The prehospital paediatric emergency care burden managed by a public ambulance service in the Western Cape, South Africa

Abstract

Background

Paediatric mortality rates in low- and middle-income countries account for over 80% of the global burden. In South Africa, one in every 33 children will not reach the age of five. Despite the high mortality rate, there is a paucity of data describing the prehospital paediatric under-five emergency care burden in South Africa. Such data are essential to inform the development of local prehospital emergency care guidelines and targeted prevention strategies.

Aim

This study describes the prehospital paediatric under-five emergency care burden managed by the Western Cape Government Health and Wellness (WCGHW) Emergency Medical Services (EMS) in South Africa.

Methods

A retrospective review of the prehospital records was conducted, extracting epidemiological and clinical data from the WCGHW EMS patient record database. The review included all paediatric cases under-five, managed between 1 January 2022 and 31 December 2023, in the Western Cape of South Africa.

Results

In the 87 457 cases, there was a similar distribution between the primary cases (50.7%) and interfacility transfers (49.3%). Most activations emanated from rural areas (47 980, 54.9%), with respiratory emergencies (30 934, 35.4%), non-cardiac pain (11 381, 13.0%) and trauma (10 831,12.4%) being the most common presenting complaints. Most cases were prioritised as priority 2 (46 034, 52.6%), with most of these being older children between one and five years old (29 008, 63.0). Low acuity cases accounted for 67.2% (58 818) of the sample, with the highest mortality occurring between 29 days and 12 months (190, 52.9.%). Most patients spent less than one hour in the prehospital setting (64 431, 73.7%), with advanced airway management (748, 43.1%) being the most common airway intervention.

Conclusion

This first description of the prehospital paediatric under-five emergency care burden managed by the WCGHW EMS reveals a unique burden, particularly regarding the high interfacility transfer rates. As illustrated in graphical abstract, these findings underscore critical considerations for healthcare planners and the prehospital training environment. Future research among this population should focus on characterising the reasons for the high interfacility transfer rates through assessments of healthcare access, EMS care quality and post-EMS follow-up.

Graphical Abstract

Key messages

• The study found a high rate of interfacility transfers (49.3%) among the prehospital paediatric under-five emergency care burden managed by the WCGHW EMS. This reflects the challenges of South Africa’s tiered healthcare system and highlights a significant burden on EMS resources.

• The predominance of medical emergencies over trauma: Unlike in high-income countries where trauma is often a leading cause of paediatric EMS activations, this study found that medical emergencies, particularly respiratory complaints (35.4%), were the most common reason for EMS usage. This aligns with WHO data on causes of paediatric morbidity and mortality in low- and middle-income countries.

• A high proportion of low acuity cases: The majority (67.2%) of cases were categorized as low acuity (routine or non-urgent). This differs from patterns seen in high-income countries and suggests potential overuse of EMS for non-emergency situations, which has implications for resource allocation and healthcare system planning.

Introduction

Emergency medical services (EMS) are essential for guaranteeing prompt transportation to the nearest hospital facility. Studies have indicated that children account for approximately 10 to 30% of all instances where EMS are activated [1, 2]. This emphasises the need for EMS providers to be well-equipped and educated to manage paediatric situations appropriately. Within this paediatric population, children under five represent a particularly vulnerable group. Under-five mortality is a crucial measure of a community’s general health and well-being. It indicates the availability of basic healthcare services, nutrition and living conditions. Internationally, infectious diseases such as pneumonia, diarrhoea and malaria continue to be a primary cause of under-five mortality, along with premature delivery and difficulties associated with childbirth [1].

By 2022, the global under-five mortality rate had decreased by 60% from 93 deaths per 1000 live births in 1990 to 37 [1]. Notwithstanding this significant advancement, enhancing child survival continues to be important. During the year 2022, there were approximately 13 400 under-five deaths per day globally, an unacceptably high number of preventable child deaths. In Africa, the absence of emergency care systems has been identified as the primary factor contributing to higher mortality rates [2, 3].

Despite recent efforts to improve paediatric emergency care, South Africa continues to grapple with significant resource challenges, resulting in persistently high under-five mortality rates [1]. In 2022, South Africa’s under-five mortality rate was 34.5 deaths per 1,000 live births. While lower than the sub-Saharan African average of 71.4 deaths per 1,000 live births, it remained considerably higher than the rates in Europe (4.3 deaths per 1,000 live births) and North America (6.1 deaths per 1,000 live births). These disparities reflect a broader regional trend: children born in sub-Saharan Africa face a mortality risk 12 times higher than those born in high-income countries (HICs) [1]. Despite substantial progress in reducing under-five mortality, South Africa failed to achieve the Millenium Development Goal (MDG) targets related to under-five mortality and continues to face significant challenges in meeting the Sustainable Development Goal (SDG) target of reducing under-five mortality to fewer than 25 deaths per 1,000 live births by 2030 [4,5,6]. It is, therefore, important to understand the under-five burden to formulate and implement targeted improvement strategies.

There remains a dearth of data describing the paediatric emergency care burden managed in the South African prehospital setting. The majority of prehospital studies examining the paediatric burden have primarily concentrated on children up to 19 years of age [7,8,9,10,11]. Characterising the prehospital emergency care burden is essential to determine the emergency care resource needs and to develop locally appropriate prehospital emergency care guidelines. The lack of published data on the most frequent emergencies has been highlighted as a critical gap in global emergency care research [2]. This study aimed to address this gap by describing the paediatric under-five emergency care burden managed by the Western Cape Government Health and Wellness (WCGHW) Emergency Medical Services (EMS).

Methods

Study design and setting

The study took the form of a retrospective review of all paediatric under-five patients managed by the WCGHW EMS in the Western Cape province of South Africa between 1 January 2022 and 31 December 2023.

The WCGHW EMS is a public emergency medical service providing unrestricted access to emergency care which facilitates transportation throughout the Western Cape province. The Western Cape is the third most densely populated province in South Africa, spanning 129 449 km² with a population of approximately 7.4 million citizens [11]. The prehospital workforce of the WCGHW EMS comprises approximately 1600 providers, stationed across 52 ambulance stations throughout the province. EMS is capable of delivering a range of emergency medical services, from simple oxygen delivery to more complex interventions like mechanical ventilation. The WCGHW EMS workforce is distributed across six districts, one urban and five rural districts throughout the province [12].

Study population and sample

The study reviewed the prehospital paediatric under-five emergency care burden managed by the WCGHW EMS. The WCGHW EMS maintains a comprehensive case registry encompassing computer-aided dispatch (CAD) data and electronic patient care records (ePCR) for each case managed. CAD data primarily depict non-clinical data recorded within the Emergency Communication Centre, detailing resource allocation for individual cases, while corresponding ePCR records encompass all clinical data documented in the field by the attending prehospital providers.

For this study, de-identified data were extracted from the WCGHW EMS patient records registry. The data included all cases (i) classified as paediatric under-five upon EMS activation and (ii) with complete CAD data and corresponding ePCR available. The study excluded paediatric patients over the age of five, cases with incomplete data, EMS activations cancelled or attended to by private EMS providers, as well as cases without associated ePCR records. The dataset used for analysis included various variables such as patient demographics, nature of emergencies, patient acuity levels, dispatch priorities, requisite level of definitive care, and emergency care interventions performed.

Data variables

Patient demographics and prevalent emergent conditions were classified in line with the World Health Organisation’s publications on under-five mortality [1, 13]. Patient age data was obtained from the ePCRs, which are completed by the attending emergency care personnel during each case. Paediatric emergencies were divided into categories such as respiratory complaint, trauma, neurological complaint, non-cardiac pain and vomiting/diarrhoea. Case types were defined as primary emergency response or interfacility transfers (IFT). Dispatch priorities were stratified into priority 1 cases, where WCGHW aims to have a prehospital provider at the patient’s location within 15 min. Priority 2 cases are those that involve less urgent situations with the aim to achieve this response within 60 min. Location was categorised as urban if the case was managed within the urban City of Cape Town district. All other locations, based on geographically spread populations, prolonged time to emergency care and limited access to specialised healthcare services were considered rural for this study [14, 15].

Patient acuity levels were established by prehospital care providers after clinical assessments based on the South African Triage Scale (SATS) classification system [16]. Acuity was denoted by colour-coded categorisation, including life-threatening (red), very urgent (orange), urgent (yellow), routine (green) and deceased (blue) [10]. Low acuity referred to routine and urgent categorisations, whereas high acuity was either very urgent or life-threatening. Patient disposition was categorised as primary, secondary or tertiary. Primary healthcare facilities encompass community clinics, while secondary facilities comprise regional and district-level facilities, and tertiary facilities include specialised tertiary and quaternary institutions. Emergency clinical interventions and medications were categorised according to the Health Professions Council of South Africa’s Clinical Practice Guidelines and scope of practice for the South African prehospital setting [17].

Advanced airway management is defined as the placement of either an Endotracheal tube or Supraglottic Airway device [18]. Time spent in EMS care refers to the period between prehospital providers’ arrival at the patient’s location to that of arriving at definitive care.

Seasonal variations were classified into spring (September to November), summer (December to February), autumn (March to May) and winter (June to August).

Data analysis

The data were processed and analysed using IBM SPSS version 29 (Armonk, NY: IBM Corp). Basic summary statistics were employed to elucidate the characteristics of all variables, while nominal and categorical variables were depicted as frequencies and proportions. A chi-square test was utilised to ascertain disparities in distribution among variables. Statistical significance was established at a p-value threshold of < 0.05.

This study adhered to the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) reporting standards for cross-sectional studies.

Results

Throughout the designated study period, the WCGHW EMS recorded 1 514 361 activations, with 15.2% specifically attributed to the paediatric population (aged 0–12 years). The remaining activations (84.8%) related to adults. Given the scope of this study, a total of 87 457 cases were deemed eligible for analysis after excluding cases involving paediatric patients older than five, instances of missing data where EMS activations were cancelled or attended to by private EMS providers, and those lacking corresponding ePCR records, as illustrated in Fig. 1.

Fig. 1

Flow diagram depicting final study sample

Table 1 Demographic characteristics of prehospital paediatric under-five emergency care burden managed by the WCGHW EMS n(%)

As depicted in Table 1, there was a similar distribution of prehospital activations in years 1 (45 597, 52.1%) and 2 (41 860, 47.9%) of the study period. Interfacility transfers constituted 49.3% (43 123) of the activations, followed by primary emergency activations for medical complaints (38 602, 44.1%) and trauma (5 732, 6.6%). Males constituted most (48 706, 55.7%) of the activations. Children between one and five years (48 553, 55.5%) accounted for most cases, followed by those between 29 days and one year (28 495, 32.6%).

Most of the activations were from rural (47 980, 54.9%) rather than urban regions (39 477, 45.1%). Respiratory emergencies (30 934, 35.4%) followed by non-cardiac pain (11 381, 13.0%) and trauma (10 831, 12.4%) were among the most common reasons for prehospital activations. Most activations were in autumn (26 849, 30.7%) and spring (20 763, 23.7%).

Table 2 Distribution of dispatch priority, triage status and time within prehospital setting n(%)

Most of the paediatric emergency care burden (46 034, 52.6%) was categorised as priority 2 during the EMS resource allocation (Table 2). Most activations for paediatrics within their first day of life were dispatched as priority 1 (2247, 80.5%); in contrast, 59.7% (29 008) of those between one and five years old were deemed less urgent (green/yellow). We noted a significant decrease in priority 1 activation as age increased (p < 0.001).

Low acuity (routine – urgent) cases accounted for 67.2% (58 818) of the sample, with nearly half of the sample being triaged as urgent (38 914, 44.5%), closely followed by very urgent (22 574, 25.8%). Some 5.4% (4 707) was triaged as life-threatening (red), with the highest mortality (190, 52.9%) noted between 29 days and 12 months. A total of 359 deaths were reported among the paediatric burden managed, which equates to 4.1 prehospital paediatric deaths for every 1000 children under the age of five managed in the prehospital setting. Most patients (64 431, 73.7%) spent less than one hour in the prehospital setting, while 188 (0.2%) spent more than five hours being managed by prehospital teams.

Table 3 Distribution by patient acuity for origin of EMS activation n(%)

Most primary EMS activations were for low acuity cases (35 184, 79.4%) (Table 3), in contrast to the proportions of high acuity cases being transferred from secondary (6357, 53.0%) and primary-level healthcare facilities (11 701, 42.4%).

As depicted in Table 4, of the 1737 (2%) patients where airway management was initiated, 748 (43.1%) underwent advanced airway management, followed by basic positioning (26.3%) and suctioning (13.0%). Face masks were the most common (71.0%) oxygenation delivery medium. Non-invasive ventilation (CPAP & HFNC) performed was nearly three times higher (20.7%) compared to invasive ventilation (8.3%). Peripheral vascular access (95.2%) was the most common form of vascular access. Only 2.2% (n = 1937) received medication, with the majority (48.5%) receiving nebulised bronchodilators, followed by benzodiazepines (11.7%) and IV dextrose (10.4%).

Table 4 Distribution of prehospital emergency care interventions and medications

Discussion

This study provides the first description of the prehospital paediatric under-five emergency care burden in the Western Cape of South Africa, contributing to the limited body of research on prehospital paediatric research in low-and middle-income countries [7,8,9, 19,20,21,22]. A key finding of our study is the high rate of interfacility transfers, accounting for nearly half of all under-five EMS activations. This contrasts with findings from high-income countries and reflects the structural complexities of the South African healthcare system [23,24,25,26]. Most transfers occurred from primary care facilities. This can be attributed to the location of community clinics, which serve primarily low-income communities. Patients in these areas often lack access to private transport and must rely on ambulances. This reliance on EMS for interfacility transfers underscores the need for strengthening primary healthcare capabilities and improving patient flow within the system.

The predominance of medical emergencies over trauma in our study aligns with the World Health Organisation data, where infectious diseases and malnutrition remain significant contributors of paediatric morbidity and mortality in low- and middle-income countries [27]. However, this contrasts with high-income countries, where trauma is a leading cause of paediatric EMS activations [21, 24, 28], although, these studies analysed data for children younger than 13 years [20, 24, 28, 29]. This underscores the need for context-specific approaches to paediatric emergency care in different global settings.

Most (79.4%) of the primary EMS activations were for low-acuity patients, yet most (72.1%) were transported to a secondary healthcare facility. This finding contrasts with high-income countries, where EMS calls predominantly involve high-acuity paediatric cases requiring hospital admission [20, 21, 24, 30]. The WHO asserts that high-acuity paediatric emergencies predominately require respiratory support [20]. Our study raises questions about EMS utilization patterns and potential overuse for non-emergency cases.

Our findings suggest that only 2.2% of the population received an intervention, a relatively small number of interventions overall for the paediatric population. Non-invasive ventilation was favoured over invasive ventilation in this study, reflecting a global trend towards less invasive respiratory support strategies in paediatric care [31,32,33]. In our study, peripheral intravenous cannulation was the most common method of vascular access, used in 95.2% of cases where vascular access was obtained. Previous research has suggested that IV infusions are often administered prophylactically in South African prehospital care, resulting in overtreatment [34]. However, our findings present a different picture. Despite the number of critically ill patients (4707), we observed a relatively low number of IV infusions (2444). This discrepancy suggests that EMS providers might be exercising more discretion in IV administration in the paediatric population. Perhaps some practitioners decided to proceed quickly to a healthcare facility, which is supported by the 73.7% of patients who spent less than one hour in the prehospital setting. Another rationale could be the paucity of paediatric and neonate-specific clinical capabilities among the entry-level prehospital providers in South Africa, who constitute 94.2% of the prehospital workforce [35].

The relatively low frequencies of high acuity prehospital interventions (advanced airway management, ventilated patient and UVC) performed among the paediatric under-five emergency care burden underscores the need for robust quality assurance mechanisms to ensure skills currency and uphold competencies among prehospital providers. Further investigation is required to understand the preparedness of the prehospital workforce to manage paediatric emergencies.

Autumn had the highest number of EMS activations (26 849, 30.7%), driven by respiratory illnesses, fever and vomiting and diarrhoea complaints. These findings support those of Krefis et al. [36] who found autumn had higher respiratory emergency department visits compared to than other seasons in Germany. In contrast, summer months were reported to result in higher incidences of EMS utilisation​ among all patient age groups​ in the United States [37].

The current study was limited in that it used non-probability sampling methods and thus can only comment on the patient data in this study collected over a set period. Accordingly, the findings cannot be generalised to areas outside the Western Cape. While this study included data over a two-year period, trends over multiple years could not be explored. The study lacked data on clinical outcomes owing to the lack of integration between prehospital and in-hospital records, hindering a comprehensive understanding of the continuum of care. Nevertheless, these findings provide valuable insights into the unique challenges and opportunities within this setting, informing targeted interventions to enhance prehospital paediatric emergency care.

Conclusion

This study is the first to characterize the prehospital paediatric emergency care burden in the Western Cape of South Africa, revealing a unique landscape distinguished by a high rate of interfacility transfers, predominantly originating from primary healthcare facilities and involving patients with urgent or life-threatening conditions. This indicates disparities in healthcare access and resource allocation, placing a substantial burden on the public EMS system. The prevalence of medical emergencies, especially respiratory complaints, calls for improved primary healthcare to prevent diseases and intervene early. The low frequency of high-acuity interventions suggests the need for quality mechanisms to maintain skills currency and uphold competencies among prehospital providers. Future research should explore the reasons for high transfer rates, healthcare access, EMS care quality, and the appropriateness of clinical capabilities of the prehospital workforce to manage the paediatric emergency care burden.