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.

Delayed Presentation and Mortality in Children With Sepsis in a Public Tertiary Care Hospital in Tanzania.

Background: Over 40% of the global burden of sepsis occurs in children under 5 years of age, making pediatric sepsis the top cause of death for this age group. Prior studies have shown that outcomes in children with sepsis improve by minimizing the time between symptom onset and treatment. This is a challenge in resource-limited settings where access to definitive care is limited. Methods: A secondary analysis was performed on data from 1,803 patients (28 days-14 years old) who presented to the emergency department (ED) at Muhimbili National Hospital (MNH) from July 1, 2016 to June 30, 2017 with a suspected infection and ≥2 clinical systemic inflammatory response syndrome criteria. The objective of this study was to determine the relationship between delayed presentation to definitive care (>48 h between fever onset and presentation to the ED) and mortality, as well as the association between socioeconomic status (SES) and delayed presentation. Multivariable logistic regression models tested the two relationships of interest. We report both unadjusted and adjusted odds ratios and 95% confidence intervals. Results: During the study period, 11.3% (n = 203) of children who presented to MNH with sepsis died inhospital. Delayed presentation was more common in non-survivors (n = 90/151, 60%) compared to survivors (n = 614/1,353, 45%) (p ≤ 0.01). Children who had delayed presentation to definitive care, compared to those who did not, had an adjusted odds ratio for mortality of 1.85 (95% CI: 1.17-3.00). Conclusions: Delayed presentation was an independent risk factor for mortality in this cohort, emphasizing the importance of timely presentation to care for pediatric sepsis patients. Potential interventions include more efficient referral networks and emergency transportation systems to MNH. Additional clinics or hospitals with pediatric critical care may reduce pediatric sepsis mortality in Tanzania, as well as parental education programs for recognizing pediatric sepsis.

Barriers and facilitators to implementing trauma registries in low- and middle-income countries: Qualitative experiences from Tanzania.

BACKGROUND: The burden of trauma in low and middle-income countries (LMICs) is disproportionately high: LMICs account for nearly 90% of the global trauma deaths. Lack of trauma data has been identified as one of the major challenges in addressing the quality of trauma care and informing injury-preventing strategies in LMICs. This study aimed to explore the barriers and facilitators of current trauma documentation practices towards the development of a national trauma registry (TR). METHODS: An exploratory qualitative study was conducted at five regional hospitals between August 2018 and December 2018. Five focus group discussions (FGDs) were conducted with 49 participants from five regional hospitals. Participants included specialists, medical doctors, assistant medical officers, clinical officers, nurses, health clerks and information communication and technology officers. Participants came from the emergency units, surgical and orthopaedic inpatient units, and they had permanent placement to work in these units as non-rotating staff. We analysed the gathered information using a hybrid thematic analysis. RESULTS: Inconsistent documentation and archiving system, the disparity in knowledge and experience of trauma documentation, attitudes towards documentation and limitations of human and infrastructural resources in facilities we found as major barriers to the implementation of trauma registry. Health facilities commitment to standardising care, Ministry of Health and medicolegal data reporting requirements, and insurance reimbursements criteria of documentation were found as major facilitators to implementing trauma registry. CONCLUSIONS: Implementation of a trauma registry in regional hospitals is impacted by multiple barriers related to providers, the volume of documentation, resource availability for care, and facility care flow processes. However, financial, legal and administrative data reporting requirements exist as important facilitators in implementing the trauma registry at these hospitals. Capitalizing in the identified facilitators and investing to address the revealed barriers through contextualized interventions in Tanzania and other LMICs is recommended by this study.

Profile and outcome of patients with emergency complications of renal failure presenting to an urban emergency department of a tertiary hospital in Tanzania.

BACKGROUND: Renal failure carries high mortality even in high-resource countries. Little attention has been paid to renal failure patients presenting acutely in emergency care settings in low-to-middle income countries (LMIC). Our aim was to describe the profile, management strategies and outcome of renal failure patients presenting with indications for emergent dialysis to an urban Emergency Department (ED) in a tertiary public hospital in Tanzania. METHODS: This was a prospective cohort study of consecutive patients (age ≥ 15 yrs) presenting to the Emergency Medicine Department of Muhimbili National Hospital from September 2017 to February 2018. All patients with renal failure and complications requiring acute dialysis were included. A structured data collection sheet was used to gather demographics, clinical presentation, management strategies and outcomes. Data were summarized with descriptive statistics. Logistic regressions were performed to determine factors associated with receiving dialysis and with mortality. RESULTS: We enrolled 146 patients, median age was 49 years (IQR 32-66 years), and 110 (75.3%) were male. Shortness of breath 67 (45.9%) and reduced urine output 58 (39.7%) were the most common presenting complaints. The most common complications were hyperkalemia 77 (53%), uremic encephalopathy 66 (45%) and pulmonary edema 54 (37%). All patients were hospitalized, and 61 (42%) received dialysis. Overall mortality was 39% (57 patients); the mortality in non-dialysed patients was 53% vs. 20% (p < 0.0005) in those receiving dialysis. 54% of patients with health insurance were dialyzed, compared to 39% who paid out of pocket (adjusted OR = 0.3, 95%CI: 0.1-0.9). Patients (≥55 years) were less likely to be dialysed (adjusted OR = 0.2 [0.1-0.9]). Independent predictors of mortality were vomiting (OR = 6.2, 95%CI: 1.8-22.2), oliguria (OR = 3.4, 95%CI: 1.2-9.5), pulmonary edema (OR = 4.6, 95%CI: 1.6-14.3), creatinine level > 1200umol/L (OR = 5.0 95%CI: 1.4-18.2), and not receiving dialysis (OR = 8.0, CI: 2.7-23.5). Female sex had a lower risk of dying (OR = 0.13, CI: 0.03-0.5). CONCLUSIONS: In this ED in LIC, acute complications of renal failure created a need for ED stabilization and emergent dialysis. Overall in-hospital mortality was high; significantly higher in undialysed patients. Future studies in LICs should focus on identification of categories of patients that will do well with conservative therapy.

Assessment of cardiopulmonary resuscitation knowledge and skills among healthcare providers at an urban tertiary referral hospital in Tanzania.

BACKGROUND: Early and effective CPR increases both survival rate and post-arrest quality of life. In limited resource countries like Tanzania, there is scarce data describing the basic knowledge of CPR among Healthcare providers (HCP). This study aimed to determine the current level of knowledge on, and ability to perform, CPR among HCP at Muhimbili National Hospital (MNH). METHODS: This was a descriptive cross sectional study of a random sample of 350 HCP from all cadres and departments at MNH from October 2015 to March 2016. Each participant completed a with 25 question multiple choice and fill-in-the-blank CPR test and a practical test using a CPR manikin where the participant was videotaped for 1-2 min. Two expert observers independently viewed the videos and rated participant performance on a structured data form. The primary outcome of interest was staff member overall performance on the written and practical CPR testing. RESULTS: We enrolled 350 HCPs from all 12 MNH clinical departments. The median participant age was 35 (IQR 29-43) years, 225 (64%) were female and 138 (39%) had clinical experience of less than 5 years. Only 57 (16%) and 88 (25%) scored above 50% in written and practical tests, respectively according to local minimum passing test score and 13(4%) and 30 (9%) scored above 75% in written and practical tests, respectively according to international minimum passing test score on CPR. The 233(67%) HCP who reported prior experience performing CPR on an adult patient scored higher on testing than those without; 40% (IQR 28-54) versus 26% (IQR 16-42) respectively, but both groups had median scores <50%. CONCLUSION: The level of CPR knowledge and skills displayed by all cadres and in all departments was poor despite the fact that most providers reported having performed CPR in the past. Since MNH is a tertiary referral hospital, it may reflect the performance of resuscitation status of other local health centers in Tanzania and other low-income countries to employ a formal system of training every HCP in CPR. Staff should be certified and assessed regularly to ensure retention of resuscitation knowledge and skills.