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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 29, No 1, January/February 2018
AFRICA
9
Despite living in close proximity to PCI facilities, only
61.3% of STEMI patients receive PCI within 24 hours.
11
This
might suggest that larger system problems contribute to further
delays.
12-14
Access is not simply a product of proximity, but also of
socio-economic status and other demographic factors.
3,15,20-22
Low-income patients living in rural areas and those without
medical insurance experience the greatest barriers to accessing
healthcare services.
20
In South Africa, 77% of all the PCI facilities
are owned by the private healthcare sector and can therefore only
be utilised by 18.1% of the population,
15
unless upfront payment
of up to $3500 (~R50 000) is made.
15
When we consider this, the proportion of South Africans who
can access PCI within 60 (53.8%) and 120 minutes (71.53%) is an
over-estimation, as access is often limited to insurance status. In
South Africa, the median driving times for uninsured patients to
the closest public PCI facility are 123.7 minutes across 170.7 km,
while only 47.8% and 63.0% of the population can access these
facilities in 60 and 120 minutes respectively. It is recommended
that patients who experience symptoms of myocardial infarction
be transported to hospital via emergency medical services
(EMS) so that suitably qualified pre-hospital emergency care
providers can start treatment and manage any complications
that might arise.
4
Locally, the majority of patients seem to be
transported privately.
12-13
Reasons for this include unfamiliarity
with emergency numbers, poor and unreliable response times
of EMS, or lack of understanding of the value of EMS use in
myocardial infarction.
12
Mistrust in the EMS is not unfounded as up to 95% of urban
and 68% of rural high-acuity responses are not serviced within
15 and 40 minutes, respectively.
23
One study has shown that in
16.7% of responses, public ambulances may take more than 12
hours to arrive in certain rural areas of the country.
24
In Africa,
EMS systems are often informal with unreliable coverage.
25
Ambulance transport may not always be feasible for Africans
with STEMI,
25
and pre-hospital delays can have significant
effects on the reperfusion times of patients regardless of their
proximity to a PCI facility.
26
For patients who cannot reach a PCI facility timeously,
pre-hospital thrombolysis is recommended.
4
At present, only
emergency care practitioners who hold a bachelor degree
qualification can administer pre-hospital thrombolysis in South
Africa.
27,28
Recommendations are that, should pre-hospital
thrombolysis be considered, it should be performed within a
well-developed coronary care network that can manage failed
thrombolysis and other complications.
28
We found that most
PCI facilities are concentrated in the urban areas. Unfortunately,
within our setting, there is misdistribution of advanced life
support (ALS) paramedics, with most practicing in urban areas.
29
Steps should be taken to promote recruitment, deployment and
retention of paramedics in these rural areas.
The utilisation of helicopter emergency medical services
(HEMS) has been suggested to improve the reperfusion times
30
of STEMIs and to deliver ALS care to patients in rural areas.
31
Considering the shortage of ground-based ALS, HEMS may
be a feasible option for delivering pre-hospital thrombolysis to
many remote communities, however, the benefit of this resource
should be offset by its cost burden in the context of low- and
middle-income countries such as South Africa.
31
Further to this,
activation of HEMS should be subject to confirmed STEMI
diagnosis by on-scene providers. Until now, 12-lead ECG
acquisition and interpretation has been a skill reserved only for
ALS providers.
27
Pre-hospital 12-lead ECG acquisition and interpretation has
also been extended to the mid-level EMS worker (emergency care
technicians), which may expedite STEMI diagnosis and decrease
reperfusion times.
32
Upskilling in this regard may be required, as
studies have shown that a delay in reperfusion may occur when
inexperienced providers doubt the ECG diagnosis.
12
Pre-hospital
12-lead ECG telemetry has been applied in developed countries
and may be used to expedite reperfusion.
33
A randomised,
controlled trial was undertaken in 2016 in South Africa to
determine the application of 12-lead ECG telemetry in this
context (pers commun).
Limitations
This study has some important limitations. Drive-time polygons
were generated based on typical (average)
driving times and
traffic conditions. Response and ambulance scene times,
which may prolong the pre-hospital time, were not taken into
consideration. In addition, for patients not utilising ambulance
transport to hospital, time to access private or public transport
was not taken into consideration.
Census data from 2011 was used as the 2016 community
survey data from Statistics South Africa provide population data
only up to municipal level, as the sample size does not allow for
analysis at ward level.
Again it is essential to reiterate that expressing access in this
study assumes that any patient can be treated at any facility.
Table 6. Proportion of South African population living within 60
and 120 minutes of a public PCI facility
Province
PCI within 60 minutes
n
(% per province)
PCI within 120 minutes
n
(% per province)
Gauteng
12.27 mil (99.7)
12.27 mil (99.7)
Western Cape
4.19 mil (71.9)
4.78 mil (82)
Northern Cape
0 (0)
0 (0)
Eastern Cape
1.22 mil (18.6)
1.48 mil (22.6)
North West
0.66 mil (18.8)
1.93 mil (55)
KwaZulu-Natal
4.78 mil (46.6)
6.72 mil (65.4)
Free State
0.82 mil (29.9)
1.81 mil (65.9)
Mpumalanga
0.73 mil (18.1)
3.13 mil (77.5)
Limpopo
6 000 (0.1)
0.26 mil (4.9)
Total,
n
(% SA)
24.6 mil (47.8)
32.6 mil (63.0)
mil: million.
Table 5. Proportion of South African population living within 60
and 120 minutes of a public or private PCI facility
Province
PCI within 60 minutes
n
(% per province)
PCI within 120 minutes
n
(% per province)
Gauteng
12.27 mil (99.7)
12.3 mil (100)
Western Cape
4.44 mil (76.1)
5.1 mil (87.6)
Northern Cape
0 (0)
29 000 (2.5)
Eastern Cape
1.96 mil (29.9)
2.68 mil (40.8)
North West
1.28 mil (36.4)
2.13 mil (60.6)
KwaZulu-Natal
4.89 mil (47.6)
6.64 mil (64.7)
Free State
0.99 mil (36.4)
1.9 mil (69.3)
Mpumalanga
0.95 mil (23.5)
3.19 mil (78.9)
Limpopo
1.06 mil (19.8)
3.04 mil (56.3)
Total,
n
(% SA)
27.86 mil (53.8)
37.0 mil (71.5)
mil: million.