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Assessment of safe endotracheal tube cuff pressures in emergency care – time for change?

  • Authors: Stein, Christopher , Berkowitz, Gary , Kramer, Efraim
  • Date: 2011
  • Subjects: Endotracheal intubation , Tracheal injury
  • Type: Article
  • Identifier: uj:5920 , ISSN 2078-5135 , http://hdl.handle.net/10210/8079
  • Description: Endotracheal intubation is performed in the prehospital and emergency department (ED) environments by advanced life support (ALS) paramedics and emergency doctors. Cuffed endotracheal tubes (ETTs) are used in adults² and more recently in children to ensure that the airway is protected, and to prevent air leakage between the wall of the trachea and the ETT during positive pressure ventilation. Cuffs are typically high volume, low pressure in their design and have a safe working pressure of <30 cm H₂O in adults and <20 cm H₂O in children.¹ Over-inflation of ETT cuffs to pressures exceeding 30 cm HO₂ may result in serious complications including tracheal stenosis, tracheal rupture and tracheo-oesophageal fistula. ³ Tracheal injury may occur after as little as 15 minutes with ETT cuff pressures exceeding 27 cm H₂O. ² To avoid tracheal injury due to emergency intubation, it is important that ETT cuff over-inflation is avoided in the pre-hospital and ED phases of emergency care. Although ETT cuff pressure manometry is optimal in determining safe ETT cuff pressure, it is standard practice in the ED and in the pre-hospital emergency care environment to assess ETT cuff pressure using palpation of the cuff ’s pilot balloon – a qualitative technique prone to subjective interpretation.
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Meeting national response time targets for priority 1 incidents in an urban emergency medical services system : more ambulances won’t help

  • Authors: Stein, Christopher , Wallis, Lee , Adetunji, Olufemi
  • Date: 2015
  • Subjects: Emergency medical services , Response time , Computer simulation
  • Language: English
  • Type: Article
  • Identifier: http://hdl.handle.net/10210/69116 , uj:17820 , Citation: Stein, C., Wallis, L. % Adetunji, O. 2015. Meeting national response time targets for priority 1 incidents in an urban emergency medical services system : more ambulances won’t help.
  • Description: Abstract: Objective: To determine the effect of increased emergency vehicle numbers on response time performance for priority 1 incidents in an urban Emergency Medical Services system using discrete-event computer simulation. Method: A simulation model was created, based on input data from part of the Emergency Medical Services operations in Cape Town. Two different versions of the model were used, one with primary response vehicles and ambulances and one with only ambulances. In both cases the models were run in seven different scenarios. The first scenario used the actual number of emergency vehicles in the real system and in each subsequent scenario vehicle numbers were increased by adding the baseline number to the cumulative total. Results: The model using only ambulances had shorter response times and a greater number of responses meeting national response time targets than models using primary response vehicles and ambulances. In both cases an improvement in response times and the number of responses meeting national response time targets was observed with the first incremental addition of vehicles. After this the improvements rapidly diminished and eventually became negligible with each successive increase in vehicle numbers. The national response time target for urban areas was never met, even with a seven-fold increase in vehicle numbers. Conclusion: This study showed that the addition of emergency vehicles to an urban Emergency Medical Services system improves response times in priority 1 incidents but alone is not capable of the magnitude of response time improvement needed to meet the national response time targets.
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Access to out-of-hospital emergency care in Africa : consensus conference recommendations

  • Authors: Stein, Christopher , Mould-Millman, Nee-Kofi , De Vries, Shaheem , Wallis, Lee
  • Date: 2016
  • Language: English
  • Type: Article
  • Identifier: http://ujcontent.uj.ac.za8080/10210/371288 , http://hdl.handle.net/10210/212660 , uj:21004 , Citation: Stein, C., Mould-Millman, N.K., De Vries, S & Wallis, L. 2016. Access to out-of-hospital emergency care in Africa : consensus conference recommendations.
  • Description: Abstract: Out-of-hospital emergency care (OHEC) should be accessible to all who require it. However available data suggests that there are a number of barriers to such access in Africa, mainly centred around challenges in public knowledge, perception and appropriate utilisation of OHEC. Having reached consensus in 2013 on a two-tier system of African OHEC, the African Federation for Emergency Medicine (AFEM) OHEC Group sought to gain further consensus on the narrower subject of access to OHEC in Africa. The objective of this paper is to report the outputs and statements arising from the AFEM OHEC access consensus meeting, held in Cape Town, South Africa in April 2015. The discussion was structured around six dimensions of access to care (awareness, availability, accessibility, accommodation, affordability and acceptability) and tackled both Tier-1 (community first responder) and Tier-2 (formal prehospital services and Emergency Medical Services) OHEC systems. In Tier-1 systems, the role of community involvement and support was emphasised, along with the importance of a first responder system acceptable to the community in which it is embedded in order to optimise access. In Tier-2 systems, the consensus group highlighted the primacy of a single toll-free emergency number , matching of Emergency Medical Services resource demand and availability through appropriate planning and the cost-free nature of Tier-2 emergency care, among other factors that impact accessibility. Much work is still needed in prioritising the steps and clarifying the tools and metrics that would enable the ideal of optimal access to OHEC in Africa.
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Burnout amongst university paramedic students in Johannesburg, South Africa

  • Authors: Stein, Christopher , Sibanda, Thulani
  • Date: 2016
  • Subjects: Emergency medical services , Burnout , Paramedic
  • Language: English
  • Type: Article
  • Identifier: http://hdl.handle.net/10210/214442 , uj:21282 , Citation: Stein, C & Sibanda, T. 2016. Burnout amongst university paramedic students in Johannesburg, South Africa.
  • Description: Abstract: Objectives: To determine the prevalence of burnout amongst students in a four year paramedic University degree programme and to assess whether there was any significant difference in the prevalence of burnout between students in the programme’s four academic years of study. Design: Cross-sectional survey. Method: All students enrolled in a four-year University paramedic degree programme were invited to participate . The questionnaire consisted of 19 questions from the Copenhagen Burnout Inventory (CBI), combined with distractor questions. Responses were analysed descriptively and One-way Analysis of Variance was used to compare CBI scores across the four academic years of study. Results: An 85% (n = 93) response rate was obtained. The overall prevalence of burnout was 31%. Mean CBI scores across all academic years of study were highest for personal burnout, followed by work-related burnout and patient care-related burnout. The highest prevalence of students with burnout was in fourth year, as was the highest prevalence of work-related and personal burnout. The second highest prevalence of students with burnout was in first year as was the highest prevalence of patient-care related burnout. No significant difference was found in CBI total burnout scores across the four academic years of study. Conclusion: Although there are no directly comparable data, the prevalence of burnout in this group of students appears high, particularly in the first and final years of study. Steps should be taken to ensure access to social and psychological support in order to avoid a negative impact on academic success and student well-being.
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Non-physician out-of-hospital rapid sequence intubation success and adverse events : a systematic review and meta-analysis

Student paramedic rapid sequence intubation in Johannesburg, South Africa : a case series

  • Authors: Stein, Christopher
  • Date: 2017
  • Subjects: Endotracheal intubation , Student , Emergency medical services
  • Language: English
  • Type: Article
  • Identifier: http://hdl.handle.net/10210/233862 , uj:23886 , Citation: Stein, C. 2017. Student paramedic rapid sequence intubation in Johannesburg, South Africa : a case series. Student paramedic rapid sequence intubation in Johannesburg, South Africa: A case series. African Journal of Emergency Medicine, 7:56–62. DOI: http://dx.doi.org/10.1016/j.afjem.2017.01.005.
  • Description: Abstract: Pre-hospital rapid sequence intubation was introduced within paramedic scope of practice in South Africa seven years ago. Since then, little data has been published on this high-risk intervention as practiced operationally or by students learning rapid sequence intubation in the pre-hospital environment. The objective of this study was to describe a series of pre-hospital rapid sequence intubation cases, including those that South African University paramedic students had participated in. Methods: A University clinical learning database was searched for all endotracheal intubation cases involving the use of neuromuscular blockers between 1 January 2011 and 31 December 2015. Data from selected cases were extracted and analysed descriptively. Results: Data indicated that most patients were young adult trauma victims with a dominant injury mechanism of vehicle-related accidents. The majority of cases utilised ketamine and suxamethonium, with a low rate of additional paralytic medication administration. 63% and 72% of patients received post-intubation sedation and analgesia, respectively. The overall intubation success rate from complete records was 99.6%, with a first pass success rate of 87.9%. Students were successful in 92.4% of attempts with a first-pass success rate of 85.2%. Five percent of patients experienced cardiac arrest between rapid sequence intubation and hospital arrival. Discussion: Students demonstrated a good intubation success and first pass-success rate. However, newly qualified paramedics require strict protocols, clinical governance, and support to gain experience and perform pre-hospital rapid sequence intubation at an acceptable level in operational practice. More research is needed to understand the low rate of post-intubation paralysis, along with non-uniform administration of post-intubation sedation and analgesia, and the 5% prevalence of cardiac arrest.
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A descriptive analysis of endotracheal intubation in a South African Helicopter Emergency Medical Service

  • Authors: Stassen, Willem , Lithgow, Alastair , Wylie, Craig , Stein, Christopher
  • Date: 2018
  • Subjects: Helicopter Emergency Medical Services , Endotracheal intubation , Airway management
  • Language: English
  • Type: Article
  • Identifier: http://hdl.handle.net/10210/289318 , uj:31389 , Citation: Stassen, W. et al. 2018. A descriptive analysis of endotracheal intubation in a South African Helicopter Emergency Medical Service.
  • Description: Abstract: Introduction: Helicopter Emergency Medical Services (HEMS) exists to supplement the operations of groundbased emergency care providers, mainly in high acuity cases. One of the important procedures frequently carried out by HEMS personnel is endotracheal intubation. Several HEMS providers exist in South Africa, with a mix of advanced life support personnel, however intubation success rates and adverse events have not been described in any local HEMS operation. Methods: This was a retrospective chart review of intubation-related data collected by a HEMS operation based in Johannesburg over a 16-month period. First-pass and overall success rates were described, in addition to perceived airway difficulty, adverse events and other data. Results: Of the 49 cases recorded in the study period, one was excluded leaving 48 cases for analysis. Most cases (n=34, 71%) involved young male trauma patients who were intubated with rapid sequence intubation. The first pass success rate was 79% (n=38) with an overall success rate of 98% (n=47). At least one factor suggesting airway difficulty was present in 29% (n=14) of cases, with most perceived airway difficulty related to the high prevalence of trauma cases. At least one adverse event occurred in 27% (n=13) of cases with hypoxaemia, hypotension and bradycardia most prevalent. Discussion: In this small sample of South African HEMS intubation cases, we found overall and first-pass success rates comparable to those reported in similar contexts.
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The effect of clinical simulation assessment on stress and anxiety measures in emergency care students

  • Authors: Stein, Christopher
  • Date: 2020
  • Language: English
  • Type: Article
  • Identifier: http://hdl.handle.net/10210/410521 , uj:34454 , Citation: Stein, C. The effect of clinical simulation assessment on stress and anxiety measures in emergency care students. DOI: https://doi.org/10.1016/j.afjem.2019.12.001.
  • Description: Abstract: Background: Clinical simulation has become widespread as a training and assessment tool across a range of health professions, including emergency care. As with any form of assessment, simulations may be associated with stress and anxiety (“distress”) which may have a negative effect on student performance if demands required by the simulation outweigh the available resources. This study aimed to assess the effect of participation by students in an emergency care simulation on an objective measure of stress and a subjective measure of anxiety. Methods: Heart rate variability (HRV) and scores from a validated state anxiety instrument (the State-Trait Anxiety Inventory) were assessed in 36 emergency medical care students participating in scheduled simulation assessments. Data recorded during a resting control period were used for comparison. Results: HRV variables showed changes in the simulation assessment group suggesting decreased variability and parasympathetic withdrawal, however these were not significantly different to control. Heart rate in the simulation assessment group increased significantly (73.5/min vs. 107.3/min, p < 0.001). State anxiety scores increased significantly both before (33.5 vs. 49.1, p < 0.001) and after (33.5 vs. 60, p < 0.001) the simulation assessment, compared to control. No linear relationship was found between any HRV variables and anxiety scores. Conclusion: Participating in an emergency care simulation assessment significantly elevated levels of anxiety in a group of 36 students, however an objective measure of stress did not identify changes significantly different to those at rest, with the exception of heart rate. The high levels of anxiety documented before and after simulation assessments may have a negative effect on performance and require further investigation.
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Age-related laryngoscopic visual acuity

South African pre-hospital emergency care personnel’s lived experiences of managing paediatric emergencies : a qualitative research design utilising one-on-one interviews

  • Authors: Mosca, Colin G. , Stein, Christopher , Lawrence, Heather
  • Date: 2021
  • Subjects: Paediatrics , Emergencies , South Africa
  • Language: English
  • Type: Article
  • Identifier: http://hdl.handle.net/10210/483510 , uj:43884 , Citation: Mosca, C.G., Stein, C. & Lawrence, H., 2021, ‘South African pre-hospital emergency care personnel’s lived experiences of managing paediatric emergencies: A qualitative research design utilising one-on-one interviews’, Health SA Gesondheid 26(0), a1558. https://doi.org/10.4102/hsag. v26i0.1558
  • Description: Abstract: Background: The phenomenon of managing paediatric emergencies in the pre-hospital environment within the South African setting is poorly understood with specific regard to what emergency care personnel are experiencing when managing paediatric emergencies. Aim: The aim of this study was to explore and describe the lived experiences of emergency care personnel in managing paediatric patients in the pre-hospital environment and to understand the meaning and the significance of these experiences. Setting: All participants were purposively sampled from emergency medical services agencies operating within the Johannesburg metropolitan city area. Methods: This study followed a qualitative, exploratory, descriptive, phenomenological design, whereby participants purposively sampled within the Johannesburg metropolitan city voluntarily consented to one-on-one interviews (n = 10). Results: Three main themes, with 11 contributing categories, were identified and contextualised with available literature. Emerging from the main themes was an overall sense that managing paediatric emergencies is a negative experience, coloured with feelings of inadequacy, stress, anxiety and even fear. Conclusions: The findings of this study provided new insights into what South African EMS are experiencing when managing paediatric emergencies, which enables future research efforts to identify research and practice gaps that are relevant to paediatric pre-hospital emergency care, and that are specific to the South African environment. Contribution: This research provides preliminary insight into the lived experiences of prehospital personnel managing paediatric emergencies as well as emerging recommendations for the improvement of the prehospital care of paediatric patients.
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The identification of factors contributing to negative handover experiences of pre-hospital emergency care personnel in Johannesburg, South Africa

  • Authors: Makkink, Andrew , Stein, Christopher , Bruijns, Stevan
  • Date: 2021
  • Subjects: Handover , Paramedic , Pre-hospital
  • Language: English
  • Type: Article
  • Identifier: http://hdl.handle.net/10210/479727 , uj:43403 , Citation: Makkink, A., Stein, C. & Bruijns, S. 2021. The identification of factors contributing to negative handover experiences of pre-hospital emergency care personnel in Johannesburg, South Africa. , DOI: https://doi.org/10.33151/ajp.18.829
  • Description: Abstract: Introduction The handover of a patient in the pre-hospital setting is different to other handover settings and therefore requires a different definition and description to that of other patient handover environments. Identifying those factors that affect the efficacy of handover could provide useful for formulating improvement strategies. Aim This research set out to describe the negative experiences of pre-hospital emergency care personnel handing over in the emergency centre in Johannesburg, South Africa, with a view to identifying potential areas for improvement. This paper reports on responses to an open-ended question that formed part of a purpose-designed, paper-based questionnaire that formed part of a mixed-methods study. Methods Data were collected from pre-hospital emergency care personnel within Johannesburg, South Africa. Responses from 140 participants were captured verbatim into Atlas.ti® for coding, analysis and interpretation using a qualitative descriptive methodology. Two themes were generated from a qualitative descriptive analysis of the data: communication barriers, and process barriers to emergency centre handover. These were confirmed by the categories and codes that made up these themes. Conclusion This study identifies some of the factors perceived by pre-hospital emergency care personnel to negatively affect emergency centre handover. It provides insights into how communication and process within the emergency centre have the potential to negatively impact emergency centre handover efficacy.
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The process of handover in the busy emergency centre : a pre-hospital perspective from Johannesburg, South Africa

  • Authors: Makkink, Andrew , Stein, Christopher , Bruijns, Stevan
  • Date: 2021
  • Subjects: Emergency centre , Handover , Prehospital
  • Language: English
  • Type: Article
  • Identifier: http://hdl.handle.net/10210/479747 , uj:43405 , Citation: Makkink, A., Stein, C. & Bruijns, S. 2021. The process of handover in the busy emergency centre : a pre-hospital perspective from Johannesburg, South Africa. , DOI: https://doi.org/10.33151/ajp.18.913
  • Description: Abstract: Background Emergency centre handover usually takes place between the pre-hospital emergency care personnel who deliver the handover and the emergency centre personnel who receive the handover. Handover that is not effective may present risks to patient safety. One factor that may affect handover delivery is the process of handover within a busy emergency centre. Methods The data reported on in this study formed the qualitative component of a sequential explanatory mixed methods study. It used faceto- face, semi-structured interviews to gather data. Fifteen interviews were conducted with pre-hospital emergency care personnel from a range of qualification and scopes in South Africa. Interviews were transcribed verbatim and imported into Atlas.ti® for coding and analysis using a qualitative descriptive methodology. Results Pre-hospital emergency care participants identified a lack of emergency centre staff available to receive handover as a barrier to effective handover and attributed this to emergency centres being overworked and understaffed. This potentiated interruptions to handover and having to deliver multiple handovers for the same patient. Pre-hospital emergency care participants indicated a preference for handing over directly to a doctor. Conclusion Several potential process barriers to effective emergency centre handover were identified, including lack of personnel to receive handover, interruptions and the need to perform multiple handovers for the same patient. Generally, these barriers were attributed to the busy understaffed and overworked nature of emergency centres. We would encourage future research in emergency centre handover, specifically from the perspective of the personnel who receive handovers.
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