Skip to main content
Download PDF
  • Research article
  • Open access
  • Published:

Harnessing inter-disciplinary collaboration to improve emergency care in low- and middle-income countries (LMICs): results of research prioritisation setting exercise

BMC Emergency Medicine volume 20, Article number: 68 (2020) Cite this article

Abstract

Background

More than half of deaths in low- and middle-income countries (LMICs) result from conditions that could be treated with emergency care - an integral component of universal health coverage (UHC) - through timely access to lifesaving interventions.

Methods

The World Health Organization (WHO) aims to extend UHC to a further 1 billion people by 2023, yet evidence supporting improved emergency care coverage is lacking. In this article, we explore four phases of a research prioritisation setting (RPS) exercise conducted by researchers and stakeholders from South Africa, Egypt, Nepal, Jamaica, Tanzania, Trinidad and Tobago, Tunisia, Colombia, Ethiopia, Iran, Jordan, Malaysia, South Korea and Phillipines, USA and UK as a key step in gathering evidence required by policy makers and practitioners for the strengthening of emergency care systems in limited-resource settings.

Results

The RPS proposed seven priority research questions addressing: identification of context-relevant emergency care indicators, barriers to effective emergency care; accuracy and impact of triage tools; potential quality improvement via registries; characteristics of people seeking emergency care; best practices for staff training and retention; and cost effectiveness of critical care – all within LMICs.

Conclusions

Convened by WHO and facilitated by the University of Sheffield, the Global Emergency Care Research Network project (GEM-CARN) brought together a coalition of 16 countries to identify research priorities for strengthening emergency care in LMICs. Our article further assesses the quality of the RPS exercise and reviews the current evidence supporting the identified priorities.

Peer Review reports

FormalPara Abreviations

ECSAs Emergency Care System Assessments

ECS Emergency Care Systems

GETI Global Emergency and Trauma Care Initiative

GEM-CARN Global Emergency Care Research Network project

HICs High-income countries

JLA James Lind Alliance

LMICs ow- and middle-income countries

RPS research prioritisation setting

RPS research priority setting

RCEM Royal College of Emergency Medicine

WHO The World Health Organization

UHC Universal health coverage

Introduction

While prevention is ideal, there is no context in which all emergencies can be averted, and prevention strategies may take years or decades to show benefit [1, 2]. Globally 90% of healthcare emergencies occur in low- and middle income countries (LMICs) [3, 4] especially in children and working age adults [5]. The World Bank Disease Control Priorities Project estimates that over half of deaths in LMICs result from conditions that could be treated with emergency care [6]. Emergency care is an essential component of universal health coverage (UHC) and serves as the first point of contact with the health system for many. However, the majority of people around the world remain without timely access to high-quality essential emergency care services, and this results in enormous disparities in outcomes [7]. People with similar injuries, for example, are nearly twice as likely to die in LMICs than in high-income countries (HICs) [8]. In HICs, Emergency Care Systems (ECS) have evolved considerably over the last 50 years alongside the development of Emergency Medicine as a distinct medical specialty, recognising the need for training, expertise and dedicated systems to care effectively for the acutely ill and injured of all ages [9]. Recent studies point to the benefits of utilising research evidence to reconfigure ECS elements in HICs [10]. As an example, a 19% reduction in risk adjusted mortality following serious injury has been observed following the introduction of major trauma centres and management networks in the UK [11].

Studies such as this one highlight the importance of defining research priorities to inform strengthening of Emergency Care Systems, but there is little research to guide policy and implementation in settings where resources are limited and prioritization is critical. World Health Assembly Resolution 72.16 calls for national-level WHO Emergency Care System Assessments (ECSAs) to define system-level gaps and priorities for action and highlights the need for a stronger evidence base to inform policy and implementation [12]. While there have been prior emergency care research priority setting (RPS) exercises oriented to the global context, these have largely focused on general frameworks or on logistical and ethical challenges of conducting emergency care research in LMICs [13,14,15], or on consensus-based prioritisation of quality indicators for emergency care provision in LMICs [16], rather than identifying specific research questions. One 2013 initiative identified potential priority research questions, though without the benefit of input from policymakers and implementers [17, 18]. Other efforts have been limited to HIC settings: the Royal College of Emergency Medicine (RCEM) collaborated with the James Lind Alliance (JLA) to engage clinicians, patients, carers and the public to prioritise the top ten research questions in the UK Emergency Medicine [19]. A wide variety of research priority setting (RPS) exercises have been undertaken by WHO in the areas of infectious and communicable disease [20]. The recent launch of the Global Emergency and Trauma Care Initiative (GETI) [21] will facilitate scale-up and roll-out of the WHO ECS Toolkit, including coordinated implementation and concentrated monitoring across countries in all WHO regions. However, WHO has not yet undertaken this process for pathways to care for people with life-threatening and/or time-sensitive conditions.

The Global Emergency Care Research Network project (GEM-CARN), an international and multidisciplinary coalition of researchers and stakeholders across different countries and regions, conducted a RPS exercise after the 2019 WHO Global Emergency Care Systems meeting to identify evidence gaps and emergency care research priorities in LMICs. In this article, we explore four phases of research prioritisation, identify seven priorities for improving emergency care systems in LMICs, assess the quality of our RPS exercise and review the current evidence available. Our RPS process was informed by using steps identified during a Cochrane International workshop on Research Priority Setting Methods [22] (see Fig. 1), published evidence reviews, consensus documents and gap analyses from country experts [5, 7, 23] as well as early data from WHO emergency care implementation activities using the WHO Emergency Care Toolkit, which includes national system-level assessments, clinical and process guidance for emergency units [24]. Details of WHO Tools and other materials used to inform the RPS process are provided in Table 1.

Fig. 1
figure 1

Wheel of Research Priority Setting Exercises (This figure was published in the Journal of Clinical Epidemiology,Volume number 66(5), Nasser M, Ueffing E, Welch V, Tugwell P, An equity lens can ensure an equity-oriented approach to agenda setting and priority setting of Cochrane Reviews, Pages 511–521. Copyright© Elsevier Inc. 2013)

Full size image
Table 1 Documents informing phase 1 of research prioritisation setting exercise
Full size table

Method

Phase 1: engaging with stakeholders, identifying questions and uncertainties

Engaging with stakeholders was the first phase of the RPS exercise Fig. 2. The 2019 WHO Global ECS meeting in Geneva, Switzerland in February 2019 presented an opportunity to convene six universities of the initial GEM-CARN project group (The University of Cape Town, South Africa; Ain Shams University, Cairo, Egypt; Manmohan Memorial Institute of Health Sciences, Nepal; University of the West Indies, Jamaica; Muhimbili University of Health and Allied Sciences, Tanzania; The University of Sheffield) with representatives from ten additional countries, bringing the total number of countries represented to 16. The convening brought together researchers from relevant disciplines including Emergency Medicine, Pre-hospital Care, Health Services Research, Public Health, Disaster Management and Defence (Military) Medicine. Beyond the GEM-CARN universities, the group included representatives from: Ministry of Health Tunisia; Philippine College of Emergency Medicine, Philippines; American Heart Association (AHA), USA; Ministry of Health Ethiopia; Scarborough General Hospital, Tobago; Ministry of Health, Iran; Sungai Buloh Hospital, Malaysia; Seoul National University Hospital South Korea; Ministry of Health, Jordan; Colombian Trauma Association, Colombia; and the University of California, San Francisco WHO Collaborating Centre for Emergency and Trauma Care, USA Fig. 3. Collaborators engaged with stakeholders to discuss current emergency care delivery across national contexts and to identify current gaps in the evidence for the effectiveness of emergency care interventions.

Fig. 2
figure 2

Four phases of Global Emergency Care Research Network Research Prioritisation Setting Exercise

Full size image
Fig. 3
figure 3

Sixteen countries participating in Global Emergency Care Research Network (GEMCARN) Research Priority Setting Exercise (Highlighted Red = GEMCARN partners, Blue = GEMCARN collaborators) Map taken from copyright free image https://www.sheffield.ac.uk/library/copyright/imagesource, country locators added with photoshop

Full size image

An overview of the WHO Emergency Care System Framework was presented [25]. The ensuing round table discussion highlighted significant evidence gaps to support Emergency Care System (ECS) development in most LMICs. The LMICs represented highlighted different stages of ECS development across and within countries- particularly with regards to prehospital care. The discussion also reflected a concentration of emergency medicine and supporting specialty expertise in university teaching hospital emergency departments/Facilities and the impact of “(lack of) ability to pay” and other non-clinical factors that impacted on patient access to ECS. It was felt that collaborative interdisciplinary research holds the potential to deliver better understanding of this ECS heterogeneity and its impact across countries. The discussion identified potential areas of interest for future research studies, including evaluating the impact of national system-level assessments on country planning and implementation. In addition, it was felt that research studies focused on understanding and developing context-relevant standards and measurement priorities for emergency care across countries were important if the effects of change and impact are to be reliably measured. Furthermore, there is a need to understand the case mix in LMICs better by matching resources with case mix such as non-communicable and end-stage diseases. The discussion reflected on the challenges of sustainable measurement of emergency care quality indicators within a limited-resource system. It was also noted that research initiatives should take account of feasibility, the need for open-access platforms, and development of low cost continuous feedback and benchmarking systems.

Phase 2: identification of important research questions

In phase 2, participants were asked to identify important research questions for improving the effective delivery of emergency care in low-resource settings. Using modified nominal group techniques [27, 28], participants were divided into three groups to brainstorm potential research questions that should be prioritized for improving emergency care in low-resource settings. Each group had a mix of LMIC and HIC contributors, an experienced researcher as chair and was asked to identify 3–5 key research questions. Eleven separate research questions were identified by the three groups (Table 2). The triage question identified 3 separate elements. The outputs from each group were merged to create a long list of research questions to be considered for prioritisation in Phase 4.

Table 2 Research questions identified in phase 2
Full size table

Phase 3: situation analysis of research capacity and challenges in low-resource settings

In Phase 3, a situation analysis facilitated reflections on the reality of conducting emergency care research in low-resource settings context. This involved a brief assessment of the current ECS research landscape as compared to the expectations and needs of each country.

Country representatives shared their experiences on the challenges they face in conducting emergency care research in LMICs. Several common themes were identified (Table 3) that could be categorised as factors to do with the external environment such as regulation and policy, the research community present and process issues linked to the conduct of research.

Table 3 Challenges of conducting Emergency Care research in LMICs
Full size table

Results

Phase 4: research prioritisation ranking

In Phase 4, to decide on priorities, a combination of a metrics-based approach (pooling individual rankings), and a consensus-based approach was used. The three groups each ranked the previously highlighted questions according to feasibility and applicability. The roundtable feedback of the scoring from each group enabled a consensus to be reached on the top seven prioritised questions. Of note, between each phase, feedback sessions were conducted.

The three groups individually scored each of the 11 questions in terms of applicability and feasibility

Merging of the ranking of questions from the 3 groups (appendix 1) identified the top questions. The 7 highest-ranking questions to prioritise (in order of decreasing priority) are listed in Fig. 4:. The top seven priority research questions address identification of context-relevant emergency care indicators, barriers to effective emergency care; accuracy and impact of triage tools; potential quality improvement via registries; characteristics of people seeking emergency care; best practices for staff training and retention; and cost effectiveness of critical care – all within LMICs.

Fig. 4
figure 4

Seven highest ranking Emergency Care research questions in LMICs. Figure created using canva graphic design software https://about.canva.com/license-agreements/free-media/

Full size image

Quality assessment of the research priority setting exercise

We assessed the quality of the RPS exercise using a checklist of nine themes of good practice as proposed by WHO (Appendix 2) [29]. It adheres to these recommendations considering the context, use of a comprehensive approach, inclusiveness, information gathering, planning for implementation, criteria for deciding on priorities, combination of consensus and metrics based approach and transparency [29]. For example; the focus of the exercise (i.e. what the exercise is about and who it is for) was clearly stated: “to identify and rank important research questions that could improve emergency care in LMICs drawing from cross country experience and expertise.”

Explicit decisions were made as to who to involve (researchers from relevant disciplines and representatives of Ministries of Health in LMICs) in setting the research priorities and why (to enable research priorities to be informed by cross country, multidisciplinary experience and, expertise). This included representation of expertise (researchers from relevant disciplines including Emergency Medicine, Pre-hospital Care, Health Services Research, Public Health, Disaster Management and Defence (Military) Medicine) and regional participation (stakeholders from 13 LMICs and 3 HICs). We deliberately selected high value information to inform the exercise, such as literature reviews, and key guidance documents (as shown in Table 1).

It was communicated to participants that translation of the research priorities to actual research studies could occur via collaborations for global health funding applications and highlighted the importance that research priorities for improving emergency care systems in LMICs are led, developed and informed by local researchers most familiar with the context and working in partnership with their patients. To decide on priorities, we used a combination of a metrics-based approach (pooling individual rankings) informing consensus-based discussions.

We are yet to define when evaluation of the established priorities and the priority setting process will take place but inevitably, the most positive evaluation would result from funding of the prioritised research questions with demonstrable subsequent improvement in corresponding elements of Emergency Care in LMICs.

Discussion

The multinational, interdisciplinary collaboration supported by the GEMCARN project has conducted research priority setting according to published standards and identified seven research priorities for strengthening Emergency Care in low resource settings - to be taken forward through formal funded studies. These highly-ranked priorities are consistent with the challenges identified in World Health Assembly Resolution 72.16. These include “poor coordination of prehospital and facility-based care; limited or no coverage of prehospital systems, especially in rural areas; shortage of fixed staff assigned to emergency units; lack of standards for clinical management and documentation; and insufficient funding.” [12] Following the RPS exercise, a PubMed search (Oct 03, 2019) was performed using the terms “emergency care”, “research priorit*”, “low income countries”, “middle income countries”, “low-middle income countries”, “developing countries”, “collaboration”, and “network” for articles published in English. The search included technical reports, reviews, books, consensus development conferences, broadly associated with emergency care systems, policies, strategies and data in low- and middle-income countries. We identified supporting evidence in relation to the emergency care research priorities for LMICs:

Emergency care system indicators

A systematic review of emergency care quality and safety indicators in low resource settings has reported a limited number of metrics, the majority of which focus on structures or processes of care rather than on patient outcomes [30]. A consensus-based set of 76 quality indicators for emergency care in LMICs was produced at the 2016 AFEM, including indicators on mortality outcomes [16]. More recently, International Federation of Emergency Medicine developed a framework for quality and safety, setting out global expectations for emergency care [31]. Therefore, it is worth considering what structure, process and outcome indicators for emergency care reflect the whole patient journey through the ECS in LMICs. The WHO is currently conducting a systematic review on emergency care indicators which will further inform this research priority.

Barriers to care

A recent systematic review identified six barriers to out-of- hospital care in LMICs [22]. These include culture, infrastructure, communication/coordination, transport, equipment and personnel. However, 56% of the included articles had a primary author from outside of the study country, which means that understanding of the pre-hospital systems maybe limited and the barriers reported may not be the important ones. These barriers are in-line previous research highlighting a lack of coverage of prehospital systems, especially in rural areas, and insufficient coordination among prehospital and facility-based providers [7]. Affordability and a range of socio-economic factors are also key barriers to the ECS as a whole [32].

Registries

Standardized emergency care registries are largely absent in most LMICs, due to a lack of standard clinical management and documentation in prehospital and facility settings [7, 33]. However, the establishment of registries is slowly increasing in response to the growing body of evidence in support of trauma registries [34, 35]. There are significant challenges to establishing trauma registries in these settings [36]. Barriers to trauma registry implementation include data quality issues, limited resources and, limitations in pre-hospital care. Additional effort is needed to identify effective means of implementation of surveillance and registry systems that are adaptable to different settings including LMICs [33]. A framework for surveillance and registry research in low-resource emergency care settings is clearly needed.

Triage

Evidence shows that inpatient and emergency department (ED) triage positively predict patient clinical outcomes, safety and waiting times [37,38,39]. However, there is a dearth of evidence supporting the validity and reliability of triage tools in LMICs [40]. Future research in this field needs to consider changes in research methodology, evaluation of triage tools with actual users, accounting for resource constraints, uniformity in the statistical evaluation and evaluation of triage impact on waiting times, resource utilisation and patient satisfaction [40].

Patient characteristics

Patients who access emergency care mostly consist of children of median age 3.2 years and adults of median age 35 years [5]. Paediatric patients account for 20–35% of all ED visits globally [41]. These patients have high mortality rates compared to similar patients in high-income countries. Increasingly, a shift is being observed in emergency care surveillance in LMICs to categories of conditions such as non-communicable diseases (NCDs) and injuries [33]. Hence, there is also a need to better describe the disease profile of patients in LMICs who seek emergency care and understand the case mix better, particularly as this will impact on outcomes of these patients, including mortality rates.

Staffing

Most countries currently face shortages in health care staff but the lack of speciality trained or skilled personnel in emergency care is a particular challenge in LMICs [42,43,44,45,46]. It has been recommended that basic lifesaving skills and first-aid training is needed for pre-hospital providers, taxi drivers and the police especially in settings where emergency responders do not exist [22]. There are also other staffing issues such as rotation of staff and security issues for staff in the emergency department that impact emergency care services.

Cost effectiveness

In the context of resource constraints common to virtually all health system settings, the cost effectiveness of interventions and services delivered is paramount. The World Bank’s Disease Control Priorities in Developing Countries has identified the most effective and cost-effective interventions across a wide range of disease conditions [47]. Some examples of highly cost-effective emergency care services in LMICs have also been identified including the provision of a “dedicated emergency unit with formal triage, oxygen for pneumonia, pulse oximetry for childhood pneumonia, treatment of acute myocardial infarction, emergency obstetric care, trauma surgery and emergency obstetric services” [7]. However, studies of the cost effectiveness of emergency care in LMICs are still at an early stage and there is a dearth of high quality evidence. This includes for example common approaches such as task-shifting from doctors to allied health professionals such as community health workers and nurses or from health facility into the community that are likely to be cost-effective and even potentially cost-saving but for which there is little strong evidence.

Conclusion

Ultimately, an evidence-to-policy stance in emergency care will be crucial for effective development in LMICs. Despite the highlighted challenging factors of external environment, research community and conduct of research facing emergency care research in LMICs, this RPS exercise has identified key research priorities to support the development of evidence, research capacity and to inform efforts to improve ECS in low-resource settings. This can guide future research and funding applications to support emergency care development for the world’s poorest billion. Such collaborations as these draw on the strength of the “South-South” cross-learning among LMIC partners in addition to a mutual reinforcement between high-income and LMIC collaborators, allowing for HIC collaborators alike to learn from the relative effectiveness of various emergency care interventions as they seek to further understand and strengthen ECS. Gradually, we will be able to build research capacity such that interventions to improve emergency care systems in LMICs will be led, developed and informed by local researchers most familiar with the context.

Availability of data and materials

All source data is provided within the manuscript, the corresponding author can address further questions.

References

  1. World Health Organization, 2002.Reducing risks, promoting healthy life. World health report. Available: https://www.who.int/whr/2002/en/whr02_en.pdf?ua=1 (Accessed 11 Mar 2020).

  2. World Health Organization, 2007. Preventing injuries and violence: A guide for Ministries of Health. Available https://apps.who.int/iris/bitstream/handle/10665/43628/9789241595254_eng.pdf;jsessionid=EC13D6B7AD8E126526B789B8B4CEF305?sequence=1(Accessed 11 Mar 2020).

  3. Reynolds T, Stewart B, Drewett I, et al. The impact of trauma care systems in low- and middle-income countries. Annu Rev Public Health 2017;38:507–532 doi: https://doi.org/10.1146/annurev-publhealth-032315-021412 [Published Online First: 11 January 2017].

  4. Peden MM, McGee K, Krug E. Injury: a leading cause of the global burden of disease, 2000. Geneva: World Health Organization; 2002.

    Google Scholar 

  5. Obermeyer Z, Abujaber S, Makar M, et al. Emergency care in 59 low- and middle-income countries: a systematic review. Bull World Health Organ. 2015;93:577–586G. https://doi.org/10.2471/BLT.14.148338 [Published Online First: 26 May 2015].

    Article  PubMed  PubMed Central  Google Scholar 

  6. Thind A, Hsia R, Mabweijano J, et al. Prehospital and emergency care. In: Debas HT, Donkor P, Gawande A, et al (eds). Essential Surgery: Disease Control Priorities, 3rd ed (1). Washington (DC): The International Bank for Reconstruction and Development / The World Bank; 2015 Apr 2. Chapter 14. Available from: https://www.ncbi.nlm.nih.gov/books/NBK333513/doi: https://doi.org/10.1596/978-1-4648-0346-8_ch14.

  7. Reynolds T, Sawe H, Rubiano A, et al. Strengthening health systems to provide emergency care. In : Jamison DT, Gelband H, Horton S, et al (eds). Disease control priorities: improving health and reducing poverty. 3rd edn. World Bank Group, Washington, DC 2017. https://www.ncbi.nlm.nih.gov/books/NBK525279/ (Accessed 11 Mar 2020).

  8. Mock C, Joshipura M, Arreola-Risa C, et al. An estimate of the number of lives that could be saved through improvements in trauma care globally. World J Surg. 2012;36(5):959–63. https://doi.org/10.1007/s00268-012-1459-6 [Published Online First: 15 March 2012].

    Article  PubMed  Google Scholar 

  9. Mason S, Coleman P, O’Keeffe C, et al. The evolution of the emergency care practitioner role in England: experiences and impact. Emerg Med J. 2006;23:435–9. https://doi.org/10.1136/emj.2005.027300 [Published Online First: 19 May 2006].

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  10. Moran CG, Lecky F, Bouamra O, et al. Changing the system — major trauma patients and their outcomes in the NHS (England) 2008–2017. EClinicalMedicine 2018;2–3:13–21. Available https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(18)30007-5/fulltext (Accessed 11 Mar 2020) doi: https://doi.org/10.1016/j.eclinm.2018.07.001 [Published Online First: 5 August 2018].

  11. Moore L, Champion H, Tardif PA, et al. Impact of trauma system structure on injury outcomes: A Systematic Review and Meta-Analysis. World J Surg 2018;42:1327–39 doi: https://doi.org/10.1007/s00268-017-4292-0 [Published Online First: 25 October 2017].

  12. Resolution WHA72.16.Emergency care systems for universal health coverage: ensuring timely care for the acutely ill and injured. In: Seventy-second World Health Assembly, Geneva, 28 May 2019. Geneva: World Health Organization; Available from: https://apps.who.int/gb/ebwha/pdf_files/WHA72/A72_R16-en.pdf (Accessed 11 Mar 2020).

  13. Aluisio AR, Waheed S, Cameron P, et al. Clinical emergency care research in low-income and middle-income countries: opportunities and challenges. BMJ Glob Health. 2019;4(Suppl 6):e001289. https://doi.org/10.1136/bmjgh-2018-001289 [Published Online First: 29 July 2019].

    Article  PubMed  PubMed Central  Google Scholar 

  14. Moresky RT, Razzak J, Reynolds T, et al. Advancing research on emergency care systems in low-income and middle-income countries: ensuring high-quality care delivery systems. BMJ Glob Health. 2019;4(Suppl 6):e001265. https://doi.org/10.1136/bmjgh-2018-001265 [Published Online First: 29 July 2019].

    Article  PubMed  PubMed Central  Google Scholar 

  15. Millum J, Beecroft B, Hardcastle TC, et al. Emergency care research ethics in low-income and middle-income countries. BMJ Glob Health. 2019;4(Suppl 6):e001260. https://doi.org/10.1136/bmjgh-2018-001260 [Published Online First: 29 July 2019].

    Article  PubMed  PubMed Central  Google Scholar 

  16. Broccoli MC, Moresky R, Dixon J, et al. Defining quality indicators for emergency care delivery: findings of an expert consensus process by emergency care practitioners in Africa. BMJ Glob Health. 2018;3:e000479. https://doi.org/10.1136/bmjgh-2017-000479 [Published Online First: 15 February 2018].

    Article  PubMed  PubMed Central  Google Scholar 

  17. Reynolds TA, Bisanzo M, Dworkis D, et al. Research priorities for data collection and management within global acute and emergency care systems. Acad Emerg Med 2013;20:1246–50 doi: https://doi.org/10.1111/acem.12261 [Published Online First: 16 December 2013].

  18. Calvello EJ, Broccoli, M, Risko N, et al. Emergency care and health systems: consensus-based recommendations and future research priorities. Acad Emerg Med 2013;20:1278–88 doi: https://doi.org/10.1111/acem.12266 [Published Online First: 16 December 2013].

  19. Smith J, Keating L, Flowerdew L, et al. An emergency medicine research priority setting partnership to establish the top 10 research priorities in emergency medicine. Emerg Med J 2017;34:454–56 doi: https://doi.org/10.1136/emermed-2017-206702 [Published Online First: 4 May 2017].

  20. Viergever RF. Health research prioritization at WHO: an overview of methodology and high level analysis of WHO led health research priority setting exercises. Geneva: World Health Organization; 2010.

    Google Scholar 

  21. World Health Organization. Global emergency and trauma care initiative,2018. https://www.who.int/emergencycare/global-initiative/en/ (Accessed 11 March 2020).

  22. Nasser M, Ueffing E, Welch V, et al. An equity lens can ensure an equity-oriented approach to agenda setting and priority setting of Cochrane Reviews. J Clin Epidemiol 2013;66(5):511–21. doi: https://doi.org/10.1016/j.jclinepi.2012.11.013 [Published Online First: 8 March 2013].

  23. Kironji AG, Hodkinson P, de Ramirez SS, et al. Identifying barriers for out of hospital emergency care in low and low-middle income countries: a systematic review. BMC Health Serv Res 2018; 18:291 doi: https://doi.org/10.1186/s12913-018-3091-0 [Published Online First: 19 April 2018].

  24. World Health Organization. Emergency care. https://www.who.int/health-topics/emergency-care#tab=tab_1 (Accessed 11 Mar 2020).

  25. World Health Organization. Emergency and trauma care. WHO emergency care system framework infographic. https://www.who.int/emergencycare/emergencycare_infographic/en/ (Accessed 11 Mar 2020).

  26. World Health Organization. Emergency and Trauma Care Activities. https://www.who.int/emergencycare/activities/en/ (Accessed 12 Mar 2020).

  27. Jones J, Hunter D. Consensus methods for medical and health services research. BMJ 1995;311(7001):376–80 doi: https://doi.org/10.1136/bmj.311.7001.376 [Published Online First: 5 August 1995].

  28. McGregor S, Henderson KJ, Kaldor JM. How are health research priorities set in low and middle income countries? A systematic review of published reports. PLoS One 2014;9:e108787 doi: https://doi.org/10.1371/journal.pone.0108787 [Published Online First: 2 October 2014].

  29. Viergever RF, Olifson S, Ghaffar A, et al. A checklist for health research priority setting nine common themes of good practice. Health Res Policy Syst 2010;8:36 doi: https://doi.org/10.1186/1478-4505-8-36 [Published Online First: 15 December 2010].

  30. Aaronson EL, Marsh RH, Guha M, et al. Emergency department quality and safety indicators in resource-limited settings: an environmental survey. Int J Emerg Med 2015;8(1):39 doi: https://doi.org/10.1186/s12245-015-0088-x [Published Online First: 31 October 2015].

  31. International Federation For Emergency Medicine 2019. An updated framework on quality and safety in emergency medicine. https://www.ifem.cc/wp-content/uploads/2019/05/An-Updated-Framework-on-Quality-and-Safety-in-Emergency-Medicine-January-2019.pdf (Accessed 11 Mar 2020).

  32. Ro YS, Shin SD, Jeong J, et al. Evaluation of demands, usage and unmet needs for emergency care in Yaoundé, Cameroon: a cross-sectional study. BMJ Open 2017;7:e014573 doi: https://doi.org/10.1136/bmjopen-2016-014573 [Published Online First: 6 February 2017].

  33. Mowafi H, Ngaruiya C, O'Reilly G, et al. Emergency care surveillance and emergency care registries in low-income and middle-income countries: conceptual challenges and future directions for research. BMJ Glob Health 2019;4(Suppl 6):e001442 doi: https://doi.org/10.1136/bmjgh-2019-001442 [Published Online First: 29 July 2019].

  34. Mock C, Juillard C, Brundage S, et al. Guidelines for trauma quality improvement programmes. Geneva: World Health Organization; 2008.

    Google Scholar 

  35. Nwomeh BC, Lowell W, Kable R, Haley K, Ameh EA. History and development of trauma registry: lessons from developed to developing countries. World J Emerg Surg 2006;1:32 doi: https://doi.org/10.1186/1749-7922-1-32 [Published Online First: 31 October 2006].

  36. Bommakanti K, Feldhaus I, Motwani G, et al. Trauma registry implementation in low- and middle-income countries: challenges and opportunities. J Surg Res 2018;223:72–86 doi: https://doi.org/10.1016/j.jss.2017.09.039 [Published Online First: 11 November 2017].

  37. Olson D, Preidis GA, Milazi R, et al. Task shifting an inpatient triage, assessment and treatment programme improves the quality of care for hospitalised Malawian children. Trop Med Int Health 2013;18:879–86 doi: https://doi.org/10.1111/tmi.12114 [Published Online First: 22 April 2013].

  38. Subash F, Dunn F, McNicholl B, et al. Team triage improves emergency department efficiency. Emerg Med J 2004;21:542–4 doi: https://doi.org/10.1136/emj.2002.003665 [Published Online First: 25 August 2004].

  39. Wiler JL, Gentle C, Halfpenny JM, et al. Optimizing emergency department front-end operations. Ann Emerg Med 2010;55:142–160 e1 doi: https://doi.org/10.1016/j.annemergmed.2009.05.021 [Published Online First: 25 June 2009].

  40. Jenson A, Hansoti B, Rothman R, et al. Reliability and validity of emergency department triage tools in low and middle income countries: a systematic review. Eur J Emerg Med 2018; 25(3):154160 doi: https://doi.org/10.1097/MEJ.0000000000000445 [Published Online First: 1 June 2018].

  41. Goh AY, Chan TL, Abdel-Latiff ME. Paediatric utilization of a general emergency department in a developing country. Acta Paediatr 2003;92:965–9. https://doi.org/10.1111/j.1651-2227.2003.tb00632.x doi:https://doi.org/10.1080/08035250310003578 (Accessed 12 Mar 2020). [Published Online First: 2 January 2007].

  42. Crisp N, Chen L. Global supply of health professionals. N Engl J Med 2014;370(10):950–7. https://www.nejm.org/doi/10.1056/NEJMra1111610?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dwww.ncbi.nlm.nih.gov (Accessed 12 Mar 2020) doi: https://doi.org/10.1056/NEJMra1111610 [Published Online First: 6 March 2014].

  43. Jayaraman S, Mabweijano JR, Lipnick MS, et al. Current patterns of prehospital trauma care in Kampala, Uganda and the feasibility of a lay-first-responder training program. World J Surg 2009;33:2512–21 doi: https://doi.org/10.1007/s00268-009-0180-6 [Published Online First: 8 August 2009].

  44. Mahmood KT, Amin F, Ayub H, et al. Management of the patient from the site of accident to the hospital/ pre-hospital care. J Pharmaceutical Sci Res 2010;2:804–808. https://www.jpsr.pharmainfo.in/Documents/Volumes/Vol2Issue12/jpsr%2002101202.pdf (Accessed 12 Mar 2020).

  45. Khan A, Zafar H, Naeem SN, et al. Transfer delay and in-hospital mortality of trauma patients in Pakistan. Int J Surg 2010;8:155–8 doi: https://doi.org/10.1016/j.ijsu.2009.10.012 [Published Online First: 21 December 2009].

  46. Nielsen K, Mock C, Joshipura M,et al. Assessment of the status of prehospital care in 13 low- and middle-income countries. Prehosp Emerg Care 2012;16:381–9. doi:https://doi.org/10.3109/10903127.2012.664245 [Published Online First: 10 April 2012].

  47. Watson SI, Sahota H, Taylor CA, et al. Cost-effectiveness of health care service delivery interventions in low and middle income countries: a systematic review. Glob Health Res Policy 2018;3:17 doi: https://doi.org/10.1186/s41256-018-0073-z [Published Online First: 8 June 2018].

Download references

Acknowledgements

Alegnta Guntie (Ministry of Health, Ethiopia) contributed to the RPS meeting, Joanne Hinde (University of Sheffield) assisted with Manuscript preparation.

Funding

Research England, QR, GCRF- Institutational Partnership Awards Round 1. Project Start date 1st February 2019.

Author information

Author notes

  1. Fiona E. Lecky and Teri Reynolds contributed equally to this work.

Authors and Affiliations

  1. School of Health and Related Research, University of Sheffield, Sheffield, and Emergency Deparment, Salford Royal Hospital, Salford, UK

    Fiona E. Lecky, Olubukola Otesile, Janette Turner, Gordon Fuller, Julie Balen, Steve Goodacre & Andrew Lee

  2. World Health Organisation, Geneva, Switzerland

    Teri Reynolds & Sara Hollis

  3. Scarborough General Hospital, Tobago, Canada

    Ian Sammy

  4. The University of West Indies, Kingston, Jamaica

    Jean Williams-Johnson, Simone French & Ishtar Govia

  5. Divsion of Emergency Medicine, Stellenbosch University, Cape Town, South Africa

    Heike Geduld

  6. University of California San Francisco, San Francisco, USA

    Andrea G. Tenner

  7. Manmohan Memorial Institute of Health Sciences, Kathmandu, Nepal

    Sujan B. Marahatta

  8. Emergency Medical Services for the Western Cape Government, Cape Town, South Africa

    Shaheem DeVries

  9. Emergency Medical Association of Tanzania (EMAT), Dar es Salaam, Tanzania

    Hendry R. Sawe

  10. Muhimbili University of Health and Allied Science, Dar es Salaam, Tanzania

    Hendry R. Sawe

  11. Ain Shams University, Cairo, Egypt

    Mohamed El-Shinawi

  12. Muhimbili National Hospital, Dar es Salaam, Tanzania

    Juma Mfinanga

  13. Neurosciences Institute, El Bosque University, Bogotá, Colombia

    Andrés M. Rubiano

  14. Colombian Trauma Association, Bogotá, Colombia

    Andrés M. Rubiano

  15. Ministry of Health, Bab Saadoun, Tunisia

    Henda Chebbi

  16. Seoul National University Hospital, Seoul, South Korea

    Sang Do Shin

  17. American Heart Association (AHA), Dallas, USA

    Jose Maria E. Ferrer

  18. Ministry of Health, Tehran, Iran

    Mashyaneh Haddadi

  19. Columbia University, Emergency Medicine, New York, NY, USA

    Tsion Firew

  20. Ministry of Health, Addis Ababa, Ethiopia

    Tsion Firew

  21. American Heart Association (AHA), Geneva, Switzerland

    Kathryn Taubert

  22. Philippine College of Emergency Medicine, Parañaque, Philippines

    Pauline Convocar

  23. Sungai Buloh Hospital, Sungai Buloh, Malaysia

    Sabariah Jamaluddin

  24. Bugando Medical Centre, Mwanza, Tanzania

    Shahzmah Kotecha

  25. Ministry of Health, Amman, Jordan

    Emad Abu Yaqeen

  26. Divsion of Emergency Medicine, University of Vermont, Burlington, Vermont, USA

    Katie Wells

  27. Division of Emergency Medicine, University of Cape Town, F51 Old Main Building, Groote Schuur Hospital Observatory, Cape Town, South Africa

    Lee Wallis

Authors
  1. Fiona E. Lecky
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Teri Reynolds
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Olubukola Otesile
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Sara Hollis
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Janette Turner
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Gordon Fuller
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Ian Sammy
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Jean Williams-Johnson
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Heike Geduld
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Andrea G. Tenner
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Simone French
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Ishtar Govia
    View author publications

    You can also search for this author in PubMed Google Scholar

  13. Julie Balen
    View author publications

    You can also search for this author in PubMed Google Scholar

  14. Steve Goodacre
    View author publications

    You can also search for this author in PubMed Google Scholar

  15. Sujan B. Marahatta
    View author publications

    You can also search for this author in PubMed Google Scholar

  16. Shaheem DeVries
    View author publications

    You can also search for this author in PubMed Google Scholar

  17. Hendry R. Sawe
    View author publications

    You can also search for this author in PubMed Google Scholar

  18. Mohamed El-Shinawi
    View author publications

    You can also search for this author in PubMed Google Scholar

  19. Juma Mfinanga
    View author publications

    You can also search for this author in PubMed Google Scholar

  20. Andrés M. Rubiano
    View author publications

    You can also search for this author in PubMed Google Scholar

  21. Henda Chebbi
    View author publications

    You can also search for this author in PubMed Google Scholar

  22. Sang Do Shin
    View author publications

    You can also search for this author in PubMed Google Scholar

  23. Jose Maria E. Ferrer
    View author publications

    You can also search for this author in PubMed Google Scholar

  24. Mashyaneh Haddadi
    View author publications

    You can also search for this author in PubMed Google Scholar

  25. Tsion Firew
    View author publications

    You can also search for this author in PubMed Google Scholar

  26. Kathryn Taubert
    View author publications

    You can also search for this author in PubMed Google Scholar

  27. Andrew Lee
    View author publications

    You can also search for this author in PubMed Google Scholar

  28. Pauline Convocar
    View author publications

    You can also search for this author in PubMed Google Scholar

  29. Sabariah Jamaluddin
    View author publications

    You can also search for this author in PubMed Google Scholar

  30. Shahzmah Kotecha
    View author publications

    You can also search for this author in PubMed Google Scholar

  31. Emad Abu Yaqeen
    View author publications

    You can also search for this author in PubMed Google Scholar

  32. Katie Wells
    View author publications

    You can also search for this author in PubMed Google Scholar

  33. Lee Wallis
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

The RPS was designed by LAW,TR,FL,AL,JB,SG,GF,JT,JWJ,IG,SM,HS,MES in the application for GCRF network funding for GEMCARN. FL, TR, SH, LAW and OO drafted “introduction”; “methods” and “results” were based on written, agreed RPS proceedings drafted by KW and OO edited by SH, TR, FL, IAS, JWJ, GF, AT, IG, JT & LAW. OO conducted the literature search and drafted findings relevant to the research priorities in “discussion”. All authors contributed to the final manuscript and approved the final submission. All authors attended the RPS in person other than AL,SG,JB and IAS who attended by videolink. As JWJ was unable to attend her colleague (SF) represented her contribution gto RPS stages 1–3

Corresponding author

Correspondence to Lee Wallis.

Ethics declarations

Ethics approval and consent to participate

Not applicable – no patient data used in study, all RPS participants are named manuscript authors or are acknowledged in the manuscript.

Consent for publication

Not applicable all RPS participants are named authors or acknowledged in the manuscript.

Competing interests

FEL,OO, LAW report grants and non-financial support from Global Challenge Research Fund, during the conduct of the study.

TR reports grants from Global Challenge Research Fund, personal fees from World Health Organisation, during the conduct of the study.

SH,JKT,JB,SG,AL report grants from Global Challenge Research Fund, during the conduct of the study.

GF,HG,FS,IG, SBM,SDV,HRS,JM, MES report non-financial support from Global Challenge Research Fund, during the conduct of the study.

SG chairs the National Institute for Health Research HTA Commissioning Committee and is Deputy Director of the HTA Programme.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Lecky, F.E., Reynolds, T., Otesile, O. et al. Harnessing inter-disciplinary collaboration to improve emergency care in low- and middle-income countries (LMICs): results of research prioritisation setting exercise. BMC Emerg Med 20, 68 (2020). https://doi.org/10.1186/s12873-020-00362-7

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12873-020-00362-7

Keywords

BMC Emergency Medicine

ISSN: 1471-227X

Contact us