Referral pathways for reperfusion of STEMI – developing strategies for appropriate intervention

2016

S Afr J Crit Care

Background. Critical care transfers (CCT) refer to the high level of care given during transport (via ambulance, helicopter or fixed-wing aircraft) of patients who are of high acuity. In South Africa (SA), advanced life support (ALS) paramedics undertake CCTs. The scope of ALS in SA has no extended protocol regarding procedures or medications in terms of dealing with these CCTs. Aim. The aim of this study was to obtain the opinions of several experts in fields pertaining to critical care and transport and to gain consensus on the skills and scope-of-practice requirements of paramedics undertaking CCTs in the SA setting. Methods. A modified Delphi study consisting of three rounds was undertaken using an online survey platform. A heterogeneous sample (n=7), consisting of specialists in the fields of anaesthesiology, emergency medicine, internal medicine, critical care, critical care transport and paediatrics, was asked to indicate whether, in their opinion, selected procedures and medications were needed within the scope of practice of paramedics undertaking CCTs. Results. After three rounds, consensus was obtained in 70% (57/81) of procedures and medications. Many of these items are not currently within the scope of paramedics' training. The panel felt that paramedics undertaking these transfers should have additional postgraduate training that is specific to critical care. Conclusion. Major discrepancies exist between the current scope of paramedic practice and the suggested required scope of practice for CCTs. An extended scope of practice and additional training should be considered for these practitioners. There is currently a critical shortage of intensive and specialist care in South Africa (SA). [1] In fact, 77% of state healthcare facilities and 16% of private healthcare facilities do not have intensive or high-care capacity.[1] Owing to this shortage, adequate district and provincial healthcare might not be available in many areas, [2] necessitating frequent transfer of patients to urban tertiary centres for specialist care.Internationally, paramedics undertaking critical care transfers (CCTs) have extended scope of practice when compared with standard emergency paramedics in order to be equipped for these high-acuity patients.[3] Locally, however, all paramedics registered as advanced life support (ALS) practitioners may undertake CCTs. [4] No extended training or additional scope of practice is given to these paramedics who might need to intervene to stabilise patients for transfer.[4] Studies have shown that adverse events (AEs) during CCTs are significant and proportionate to the level of training and experience of the transferring practitioner. [5,6] A prospective 1-year audit conducted in SA in 2001 focused on CCTs of paediatric patients in a low-resource setting.[7] The study found that the transfers were predominantly undertaken by paramedics (82%) via road ambulance (76%). [7] It was found that a number of technical AEs such as inadequate monitoring, absent venous access, and malpositioning of e...

Section: Discussionmentioning

confidence: 99%

The capabilities and scope-of-practice requirements of advanced life support practitioners undertaking critical care transfers: A Delphi study

Venter

2016

S Afr J Crit Care

“…4 Locally, the majority of patients seem to be transported privately. 12 - 13 Reasons for this include unfamiliarity with emergency numbers, poor and unreliable response times of EMS, or lack of understanding of the value of EMS use in myocardial infarction. 12 …”

Section: Discussionmentioning

confidence: 99%

The proportion of South Africans living within 60 and 120 minutes of a percutaneous coronary intervention facility

Wallis

Vincent-Lambert

et al. 2018

CVJA

SummaryIntroductionTimely reperfusion, preferably via percutaneous coronary intervention (PCI) following myocardial infarction, improves mortality rates. Emergency medical services play a pivotal role in recognising and transporting patients with ST-elevation myocardial infarction directly to a PCI facility to avoid delays to reperfusion. Access to PCI is, in part, dependant on the geographic distribution of patients around PCI facilities. The aim of this study was to determine the proportion of South Africans living within 60 and 120 minutes of a PCI facility.MethodsPCI facility and population data were subjected to proximity analysis to determine the average drive times from municipal ward centroids to PCI facilities for each province in South Africa. Thereafter, the population of each ward living within 60 and 120 minutes of a PCI facility was extrapolated.ResultsApproximately 53.8 and 71.53% of the South African population live within 60 and 120 minutes of a PCI facility. The median (IQR, range) drive times and distances to a PCI facility are 100 minutes (120.4 min, 0.7–751.8) across 123.6 km (157.6 km, 0.3–940.8).ConclusionBased on the proximity of South Africans to PCI facilities, it seems possible that most patients could receive timely PCI within 120 minutes of first medical contact. However, this may be unlikely for some due to a lack of medical insurance, under-developed referral networks or other system delays. Coronary care networks should be developed based on the proximity of communities to 12-lead ECG and reperfusion therapies (such as PCI facilities). Public and private healthcare partnerships should be fortified to allow for patients without medical insurance to have equal accesses to PCI facilities.

“…Locally, 77% of the PCI-facilities are only accessible to 18.1% of the population. These disparities are echoed by a local study mentioning that 70% of patients in the public sector are cared for by 30% of doctors while four provinces do not have a single registered cardiologist [24] . These gaps, albeit non-significant, are illustrated in this study by a negative correlation between the amount of private cath labs and those with medical insurance.…”

Section: Discussionmentioning

confidence: 99%

“…Africa is no stranger to this inequitable dissemination of resources based on socio-economic status and geographic locale [14] , [24] , [25] , [26] . Owing to the disarray of the local public transport system [27] , the high cost of travel [14] and the unreliable nature of the public EMS system [12] , [13] , even those living in close proximity to the urban concentrated PCI-facilities, might still not be able to access these in a timely manner.…”

Section: Discussionmentioning

confidence: 99%

Percutaneous coronary intervention still not accessible for many South Africans

African Journal of Emergency Medicine

Wallis

Lambert

et al. 2017

IntroductionThe incidence of myocardial infarction is rising in Sub-Saharan Africa. In order to reduce mortality, timely reperfusion by percutaneous coronary intervention (PCI) or thrombolysis followed by PCI is required. South Africa has historically been characterised by inequities in healthcare access based on geographic and socioeconomic status. We aimed to determine the coverage of PCI-facilities in South Africa and relate this to access based on population and socio-economic status.MethodsThis cross-sectional study obtained data from literature, directories, organisational databases and correspondence with Departments of Health and hospital groups. Data was analysed descriptively while Spearman’s Rho sought correlations between PCI-facility resources, population, poverty and medical insurance status.ResultsSouth Africa has 62 PCI-facilities. Gauteng has the most PCI-facilities (n = 28) while the Northern Cape has none. Most PCI-facilities (n = 48; 77%) are owned by the private sector. A disparity exists between the number of private and state-owned PCI-facilities when compared to the poverty (r = 0.01; p = 0.17) and insurance status of individuals (r = −0.4; p = 0.27).ConclusionFor many South Africans, access to PCI-facilities and primary PCI is still impossible given their socio-economic status or geographical locale. Research is needed to determine the specific PCI-facility needs based on geographic and epidemiological aspects, and to develop a contextualised solution for South Africans suffering a myocardial infarction.