Browsing by Author "Stassen, Willem"

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    Coronary care networks in the resource-limited setting : systems of care in South Africa
    (Stellenbosch : Stellenbosch University, 2018-12) Stassen, Willem; Kurland, Lisa; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine. Emergency Medicine.
    ENGLISH SUMMARY : BACKGROUND: Owing to an epidemiological transition observed throughout Sub-Saharan Africa, South Africa is experiencing an increase in the incidence of myocardial infarction. ST-elevation myocardial infarction (STEMI) occurs commonly in South Africa and at much younger ages than observed elsewhere in the world. Emergent treatment in the form of coronary reperfusion is required to reduce morbidity and mortality following STEMI. Political and socio-economic factors have led to large disparities in emergency healthcare access for many South Africans. Well organised networks of care (coronary care networks, CCNs) that seamlessly integrate prehospital care, in-hospital assessment and percutaneous coronary intervention is recommended to reduce mortality for these patients. CCNs are underdeveloped and under-studied in South Africa. To this end, the aims of this project was to examine the current state of Coronary Care Networks in South Africa, a low- to middle income country and to provide recommendations for future development of such networks. METHODS: This project was comprised of four studies. Study I was a cross-sectional descriptive study that aimed at determining the current PCI-capable facilities in South Africa and sought correlations between the resources, population, poverty and insurance status using Spearman’s Rho. Study II utilised proximity analysis to determine the average drive times of South African municipal wards (geopolitical subdivisions used for electoral purposes) to the closest PCI-capable facility for each South African province. It further determined the proportion of South Africans living within one and two hours respectively, from such a facility. Study III combined data obtained from Studies I and II with network optimisation modelling to propose an optimised reperfusion strategy for patients with STEMI, based on proximity, using the North West province as a case study. Finally, Study IV employed qualitative methodology to determine the barriers and facilitators to developing CCNs in South Africa by performing interviews with individuals working with the South African contexts of coronary care. RESULTS: South Africa has 62 PCI-capable facilities, with most PCI-facilities (n=48; 77%) owned by the private healthcare 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) (Study I). This means that reperfusion by PCI is likely inaccessible to many despite approximately, 53.8% and 71.53% of the South African population living within 60 and 120 minutes of a PCI facility (Study II). Yet, we provide an efficient and swift model that provides a recommendation for the best reperfusion strategy even in the instance of a large amount of ward data with these additional constraints. This model can be run in realtime and can guide reperfusion decisions at the bedside or form the basis of regional reperfusion guidelines, and CCN development priorities (Study III). When considering the local CCN, we found an under-resourced CCN that is not prioritised by policymakers and displays considerable variation in performance based on time of day and geographic locale. Specific barriers to the development of CCNs in South Africa included poor recognition and diagnosis of STEMI, inappropriate transport and treatment decisions, and delays. Facilitators to the development of CCNs were regionalised STEMI treatment guidelines, further research and prehospital thrombolysis programmes (Study IV). CONCLUSION: South Africa has a shortage of PCI facilities. Even in areas with high concentrations of PCI facilities. In addition, many patients may not be able to access care due to socio-economic status. When considering proximity alone, most South Africans are able to access PCI within guideline timeframes. Despite this, prehospital thrombolysis should still be considered in some areas – as demonstrated by a novel approach that combines geospatial analysis and network optimisation modelling. This approach is able to efficiently determine the optimum reperfusion strategy for each geographic locale of South Africa. Current CCNs in South Africa are under-resourced, over-burdened and not prioritised. Future efforts should aim at improving STEMI recognition and diagnosis to decrease delays to reperfusion. The findings described should be considered and integrated into a future model of CCNs within South Africa, towards improving reperfusion times and finally morbidity and mortality.
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    Medication storage in Emergency Medical Services : temperature ranges from a South African sample
    (Emergency Care Society of South Africa, 2021) Wylie, Craig A.; Rambharose, Sanjeev; Ebrahim, Ismaeel; Hickman, Nicky; Wallis, Lee A; Stassen, Willem
    Background: Pre-hospital emergency care providers working in emergency medical services (EMS) are licenced to administer medication to the acutely ill and injured. In South Africa, there are significant seasonal variations in temperature, sometimes far exceeding the recommended medication storage temperature. The aim of this study was to determine the summer temperature ranges inside select emergency vehicles and storage facilities in four provinces in South Africa. Methods: A prospective, observational study was conducted in four (Cape Town, Western Cape; Johannesburg, Gauteng; Durban, KwaZulu-Natal; Potchefstroom, North West) provinces during the summer (February – March) months of 2019. A continuous temperature monitoring device was placed in the medication storage room, the response vehicle drug bags, and an ambulance at a single private EMS base in each of the provinces. Temperature data were recorded in fifteen-minute intervals. The data were extracted after six weeks and subjected to descriptive analysis. Data were also analysed in six-hourly strata to account for daily temperature variations. Results: A total of 36 002 temperature readings were recorded during the study period. The mean (range) temperature across the four bases was 25.4°C (13.1–56.8) for ambulances, 25.7°C (13.3–49.1) for primary response vehicles, and 24.4°C (17.3–33.9) for medication storage facilities. The highest mean (range) temperatures, of 33.7°C (20.4–47.9), were recorded in a Johannesburg-based primary response vehicle between 12h00 and 18h00. Conclusion: Current medication storing and transporting practices not maintain temperatures according to the recommended storage conditions. Further investigation should address the implication of temperature fluctuations on medication degradation, and a sustainable, cost-effective solution should be developed to store medication in the pre-hospital setting.
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    Percutaneous coronary intervention still not accessible for many South Africans
    (Elsevier, 2017-09) Stassen, Willem; Wallis, Lee; Lambert, Craig; Castren, Maaret; Kurland, Lisa
    Introduction: The 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. Methods: This 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. Results: South 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). Conclusion: For 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.
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    South African paramedic perspectives on prehospital palliative care
    (BMC (part of Springer Nature), 2020-10-08) Gage, Caleb Hanson; Geduld, Heike; Stassen, Willem
    Background: Palliative care is typically performed in-hospital. However, Emergency Medical Service (EMS) providers are uniquely positioned to deliver early palliative care as they are often the first point of medical contact. The aim of this study was to gather the perspectives of advanced life support (ALS) providers within the South African private EMS sector regarding pre-hospital palliative care in terms of its importance, feasibility and barriers to its practice. Methods: A qualitative study design employing semi-structured one-on-one interviews was used. Six interviews with experienced, higher education qualified, South African ALS providers were conducted. Content analysis, with an inductive-dominant approach, was performed to identify categories within verbatim transcripts of the interview audio-recordings. Results: Four categories arose from analysis of six interviews: 1) need for pre-hospital palliative care, 2) function of pre-hospital healthcare providers concerning palliative care, 3) challenges to pre-hospital palliative care and 4) ideas for implementing pre-hospital palliative care. According to the interviewees of this study, pre-hospital palliative care in South Africa is needed and EMS providers can play a valuable role, however, many challenges such as a lack of education and EMS system and mindset barriers exist. Conclusion: Challenges to pre-hospital palliative care may be overcome by development of guidelines, training, and a multi-disciplinary approach to pre-hospital palliative care.