Evaluating the prerequisites for adapting a paediatric nighttime telemedicine and medication delivery service to a setting with high malarial burden: A cross-sectional pre-implementation study.

OBJECTIVE: We sought to evaluate the prerequisites (demand, interest, feasibility) for adapting a paediatric nighttime telemedicine and medication delivery service (TMDS) to Ghana. METHODS: A cross-sectional survey of households and associated healthcare providers was conducted in urban and rural Ghana. Households were identified through randomised geospatial sampling; households with at least one child <10 years were enrolled. Household surveys collected information relating to demographics, household resources, standardised case scenarios, recent paediatric health events, satisfaction with healthcare access, and interest in TMDS intervention models. Providers were identified by households and enrolled. Provider surveys collected provider type, hours of operation, services, and opinions of a TMDS model. RESULTS: A total of 511 (263 urban, 248 rural) households and 18 providers (10 urban, 8 rural) were surveyed. A total of 262 health events involving children <10 years were reported, of which 47% occurred at night. Care was sought for >70% of health events presenting at night; however, care-seeking was delayed until morning or later for >75% of these events; 54% of households expressed dissatisfaction with their current access to paediatric care at night; 99% of households expressed that a nighttime TMDS service for children would be directly useful to their families. Correspondingly, 17 of 18 providers stated that a TMDS was needed in their community; >99% of households had access to a cellular phone. All households expressed willingness to use their phones to call a TMDS and allow a TMDS provider into their homes at night. Willingness to pay and provider-recommended price points varied by setting. CONCLUSIONS: Prerequisites for adapting a TMDS to Ghana were met. A nighttime paediatric TMDS service was found to be needed, appealing, and feasible in Ghana. These data motivate the adaptation of a TMDS to urban and rural Ghana.

Authorship representation in global emergency medicine: a bibliometric analysis from 2016 to 2020.

INTRODUCTION: High-income country (HIC) authors are disproportionately represented in authorship bylines compared with those affiliated with low and middle-income countries (LMICs) in global health research. An assessment of authorship representation in the global emergency medicine (GEM) literature is lacking but may inform equitable academic collaborations in this relatively new field. METHODS: We conducted a bibliometric analysis of original research articles reporting studies conducted in LMICs from the annual GEM Literature Review from 2016 to 2020. Data extracted included study topic, journal, study country(s) and region, country income classification, author order, country(s) of authors' affiliations and funding sources. We compared the proportion of authors affiliated with each income bracket using Χ2 analysis. We conducted logistic regression to identify factors associated with first or last authorship affiliated with the study country. RESULTS: There were 14 113 authors in 1751 articles. Nearly half (45.5%) of the articles reported work conducted in lower middle-income countries (MICs), 23.6% in upper MICs, 22.5% in low-income countries (LICs). Authors affiliated with HICs were most represented (40.7%); 26.4% were affiliated with lower MICs, 17.4% with upper MICs, 10.3% with LICs and 5.1% with mixed affiliations. Among single-country studies, those without any local authors (8.7%) were most common among those conducted in LICs (14.4%). Only 31.0% of first authors and 21.3% of last authors were affiliated with LIC study countries. Studies in upper MICs (adjusted OR (aOR) 3.6, 95% CI 2.46 to 5.26) and those funded by the study country (aOR 2.94, 95% CI 2.05 to 4.20) had greater odds of having a local first author. CONCLUSIONS: There were significant disparities in authorship representation. Authors affiliated with HICs more commonly occupied the most prominent authorship positions. Recognising and addressing power imbalances in international, collaborative emergency medicine (EM) research is warranted. Innovative methods are needed to increase funding opportunities and other support for EM researchers in LMICs, particularly in LICs.

White Paper on Early Critical Care Services in Low Resource Settings.

This White Paper has been formally accepted for support by the International Federation for Emergency Medicine (IFEM) and by the World Federation of Intensive and Critical Care (WFICC), put forth by a multi-specialty group of intensivists and emergency medicine providers from low- and low-middle-income countries (LMICs) and high-income countries (HiCs) with the aim of 1) defining the current state of caring for the critically ill in low-resource settings (LRS) within LMICs and 2) highlighting policy options and recommendations for improving the system-level delivery of early critical care services in LRS. LMICs have a high burden of critical illness and worse patient outcomes than HICs, hence, the focus of this White Paper is on the care of critically ill patients in the early stages of presentation in LMIC settings. In such settings, the provision of early critical care is challenged by a fragmented health system, costs, a health care workforce with limited training, and competing healthcare priorities. Early critical care services are defined as the early interventions that support vital organ function during the initial care provided to the critically ill patient-these interventions can be performed at any point of patient contact and can be delivered across diverse settings in the healthcare system and do not necessitate specialty personnel. Currently, a single "best" care delivery model likely does not exist in LMICs given the heterogeneity in local context; therefore, objective comparisons of quality, efficiency, and cost-effectiveness between varying models are difficult to establish. While limited, there is data to suggest that caring for the critically ill may be cost effective in LMICs, contrary to a widely held belief. Drawing from locally available resources and context, strengthening early critical care services in LRS will require a multi-faceted approach, including three core pillars: education, research, and policy. Education initiatives for physicians, nurses, and allied health staff that focus on protocolized emergency response training can bridge the workforce gap in the short-term; however, each country's current human resources must be evaluated to decide on the duration of training, who should be trained, and using what curriculum. Understanding the burden of critical Illness, best practices for resuscitation, and appropriate quality metrics for different early critical care services implementation models in LMICs are reliant upon strengthening the regional research capacity, therefore, standard documentation systems should be implemented to allow for registry use and quality improvement. Policy efforts at a local, national and international level to strengthen early critical care services should focus on funding the building blocks of early critical care services systems and promoting the right to access early critical care regardless of the patient's geographic or financial barriers. Additionally, national and local policies describing ethical dilemmas involving the withdrawal of life-sustaining care should be developed with broad stakeholder representation based on local cultural beliefs as well as the optimization of limited resources.

Skill and knowledge retention after training in cardiopulmonary ultrasound in Ghana: an impact assessment of bedside ultrasound training in a resource-limited setting.

OBJECTIVE: Brief training courses in bedside ultrasound are commonly done by visiting faculty in low-income and middle-income countries, and positive short-term effects have been reported. Long-term outcomes are poorly understood. We held a training course on a cardiopulmonary ultrasound (CPUS) protocol over two separate 10-day periods in 2016. In 2017, 9-11 months after the initial training, we assessed skill and knowledge retention as well as perceived impact on local practice. METHODS: A written test using six clinical vignettes and an observed structured clinical examination were used to assess theoretical knowledge and practical skills. Additionally, in-person interviews and a written survey were completed with the physicians who had participated in the initial training. RESULTS: All 20 participants passed the written and clinical examination. The median follow-up test score was 10 out of 12, compared with a median score of 12 on a test completed immediately after the initial training. Physicians identified the ability to narrow their differential diagnosis and to initiate critical interventions earlier than without ultrasound as a key benefit of the CPUS training. They rated the cardiac, abdominal and inferior vena cava components of the CPUS protocol as most relevant to their everyday practice. CONCLUSION: Long-term ultrasound knowledge and skill retention was high after a brief and intensive training intervention at an academic tertiary hospital in Ghana. Clinicians reported improvements in patient care and local practice patterns.

Sustainable Resuscitation Ultrasound Education in a Low-Resource Environment: The Kumasi Experience.

BACKGROUND: Point-of-care-ultrasound (POCUS) is an increasingly important tool for emergency physicians and has become a standard component of emergency medicine residency training in high-income countries. Cardiopulmonary ultrasound (CPUS) is emerging as an effective way to quickly and accurately assess patients who present to the emergency department with shock and dyspnea. Use of POCUS, including CPUS, is also becoming more prevalent in low- and middle-income countries (LMICs); however, formal ultrasound training for emergency medicine resident physicians in these settings is not widely available. OBJECTIVES: To evaluate the feasibility of integrating a high-intensity ultrasound training program into the formal curriculum for emergency medicine resident physicians in an LMIC. METHODS: We conducted a pilot ultrasound training program focusing on CPUS for 20 emergency medicine resident physicians in Kumasi, Ghana, which consisted of didactic sessions and hands-on practice. Competency was assessed by comparing pretest and posttest scores and with an Objective Structured Clinical Examination (OSCE) performed after the final training session. RESULTS: The mean score on the pretest was 61%, and after training, the posttest score was 96%. All residents obtained passing scores above 70% on the OSCE. CONCLUSION: A high-intensity ultrasound training program can be successfully integrated into an emergency medicine training curriculum in an LMIC.