RESEARCH

 

Emergency care research priorities in South Africa

 

 

D J van Hoving^I; B K Barnetson^II; L A Wallis^III

^IMB ChB, Dip PEC (SA), MMed (Em Med), MScMedSci (Clin Epi); Division of Emergency Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, Cape Town, South Africa
^IIMB ChB; Division of Emergency Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, Cape Town, South Africa
^IIIMB ChB, FCEM, MD; Division of Emergency Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, Cape Town, South Africa

Correspondence

 

 

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ABSTRACT

BACKGROUND: Emergency care research is rarely undertaken in low- and middle-income countries. A manageable 'road map' for research in South African (SA) emergency care is needed to address research gaps.
OBJECTIVE: To identify, collate and prioritise research topics from identified knowledge gaps in emergency care in SA.
METHODS: Seventy-six individuals were invited to participate in a modified Delphi study. Participants were requested to suggest important research topics before rating them. Consensus was achieved when >75% of participants strongly agreed or disagreed. Participants then ranked the agreed statements before selecting the most appropriate methodology relating to study design, funding and collaboration.
RESULTS: Three hundred and fifty topics were suggested by 31 participants. Topics were collated into 123 statements before participants rated them. Consensus was achieved for 39 statements. The highest-ranked priority in the prehospital group was to determine which prehospital interventions improve outcomes in critically ill patients. The competence of emergency care providers in performing common lifesaving skills was deemed the most important in clinical emergency care. Implementing and reviewing quality improvement systems scored the highest under general systems and safety management. Only 22 statements achieved consensus regarding study design. The National Department of Health was the preferred funding source, while private organisations and emergency care societies were identified as possible collaborative partners.
CONCLUSION: This study provides expert consensus on priority research areas in emergency care in SA as a guide for emergency care providers to ensure evidence-based care that is relevant to the SA population.

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Health research has a high value to society and has resulted in a noteworthy improvement in healthcare. South Africa (SA) has a quadruple burden of disease that is being addressed by the strategic priorities of the National Department of Health (NDoH).^[1] A continuous reduction in morbidity and mortality can only be guaranteed if research is ongoing, if the efficacy and adverse effects of medical interventions are continuously monitored, and by ensuring that research is relevant to a specific patient population.^[2]

High-quality healthcare implies practice that is consistent with the current best evidence.^[3] It is essential to know which interventions work and which do not, and which are likely to be harmful. This becomes vitally important in settings with a mismatch between the burden of disease and available resources. While healthcare professionals in low- and middle-income countries (LMICs) should use evidence-based decisions in day-to-day patient care, implementing evidence-based medicine remains difficult.^[4] Since the majority of studies are done in high-income countries for high-income countries relating to health conditions important to high-income countries,^[5] their limited applicability and transferability to LMICs creates a knowledge vacuum in LMICs, including SA.^[4]

Research in the field of emergency care specifically related to LMICs is sparse. A single consensus study related to clinical research priorities, emergency centre management and administration exists,^[6] but there are no lists or identified gaps for any aspects of emergency or acute care specific to SA.

Research related to emergency care in SA demands a manageable 'road map' to address the research gaps. This study aimed to identify, collate and prioritise research topics from identified knowledge gaps in emergency care in SA.

 

Methods

Study design

A three-phase modified Delphi study was undertaken from 1 March 2012 to 5 April 2013. The Delphi study design was modified in that each phase was limited to only two or three rounds (Fig. 1).

Ethics approval was obtained from the Human Research Ethics Committee, Stellenbosch University, Tygerberg, Cape Town (Reference S12/02/034).

Study population

Seventy-six participants were invited to represent the expert panel (Appendix 1). They included doctors, nurses, prehospital care providers, and policy makers from all the provinces in SA. Invited panel members were given the option of appointing a representative in their place.

Data collection and management

All potential panel members were invited by e-mail, and participation implied consent. An online survey tool (SurveyMonkey) was used to facilitate the process. The views of all participating panellists were given equal weight. Participants were given 4 weeks to complete each round; weekly reminders were sent by e-mail until a response was received or the 4 weeks had expired.

All panel members were invited to participate in rounds 1 and 2 of phase 1 and re-invited for the first round of phases 2 and 3.

In phase 1 (identifying research topics), participants were requested to suggest important research topics in five categories of emergency care (adult emergency care, paediatric emergency care, prehospital emergency care, emergency nursing care, and a 'general' section for any other area related to emergency care). An example was provided for each category, and categories were randomised to avoid question order bias. The suggested research topics were then collated

into 123 research statements. Participants were then asked to rate their agreement that each statement was a priority for research in emergency care in SA. A 10-point Likert scale was used, and consensus was achieved when >75% of participants strongly agreed (scores 8 - 10) or strongly disagreed (scores 1 - 3). The mean score for each statement was calculated, while statements completed as 'not applicable' were excluded. Surveys were then individualised, and participants were presented with all non-consensus statements. Both the participant's rating score and the mean rating score for each non-consensus statement were provided to allow participants to consider an alternative rating score.

In phase 2 (prioritising research topics), consensus statements from phase 1 were regrouped into three new categories: (i) prehospital; (ii) clinical; and (iii) general systems and safety. Panellists were asked to rank the statements in each category in order of importance. Categories per se and statements within each category were randomised to prevent question order bias. Participants could exclude statements by indicating them as 'not applicable' to their area of expertise. Submission was blocked until all statements were either ranked or excluded. The overall rank order per category was subsequently determined. For each participant, the first ranked statement (i.e. most important) was given a value of 1. The lowest-ranked or least important statement received the value of the number of statements in that category less the number of statements selected as 'not applicable'. An average ranking score was calculated for every

statement by adding the values given by all participants, and dividing that by the number of participants that ranked that specific statement; the top ranking statement would therefore have the lowest average score (Table 1).

The ranked statements were presented to the participants. The categories were randomised, but the statements in each category were presented in the order of the average ranking scores achieved. Both the participant's ranking score and the mean ranking score were provided to allow participants to consider an alternative ranking score.

For the final phase (best approach to prioritised research topics), participants were requested to choose one or more study design options. Participants were also given the option of using free text to suggest funding and collaboration options for each statement. Participants were again allowed to select 'not applicable' to exclude themselves from that statement if they considered the topic out of their area of expertise. Only the study design options for each research statement were redistributed to determine consensus.

Collected data were transferred to and analysed on a password-protected electronic spreadsheet (Microsoft Office Excel 2010, Microsoft Corporation, USA).

 

Results

Seventy-six panel members were invited to participate in the study. Two medical and three nursing panel members appointed representatives in their place. The response statistics for all study phases are summarised in Fig. 2.

 

 

Three hundred and fifty research topics were suggested by 31 participants (41%). The suggested topics were collated into 123 research statements. Seventy-five of the original 76 panel members were invited to rate their agreement of the proposed collated research statements as a priority for research in emergency care in SA (one panel member was unintentionally not invited). Thirty-one (41%) responded, and consensus was achieved for 11 statements. The remaining statements were resent for re-rating. Consensus was achieved for 39 statements after 25 participants (81%) changed their initial scores.

These statements were then grouped into the three categories as described under 'Methods'. One of the statements was only identified late in the study and was subsequently not included. The consensus statements were ranked by 29 panel members (39%). Statements were re-ordered according to their average ranking scores achieved. The Delphi process used to determine consensus regarding the ranking of the research statements was completed by 19 participants (65%). Tables 2, 3 and 4 provide the final consensus ranking order of consensus priority statements in each category.

The response rate for suggesting study design options was 28% (n=21); only three statements initially achieved consensus. The last round of the study (reconsidering study design options) was completed by 15 participants (71%). An additional 22 statements achieved consensus regarding the most appropriate study design to use (Tables 2 - 4).

One to three suggestions per statement for funding options were received for 32 (84%) of the 38 statements. The NDoH (n=26) and private organisations (n=12) were most often indicated as potential funding sources. One to two collaboration suggestions per statement were provided for 29 statements (76%). Private organisations (n=7) and emergency care-related societies (n=7) were considered as options with which to do collaborative work.

 

Discussion

Thirty-nine statements related to emergency care were identified as high priorities for the SA setting.

Prehospital emergency care

Prehospital interventions on patient outcomes were ranked first among prehospital research priorities. The need to substantiate clinical care by evidence and to use clinically relevant performance measures was echoed by studies from Europe and the USA, including both adult and child populations.^[7-9] There have been substantial international debates regarding the scope of prehospital care, and it is clear that the issue has not been resolved. The SA emergency medical services system has adopted the Anglo-American system, which minimises on-scene time (as opposed to the Franco-German model, which includes prehospital physicians with an extensive scope of practice and very advanced technology).^[10] A prolonged on-scene time, usually as a result of additional prehospital interventions, has been shown to be detrimental to patient outcomes (especially in trauma); it is therefore important to ensure that only the necessary interventions, backed by substantial evidence, are performed.^[11]

Appropriate management strategies ranked second in the prehospital group. Any pre-hospital system faces challenges with the acquisition and appropriate allocation of assets and resources, including human resources.^[12] SA has been losing significant numbers of prehospital practitioners with advanced training over the past decade.^[13] Poor working conditions, physical security and economic considerations were identified as some of the main 'push' factors.^[13] Govender et al.^[14]also hinted that current measures are inadequate to actively manage the shortages of prehospital practitioners with advanced training and their migration out of SA.

Clinical emergency care

Emergency care (prehospital, medical and nursing) is a procedure-orientated field that requires adequate knowledge and skills to diagnose and manage acute aspects of illnesses and injuries.^[15] Overcrowding and prolonged length of patient stay mean that the management of critically ill and trauma patients frequently extends beyond initial stabilisation in the emergency centre when intensive care unit capacity is limited (and exhausted). The consequences were reflected in the research priorities related to clinical emergency care, where statements relating to competence in managing critically ill patients featured repeatedly.

However, SA-trained healthcare providers have always been sought after internationally owing to the high quality and standard of their medical education and their hands-on experience.^[16] The focus on competence is also in stark contrast to other international studies, which highlighted clinical outcomes as their top research priorities.^[17,18] Emergency medicine is still a relatively young specialty in SA, with the focus on competence revealing that it is still establishing its place in the broader medical field.

The burden of disease and patient conditions presenting to emergency centres ranked third in the clinical emergency care section. Knowing the acuity mix of patients presenting to emergency centres is essential to plan service delivery accurately. The efficient deployment of staff relative to temporal patterns of patient presentations and developing strategies for dealing with non-referred minor cases has been highlighted previously.^[19] This information can also help in identifying key areas to optimise patient flow from as early as the initial presentation to the emergency medical service, so that emergencies can be dealt with promptly and appropriately.^[19]

The emergency medicine setting is a unique environment of high patient volumes, brief clinical encounters, and patients from all age groups representing a spectrum of acuity. Risk stratification is the initial step towards a personalised patient care plan to ensure that patients are safely managed and appropriately investigated. Although the identification of appropriate markers of severity (5th-ranked statement) was identified as an international priority,^[17] it would be just as useful, or even more useful, in resource-limited settings. The early identification of disease severity and subsequent focused management of high-risk patients is therefore as important from a healthcare economics point of view as from a morbidity and mortality perspective.

General systems and safety management

The expectation and requirement to deliver safe and high-quality emergency care have never been greater. Healthcare systems are not as reliable as has been thought, and high-quality care is often lacking.^[20,21] Cost-effectiveness of emergency medical interventions and quality assurance are considered global priorities.^[6,21] According to the Institute of Medicine in the USA, a healthcare system should aim to be safe, effective, efficient, patient-centred, timely and equitable.^[20] Components of emergency care that can improve quality and patient safety include well-trained and motivated staff, appropriate physical structures, effective processes to enable high-quality care, co-ordinated clinical pathways supported by best evidence-based practice, and monitoring objective outcome measures to reflect continuous quality improvement (e.g. diagnostic errors, mortality and morbidity rates, etc.).^[22]

Study limitations

Purposeful sampling was used for the panel selection, the criteria being that experts were identified by their specialist qualification and roles as leaders in their fields or heads of academic institutions or societies. Policymakers remained largely non-contactable, limiting the knowledge gained pertaining to policies and resource allocation at provincial or national levels.

Participants in a Delphi study have an interest and involvement in the question being examined. Researcher and subject bias is a known limitation, but the wide range of panellists should offset this. The opinion of a subset of experts with special interests in certain aspects of emergency care (e.g. paediatric emergency care) may have been under-represented.

The lack of participant discussion may have prevented participants from changing their views and responding according to the majority opinion.

Collating free text statements was undertaken in an effort to reduce the number of statements to avoid panel fatigue and attrition. Abstraction may have led to omission of details and potential over simplification of suggested priority topics.

The response rate and consensus thresholds (75%) mean that final agreement is not implied; guidelines for further research were essentially identified.

 

Conclusion

This study provides expert consensus on the current priority research areas in emergency care in SA. It can ultimately guide emergency care providers to serve the SA population with evidence-based emergency medical care that is relevant.

Acknowledgement. We thank Ms Rachel Allgaier for her input on the initial proposal.

 

References

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Correspondence:
D J van Hoving
nvhoving@sun.ac.za

Accepted 20 October 2014.

 

 

Appendix 1 - Click to enlarge