A retrospective review of advanced life support interfacility transfers of the public sector emergency medical service in the Western Cape Province, South Africa
Article Sidebar
Main Article Content
Abstract
Background. The need for critical care transfers (CCTs) has increased in recent years owing to the growing prevalence of high-acuity patients who require access to specialised care and/or resources that are not readily available at the facility where they find themselves. During their transfer from one facility to another, critically ill and injured patients commonly require ongoing care, monitoring and interventions that can only be provided by transfer teams with advanced training and appropriate equipment. In South Africa (SA), these transfers are undertaken mainly by advanced life support (ALS) providers with variable amounts of training. Understanding the demographics and needs of CCT patients in specific contexts is essential to inform training and policy.
Objectives. To broadly describe the population of adult patients undergoing CCTs facilitated by the public sector emergency medical service (EMS) in the Western Cape Province, South Africa. Patient demographics (age and gender), time intervals (response time, scene time, transfer time), primary diagnosis (respiratory, cardiovascular, gastrointestinal tract, and others), attachments, and clinical or pharmacological interventions.
Methods. A retrospective descriptive analysis was conducted on electronic patient care records (ePCRs) logged in the EMS’s Computer-Aided Dispatch (CAD) database from January 2018 to December 2021. As no universal criteria currently exist for distinguishing a CCT from another transfer, our focus was on cases that required ALS care during the transfer.
Results. During the study period, 25 635 adult patients underwent ALS transfers, with a nearly equal gender distribution. The median patient age was 40 (range 18 – 101) years. Sixty percent of patients were triaged as orange upon arrival (for urgent management) and the remainder red (for emergency or immediate management). Average response, preparation, and transport times spent (minutes:seconds) were 7:10, 16:58, and 12:56, respectively. Respiratory disease (17.9%), cardiovascular disease (12.2%), and central nervous system disorders (12.0%) were the most prevalent clinical conditions. Non-invasive blood pressure monitors (98%) and pulse oximeters (96%) were commonly used devices. Medications were administered to 22% of patients, primarily via intravenous injection (7.5%) and continuous infusion (6.7%). Morphine (4.3%), midazolam (6.4%), and adrenaline (2.0%) were frequently utilised medications. These findings highlight the demographic profile, clinical conditions, and critical care aspects involved in ALS patient transfers, emphasising the complexity and urgency of prehospital medical transport.
Conclusion. This study analyses adult patients undergoing ALS transfers by a public sector EMS in the Western Cape, SA (2018 - 2021), providing insights into the transferred patient population. It highlights the importance of continuous patient monitoring, especially electrocardiograms (ECGs), and reveals inconsistencies in medication practices, indicating the need for improved training. The findings stress the necessity for standardised protocols and structured training programmes to inform educational initiatives, equipment procurement, and the critical care retrieval services (CCRS) curriculum development. Additionally, this research can help establish clinical standards for dispatching specific ALS cadres based on patient needs.
Article Details
Issue
Section
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
The SAJCC is published under an Attribution-Non Commercial International Creative Commons Attribution (CC-BY-NC 4.0) License. Under this license, authors agree to make articles available to users, without permission or fees, for any lawful, non-commercial purpose. Users may read, copy, or re-use published content as long as the author and original place of publication are properly cited.
Exceptions to this license model is allowed for UKRI and research funded by organisations requiring that research be published open-access without embargo, under a CC-BY licence. As per the journals archiving policy, authors are permitted to self-archive the author-accepted manuscript (AAM) in a repository.
How to Cite
References
1. Dunn MJG, Gwinnutt CL, Gray AJ. Critical care in the emergency department: Patient transfer. Emerg Med J 2007;24(1):40-44. https://doi.org/10.1136/emj.2006.042044
2. NeelyAH,PonshunmugamA.AqualitativeapproachtoexamininghealthcareaccessinruralSouth Africa. Soc Sci Med 2019;230:214–221. https://doi.org/10.1016/j.socscimed.2019.04.025
3. Gumede DM, Taylor M, Kvalsvig JD. Engaging future healthcare professionals for rural health services in South Africa: Students, graduates and managers’ perceptions. BMC Health Serv Res 2021;21(1):220 https://doi.org/10.1186/s12913-021-06178-w
4. Ashokcoomar P. Inter-healthcare facility transfer of critically ill neonates: The development of a programme for emergency medical care in the South African context. Durban University of Technology, South Africa, 2018. http://hdl.handle.net/10321/3245 (accessed 20 January 2024). https://doi.org/10.51415/10321/3245
5. Puchalski Ritchie LM, Khan S, Moore JE, et al. Low- and middle-income countries face many common barriers to implementation of maternal health evidence products. J Clin Epidemiol 2016;76:229-237. https://doi.org/10.1016/j.jclinepi.2016.02.017
6. Scribante J, Bhagwanjee S. National audit of critical care resources in South Africa: Unit and bed distribution. S Afr Med J 2007;97(12):1311.
7. Kautzky K, Tollman SM. A perspective on primary health care in South Africa: Primary health care: In context . South African Health Review 2008;1. https://doi/10.10520/EJC35514 (accessed 3October 2023).
8. Corke C, de Leeuw E, Lo SK, George C. Predicting future intensive care demand in Australia. Crit Care Resusc J Australas Acad Crit Care Med 2009;11(4):257-260. https://doi.org/10.1016/S1441- 2772(23)01284-X
9. Komashie A, Ward J, Bashford T, et al. Systems approach to health service design, delivery and improvement: A systematic review and meta-analysis. BMJ Open 2021;11(1):e037667. https://doi. org/10.1136/bmjopen-2020-037667
10. Droogh JM, Smit M, Absalom AR, Ligtenberg JJ, Zijlstra JG. Transferring the critically ill patient: Are we there yet? Crit Care 2015;19(1):62. https://doi.org/10.1186/s13054-015-0749-4
11. Alabdali A, Fischer JD, Trivedy C, Lilford R. A systematic review of the prevalence and types of adverse events in interfacility critical care transfers by paramedics. Air Med J 2017;36(30:116-121. https://doi.org/10.1016/j.amj.2017.01.011
12. Bourn S, Wijesingha S, Nordmann G. Transfer of the critically ill adult patient. BJA Educ 2018;18(3):63-68. https://doi.org/10.1016/j.bjae.2017.11.008
13. VenterM,StantonD,ConradieN,JordaanL,VenterC,StassenW.Theneedforsettingstandardsin critical care transfers. South Afr J Crit Care 2017;33(1):32–39. https://doi.org/10.7196/SAJCC.2017. v33i1.319
14. Venter C, Conradie N, Venter M, et al. A proposed definition of Critical Care Retrieval in the South African context. S Afr J Pre-Hosp Emerg Care 2021 Jul;2(1). https://www.journals.ac.za/index.php/ sajpec/article/view/4477. https://doi.org/10.24213/2-1-4477
15. Andrews S, Catlin S, Lamb N, Christensen M. A dedicated retrieval and transfer service: The QUARTS Project. Nurs Crit Care 2008;13(3):162-168. https://doi.org/10.1111/j.1478- 5153.2008.00272.x
16. Senekal ACG, Vincent-Lambert C. Experiences of emergency care providers conducting critical care transfers in Gauteng Province, South Africa. South Afr J Crit Care 2022;37(3):92–96. https:// doi.org/10.7196/SAJCC.2021.v37i3.487
17. Gimenez FMP, de Camargo WHB, Gomes ACB, et al. Analysis of adverse events during intrahospital transportation of critically ill patients. Crit Care Res Pract 2017:6847124. https://doi. org/10.1155/2017/6847124
18. Cuschieri S. The STROBE guidelines. Saudi J Anaesth 2019;13(Suppl 1):S31-4. https://doi. org/10.4103/sja.SJA_543_18
19. WesternCapeGovernment.Medicalemergencytransportandrescue.https://www.westerncape.gov. za/service/medical-emergency-transport-and-rescue-metro. (accessed 22 January 2020].
20. Gilbert EH, Lowenstein SR, Koziol-McLain J, Barta DC, Steiner J. Chart reviews in emergency medicine research: Where are the methods? Ann Emerg Med 1996;27(3):305–308. https://doi. org/10.1016/s0196-0644(96)70264-0
21. Seggie J. Editor’s choice. Trauma: South Africa’s other epidemic. S Afr Med J 2013;103(9):589–590. 22. Finn J, Dixon JM, Moreira F, et al. Patterns of on-scene and healthcare system trauma deaths in the Western Cape of South Africa. World J Surg 2024;48(2):320–330. https://doi.org/10.1002/wjs.12043 23. Statistics South Africa. Rising non-communicable diseases: A looming health crisis. Statistics South
Africa. 2023 https://www.statssa.gov.za/?p=16729. (accessed 22 February 2024).
24. Mayosi BM, Lawn JE, van Niekerk A, Bradshaw D, Karim SSA, Coovadia HM. Health in South Africa: Changes and challenges since 2009. Lancet 2012;380(9858):2029-2043. https://doi.
org/10.1016/S0140-6736(12)61814-5
25. Kabudula CW, Houle B, Collinson MA, et al. Progression of the epidemiological transition in a rural South African setting: Findings from population surveillance in Agincourt, 1993–2013. BMC Public Health 2017;17(1):424. https://doi.org/10.1186/s12889-017-4312-x
26. Maslo C, Friedland R, Toubkin M, Laubscher A, Akaloo T, Kama B. Characteristics and outcomes of hospitalised patients in South Africa during the COVID-19 omicron wave compared with previous waves. JAMA 2022;327(6):583–584. https://doi.org/10.1001/jama.2021.24868
27. Mbunge E. Effects of COVID-19 in South African health system and society: An explanatory study. Diabetes Metab Syndr Clin Res Rev 2020;14(6):1809–1814. https://doi.org/10.1016/j. dsx.2020.09.016
28. Hadian M, Mozafari MR, Mazaheri E, Jabbari A. Challenges of the health system in preventing non-communicable diseases: Systematised review. Int J Prev Med 2021; 12:71. https://doi. org/10.4103/ijpvm.IJPVM_487_20
29. Douglas M, Kgatla N, Sodi T, et al. Facilitators and barriers in prevention of cardiovascular disease in Limpopo, South Africa: A qualitative study conducted with primary health care managers. BMC Cardiovasc Disord 2021;21:492. https://doi.org/10.1186/s12872-021-02290-1
30. Cappuccio FP, Miller MA. Cardiovascular disease and hypertension in sub-Saharan Africa: Burden, risk and interventions. Intern Emerg Med 2016;11:299–305. https://doi.org/10.1007/ s11739-016-1423-9
31. Martin T. Transporting the adult critically ill patient. Surg Oxf 2021;39(1):15–21. https://doi. org/10.1016/j.mpsur.2020.11.006
32. Branson RD, Rodriquez D. Monitoring during transport. Respir Care 2020;65(6):882–893. https:// doi.org/10.4187/respcare.07796
33. Mindray North America. Monitoring patients during transport. https://www. mindraynorthamerica.com/monitoring-patients-during-transport (accessed 23 January 2024).
34. Dar M, Swamy L, Gavin D, Theodore A. Mechanical-ventilation supply and options for the
COVID-19 pandemic. Leveraging all available resources for a limited resource in a crisis. Ann Am
Thorac Soc 2021;18(3):408–416. https://doi.org/10.1513/AnnalsATS.202004-317CME
35. Möhlenkamp S, Thiele H. Ventilation of COVID-19 patients in intensive care units. Herz
2020;45(4):329–331 https://doi.org/10.1007/s00059-020-04923-1
36. Wylie C, Welzel T, Hodkinson P. Waveform capnography in a South African prehospital
service: Knowledge assessment of paramedics. Afr J Emerg Med 2019;9(2):96–100. https://doi.
org/10.1016/j.afjem.2019.01.010
37. Nagler J, Krauss B. Capnography: A valuable tool for airway management. Emerg Med Clin North Am 2008;26(4):881–897. https://doi.org/10.1016/j.emc.2008.08.005
38. Kupnik D, Skok P. Capnometry in the prehospital setting: Are we using its potential? Emerg Med J 2007;24(9):614-617. https://doi.org/10.1136/emj.2006.044081.
39. Patel SB, Kress JP. Sedation and analgesia in the mechanically ventilated patient. Am J Respir Crit Care Med 2012;185(5):486–497. https://doi.org/10.1164/rccm.201102-0273CI
40. Hylén M, Akerman E, Alm-Roijer C, Idvall E. Behavioral Pain Scale – translation, reliability, and validity in a Swedish context. Acta Anaesthesiol Scand 2016;60(6):821–828. https://doi. org/10.1111/aas.12688
41. Ayasrah SM, O’Neill TM, Abdalrahim MS, Sutary MM, Kharabsheh MS. Pain assessment and management in critically ill intubated patients in Jordan: A prospective study. Int J Health Sci 2014;8(3):287–298. https://doi.org/10.12816/0023981
42. Taylor DM, Chen J, Khan M, et al. Variables associated with administration of analgesia, nurse- initiated analgesia and early analgesia in the emergency department Emerg Med J 2017;34:13-19. https://emj.bmj.com/content/34/1/13. https://doi.org/ 10.1136/emermed-2016-206044
43. Hiilcrom. Three factors that could be impacting your ECG interpretation. https://www.hillrom. eu/en/knowledge/article/three-factors-that-could-be-impacting-your-ecg-interpretation/. (accessed 4 October 2023).
44. Milligan JE, Jones CN, Helm DR, Munford BJ. The principles of aeromedical retrieval of the critically ill. Trends Anaesth Crit Care 2011;1(1):22–26. https://doi.org/10.1016/j.cacc.2010.07.019
45. Elliott M, Endacott R. The clinical neglect of vital signs’ assessment: An emerging patient safety
issue? Contemp Nurs 2022;58(4):249–252. https://doi.org/10.1080/10376178.2022.2109494
46. Moreno-Serra R, Anaya-Montes M, León-Giraldo S, Bernal O. Addressing recall bias in (post-) conflict data collection and analysis: Lessons from a large-scale health survey in Colombia. Confl
Health 2022;16:14. https://doi.org/10.1186/s13031-022-00446-0
47. Giusti ACBD, Cornélio ME, de Oliveira EM, Giguère JF, Gallani MCBJ. Standard practices in cardiac monitoring: Training needs of intensive care unit nurses. BMC Nurs 2024;23:82. https:// doi.org/10.1186/s12912-024-01742-1
48. Pota V, Coppolino F, Barbarisi A, et al. Pain in intensive care: A narrative review. Pain Ther 2022;11(2):359–367. https://doi.org/10.1007/s40122-022-00366-0
49. Nordness MF, Hayhurst CJ, Pandharipande P. Current perspectives on the assessment and management of pain in the intensive care unit. J Pain Res 2021;14:1733. https://doi.org/10.2147/ JPR.S256406
50. Moyen E, Camiré E, Stelfox HT. Clinical review: Medication errors in critical care. Crit Care 2008;12(2):208. https://doi.org/10.1186/cc6813
51. Bourne RS, Phipps DL, Jennings JK, et al. Medication safety for intensive care patients transferring to a hospital ward: A hierarchical task analysis. Hum Factors Health 2022; 2:100030. https://doi.org/10.1016/j.hfh.2022.100030
52. Health Professions Council of South Africa. Clinical Practice Guidelines for Emergency Care Providers. Health Professions Council of South Africa, 2018. https://www.hpcsa.co.za/ Uploads/EMB/CLINICALPRACTICEGUIDELINESPROTOCOLS- JULY 2018.pdf (accessed 17 September 2025).
53. Venter M, Stassen W. A national retrospective descriptive analysis of critical care transfers in the private sector in South Africa. S Afr Med J 2023;113:e672. https://doi.org/10.7196/ SAMJ.2023.v113i8.672
54. Laws S, Wang C, Halter M. Knowledge, attitudes and practices of UK paramedics regarding pharmacology and the legal, management and administration aspects of medicines: A cross- sectional online quantitative survey. Br Paramed J 2020;5(2):1–9. https://doi.org/10.29045/14 784726.2020.09.5.2.1
55. Leggio WJ, Grawey T, Stilley J, Dorsett M. EMS curriculum should educate beyond a technical scope of practice: Position statement and resource document. Prehosp Emerg Care 2021;25(5):724–729. https://doi.org/10.1080/10903127.2021.1925793
56. Alanazi A. Intubations and airway management: An overview of hassles through third millennium. J Emerg Trauma Shock 2015;8(2):99–107. https://doi.org/10.4103/0974- 2700.145401
57. Laatz D, Welzel T, Stassen W. Developing a South African Helicopter Emergency Medical Service Activation Screen (SAHAS): A Delphi study. Afr J Emerg Med 2019;9(1):1–7. https:// doi.org/10.1016/j.afjem.2018.09.001
58. Murdoch I, Sajjanhar T, Tibby S, Hatherill M, Marsh M. Cost-effectiveness of a paediatric retrieval service. Crit Care 1997;1(1):P126. https://doi.org/10.1186/cc97
59. Newton PR, Naidoo R, Brysiewicz P. The appropriateness of emergency medical service responses in the eThekwini district of KwaZulu-Natal, South Africa. S Afr Med J 2015;105(10):844-847. https://doi.org/10.7196/SAMJnew.8273
60. Conradie NJ, Vincent-Lambert C, Stassen W. A comparison of the content taught in critical care transportation modules across South African bachelor’s degrees in emergency medical care. South Afr J Crit Care. 2022 May 6;38(1):10.7196/SAJCC.2022.v38i1.498. https://doi. org/10.7196/SAJCC.2022.v38i1.498