Introduction

The World Health Assembly Resolutions 60.22, 68.fifteen, and 72.16 all highlight the meaning gap betwixt the need for and the provision of emergency care that currently exists globally [ 1 , 2 , three ]. Low-income countries behave more than iii times the brunt of disease for emergency conditions in terms of inability-adjusted life years (DALYs) than do loftier-income countries, while emergency usage rates in low-income countries are 3% of those of high-income countries [ 4 ]. Equally more than and more countries feel population and economical growth, globalization, rapid urbanization, and progression through the demographic transition, the demand for stiff systems to address both the intendance and prevention of trauma, communicable diseases, and non-infectious disease volition only go along to grow.

Emergency care systems – which broadly include the provision of both acute and emergency care and services – are comprised of at least five major components: individual and community capacity, preparedness, and resilience; delivery of appropriate out-of-hospital care by laypersons; a means of access to formal services by the public; ship and/or delivery of appropriate pre-hospital intendance by trained professionals; and clinical care and referral networks [ 5 , 6 ]. The specialty of emergency medicine (EM) – a unique discipline with a well-defined and universal prepare of technical and cerebral skills – has developed over the last 50 years to lead the provision of clinical care by training not simply physicians, merely besides other healthcare personnel at all levels. Additionally, the specialty of EM besides serves as a guide for the overall evolution of emergency care systems through a focus on core concepts and strategies aimed at reducing morbidity and mortality of emergent weather condition and to provide secondary illness prevention [ 5 , vi , 7 , 8 , 9 , 10 ].

Although nonetheless a relatively young specialty, EM has been expanding rapidly across the globe, and more than 50 national EM organizations are now members of the International Federation for Emergency Medicine (IFEM) [ 11 ]. Although some concepts, such as burden of disease and resource availability, are unique to each local context, the specialty of EM provides a unique opportunity where partnerships can develop to share universal content as well as established resource in education and preparation relevant to loftier-resource settings, low-resource settings, or both. To date, the development of EM in many countries has occurred in part because of educational partnerships between nations or regions where 1 partner has more than feel with EM equally a specialty. Such partnerships can occur regardless of each state's income level, just often involve partnerships between a high-income state and a low- or middle-income country (LMIC) [ 12 , thirteen , 14 , 15 ].

Though programs adult from such educational partnerships are increasingly common, there is little to describe their features. One review describes some of the features of training programs in LMICs, but it does not specifically focus on programs resulting from partnerships [ 16 ]. Additionally, at that place is some guidance in the literature as to how to approach the cosmos of these training programs as well every bit the overall evolution of EM, only this data is at present outdated and there is little information specific to training and education [ 17 ] In this systematic review, nosotros aim to address this gap by highlighting the scope, content, and features of EM programs developed in LMICs through partnerships.

Methods

An electronic search using PubMed, Spider web of Scientific discipline, CINAHL, and EMBASE was conducted for all available publications to the date of the search (thirty August 2018) without restriction on the scope of the EM content, the training level of the learners (i.e. medical student, nurse, mid-level, doc), or the length of the program (defined here as short duration – up to one month, medium duration – betwixt one month and one yr, and long duration – more than one year). The search strings may be found in Supplement one. We have defined an EM training programme as "structured educational activity and/or training in the methods, procedures, and techniques of acute or emergency care". Inclusion criteria adamant a priori were EM training programs developed in the hospital or clinical setting in an LMIC – as defined by the Earth Bank at the fourth dimension of the search – and supported past at least one higher-resource international partnership [ eighteen ]. In-hospital programs were targeted as, in our experience, partners often seek out institutions given the oftentimes more familiar workforce and resources also equally the perception that training is probable to have the highest affect in this setting. Manuscripts focusing only on pre-hospital or non-clinical providers were excluded. Manuscripts with a predominant focus on other specialties (i.e. obstetrics/neonatal care and emergency surgery) were excluded. Only manuscripts in English were considered. Systematic reviews and abstracts/posters were excluded. 2 reviewers screened each abstract with conflicts resolved after a third review to determine the included manuscripts.

The included manuscripts were and then scored by the reviewers in order to select and more than closely examine a high-quality subset. Each manuscript was scored by ii reviewers and manuscripts with scores differing by more than 3 points (north = thirteen) or that differed betwixt reviewers across the threshold for inclusion (northward = xix) were reviewed and scored a third time. Scoring (0–2 points for each category) focused on 7 areas: manuscript pattern, overall quality, overall clarity, ethical considerations, significance, description and/or study of program attributes and/or learner or clinical outcomes, and type of providers (Supplement 2). The methods used for this scoring were adapted from methods established in other reviews in the field of global EM [ nineteen ]. The reviewers' scores were then averaged for a last score on each manuscript. On review of the average scores, the upper quartile was found to exist designated by a score of 12 and above. Manuscripts were then labeled every bit 'low-scoring' (below 12) or 'high-scoring' (12 or above).

Abstracts were screened using Covidence (Melbourne, Australia). Statistical analyses (Krippendorf's blastoff for nominal and for interval data for 2 or more than reviewers) were done using Microsoft Excel and Stata/IC v15.ane (StataCorp; College Station, Texas The states). The report was registered and canonical by PROSPERO (Registration: CRD42018100194).

Results

The search produced 7702 results. A total of 2433 duplicates were removed prior to screening, leaving 5269 studies to be screened past two reviewers. From this, 105 manuscripts met inclusion criteria for scoring. Of these, four were found to be in high income countries, six could not exist obtained, and one was found to be a indistinguishable, leaving 94 manuscripts in the concluding analysis (Figure ane). Programs in 42 countries are represented in these manuscripts (Effigy 2).

Figure one

PRISM chart.

Figure two

Low- and centre-income countries with programs highlighted in the 94 abstracts.

Of these manuscripts, 30 focus on EM programs with a broad scope, 18 focus on trauma grooming, 17 on pediatric training, and 16 on ultrasound training. Most programs focus on physician-learners; notwithstanding, 17 programs railroad train physicians and nurses together, and 15 train multidisciplinary teams (physicians and/or nurses along with other clinical and non-clinical professionals and/or staff). Additionally, eight programs focus solely on nurses and six on medical students. Finally, more than one-half of the programs are of curt duration. Only three are of medium elapsing, and fifteen are of long duration (Table one).

Table 1

Summary of the 94 included manuscripts.

* Physicians and/or nurses along with other clinical and non-clinical professions and/or staff.

The manuscripts were then scored in gild to highlight a high-quality subset. When assessing the inter-rater reliability of the raw scores among the reviewers, the reviewers' scores agreed +/–2 points 74.7% of the time (Krippendorff's blastoff 0.732). When assessing the inter-rater reliability to distinguish "depression-scoring" from "high-scoring" manuscripts, the reviewers agreed fourscore.0% of the time (Krippendorff's alpha 0.526). A total 26 manuscripts received an average score of 12 and in a higher place.

Overview of Loftier-Scoring Manuscripts

Fifteen of the high-scoring manuscripts focus on vii specific content areas (ultrasound, trauma, pediatrics, pediatric trauma, neurological emergencies, toxicological emergencies). They span the years 2012–2018, are published in twelve journals, and highlight work in thirteen countries (Table 2) [ 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , xxx , 31 , 32 , 33 , 34 ]. Xi of the manuscripts discuss general EM programs. These span the years 1999–2018, are published in 10 different journals, and highlight work in nine countries (Tabular array 3) [ 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 ]. The components of the 11 manuscripts on broadly focused EM training programs are further highlighted here. Post hoc review of the other 83 included manuscripts demonstrated that results and the conclusions drawn from the eleven high-scoring manuscripts were representative of the larger group.

Table 2

Overview high-scoring manuscripts on content-specific EM programs.

Table 3

Overview loftier-scoring manuscripts on broad EM programs.

Broadly-focused EM Training Programs: Program Components

Participants include nurses (2 programs), medical students (two programs), doc administration (1 program), physicians (five programs), and nurses and physicians together (one programme). All of the manuscripts draw all or a subset of the following components: goals/objectives, program certification/recognition, curriculum outline/content, methods of assessment, funding, logistics, educational resource, outcomes, and challenges (Tabular array 4).

Table four

Program components from the selected manuscripts on broad EM programs.

Goals and Objectives

Each of the eleven programs conducted formal needs assessments and/or had focus group discussions to place learning gaps and to determine the content, manner, and/or duration of each program, fulfilling the first two steps Kern et al.'south six-stride model for curriculum development [ 46 ]. These efforts drew upon the strengths and experiences of the instructors while considering the cognition level of the learners and using familiar teaching styles and/or providing orientation to new instructional methods. I manuscript highlights a pilot study prior to full implementation of a program [ 35 ]. Three studies highlight teacher (both international and local) development and orientation prior to commencement of the program [ 38 , 41 , 42 ].

Certification/Recognition

More half of the manuscripts talk over alignment with local or national governing bodies, such as the Ministry of Health (MoH) regarding formal recognition, licensing, and/or certification of their corresponding programs.

Curriculum Outline/Components

The curricula highlighted in these manuscripts bridge curt, foundational programs to medium-length programs with abbreviated, comprehensive EM curricula to total-length residency programs (of at least three years). All offer mixed learning methods ranging from traditional didactic lectures and small group discussions (i.east. periodical clubs and instance-based sessions) to hands-on practical sessions and workshops, such every bit simulation and procedural training. Curricula are often organized into blocks or modules by topics or organ systems. Longer programs classify one to iii one-half-days every 1 or two weeks for learning sessions in add-on to daily bedside clinical didactics. Volunteer patients, mannequins, laminated algorithms, white boards, and other simulation materials likewise as video/online materials, handbooks, and textbooks are highlighted every bit curriculum tools. Many programs incorporate pediatrics likewise. All residency programs list the requirement of off-service rotations, such as surgery, anesthesia, and disquisitional care. Only one manuscript offers extensive online access to their curriculum map and resources [ 41 ]. One of the curt programs emphasizes the demand for refresher courses, particularly when limited curricula are offered and/or baseline knowledge is varied or limited [ 39 ]. One manuscript specifically evaluates the acceptability of a novel-to-context learning modality (small-scale group sessions) inside the overall plan [ 45 ].

Methods of Assessment

All programs have a written component of assessment. These examinations consist of multiple-choice questions, short-answer, and/or essay questions. Many manuscripts highlight programs that also accept practical examinations – skills stations, oral and/or case-based examinations every bit well equally objective structured clinical examinations (OSCEs). Longer programs also often track attendance and require example and/or procedure logs with minimum required numbers. Minimum passing requirements for examinations and omnipresence, when specified, range from 70–80%. There are ofttimes end-of rotation evaluations and functioning audits, especially for residency programs with off-service rotations. At that place is commonly ongoing informal feedback and mentorship. One program mentions requiring a thesis [ 44 ].

Funding

Three of the 11 manuscripts do non discuss how their programs are supported, while the others note a combination of private donors, non-turn a profit organizations, healthcare organizations, and funding from universities in college-resource settings. Manuscripts that mention their funding sources notation a mix of self-funding or subsidized funding for international faculty. Among the larger funding sources listed are the Abbott Fund, USAID, Grand Challenges, and Projection Hope. Salary for learners in residency programs and fees for learners for not-residency programs are less clear – at to the lowest degree one plan notes that there are no fees for their learners, and those who had to travel for the program received room and board [ 36 ].

Logistics

All of the programs involve international visiting faculty for ongoing full or supervisory support either in person and/or via teleconferencing, messaging, or other methods of remote appointment. Visiting kinesthesia contributions are described every bit ranging from one week up to multiple years onsite and/or remotely. Longer programs tend to have curricula that repeat one or more times over the course of the program. Train-the-trainer techniques are used in two of the programs [ 39 , 43 ]. Two programs mention their learner-to-instructor ratio for hands-on sessions (a range of iii–6:1) [ 38 , 45 ]. One program is structured to accept two identical sessions daily in order to adjust the learners, who must provide continuous coverage in the clinical setting [ 35 ].

Educational Resources

Content for the curricula is drawn from a variety of sources – usually initially from EM content belonging to the high-resources partner. Specific materials and organizations listed among the programs for reference include basic life support (BLS), advanced cardiac life support (ACLS), advanced trauma life support (ATLS), pediatric advanced life support (PALS), textbooks (specifically Tintinalli, Rosen, and Goldfrank, amid others), World Wellness System (WHO) resources (such every bit Integrated Management of Adolescent and Developed Illness and Integrated Management of Babyhood Illnesses), Canadian Association of Emergency Physicians (CAEP), American College of Emergency Physicians (ACEP), IFEM, Order for Academic Emergency Medicine (SAEM), African Federation for Emergency Medicine (AFEM), European Society for Emergency Medicine (EuSEM), World Association for Disaster and Emergency Medicine (WADEM), Australasian Society for Emergency Medicine (ASEM), Consortium of Universities for Global Health (CUGH), Johns Hopkins Global Health, international EM journals (i.east. International Journal of Emergency Medicine), and American and Canadian graduate medical education (GME) resources.

Outcomes

Knowledge conquering, clinical performance, and/or learner confidence/cocky-assessment are amongst the outcomes listed for almost all of the programs. All programs conduct immediate assessments; however, many of the programs also assess cognition memory at a variety of time points: 8 weeks, three months, six months, and one twelvemonth. Additionally, some programs highlight the number of graduates as well every bit the number of individuals yet practicing in EM. None of the program outcomes extend beyond the learner, although future studies of clinical outcomes are mentioned in ane manuscript [ 43 ].

Challenges

Challenges common to many of the programs include establishing the condition and culture of practice of EM in low-resources, novel settings. Additionally, the manuscripts describe how differences in telescopic, practise, and content between the loftier-resource and depression-resource settings every bit well as amid plan sites within low-resource settings require translation and adaptation of whatever shared educational resources and techniques. Overall resources limitations for learning as well as practice materials are often noted. Language barriers (for both instruction and materials) also as issues with remote connectedness and utilise of local and remote technologies are also highlighted. Additionally, lack of continuity and connection between learners and the rotating visiting kinesthesia – who may be present in person for as trivial as one calendar week – leads to reduced engagement and morale. Decay in knowledge, especially after short programs, is also a concern, with re-assessment between 2–3 months highlighted every bit potentially an ideal fourth dimension for re-assessment or refresher training. Difficulties with both learner (e.g. omnipresence given the requirement of ongoing continuous clinical duties still required during many of the programs) and curriculum flexibility leads to attrition for many programs. There are also ongoing concerns regarding sustainable funding highlighted in several of the manuscripts – for the plan, for visiting faculty, likewise as for learners/graduates.

Word

These manuscripts describe many types of EM programs being implemented via partnerships worldwide to train in-hospital personnel disquisitional for the overall development of emergency care systems – from curt, focused courses on topics such as ultrasound training or trauma training to full residency programs. The most established programs are those that are of at least one twelvemonth in duration and those with formal integration into the healthcare and/or medical education system of the country (e.g. supported by the MoH). These programs tin can then offer official certification and/or credentialing to ensure that graduates will take both potential positions and financial security as well as a career path every bit EM develops and the culture of exercise changes.

All of the programs involve on-site and/or remote international faculty for varying lengths of fourth dimension; however, programs in which at least a cadre subset of faculty are involved in contiguous teaching through the elapsing of the programme foster stronger partnerships and allow for continuity of evaluation every bit well as continuous improvement and adaptation of the program. Given the differences in resources and culture of practice, all visiting faculty demand at to the lowest degree prior experience in education/preparation and low-resource environments and/or a comprehensive orientation to the site prior to providing instruction. One manuscript describes the challenges of alien expectations between instructors and learners due to the limited preparation and feel by the visiting faculty [ 38 ].

Furthermore, the use of international kinesthesia is rarely sustainable, especially when back up for these kinesthesia is non available. Programs that involve a train-the-trainer component every bit well as faculty development are essential, although limitations of these models (peculiarly dilution of education) must be kept in mind and addressed using other mechanisms such as refresher courses and mentorship or preceptor programs. Additionally, given the increasing familiarity with and use of technology, non-traditional training mechanisms such every bit the utilize of messaging applications and other mobile technology-based training tools should be considered, especially equally they can be effective mechanisms to extend training beyond contiguous interactions and/or to go on training during protracted and/or complex emergencies [ 47 , 48 , 49 ].

These programs also highlight the inability to simply transfer EM curricula from ane setting to some other. Some cardinal concepts tin can be shared, as is evidenced by international guidelines for curricula, and in that location are several groups that have offered open-access materials that are already adjusted to low-resource settings to varying degrees (Tabular array 5). In guild to be constructive, however, the evolution of curricula – whether abbreviated or a full residency program – must exist preceded by needs assessments, focus-grouping discussions, and knowledge of the epidemiology and burden of disease as well every bit the civilisation of practice, didactics, learning, and assessment of the implementation site [ 50 , 51 , 52 ]. Additionally, language barriers must be overcome both in didactics every bit well as in written and electronic materials [ 53 ]. Finally, at that place must exist inter-sectoral engagement and collaboration between the health and pedagogy sectors in lodge to recruit, develop, and sustain a quality workforce that is matched to overall service commitment capacity and population needs [ 54 ].

Table 5

Sample list of curricula and content resources.

* Accessed: May 2019; the authors practise not specifically endorse whatsoever particular resource, nor do they verify the accuracy of the content listed at the sites higher up.

Finally, in order to continue to accelerate EM training and the overall provision of emergency intendance, programs must include grooming in quality improvement (QI) and research, topics not traditionally taught in many medical and nursing schools in low-resource settings. To illustrate this indicate, less than half of the programs mention a component of QI and/or research, and only two of the manuscripts accept a local start author [ 31 , 44 ]. Furthermore, in guild to determine which methods of grooming are most effective, nosotros must move beyond metrics regarding knowledge acquisition and attitude and eventually await to patient-, customs-, and population-based outcomes [ 55 ]. Simply three of the manuscripts evaluate patient and/or clinical outcomes every bit a result of their training programs [ 20 , 26 , 31 ].

Despite ongoing piece of work to develop metrics and quality indicators for emergency care and research and to provide guidance in the development of emergency care systems (as evidenced by the WHO's Emergency, Trauma and Acute Care Program), at that place is still very footling research that has focused specifically on the bear upon of training programs [ nine , 56 , 57 , 58 , 59 , threescore , 61 , 62 , 63 ]. These programs are an integral role of the foundation of a sustainable emergency care arrangement, not but at the facility level, but indirectly within the community and the pre-hospital system as well, therefore, further investigation of and enquiry on these programs is imperative to sustain and to keep to expand EM every bit a specialty and emergency care systems globally.

Limitations

Overall, we used just four search engines and excluded programs in the grayness literature without peer review (i.eastward. abstracts) – an area in which many more than programs are likely highlighted based on an informal review of the excluded abstracts. As well, our results are limited to manuscripts only in English language. Additionally, the search terms used to define this quickly irresolute and developing field were hard to specify, leading to one additional manuscript that was identified on breezy review that could take been included in this study [ 64 ]. Furthermore, partnerships are besides not always fabricated explicit in many manuscripts; since our study focused on programs developed through educational partnerships, nosotros may have missed manuscripts in the screening procedure where this was not clearly defined [ 65 ]. This challenge further emphasizes the need for standardization of practice and sharing of knowledge and experience in this field. Finally, our scoring process was developed from tools used in other reviews and was non formally tested with our results; however, it has been used to evaluate literature in field of global EM, and post hoc review demonstrated that the conclusions drawn from the high-scoring manuscripts were representative of the larger group [ 19 ]. Despite these limitations, withal, this report still identifies a wide range of EM preparation programs, and it highlights programmatic components essential for effective partnerships and successful implementation.

Conclusions

Preparation in EM is an essential component to developing strong emergency care systems. This written report identifies a wide range of EM training programs developed through partnerships that are representative of the programs that exist globally and highlight programmatic components essential to the evolution of effective programs. Sharing noesis and do beyond loftier- and low-resource settings can be an effective mechanism for the global development of programs within a specialty, however pregnant adaptation to the educational setting equally well as truthful investment and partnership must occur, fifty-fifty for short-term programs. Fifty-fifty when all of the complexities and components are addressed, there are still limitations to this do. Short-term programs need to aggrandize across the few topics that are represented now, and we must invest in comprehensive, long-term emergency care preparation and professional development programs. Finally, as tools and guidance regarding the development of emergency care systems increase, a stiff focus on strengthening educational practices every bit well every bit evaluating their bear upon through enquiry is imperative.