Emergency Medicine in the Developing World ... - Wiley Online Library

SPECIAL CONTRIBUTION

Emergency Medicine in the Developing World: A Delphi Study Peter W. Hodkinson, MPhil(EM), and Lee A. Wallis, MD, FRCS, FCEM

Abstract Objectives: Emergency medicine (EM) as a specialty has developed rapidly in the western world, but remains largely immature in developing nations. There is an urgent need for emergency services, but no clear guidelines are available on the priorities for establishing EM in the developing world. This study seeks to establish consensus on key areas of EM development in developing world settings, with respect to scope of EM, staffing needs, training requirements, and research priorities. Methods: A three-round Delphi study was conducted via e-mail. A panel was convened of 50 EM specialists or equivalent, with experience in or interest in EM in the developing world. In the first round, panelists provided free-text statements on scope, staffing, training, and research priorities for EM in the developing world. A five-point Likert scale was used to rate agreement with the statements in Rounds 2 and 3. Consensus statements are presented as a series of synopsis statements for each of the four major themes. Results: A total of 168 of 208 statements (81%) had reached consensus at the end of the study. Key areas in which consensus was reached included EM being a specialist-driven service, with substantial role for nonphysicians. International training courses should be adapted to local needs. EM research in developing countries should be clinically driven and focus on local issues of importance. Conclusions: The scope and function of EM and relationships with other specialties are defined. Unambiguous principles are laid out for the development of the specialty in developing world environments. The next step required in this process is translation into practical guidelines for the development of EM in developing world settings where they may be used to drive policy, protocols, and research. ACADEMIC EMERGENCY MEDICINE 2010; 17:765–774 ª 2010 by the Society for Academic Emergency Medicine Keywords: emergency medicine, consensus, health planning, developing countries

I

ncreasing levels of trauma and chronic illness, as well as a background of high levels of communicable diseases and maternal and child mortality, exist in

From The Division of Emergency Medicine, University of Cape Town & Stellenbosch University, Bellville, South Africa. Received September 10, 2009; revisions received December 19, 2009, March 1, 2010, and March 23, 2010; accepted April 2, 2010. This paper was presented in part at the Emergency Medicine in the Developing World Conference, Cape Town, South Africa, November 24–26, 2009. The study was funded in part by a small grant from the Emergency Medicine Society of South Africa. The funder had no role in the study design, data collection, data analysis, data interpretation, writing of the paper, or decision to submit for publication. Supervising Editor: Gary B. Green, MD, MPH. Address for correspondence and reprints: Peter W. Hodkinson; e-mail: [email protected]. A related commentary appears on pages 762 and 758.

ª 2010 by the Society for Academic Emergency Medicine doi: 10.1111/j.1553-2712.2010.00791.x

the developing world.1 Adequate prehospital emergency care is rarely available in such settings, and in-hospital emergency services are often delivered by inexperienced or unskilled staff, without specific training or adequate supervision.2 There is clear evidence that well-established systems of emergency care can reduce mortality and morbidity from many common conditions in the developing world.3 Furthermore, there is patient demand for such services.4 Although there are well-formulated guidelines for specific diseases which cover aspects of clinical emergency care (for example, malaria, AIDS, and specific trauma entities such as head injury), they do not attempt to prioritize the care or to guide the overall structure and management of the emergency department (ED).5–7 Much has been written about the development of systems of emergency care in developed world settings.8–10 However, comprehensive emergency medicine (EM) systems are lacking in most developing countries, perhaps due to the emphasis (and budget

ISSN 1069-6563 PII ISSN 1069-6563583

765

766

Hodkinson and Wallis

prioritization) that has been placed on primary health care and preventative medicine.4,11 There is an urgent need to determine key strategies to help guide EM development in the developing world.12 These must be practical, take into account existing health care systems, and allow direct integration into these systems.8,13 Although the World Health Organization has published guidelines for the core components of a prehospital service and for trauma care, there are no holistic guidelines for EM services or a roadmap for establishment of emergency services in low- and middle-income countries.7,14 The Delphi technique has been used widely in the health care field to identify consensus among a group of experts and to develop priorities and strategic approaches. This is a method of structuring communication among experts grouped in a panel, which can provide valuable contributions to resolve a complex problem.15 The Delphi technique benefits from group feedback and anonymity of responses and provides a solution to managing a group of experts spread around the world.16 We undertook a Delphi study to seek consensus on key areas of EM development in developing world settings, with respect to the scope of EM, staffing needs, training requirements, and research priorities. Results of the study are intended to contribute toward a framework for the development of generic guidelines for establishing EM in the developing world. METHODS Study Design A three-round Delphi study was undertaken via e-mail from June 2008 to March 2009. Potential panel members were identified by the authors using various sources: memberships and mailing lists of the American College of Emergency Physicians (ACEP): International Ambassadors listings; Emergency Medicine Society of South Africa (EMSSA) 2007 Conference: Participants; Ethiopian North American Health Professionals Association (ENAHPA); European Society for Emergency Medicine; International Emergency Medicine Special Interest Group of Australasian College of Emergency Medicine (IEMSIG); International Federation of Emergency Medicine (IFEM); and Society for Academic Emergency Medicine (SAEM): 2007 Consensus Conference Participants. The Delphi process has been well described elsewhere.17–20 This study was not a classical Delphi study because there were only three rounds, but in other respects it was a classic, rather than modified Delphi, in that Round 1 consisted of open-ended questions rather than a structured questionnaire. All potential participants were contacted by e-mail with an explanation and invitation to participate. All data were collected and analyzed on a Microsoft Excel (2007, Microsoft Corp., Redmond, WA) spreadsheet. Participants were reminded at 2-week intervals by e-mail until they responded or the specified time deadlines expired (3 months for Rounds 1 and 2 and 2 months for Round 3). Ethics approval was obtained from the Ethics Committee of the University of Cape Town, and all

•

EM IN THE DEVELOPING WORLD: A DELPHI STUDY

participants consented to take part. Anonymity was maintained so that recipients were unaware of the other participants’ identities, and the views of all participating panelists were given equal weight. Study Setting and Population Panel criteria were established as medical doctors ⁄ physicians with the following criteria (self-reported): 1) qualification as an EM specialist or equivalent (meaning EM experience of at least 5 years) and 2) experience in working in the developing world or a demonstrated interest and expertise (through membership and ⁄ or activity in international EM affairs) in the development of EM in the developing world (as defined by the United Nations Development Program–Human Development Indices: A Statistical Update 2008–HDI rankings, 2008).21 Study Protocol, Measurements, and Data Analysis Round 1. The first round asked participants to propose issues that should form part of the minimum standards for emergency care in the developing world. Free-text statements were requested with specific leading questions as shown in Table 1. These responses were collated and summarized (keeping the participants wording ⁄ meaning as far as possible) for presentation at Round 2. Participants were also asked to give information on where they worked, their years of experience in the EM field, and their association with the developing world to characterize the participants. Round 2. The collated Round 1 statements were sent as an Excel spreadsheet to all participants (following a small pilot study to test the spreadsheet ⁄ data capture method). Statements were, as far as possible, worded in a positive fashion to avoid double negatives and because it was thought agreement with a positive statement carried more weight than disagreement with a negative one. Panelists were asked to rate the importance of each statement on a five-point Likert scale

Table 1 Structure ⁄ Themes for Free-text Statements in Round 1. 1. Scope of emergency care (hospital and prehospital) What should this care include? Where is the divide from FM or critical care, etc.? What are the core functions of an emergency service? 2. Staffing of EDs How should they be staffed? What is the role of nonphysicians? 3. Training of staff in emergency care How should staff be trained? What is the value of life support courses? What formal training is required? Who should train? 4. Research in emergency care What should be researched? Who should do the research? What are the priorities for research in the developing world? What are the important questions to answer? FM = family medicine.

ACAD EMERG MED • July 2010, Vol. 17, No. 7

•

www.aemj.org

(1 = strongly disagree; 2 = disagree; 3 = neither agree nor disagree; 4 = agree; 5 = strongly agree).22 Participants were also encouraged to comment on each statement. Results were analyzed for frequency of response and items reaching positive or negative consensus were not carried forward to Round 3. Positive consensus was defined as at least 80% of respondents ranking 4 or 5 for a statement; negative consensus was defined as at least 80% of respondents ranking 1 or 2. Round 3. Statements not reaching consensus were resent to panel members, along with the other panel members’ combined scores and their own Round 2 scores for each statement. They were asked to reconsider their scoring of these statements to seek consensus. Figure 1 shows the flow of the Delphi process.

Figure 1. Delphi process flow.

767

RESULTS The initial invitation to participate went out to 93 individuals, of whom 53 (59%) agreed to participate. Of these, 50 individuals responded to Rounds 2 and 3 and therefore constituted the Delphi panel. Three individuals who had agreed to take part did not respond further. Characterization of Panelists Classification of panelists according to the United Nations Development Program–Human Development Indices: A Statistical Update 2008–HDI Rankings. 2008,21 showed that 34% of panelists (17 ⁄ 50) lived and worked in the developing world (countries having low or medium human development indices—Azerbaijan, India, Jamaica, Kenya, Malawi, South Africa, and

768


Thailand). An additional 38% (19 ⁄ 50) lived in the developed world but assisted in the developing world (Cambodia, Thailand, Ethiopia, India, Kosovo, Madagascar, Papua New Guinea, South Africa, Sri Lanka, Tanzania, Uganda, and West Indies [and some individuals who worked in several developing countries]). The remaining 28% (14 ⁄ 50) lived and worked in the developed world (Australia, Czech Republic, Hong Kong, Korea, Sweden, United Kingdom, and United States). A total of 785 years of experience in EM were represented by the panelists (range = 5–42 years; mean ± SD = 15.2 ± 8.3). Almost half (46%) of panelists had 10–20 years’ experience in EM; 30% had more than 20 years’ experience. Consensus Statements The response rate of agreement to take part in the study was 53 of 93 (57%); for Round 1, 38 of 53 (72%); and for Rounds 2 and 3, 50 of 53 (94%). At the end of Round 2, there was positive consensus in 132 statements of 208 (64%) and no negative consensus. Of 76

•


statements resent in Round 3, positive consensus was reached in an additional 36 statements, bringing the overall positive consensus to 168 of 208 (81%). A synopsis of statements achieving positive consensus, as well as the nonconsensus issues are presented for each of the four areas (scope, staffing, training, and research) as Tables 2–5 (the full list of statements as well as the relative ‘‘consensus scoring’’ is available in Data Supplement S1, available as supporting information in the online version of this paper). Negative Consensus A single statement, which held that paramedics would not benefit from training by EM specialists, achieved negative consensus. 1. Scope of EM Consensus . Issues. The definition of emergency care should include 24-hour access for any unscheduled episode of an acute health care problem. This should

Table 2 Synopsis of Consensus Statements on Scope of EM in Developing Countries 1. The definition of emergency care includes any unscheduled episode of care sought by a patient with an acute health problem and should include all ages. 2. The scope of EM will in part be determined by the configuration of the rest of the health care system and should utilize realistic local medical, technical, human, and financial resources, but EM should be developed according to rational policies instead of historical precedent. There should be emphasis on conditions where cost-effective intervention can lead to a demonstrable health benefit. 3. EM must include prehospital and hospital practice. 4. Core issues in prehospital care should include community first aid and CPR development, prehospital ambulance ⁄ transport service, primary care practitioners with basic EM skills, development of rapid transportation rather than advanced prehospital care, starting treatment at the site of the event ⁄ point of illness, and delivery of care largely by nonphysicians. 5. EM should be responsible for management of mass casualty incidents ⁄ disasters with an integrated prehospital and hospital response to disasters. 6. Hospital EDs must have 24-hour open access to all who seek acute health care, with a robust triage system. 7. A short stay ⁄ overnight area is useful to monitor patients before final decision-making. 8. Hospital EDs should provide for a maximum of 24 hours of care from entry to exit. 9. Emergency services must provide access to health care and treatment; screen and stabilize at the prehospital level; and provide hospital reception ⁄ assessment ⁄ triage and evaluation of unscreened, undifferentiated complaints to identify life ⁄ limb ⁄ sensory threatening injuries and illness problems. 10. There should be proficiency in treatment including initial management and stabilization, resuscitation of unstable patients to point of hemodynamic stability, diagnosis and early diagnostics, and treatment and definitive care in some cases. 11. EM should provide a clear referral pathway to a higher-functioning specialist center and have the capacity to make effective and efficient disposition decisions and transfer patients to all levels of a health system. EM also may serve in a gate keeping role in managing short-term patients to control hospital admissions. 12. The core function is to minimize suffering and reduce mortality and morbidity. 13. Aim to deliver care within a time frame of early and immediate care (‘‘golden hour’’) to provide live-saving care given when it is most effective. Aim for triage and treatment of patients with life or limb threatening ailments within 10 minutes. 14. Take responsibility for communication with patients and families, as well as communication and liaison with inpatient teams and primary care health workers. 15. Nonclinical but nevertheless core functions of an emergency service must include teaching to all levels of health care workers and inpatient colleagues, attention to patient safety and avoidance of iatrogenesis, data collection to influence decision making and future research development, and ‘‘outreach’’ to teach public and community providers. 16. The ED must be established as an independent department, not subservient to other departments, and needs to advocate for change to decision-making bodies. 17. There is a continuum with blurred margins between FM, EM, and critical care. EM has a focus on immediate care, while family medicine’s focus is on prevention and referral (of stable patients), but should be equipped and skilled to start emergency care in the absence of other emergency services. 18. Practice guidelines should include quality assurance and quality improvement oversight. Nonconsensus Statements 1. Core functions of EM: multiple investigations and ongoing management. 2. Spectrum of EM care: —Patients triaged as ‘‘green’’ or minor should be seen and managed by FM. —Conditions presenting more than 72 hours after onset are the responsibility of FM. CPR = cardiopulmonary resuscitation; FM = family medicine.


•

www.aemj.org

769

Table 3 Synopsis of Consensus Statements on Staffing of EDs in Developing Countries 1. Trauma and medical emergencies should be combined into one ED. Staff should be permanently assigned to the ED, and staff (at all levels) need specific training and skills for the provision of emergency care. 2. Developing countries need to improve doctor ⁄ population ratios by increasing doctor numbers and retaining them. 3. Setting a minimum staffing standard is essential (even if not achievable immediately). 4. All EDs should have at least one EM specialist for leadership and supervision. EDs should be staffed by physicians trained to a predetermined level of EM not necessarily specialists. EDs should have a core of full-time doctors who need not be specialists but need to be experienced and motivated. 5. ED nursing staff should be responsible for appropriate triaging of patients. 6. Nonphysicians (physician assistants, clinical officers, etc.) are central to the EM system and serve a crucial role in providing emergency medical care and services in countries with physician shortages. They may only work under clear management lines of accountability. 7. Specific roles for nonphysicians (nondoctors) in the ED include life-saving care in the initial stages; cardiopulmonary resuscitation as per protocols; recognition of signs and symptoms in acute situations; triage; assisting doctors with procedures (intubation, central venous access, intercostal tube drainage, and suprapubic cystostomy); safe patient transport; safe patient movement; cast placement; nebulization; intravenous access; recording of vital signs; basic wound care; suturing of wounds; and splinting and crutch preparation. 8. EDs should be staffed with sufficient human resources to provide quality, compassionate care to all patients. Staff numbers should be based on the desired target waiting times for each priority of patient type, should meet or work toward international standard ratios (e.g., doctor ⁄ nurse per number of patients ⁄ population served), and staffing should be in response to resources available and demand. 9. Working hours should be divided into day and night shifts of no more than 12 hours. Nonconsensus Statements 1. Any health professional can be taught how to provide initial assessment and management of the critically ill patient. Doctors in the ED 2. Hospital EDs require at least one EM specialist on duty per shift. 3. Highly trained staff should focus solely on direct patient care. Nurses in the ED 4. Must have undergone specialized EM training and completed all three ALS courses (ACLS, ATLS, APLS). 5. Should provide much of the definitive care for minor and intermediate conditions. 6. Should be in charge of all drugs and drug administration in the ED. 7. Must have critical care, community, midwife, and pediatric experience. Nonphysicians in the ED 8. Role is to assist EM doctors to perform their duties and should be limited to triaging and nursing duties. 9. Should only be considered in situation where there are not enough EM doctors. ALS = advanced life support; APLS = advanced pediatric life support; ATLS = advanced trauma life support.

include prehospital care (encompassing first aid, transport systems, emergency care by primary health care providers) and mass casualty situations. EDs should have a clear referral pathway, a short-stay ward is beneficial, and patient care should not extend beyond 24 hours after presentation. Important functions of the ED staff include management; research; training; and communication with other health care providers, patients, and family. EM needs to be an independent department and the scope should be tailored to local resources and policies as far as possible. Core functions of an ED should include prehospital (basic life support and rapid transportation); mass casualty incident response and management; assessment (reception, triage, recognition of emergencies, screening, and stabilization); resuscitation (golden hour, reducing morbidity and mortality); stabilization; diagnosis; treatment (+ ⁄ ) definitive, minimization of suffering); and transfer. Statements . Reaching Consensus After Round 3 (But Not After Round 2). EM should concentrate on conditions where treatment results in a demonstrable and cost-effective health benefit. Prehospital care should include rapid transportation rather than advanced care and may be administered by nonphysicians in most cases. EDs benefit from a short-stay ward, but should provide care only for the first 24 hours.

Nonconsensus . Issues (After Rounds 2 and 3). The definition of EM to include early delivery of measures to improve primary health care, referral, and transport services; EM to provide 24-hour outpatient care; and the scope of EM should include performing multiple investigations and ongoing patient management. With respect to the relationship between EM and family medicine (FM), all minor patients; patients triaged ‘‘green’’; or patients presenting with any condition more than 72 hours after onset of the condition should be seen by FM practitioners. 2. Staffing Consensus . Issues. The hospital ED should have a combined trauma and medical emergency unit. The challenge is to improve developing world doctor to population ratios, with the target being predetermined minimum standards. Specific EM training should be given to all levels of ED staff. Doctors in the ED should ideally be led by at least one EM specialist, with a core of full-time doctors. Nurses should be responsible for triage in the ED, while nonphysicians must work under clear lines of accountability. Suggested parameters to guide what are adequate staff numbers in the ED include provision of quality and compassionate care to all, attainment of target waiting times, and ⁄ or as per available recourses and demand.

770


•


Table 4 Synopsis of Consensus Statements on Training in EM in Developing Countries 1. Training must form the cornerstone of any EM development program, such that one of the most important functions of an EM specialist leading an ED is to train other staff. It must be continuous and ongoing. 2. Training should be centrally overseen for coordinated and rational local development, but with local ownership, and progressive local control and provision of training programs. 3. Collaboration with the developed world in EM training is vital, but training that originates from developed countries should be modified to reflect the realities of developing world practice. Expert trainers from abroad initially and local knowledge should facilitate training local trainers (as well as local trainers in established specialties [e.g., surgeons, anesthetists, pediatrics, etc.]). 4. Trainers should be experienced providers who are skilled at education and have been ‘‘trained to train.’’ Peer training is ideal with doctors overseeing the training program for other levels. 5. Practical ‘‘hands-on’’ training (direct supervision and feedback) is more appropriate than formal teaching. Distance education is a key area to develop in EM. 6. A core curriculum, modified with locally relevant material, should be established, as well as a list of goal competencies for each grade of health care professional to support on the job teaching, with annual setting of desired goals of achievement for individuals. 7. Short focused courses should be used when total EM training time is less than 1 year. 8. All levels of ED staff must have appropriate BLS training. 9. Life support courses (BLS, ACLS, APLS ⁄ PALS, NALS, ATLS, etc.) should be tailored to local resources and local practice; are suitable for any health care provider, not only doctors; are credible enough that participants are likely to share skills with colleagues who have not attended; and should facilitate local doctors to become trainers as soon as possible, to run these courses independently. 10. All undergraduates should have EM lectures and rotation through accredited EM units, and life support courses should form part of the undergraduate curriculum. 11. Consultants in EDs should ideally have a specialist qualification, with specialist training accredited by a national body. ‘‘Grandfathering’’ of experienced personnel is vital initially so that trainers’ credentials do not slow the development of EM. 12. EM specialists should be trained in a formal postgraduate training program in EM of 3–4 years’ duration, with training provided at the local level wherever possible, with some exposure to advanced systems. 13. EM specialist training should include: a minimum of 18 months in the ED, intensive and critical care, anesthetics, orthopedics, pediatrics, medicine, obstetrics and gynecology, and prehospital emergency care and systems. 14. Life support courses (BLS, ACLS, APLS ⁄ PALS, NALS, ATLS, etc.): should not be the only or main requirement for EM training. 15. Training for nonphysicians working in the ED should be provided at the local level with some exposure to more advanced EM systems. ED nurses need supervised training in the ED for 1 month to get acclimatized to the ED procedures and protocols. 16. Training in and use of ultrasound should be promoted in developing world EDs. Nonconsensus Statements Teaching Methods 1. Simulator training provides enough worthwhile exposure to justify the investment for developing countries. Life Support Courses (BLS, ACLS, APLS ⁄ PALS, NALS, ATLS, etc.) 2. Should be seen as core competencies and mandatory requirement for staff. 3. Are only of value as part of the junior year of postgraduate training. 4. Are useful if justified by the case load of specific emergencies dealt with. 5. Should be combined into one course developed by EM physicians and available to all EM physicians. 6. Are not the most cost-effective way of delivering training. 7. Are not the top priority for ED staff. Doctors in Developing Countries 8. Specialists require long and complex training that is only appropriate in large urban or high-patient-load environments. Nurses and Nonphysicians Working in the ED 9. Nurses should undergo ACLS training at a minimum. 10. Training is best done in short didactic courses rather than long training programs. 11. Nonphysicians need a minimum training period of 1 year in the ED. Training: EM Trainers 12. Basic training for nonspecialist doctors can be done by nurses ⁄ paramedics, etc. ACLS = advanced cardiac life support, APLS = advanced pediatric life support; ATLS = advanced trauma life support; BLS = basic life support; NALS = neonatal advanced life support; PALS = pediatric advanced life support.

Statements . Reaching Consensus After Round 3 (But Not After Round 2). Nonphysicians perform a central role, especially where there are physician shortages. International standard ratios of staff to patient numbers are useful to determine staffing levels. Working hours should be divided into shifts of no more than 12 hours. Nonconsensus . Issues (After Rounds 2 and 3). With regard to doctors, there should be at least one EM specialist on duty on every shift; doctors should only be involved in direct patient care that cannot be provided by others. In terms of nursing staff, nurses must provide much of the

definitive care for minor and intermediate conditions; must have specific EM training; must have advanced life support (ALS) training; must have critical care, midwifery, and pediatric experience; and should be responsible for drugs and drug administration. Nonphysicians’ role should be limited to triage and nursing duties and are only necessary where there are insufficient doctors. 3. Training Consensus . Issues. Training must form the cornerstone of EM development, and collaboration with the


•

www.aemj.org

771

Table 5 Synopsis of Consensus Statements on EM Research in Developing Countries 1. Research efforts should be clinically driven and focus on local issues of importance and must be a key component of any program involving emergency care. 2. Broad-based research courses are important foundations to quality research. Collaboration between developing and developed world are the ideal for resources and research skills. 3. EM research requires allocation of dedicated resources. Cost–benefit analysis should be used in assessing the potential of research projects. Sponsorship is important in establishing and resourcing research. 4. Research projects should be centrally coordinated for expert input and to reduce duplication. 5. Research can be performed by any of the staff associated with an ED. 6. Focus should be on observational studies and epidemiologic research in the areas of establishing need for services, trauma and injury prevention, and cardiovascular disease; ED organizational research and system design studies; and outcomes research: what is the real benefit of new measures ⁄ policies ⁄ medications. 7. Research on implementation of changes, protocols, and guidelines in resource poor settings is a priority. 8. Research on the management and administration of EDs should include: cost-effectiveness of care, research on whether developed world EM systems work in the developing world, emergency care access and delivery, effectiveness of training endeavors and their impact on patient care, impact of emergency care on society, appropriate and affordable technology, and interventions and investigations that are necessary and shorten or prevent hospitalization. 9. Specific studies on the following clinical aspects of emergency care are a priority: development of evidence-based algorithms; triage; patient safety; clinical procedures that help to define life-saving conditions; infectious diseases; local antibiotic profiles; HIV management issues and programs; drug-resistant infections; vulnerable patient groups such as the newborn, the elderly, pregnant women, and trauma victims; management of trauma in resource-poor settings; management of wounds and fractures in resource poor settings; and pediatric fluid management. Nonconsensus Statements 1. EM research is a lesser priority than EM training. 2. EM research should focus on the following key areas: • Laboratory studies of basic disease processes. • Development of animal models to study pathophysiology of common problems. • Medicolegal aspects. • Studies of drugs or equipment. • Qualitative research into disaster medicine. • Management and prevention of natural disasters.

developed world is vital to achieve this, along with training of trainers. All levels of staff must have basic life support training. A core curriculum should be established with locally relevant material for training, as well as goal competencies for all grades. EM training (including life support courses) and rotation in ED units is essential for undergraduate doctors. EM specialist training must be a nationally accredited 3- to 4-year program run at a local level wherever possible with core rotations through emergency units, critical care, anesthetics, orthopedics, pediatrics, medicine, obstetrics and gynecology, and prehospital emergency care systems. Statements . Reaching Consensus After Round 3 (But Not After Round 2). Hands-on training is superior to formal teaching, and short courses are effective especially for nonspecialist training. Distance education should be developed. Life support courses (basic life support [BLS], advanced cardiac life support [ACLS], advanced pediatric life support ⁄ pediatric advanced life support [APLS ⁄ PALS], neonatal advanced life support [NALS], advanced trauma life support [ATLS], etc.) for all levels of health care providers should be tailored to local resources and practice and should facilitate local doctors to become trainers. Teaching from other specialties is important for EM specialist trainees. Grandfathering of experienced personnel is vital initially in the development of the specialty. Ultrasound training and use should be promoted. Nonconsensus . Issues (After Rounds 2 and 3). Simulator training is worthwhile for EM in the developing world. Life support courses should be seen as manda-

tory and core competencies, are only of value in the junior years of specialist training, should be combined into one course for EM, must be justified by the local case load of patients dealt with in the courses, and are not a priority for ED staff. EM specialist training is only necessary in high-volume urban centers, and short courses are initially more appropriate than specialist training. With regard to who trains, basic training for doctors can be done by nurses and paramedics. Nurses should undergo ACLS training at a minimum. Nonphysicians are best trained by short didactic courses rather than long programs, and training for nonphysicians should be at least 1 year long. 4. Research Consensus . Issues. Research must be clinically driven by locally important issues. Collaboration with the developed world is ideal to facilitate research. Dedicated resources are necessary, as is sponsorship of research; the cost benefit of research programs must be considered early. Outcome-based research is vital to examine the benefits of new technology, training, policies, and drugs, as well as the cost-effectiveness of such changes. Focus should be on epidemiologic studies such as trauma, injury prevention, cardiovascular disease, and the requirements for EM. Specific priority areas for developing world EM research include evidence-based algorithms, triage, patient safety, life-saving procedures, infectious diseases, antibiotic profiles, vulnerable patient groups, and trauma management. Statements . Reaching Consensus After Round 3 (But Not After Round 2). Research is a key component of

772


any EM program, and all research should be centrally coordinated. Broad-based courses on research techniques are an important foundation. Specific priority areas for research are HIV management, drug-resistant infections, pediatric fluid management, and whether developed world systems work in the developing world. Nonconsensus . Issues (After Rounds 2 and 3). Research is a lesser priority than training in EM. Specific priority issues for research include laboratory studies, animal models, medicolegal aspects, drug ⁄ equipment studies, qualitative research into disaster medicine, and management and prevention of natural disasters. DISCUSSION Evolution of the Study Through the Delphi Process There was widespread consensus among the panel on the priorities for developing world EM. Perhaps unsurprisingly, priorities were in line with those in EM systems established in the countries of origin ⁄ training of the panelists. This was demonstrated by the overlap in many of the suggestions that were collated in Round 1 and then the degree of positive consensus (64%) in Round 2. The thresholds for consensus were high at 80%, and it is interesting to note that had the positive threshold been set at 75 or 70% of panelists rating 4 or 5, and then the Round 2 consensus would have been 72 or 78%, respectively, closer to the final Round 3 consensus of 81%, demonstrating that many statements were in the 70% to 79% of positive consensus vicinity at the end of Round 2. Of the 36 statements that achieved consensus in Round 3 but not Round 2, in the majority (75%) of cases the change from Round 2 to 3 was less than 20% (i.e., 10 panel members changing their Likert rating from 3 or less to 4 or 5), presumably swayed by further consideration and seeing their colleagues’ ratings. Statements that had a ‘‘neutral’’ or more negative bias in Round 2 tended not to change substantially, except for a few exceptions discussed below where the consensus became substantially more negative. The scope of EM was considered to include prehospital and hospital care, the specific nature of which would be dependent on the structure of the health system in a given setting. Panelists agreed that EM services must be available 24 hours a day, include a triage system, and operate in a designated independent department, with referral of stabilized patients to other specialties where appropriate. The key function of EM was considered to be immediate care of patients with an acute health problem, and although the distinction between emergency care, FM, and critical care may be blurred in some cases, it was not considered feasible to generalize with time limits or other parameters which patients ‘‘belong’’ to which providers, due to the range of conditions and presentations in EM. Contentious issues included what level of care should be provided by prehospital services, with consensus to screen and stabilize with rapid transportation to hospital, rather than provide advanced care at the scene. The panel was clear that multiple investigations and ongoing management were not part of the scope of EM.

•


Provision of medical care in the developing versus developed countries is most notably differentiated by the limitation of resources, as well as the burden of disease. Resource limitation extends to a severe shortage of medical practitioners as well as skilled health care personnel in all cadres. There was consensus that EM specialists were vital in the development of EM in the developing world, but importantly, not only in a clinical role, but also for management, training, and development of services. Since the panel constituted EM specialists or equivalent, this was an expected result. It was agreed that trained (although not necessarily through any specific or mandatory ALS type course) nursing staff should be responsible for triaging of patients. Nonphysicians were also advocated as central to the EM system (and notably not only when there were insufficient doctors), with clearly defined roles and responsibilities but under supervision of doctors. The current functioning and role of non-physicians in the ED varies widely in different countries throughout the developed and developing world, which may have influenced the varied responses of panel members in relation to staffing norms. The panel highlighted the need for training at the local level, with some exposure to more advanced systems. Optimal training was considered to consist of substantial hands-on training (direct supervision and feedback) rather than formal didactic teaching. One of the key roles of an EM specialist was felt to be teaching of all cadres of staff working in the ED. It was thought that international trainers provide useful technical assistance in the early stages of establishing EM, but building local capacity for training must be prioritized to ensure sustainability. The role of internationally accredited ALS training courses was contentious, with some panel members contending that such courses were wholly inappropriate for medical practitioners in the developing world, given the difference in disease burden, the high cost of such courses, and unavailability of such training in local settings. Other panelists considered such qualifications to be credible and mandatory for EM practice, although most acknowledged the need to tailor such courses to the practice and disease burden in low income settings. There was clear consensus on the importance of specialists to EM services, with development of specialist training a priority in development. Consensus on points of particular note (where there was substantially more positive consensus in Round 3) were who performs the training: peer training is vital and important, local trainers from established specialties have a lot to offer, and experts from abroad are vital initially, but should strive to train local trainers for long-term sustainability. There was consensus that EM research should be implementation-focused and should include observation studies, cost-effectiveness of EM interventions, access to and delivery of EM care, implementation of EM algorithms and guidelines, and the impact of EM training. Training in research methods and appropriate mentoring was thought to be best provided initially through collaboration with institutions in the developed world, until sufficient local capacity is established. There were clear views that research that could be conducted in


•

www.aemj.org

the developed world was not a priority in the developing world (such as laboratory and animal studies and medicolegal issues), while there are many issues in the developing world that lend themselves to specific and meaningful research outcomes that cannot be replicated elsewhere. Many of the priorities would seem to be idealistic in low resources settings, for example, that EDs should be specialist-led. However, we believe that it is important to set clear goals and minimum standards for development of EM. We recommend that priority needs to be given to identifying individuals as potential specialists, and improving access to training programs, be they international or locally driven as one of the initial steps in establishing emergency care. Much of the current literature in this field deals with the need for EM in the developing world and how to implement EM at a policy level, rather than the details of the priorities as these data suggest. Several papers address broad concepts of prioritization very much in agreement with the consensus of this study, with emphasis on training and specialty development.1,4 Holliman et al.23 provide detailed recommendations based on the experiences of several experts who again are very much in concordance with the outcomes of this study—focusing on ED development, training, funding, specialist, and specialty development, and integration of the various aspects of emergency care.

773

are no universally accepted or evidence-based criteria to define consensus, and 80% positive (or negative) response was chosen as a reasonable threshold given the nature of the statements in this study.17,25 Likewise, there is no acceptable response rate: the response rate in this study was high—likely due to the persistent follow-up of panelists and interest in the study as the results became more evident.25 Consensus methodology has its shortcomings, and the most cited of these are that participants are not able to discuss issues and that the process may encourage participants to change their views according to the majority opinion.17 The large panel in this study, with common background training, would mitigate this to some extent. The degree of consensus in this study is high—82% of statements achieved positive consensus (which may be interpreted as evidence that panelists were ‘‘swayed’’ by the majority opinion). This must be seen in the context that, when collating free-text statements, most statements were worded in a positive manner (although in retrospect it is possible that some information has been lost in this manner). It is important to note that Delphi methodology does not necessarily identify agreement: there is a difference between agreement and consensus, which means that these consensus statements are not a standard for prioritizing EM development—they are rather guidelines (which also, by their nature, identify areas for further debate and research).17

LIMITATIONS The study was not comprehensive in all aspects of emergency care, but key areas were identified—scope, staffing, training, and research—which should be sufficient to guide countries in the development of EM as a specialty. Panel Composition The choice of the expert panel is a potential limitation in Delphi studies, as it may be influenced by the researchers’ own sphere of contacts. By setting clear definitions and inviting a large panel, it is hoped that this effect is minimized. Only medical practitioners were included in this panel, but useful information may have been lost in excluding other practitioners (nurses, prehospital staff, and physician assistants). By virtue of the scarcity of the specialty in the developing world, and the difficulty in contacting those in the developing world (especially by e-mail),24 there is perhaps some underrepresentation of personnel who live and work full time in the developing world. However, the panel members included many very experienced, leading figures in international EM, giving a qualified perspective on the various issues raised. It is possible that including doctors working in other fields that are more established in the developing world (such as medicine, surgery, pediatrics, etc.) may have useful information to add, but our experience is that there is little understanding of EM and its role and development outside of the specialty in the developing world setting. Consensus Methodology Consensus methodology is a means of obtaining expert opinion and turning this into a reliable measure. There

CONCLUSIONS This study established consensus in key areas to be considered in EM in developing countries. The next step is dissemination of these findings and development of practical guidelines for EM in developing world settings. More detailed input on specific issues and their relevance to local practice and conditions should be sought, most probably by means of focus group discussions from practitioners in a range of geographical settings. The study highlighted an urgent need to develop high-quality, standardized, and appropriate EM training material that is affordable and available for developing world settings. The expert panel consisted of the following individuals who we would like to acknowledge for all the time, energy, and enthusiasm they gave to the study (with the developing country they presently or in the past have worked or assisted in where applicable): K. Alagappan (United States), V. Anantharaman (Indonesia), T. Andersson (Sweden), R. Atilla (Turkey), B. Bevins (Kenya), M. Bisanzo (Uganda), G. Bodiwala (UK), B. Bonner (South Africa), S. Bruijns (South Africa), P. Cameron (Australia), S. Campbell (Ethiopia), T. Coats (UK), K. Cohen (South Africa), B. Corder (various), M. Cox (Tanzania), S. Curran (Sri Lanka), C. Curry (Papua New Guinea), P. Danders (United States), S. de Ries (South Africa), J. Ducharme (West Indies ⁄ Kuwait), A. Engelbrecht (South Africa), E. Fihe (Ethiopia), M. Fitzgerald (various), H. Geduld (South Africa), C. Graham (Cambodia ⁄ Thailand), S. Hathirat (Thailand), C. Hobgood (United States), S. Inglis (Papua New Guinea), D. Jerrard (United States), A. Kelly (various), W. Kloeck (South Africa), F. Lamond (various), F. Lateef (Singapore), J. Lex (United States), W. Lubinga (South Africa), K. Mackway-Jones (UK), I. Maconochie (UK), S. Mardel (various), Z. Mohamed (South Africa), E. Molyneux (Malawi), T. Mulligan (various), K. O’Hanlan (Kosovo), G. O’Reilly (Sri Lanka ⁄ India), T. Rainer (Hong Kong), B. Rajapakse (Sri Lanka),

774


T. Ramakrishnan (India), G. Ramalanjaona (Madagascar), S. Rennie (Australia), C. Robertson (South Africa), I. Sammy (Trinidad & Tobago), J. Seblova (Czechozlavakia), H. Sule (Azerbaijan), J. Suozzi (Uganda), B. Suter (various), S. Trakulsrichai (Thailand), C. van Loggerenberg (South Africa), P. van Rensburg (South Africa), S. Wang (Korea), and J. Williams-Johnston (Jamaica).

16.

17. References 1. Smith J, Haile-Mariam T. Priorities in global emergency medicine development. Emerg Med Clin N Am. 2005; 23:11–29. 2. Curry C. A perspective on developing emergency medicine as a speciality. Int J Emerg Med. 2008; 1:163–7. 3. Kirsh TD. Emergency medicine around the world. Ann Emerg Med. 1998; 32:237–8. 4. Razzak JA, Kellerman AL. Emergency medical care in developing countries: is it worthwhile? Bull World Health Org. 2002; 80:900–5. 5. World Health Organization. WHO Guidelines for the Treatment of Malaria. Geneva, Switzerland: World Health Organization, 2006. 6. World Health Organization. Priority Interventions: HIV ⁄ AIDS Prevention, Treatment and Care in the Health Sector. Geneva, Switzerland: World Health Organization, 2009. Available at: http://www.who. int/hiv/pub/priorityinterventions. Accessed Apr 8, 2010. 7. Mock C, Lormand JD, Goosen J, Joshipura M, Peden M. Guidelines for Essential Trauma Care. Geneva, Switzerland: World Health Organization, 2004. 8. Arnold JL. Lessons learned from international emergency medicine development. Emerg Med Clin N Am. 2005; 23:133–47. 9. Molyneux E, Robertson A. Emergency medicine in differently resourced settings: what can we offer each other? Emerg Med J. 2002; 19:378–9. 10. Arnold JL, Corte DF. International emergency medicine: recent trends and future challenges. Eur J Emerg Med. 2003; 10:180–8. 11. World Health Organization. Declaration of AlmaAta: International Conference on Primary Health Care. Alma-Ata, USSR, 6-12 September 1978. Available at: http://www.who.int/hpr/NPH/docs/ declaration_almaata.pdf. Accessed Apr 8, 2010. 12. Doney MK, Macias DJ. Regional highlights in global emergency medicine development. Emerg Med Clin N Am. 2005; 23:31–44. 13. Arnold LK, Fernandes WG, Altman RS. Hot topics in international emergency medicine. Emerg Med Clin N Am. 2005; 23:57–83. 14. Sasser S, Varghese M, Kellermann A, Lormand JD. Prehospital Trauma Care Systems. Geneva, Switzerland: World Health Organization, 2005. 15. Linstone HA, Turoff M. Introduction. In: Linstone HA, Turoff M, eds. The Delphi Method: Techniques

18.

19.

20.

21.

22. 23.

24.

25.

•


and Applications. Reading, MA: Addison-Wesley Publishing Company, 1975: 3–12. Landeta J. Current validity of the Delphi method in social sciences. Technol Forecasting Soc Change. 2006; 73:467–82. Williams PL, Webb C. The Delphi technique: a methodological discussion. J Adv Nurs. 1994; 19:180–6. Ospina MB, Bond K, Schull M, Innes G, Blitz S, Rowe BH. Key indicators of overcrowding in Canadian emergency departments: a Delphi study. Can J Emerg Med. 2007; 9:339–46. Wallis L, Carley SD, Hodgetts CT. A procedure based alternative to the injury severity score for major incident triage of children: results of a Delphi consensus process. Emerg Med J. 2006; 23:291–5. Crawford IW, Mackway-Jones K, Russell DR, Carley SD. Delphi based consensus study into planning for chemical incidents. Emerg Med J. 2004; 21:24–8. United Nations. Composition of Macro Geographical (Continental) Regions, Geographical Sub-regions, and Selected Economic and Other Groupings. Available at: http://unstats.un.org/unsd/ methods/m49/m49regin.htm#developed. Accessed Apr 9, 2010. Likert A. A technique for the measurement of attitudes. Arch Psychol (Frankf). 1932; 22:1–55. Holliman J, Van Rooyen MJ, Green GB, et al. Planning recommendations for international emergency medicine and out-of-hospital care system development. Acad Emerg Med. 2000; 7:911–7. Harris DR, Connolly H, Christenson J, Innes G. Pitfalls of email survey research [abstract]. Can J Emerg Med. 2003; 5:80. Hasson F, Keeney S, McKenna H. Research guidelines for the Delphi survey technique. J Adv Nurs. 2000; 32:1008–15.

Supporting Information: The following supporting information is available in the online version of this paper: Data Supplement S1. Full list of statements with positive percentage consensus for each statement in Rounds 2 and 3, and negative percentage consensus for Round 3. The document is in PDF format. Please note: Wiley Periodicals Inc. is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing material) should be directed to the corresponding author for the article.