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Abstract
Background The aim of this study was to determine whether the current South African Emergency Medicine Curriculum is appropriate for the burden of disease seen by registrars in Cape Town Emergency Centres.
Method This is a cross-sectional retrospective audit of patients presenting to a range of secondary level emergency centres (ECs) in Cape Town. The type of clinical presentations, investigations done and procedures performed were analysed. Basic descriptive statistics are presented.
Results A total of 1283 clinical presentations from three secondary level ECs in Cape Town were collated. Of these clinical presentations, 47 were not included in the South African Emergency Medicine curriculum; in addition, two were only included in the paediatrics section. 115 procedures were tabled, of these, 11 were not included in the curriculum. 730 investigations were tabled; 527 were not included in the curriculum.
Conclusions The curriculum did not cover all the clinical conditions, procedures and investigations encountered by emergency medicine (EM) registrars in Cape Town. In addition, there were multiple categories in the curriculum that were not encountered in EM practice at all. The investigations section of the curriculum correlated particularly poorly with the skills needed for the burden of disease seen in ECs in Cape Town. The curriculum should be redrafted guided by a practice analysis of EM.
- Curriculum
- post graduate education
- emergency medicine
- scope of practice
- practice analysis, education
- teaching
- emergency care systems
- emergency departments
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- Curriculum
- post graduate education
- emergency medicine
- scope of practice
- practice analysis, education
- teaching
- emergency care systems
- emergency departments
Introduction
Emergency medicine (EM) is a new specialty in South Africa and, as such, the scope of practice is still being defined in that context.1–4 The scope, frequency and acuity of presenting complaints and diagnoses seen in emergency centres (ECs) in South Africa should be used to guide curriculum development, training and assessment of EM registrars. Better understanding the patients seen in ECs would provide a foundation to help develop the existing core curriculum for EM training in South Africa.5 It would help to ensure that locally produced specialists are appropriately trained for the patients they will see in their ECs.
South Africa is a country of 49 million people living within a mixture of ‘developed’ and ‘developing’ nation conditions (Census Estimate Mid-Year 2009).6 The population face multiple disease processes such as infectious diseases (tuberculosis and HIV), trauma (violence and motor vehicle accidents) and chronic disease (diabetes, heart disease and malignancy), as well as mental health disorders.7 8 The burden from mental health disorders is linked to substance abuse, especially from alcohol and amphetamines, known locally as tik. Thus, the population faces diseases linked to poverty and diseases associated with affluence; diseases that occur in very different socioeconomic groups.
In this context, there is a dire need for EM: in recognition of this, in 2003 it was established as a specialty. As with most young disciplines, the scope of practice is still being defined,1–4 but is multidisciplinary, and concerned with ‘resuscitation, stabilisation and appropriate disposition’ of patients.1 The profile is different from those of developed countries in case mix, but also has different challenges in terms of difficult work environments.
One of the first steps in establishing a new specialty is defining the core curriculum against which specialists will train. The South African EM curriculum5 was drafted prior to commencement of the EM training programme, and was based on international curricula. Despite the fact that the curriculum is intended only as a guide, it is essential that it is relevant to the workload actually experienced on a daily basis in ECs by EM trainees. Although a curriculum for EM can be guided by those already established (such as those in the USA, UK and Australia),9–12 these do not necessarily apply to South Africa. A locally produced curriculum is essential.
The current curriculum directs a training rotation: a 4-year programme in which registrars rotate through 3-month blocks encompassing Trauma, Paediatrics, ICU, EM, Obstetrics and Gynaecology, Anaesthetics and EMS. At least 2 years are spent in ECs. Encompassed in these EC rotations is experience in Orthopaedics and General Surgery. In addition, time is spent in ENT, Ophthalmology and Psychiatry. Registrars write a primary examination composed of clinically orientated basic science questions on Anatomy, Physiology, Pharmacology and Pathology; the final exam is clinical. It is expected that on admission to the registrar programme, trainees will have completed Advanced Cardiac Life Support (ACLS), Advanced Trauma Life Support (ATLS) and Advanced Paediatric Life Support (APLS) or Paediatric Advanced Life Support (PALS) courses. Registrars are also expected to complete five short courses, ranging from the Emergency Management of Severe Burns to Major Incident Medical Management and Support.13
There are currently five EM registrar training programmes in South Africa: the University of the Witwaterstrand, Pretoria University, Limpopo University, the University of Kwa-Zulu Natal and the Joint Division of Emergency Medicine at the University of Cape Town (UCT) and Stellenbosch University (SUN) (in the Western Cape Province). The UCT/SUN programme trains 22 registrars from South Africa and an additional 16 from various other countries; all other programmes together train an additional 24 registrars. Although the majority of trainees gain their experience on the UCT/SUN platform, it is unclear whether they are being exposed to a profile of patients that is in line with their training curriculum. If not, changes to the curriculum will be required.
There is very limited research into the case mix occurring in ECs in the setting under study. Most research looking at burden of disease is derived from mortality figures, and, as such, does not include those diseases contributing to morbidity.7 8 14 In addition, these figures reflect the population seen by all medical specialities and not specifically EM. There are some small studies, limited to primary care settings or single secondary level ECs that examine the EM case mix in the Western Cape,15–17 but none of these studies has addressed the question of whether the patients seen are in line with the national EM training curriculum.
International EM curricula9–12 are constantly being refined guided by evidence and expert consensus; in one such recent study, a single-centre EC practice analysis was mapped to the national EM curriculum for the UK,18 and concluded that the curriculum covered all the topics seen in the EC. An evidence-based answer is needed to the same question in RSA ECs.
The South African curriclum5 is meant as a guide to major topics, and is not based on the scope of practice of EM. It is presented as a list of groupings, with no weighting attached to each area, and the investigations and procedures required for those groupings are not paired to the clinical conditions. It is divided into three different sections: a primary component that encompasses anatomy, pharmacology, physiology and pathology, and is grouped into very broad categories (such as surface anatomy, or cellular injury and adaptation). The syllabus for the final examination is grouped variously by subspeciality areas (eg prehospital emergency care), symptom complexes (such as acute signs and symptoms in adults), systems (like cardiovasular emergencies) and procedures (for instance, emergency wound management). The final section describes training objectives for the 4-year rotation, and discusses which specialties need to be covered and how much time should be spent in each of these. In addition, it lists the required skills to be gained within all those areas, eg ECG interpretation. ECG interpretation is, however, not listed as a skill in the syllabus for the final exam.
International scope of practice in EM may well differ from that seen in South Africa. An accurate assessment of workload, case mix and acuity level of presentations at ECs is essential to help define the scope of training for EM registrars, including their core curriculum, examination syllabus (both primary and final examinations) and registrar rotation through clinical areas.
This study was undertaken to determine whether EM trainees in the Western Cape are working in line with the EM curriculum.
Methods
A cross-sectional, retrospective audit was carried out of patients presenting to ECs in Cape Town.
Study setting
The study was conducted at three training sites for EM registrars, with a combined annual EC attendance of 118 000 patients:
Victoria Hospital
New Somerset Hospital
Paarl Hospital.
Inclusion and exclusion
Patients were considered for inclusion if they presented to the study site ECs within the defined time period. Data were excluded if the folders were not accessible, or if the patient had incomplete medical notes (such as ‘left before being seen’).
Data collection
Data were collected on randomly chosen 24 h periods on one week date and one weekend date, over two separate time periods (one in summer (March) and one in winter (August/September)). The patient list was collected from EC patient registers.
Data collected by the Principal Investigator included:
Demographics
Time of presentation
Mode of presentation
Triage category
Presenting complaint
Final diagnosis or differential
Investigations and procedures
Disposition.
The presenting complaints or diagnoses were classified according to the authors' discretion.
The presenting complaint (as recorded by the triager) and the final diagnosis (as recorded by the doctor) were grouped together as clinical complaints. The results were tabled and ranked according to frequency of presentation. If an existing medical condition was deemed to be relevant to the presenting complaint, this was included as an additional diagnosis. If the patient presented with more than one diagnosis then these were counted as more than one presentation: for example, a patient who was involved in a motor vehicle accident may have had multiple injuries such as a pneumothorax, a fractured femur and a head injury–these would all be standalone presentations. If the presenting complaint and final diagnosis differed, they were both added as standalone conditions. The total number of clinical presentations, therefore, exceeds the number of patients investigated.
Presenting complaints and final diagnoses were varied, depending on the clinicians completing the paperwork. To counter this, wording was standardised. The clinical diagnoses were then grouped into general categories: Thus, a chest infection is grouped as lower respiratory tract infection; however, this also encompasses pneumonia, infective exacerbation of chronic obstructive airway disease and bronchitis. Tuberculosis was standalone, as this is a chronic condition. Similar processes were applied to each symptom and/or diagnosis.
Procedures were those tasks performed by clinicians requiring particular skills training, and included investigations requiring particular skills, such as pleural taps and lumbar punctures. Investigations were deemed to be those that were performed by other technical staff, such as blood tests or radiology, but required interpretation by clinical staff.
Data were collated in a Microsoft Excel document using pivot tables, and then mapped to the current South African EM curriculum.
The acuity of presentations was also recorded, (Microsoft Excel 2008 for Mac version 12.2.6) using the South African Triage Score.19–23
Ethical approval was granted by the UCT Faculty of Health Sciences Ethics Committee (REC REF: 313/2008). All data were stored in an anonymous fashion on a password-protected work computer.
Results
In total, 697 patients were seen during the study period across the three ECs. Of these, 83 (11.9%) folders were not found and 44 patients (6.3%) absconded before being seen. The total number of folders searched was 569 (81.6%). Table 1 summarises the results.
Summary of results
The top clinical presentations are presented in table 2. Table 2a shows all the presentations and is available online. Where there is no corresponding category in the syllabus, this is marked with a dash. Those with (P) next to the classification are listed only under paediatrics in the curriculum. There were 1283 separate diagnoses.
Top clinical presentations
The most frequent clinical complaint involved trauma, specifically blunt injury (5.9%), which includes assaults, motor vehicle accidents and falls. The second most frequent was abdominal pain (4.9%). Of the top 10 clinical complaints, seven are covered by the curriculum, and an additional one is only covered in the paediatrics section. Of note, there were multiple clinical complaints that were seen only once or twice.
The top procedures performed are presented in table 3. Table 3a shows all the procedures and is available online. A total of 115 procedures were performed; the most frequent five procedures were suturing, plaster of Paris, LP, joint reduction, and incision and drainage. Of these, only three are covered in the curriculum. Regional anaesthesia and procedural sedation were performed 1.7% and 5.2% of the time respectively.
Top procedures
The top investigations that were ordered are presented in table 4. Table 4a shows all the investigations and is available online. There were 730 investigations performed; the five most frequent were chest x-ray (CXR), full blood count (FBC), creatinine urea and electrolytes (CUE), ECG and other x-rays. Of these, only CUE is referred to in the curriculum. Ultrasound was performed 4.5% of the time.
Top investigations
Discussion
EM is a new specialty in South Africa,1–4 and the curriculum and registrar rotation requirements are based largely on consensus and international curricula9–12 – it is not evidence-based. These international curricula may not be appropriate for training in the current setting, where the burden of disease is large and little is known about the case mix involved. This practice analysis is an important step towards definition of the scope of knowledge and technical skills important for training of EM registrars locally.
In this study, the top clinical complaints were blunt injury, abdominal pain, breathlessness, lower respiratory tract infections, soft tissue injury, lacerations, chest pain, TB, gastroenteritis, fever, diarrhoea and cough (table 2). Table 2a shows all the clinical conditions and is available as a web extra. This list would suggest that training should focus on trauma, the respiratory, abdominal system and cardiovascular systems, and infectious diseases. Considering the limitations of this study discussed below, these data are likely to suggest a trend, rather than definitive numbers, and may not be accurate enough to use as a basis to draft an EM curriculum.
With regard to investigations (table 3), the majority performed were blood tests and radiology. Ultrasound is an emerging tool in South African EM; this was performed in 4.5% of cases, often as an elective by radiographers. Many of these were gynaecological investigations. This suggests that point of care ultrasound is an important part of the EM curriculum, in terms of academic knowledge and skills development.
A wide range of procedures were performed (table 4), the most common of which (by far) was suturing. Clearly, EM specialists should be expert in this field, and adequate time should be allocated in skills training for advanced suture techniques. This is currently required in the curriculum (registrars need to pass the Basic Surgical Skills Course). Regional anaesthesia was used in only 1.7% of cases. This is a valuable skill in the setting of ECs in the RSA, where patient load and low staffing levels do not allow for adequate monitoring of a sedated patient. The infrequent use of this skill reflects the lack of training of clinicians for this specific skill.
It may be that some of the procedures, investigations or even clinical conditions seen in ECs in the Western Cape are not appropriate for the current setting or scope of practice. In addition it may be that there are some things currently not done that should be incorporated into practice. This may mean that either the curriculum or current practice may need changing. There needs to be further research in more detail in this regard before it can be determined whether this is the case. Although a curriculum needs to be tailored to local conditions, the aim should be to teach international gold standards, as well as fulfilling the role required for specific circumstances. This is not an easy task.
Limitations
There are several limitations to this study.
Sample hospitals
All hospitals involved in this study were secondary-level hospitals. Most major polytrauma cases bypass the secondary-level facilities, and, anecdotally, most minor cases are seen at primary level. Similarly, burns cases may be under-represented as dedicated burns units are not housed at this level of care. Similar arguments may be made for other case types, and a larger study across more sites would be helpful to address this concern.
Data collection
Data collection systems in state hospitals in Cape Town are not accurate: patient registers are dependent on the accuracy of the data enterer. An 81% recovery rate of folders is reasonable, although the missing 19% of cases may have changed the patient profile somewhat. Data collected from patient folders are dependent on the note-keeping of clinicians, which is generally poor. For the purposes of this study, only what was actually written by the clinician could be recorded, not what should have been done.
How should this information be used? In order to extrapolate the data to a guided curriculum, one would need to fulfil several conditions. First, the data would need to be accurate. An ongoing audit, ideally provided by an accurate EC computer system across multiple hospitals providing all levels of care and serving the whole of the Western Cape, would provide this information. This should be able to group curriculum components by frequency of presentation and acuity of condition. Second, expert consensus would be needed to develop a workable organisation of grouping of symptoms, clinical conditions (possibly using ICD10 coding), investigations and procedures, and integrate these with the knowledge needed both for primary and final examination levels. Last, the above would need to be presented in a matrix to guide both learners and examiners.
An international workgroup has been set up by the International Federation of Emergency Medicine to draft a curriculum for the EM medical school curriculum.24 25 This is a starting point to developing set standards and programmes worldwide.
Conclusion
The EM training curriculum in South Africa needs to be more clearly defined to guide development of the specialty. This will be a complex and lengthy procedure. More data are needed to inform the process, of which this study is an important first step. An accurate and appropriate curriculum will help to improve standards of care over time.
References
Footnotes
Competing interests None.
Ethics approval This was granted by the University of Cape Town Ethics Committee.
Provenance and peer review Not commissioned; externally peer reviewed.