual factors were identified that affected the effectiveness of quality systems, centred around leadership, vision and mission, and quality system infrastructure and capacity, guided by the need for comprehensive yet pragmatic strategic policies and standards. A total, 104 quality indicators reached consensus agreement including, 90 clinical QIs, across 15 subcategories, and 14 non-clinical QIs across two subcategories. Amongst the clinical category, airway management (n=13 QIs; 14%); out-of-hospital cardiac arrest (n=13 QIs; 14%); and acute coronary syndromes (n=11 QIs; 12%) made up the majority. Within the non-clinical category, adverse events made up the significant majority with nine QIs (64%). There was mixed inter-rater reliability of the individual methods. There was similarly poor to moderate correlation of the results obtained between the individual methods (Spearman’s rank correlation=0.42,p<0.001). From a series of 104 QIs, 11 were identified that were shared between the individual methods. A further 19 QIs were identified and not shared by each method, highlighting the benefits of a multimethod approach.
CONCLUSION
For the purposes of this study we focused on the technical competence aspect of quality, in developing our measurement framework. Towards this, we identified a significant number of QIs assessed to be valid and feasible for the South African prehospital emergency care setting. The majority of which are centred around clinically focused processes of care, measures that are lacking in current performance assessment in EMS in South Africa. However, we also discovered the importance and influencing role of the individual practitioners and quality system in which the QIs will be implemented, a point highlighted across all the methodologies and studies. Given the potential magnitude of this influence, it is of the utmost importance that any measurement framework examining technicalquality, have equal in-depth understanding of these factors in order to be successful.

Implementation Science Protocol for a participatory, theory-informed implementation research programme in the context of health system strengthening in sub-Saharan Africa (ASSET-ImplementER)

Background ASSET (Health System Strengthening in Sub-Saharan Africa) is a health system strengthening (HSS) programme that aims to develop and evaluate effective and sustainable solutions that support high-quality care that involve eight work packages across four sub-Saharan African countries. Here we present the protocol for the implementation science (IS) theme within ASSET that aims to (1) understand what HSS interventions work, for whom and how; and (2) how implementation science methodologies can be adapted to improve the design and evaluation of HSS interventions within resource-poor contexts.

Pre-implementation phase The IS theme, jointly with ASSET work-packages, applies IS determinant frameworks to identify factors that influence the effectiveness of delivering evidence-informed care. Determinants are used to select a set of HSS interventions for further evaluation, where work packages also theorise selective mechanisms to achieve the expected outcomes.

Piloting phase and rolling implementation phase Work-packages pilot the HSS interventions. An iterative process then begins involving evaluation, refection and adaptation. Throughout this phase, IS determinant frameworks are applied to monitor and identify barriers and enablers to implementation in a series of workshops, surveys and interviews. Selective mechanisms of action are also investigated. In a final workshop, ASSET teams come together, to reflect and explore the utility of the selected IS methods and provide suggestions for future use.

Structured templates are used to organise and analyse common and heterogeneous patterns across work-packages. Qualitative data are analysed using thematic analysis and quantitative data is analysed using means and proportions.

Conclusions We use a novel combination of implementation science methods at a programmatic level to facilitate comparisons of determinants and mechanisms that influence the effectiveness of HSS interventions in achieving implementation outcomes across different contexts. The study will also contribute conceptual development and clarification at the underdeveloped interface of implementation science, HSS and global health.

The scope of operative general paediatric surgical diseases in South Africa—the Chris Hani Baragwanath experience

Background
Infectious diseases have always been the lime light of global health with very little focus on childhood surgical conditions despite the fact that children constitute about half of the population in LMICs. A significant proportion of the burden of global disease can be reduced by surgical intervention. South Africa is one of the pioneers of the practice of paediatric surgery in Africa with a great burden of paediatric surgical conditions.

Few studies, if any, have investigated the burden of operative paediatric surgical procedures in South Africa. Therefore, this retrospective study aimed to look at the scope of operative paediatric surgical procedures at the Chris Hani Baragwanath Academic Hospital (CHBAH) based in Johannesburg, South Africa, and reports on the numbers of elective and emergency procedures over a 12-month study period.

Results
There were 1699 operative general paediatric surgical procedures of which 61.7% were electives and 38.3% were emergencies. The scope of general paediatric surgical conditions operated on fell under the categories of congenital anomalies, infections and tumours. Of these, surgeries for congenital anomalies were performed in almost all the subspecialties.

Conclusion
There is a high operative paediatric surgical burden at the CHBAH. The role of paediatric surgical care as an essential component of global health cannot be underrated.

Diagnostic assistance to improve acute burn referral and triage : assessment of routine clinical tools at specialised burn centres and potential for digital health development at point of care

Background: Inappropriate referral of patients for specialised care leads to overburdened health systems and improper treatment of patients who are denied transfer due to a scarcity of resources. Burn injuries are a global health problem where specialised care is particularly important for severe cases while minor burns can be treated at point of care. Whether several solutions, existing or in development, could be used to improve the diagnosis, referral and triage of acute burns at admission to specialised burn centres remains to be evaluated.

Aim: The overarching aim of this thesis is to determine the potential of diagnostic support tools for referral and triage of acute burns injuries. More specifically, sub-aims include the assessment of routine and digital health tools utilised in South Africa and Sweden: referral criteria, mortality prediction scores, image-based remote consultation and automated diagnosis.

Methods: Studies I and II were two retrospective studies of patients admitted to the paediatric (I) and the adult (II) specialised burn centres of the Western Cape province in South Africa. Study I examined adherence to referral criteria at admission of 1165 patients. Logistic regression was performed to assess the associations between adherence to the referral criteria and patient management at the centre. Study II assessed mortality prediction at admission of 372 patients. Logistic regression was performed to evaluate associations between patient, injury and admission-related characteristics with mortality. The performance of an existing mortality prediction model (the ABSI score) was measured. Study III and IV were related to two image-based digital-health tools for remote diagnosis. In Study III, 26 burns experts provided a diagnosis in terms of burn size and depth for 51 images of acute burn cases using their smartphone or tablet. Diagnostic accuracy was measured with intraclass correlation coefficient. In Study IV, two deep-learning algorithms were developed using 1105 annotated acute burn images of cases collected in South Africa and Sweden. The first algorithm identifies a burn area from healthy skin, and the second classifies burn depth. Differences in performances by patient Fitzpatrick skin types were also measured.

Results: Study I revealed a 93.4% adherence to the referral criteria at admission. Children older than two years (not fulfilling the age criterion) as well as those fulfilling the severity criterion were more likely to undergo surgery or stay longer than seven days at the centre. At the adult burn centre (Study II), mortality affected one in five patients and was associated with gender, burn size, and referral status after adjustments for all other variables. The ABSI score was a good estimate of mortality prediction. In Study III experts were able to accurately diagnose burn size, and to a lesser extent depth, using handheld devices. A wound identifier and a depth classifier algorithm could be developed with assessments of relatively high accuracy (Study IV). Differences were observed in performances by skin types of the patients.

Conclusions: Altogether the findings inform on the use in clinical practice of four different tools that could improve the accuracy of the diagnosis, referral and triage of patients with acute burns. This would reduce inequities in access to care by improving access for both paediatric and adult patient populations in settings that are resource scarce, geographically distant or under high clinical pressure.

First Intraoperative Radiation Therapy Center in Africa: First 2 Years in Operation, Including COVID-19 Experiences

PURPOSE
There is a shortage of radiation therapy service centers in low- to middle-income countries. TARGIT–intraoperative radiation therapy (IORT) may offer a viable alternative to improve radiation treatment efficiency and alleviate hospital patient loads. The Breast Care Unit in Johannesburg became the first facility in Africa to offer TARGIT-IORT, and the purpose of this study was to present a retrospective review of patients receiving IORT at this center between November 2017 and May 2020.

PATIENTS AND METHODS
Patient selection criteria were based mainly on the latest American Society of Radiation Oncology guidelines. Selection criteria included early-stage breast carcinoma (luminal A) and luminal B with negative upfront sentinel lymph node biopsy that negated external-beam radiation therapy (EBRT). Patient characteristics, reasons for choosing IORT, histology, and use of oncoplastic surgery that resulted in complications were recorded.

RESULTS
One hundred seven patients successfully received IORT/TARGIT-IORT. Mean age was 60.8 years (standard deviation, 9.3 years). A total of 73.8% of patients presented with luminal A, 15.0% with luminal B, and 5.6% with triple-negative cancer. One patient who presented with locally advanced breast cancer (T4N2) opted for IORT as a boost in addition to planned EBRT. Eighty-seven patients underwent wide local excision (WLE) with mastopexy, and 12 underwent WLE with parenchymal. Primary reasons for selecting IORT/TARGIT-IORT were distance from the hospital (43.9%), choice (40.2%), and age (10.3%).

CONCLUSION
This retrospective study of IORT/TARGIT-IORT performed in Africa confirms its viability, with low complication rates and no detrimental effects with breast conservation, resulting in positive acceptance and the potential to reduce Oncology Center patient loads. Limitations of the study include the fact that only short-term data on local recurrence were available. Health and socioeconomic value models must still be addressed in the African setting.

Quality of recovery after total hip and knee arthroplasty in South Africa: a national prospective observational cohort study

Background
Encouraged by the widespread adoption of enhanced recovery protocols (ERPs) for elective total hip and knee arthroplasty (THA/TKA) in high-income countries, our nationwide multidisciplinary research group first performed a Delphi study to establish the framework for a unified ERP for THA/TKA in South Africa. The objectives of this second phase of changing practice were to document quality of patient recovery, record patient characteristics and audit standard perioperative practice.

Methods
From May to December 2018, nine South African public hospitals conducted a 10-week prospective observational study of patients undergoing THA/TKA. The primary outcome was ‘days alive and at home up to 30 days after surgery’ (DAH30) as a patient-centred measure of quality of recovery incorporating early death, hospital length of stay (LOS), discharge destination and readmission during the first 30 days after surgery. Preoperative patient characteristics and perioperative care were documented to audit practice.

Results
Twenty-one (10.1%) out of 207 enrolled patients had their surgery cancelled or postponed resulting in 186 study patients. No fatalities were recorded, median LOS was 4 (inter-quartile-range (IQR), 3–5) days and 30-day readmission rate was 3.8%, leading to a median DAH30 of 26 (25–27) days. Forty patients (21.5%) had pre-existing anaemia and 24 (12.9%) were morbidly obese. In the preoperative period, standard care involved assessment in an optimisation clinic, multidisciplinary education and full-body antiseptic wash for 67 (36.2%), 74 (40.0%) and 55 (30.1%) patients, respectively. On the first postoperative day, out-of-bed mobilisation was achieved by 69 (38.1%) patients while multimodal analgesic regimens (paracetamol and Non-Steroid-Anti-Inflammatory-Drugs) were administered to 29 patients (16.0%).

Conclusion
Quality of recovery measured by a median DAH30 of 26 days justifies performance of THA/TKA in South African public hospitals. That said, perioperative practice, including optimisation of modifiable risk factors, lacked standardisation suggesting that quality of patient care and postoperative recovery may improve with implementation of ERP principles. Notwithstanding the limited resources available, we anticipate that a change of practice for THA/TKA is feasible if ‘buy-in’ from the involved multidisciplinary units is obtained in the next phase of our nationwide ERP initiative.

Delayed presentation of subaxial cervical spine dislocations: A retrospective review of 14 cases managed at a specialist spinal surgery unit in Durban, South Africa

Background: The subaxial cervical spine is the most commonly injured region of the spinal column and these injuries are frequently missed. The objective of this case series (n=14) was to highlight the issues encountered with delayed presentation (> 2 weeks) of sub axial cervical spine dislocations/fracture dislocations and the outcomes following surgical management of these injuries.

Methods: We analyzed 14 adults with 9 unifacet and 5 bifacet dislocations who presented after a mean delay of 27.3 days. Demographic profile, mechanism of injury, reasons for delayed presentation, pre-operative imaging studies, clinical presentation, surgical management, complications and outcomes were analyzed. A literature review was also undertaken to assess the incidence, etiology and outcomes associated with these injuries and highlight methods available for appropriate screening of the cervical spine in an attempt to mitigate delays.

Results: Pre-operative reduction with skull traction was unsuccessful in 3 out of 5 bifacet dislocations while all but one unifacet dislocations were reduced successfully. All injuries were managed operatively with anterior cervical discectomy and fusion (ACDF) with instrumentation.

Posterior release prior to anterior discectomy and fusion were performed in 3 patients where dislocations were irreducible pre-operatively. Neurological improvement was seen in 9 patients.

Conclusions: A favorable outcome can be expected following surgery for delayed presentation of sub axial cervical spine injuries, especially in the resource limited, low- and middle-income countries (LMICs).

Quality indicators for the diagnosis and surgical management of breast cancer in South Africa

Introduction: Quality indicators (QIs) for breast cancer care have been developed and applied in high-income countries and contributed to improved quality of care and patient outcomes over time.

Materials and methods: A modified Delphi process was used to derive expert consensus. Potential QIs were rated by a panel of 17 breast cancer experts from various subspecialties and across South African provinces. Each QI was rated according to importance to measure, scientific acceptability and feasibility. Scoring ranged from 1 (no agreement) to 5 (strong agreement). Inclusion thresholds were set a priori at mean ratings ≥4 with a coefficient variation of ≥25%. Levels of evidence were determined for each indicator.

Results: The literature review identified 790 potential QIs. After categorisation and removal of duplicates, 52 remained for panel review. There was strong consensus for 47 which were merged to 30 QIs by exclusion of similar indicators and indicator grouping. The final set included eight QIs with level I or II evidence and two QIs with level III evidence which were deemed “mandatory” due to clinical priority and impact on care. The remaining QIs with lower-level evidence were grouped as eight “recommended” QIs (regarded as standard of care) and twelve “optional” QIs (not regarded as standard of care).

Conclusion: A regional set of QIs was developed to facilitate standardised treatment and auditing of surgical care for breast cancer patients in South Africa. Routine monitoring of the ten mandatory QIs, which were selected to have the most substantial impact on patient outcome, is proposed.

Towards a framework approach to integrating pathways for infection prevention and antibiotic stewardship in surgery: a qualitative study from India and South Africa

Background The surgical pathway remains a hard to reach, critical target for antimicrobial stewardship (AMS) and infection prevention and control (IPC). We investigated the drivers for surgical AMS and IPC, across cardiovascular and thoracic surgery (CVTS) and gastrointestinal surgery teams in two academic hospitals in South Africa (SA) and India. Materials and methods An ethnographic observational study of IPC and AMS was conducted (July 2018–August 2019), with data gathered from 190 hours of non-participant observations (138 India, 60 SA); face-to-face interviews with patients (6 India, 7 South Africa), and healthcare professionals (HCPs) (44 India, 61 SA); and, in-depth patient case studies (4 India, 2 SA). A grounded theory approach aided by Nvivo 11 software, analyzed the emerging themes. An iterative and recursive process of moving between the coded data and the higher-level themes, ensured saturation of the themes. The multiple modes of enquiry enabled cross-validation and triangulation of findings. Results Across surgical pathways, multiple barriers exist impeding effective IPC and AMS practices. The existing, implicit roles of HCPs (including nurses, and senior surgeons) are overlooked as interventions target junior doctors, bypassing the opportunity for integrating care across the surgical team members. Critically, the ownership of decisions remains with the operating surgeons and entrenched hierarchies restrict the integration of other HCPs in IPC and AMS. Conclusions IPC and AMS are not integrated in surgery. Identifying the implicit existing HCPs roles in IPC and AMS is critical and will facilitate the development of effective and transparent processes across the surgical team for IPC and AMS. Developing a framework approach that includes nurse leadership, empowering pharmacists and engaging surgical leads is essential for integrated care.

Outcomes of paediatric patients ventilated in a high-care area outside an intensive care unit

Background. Limited availability of paediatric intensive care beds in the public sector is a major challenge in South Africa. It often results in patients being ventilated in a high-care area (HCA) outside an intensive care setting. The outcomes of paediatric patients ventilated outside a paediatric intensive care unit (ICU) are not well documented.

Objectives. To describe characteristics and outcomes of patients ventilated in a paediatric HCA.

Methods. A retrospective chart review of children (0 – 16 years) requiring mechanical ventilation in the HCA at Chris Hani Baragwanath Academic Hospital, Johannesburg, between 1 February and 31 October 2015 was performed.

Results. A total of 214 patients required mechanical ventilation during the study period. Fifty-four percent were male and 91.1% were HIV-negative. The most common diagnoses were acute lower respiratory tract infections (59.3% of the post-neonatal group, 28.8% of the neonatal group) and sepsis (6.8% of the post-neonatal group, 28.8% of the neonatal group). The ultimate rate of acceptance to an ICU was 69.0%. Only 41.6% of cases referred to an ICU were initially accepted, with limited bed availability being the main reason for refusal. Patients with respiratory illnesses were more likely and those with neurological illness less likely to be accepted to an ICU. Patients with low-risk diagnoses were more likely to be accepted than those with very high-risk diagnoses. The overall mortality rate was 32.2%, with 52.2% of these deaths occurring in the HCA. Patients aged 1 – 5 years had the highest mortality rate (48.0%). Lower respiratory tract infections (36.8%) and sepsis (20.6%) were the main causes of death. The mortality rate of suitable ICU candidates in the HCA was higher than that in an ICU (33.3% v. 24.3%). The standardised mortality ratio (SMR), as predicted by the Paediatric Index of Mortality 3 score, for all patients who died in the HCA was 3.3, while the SMR for patients who died in an ICU was 1.3. The odds ratio for mortality of suitable candidates ventilated in the HCA v. patients who were ventilated in an ICU was 1.80 (95% confidence interval 1.39 – 6.03).

Conclusions. Although a reasonable number of paediatric patients ventilated in an HCA survive, survival is lower than in those ventilated in an ICU. However, offering life-supporting therapies in an HCA may offer benefit where ICU care is unavailable. Emphasis needs to be placed on improving access to ICU care as well as optimising the use of available resources.