Downloaded When Internet Is Available but Accessed Later

Table of Contents List of Figures ...... 3 List of Tables ...... 3 Glossary...... 4 Abbreviations ...... 5 Executive Summary ...... 6 1. Introduction ...... 7 2. Defining Emergency Care ...... 8 3. Defining Public Health ...... 13 4. Emergency Care in East Africa ...... 17 5. Understanding the problem: regional considerations ...... 23 5.1 Defining the scope of emergency care systems and providers ...... 23 5.2 Shifting attention to the non-physician health work force ...... 27 5.3 Integrating fragmented systems across the healthcare sector ...... 30 5.4 Financing of healthcare and the burden of corruption and mismanagement ...... 31 5.5 Identifying barriers to accessing care ...... 34 5.6 Utilizing emerging technology and innovative approaches ...... 36 5.7 Accessing and appraising guidelines and resources ...... 38 5.8 Demand for skills beyond technical medical care ...... 42 6. Lessons from evidence based interventions ...... 44 6.1 Education and training initiatives ...... 44 6.2 Focusing on department operations and nurse leadership ...... 46 6.3 Pre-hospital care: alternative transport and communication systems ...... 48 6.4 Use of GIS technology for development of regionalized referral networks ...... 52 7. Applying public health leadership principles ...... 55 8. Redefining emergency medicine professionals as public health leaders in East Africa ...... 57 9. Conclusions ...... 60 10. Recommendations ...... 61 Appendix A: Competencies ...... 62 References ...... 63

List of Figures Figure Description pp. 1 The top ten causes of death in low-income countries and high-income countries 8 2 Emergency medical services as depicted by the US NHTSA 10 3 WHO conceptualization of an emergency care system framework 11 4 Geographic boundaries of the East African emergency medicine community 17 5 Burden of disability from emergency conditions by income and region 18 6 Burden of death and disability and emergency utilization rates by country 18 7 Burden of mortality by country from road traffic injuries among men aged 15-44 21 years per 100,000 population 8 Schematic of Rwanda’s healthcare system 31 9 Areas in which African emergency medicine specialists feel least equipped 43 10 Development needs identified by African emergency medicine graduates 44 11 Motorcycle ambulance in Malawi driven by community health workers 52 12 Use of smartphone applications and GIS data to identify hotspots for road traffic 55 accidents relative to the location of emergency care facilities

List of Tables Table Description pp. 1 Targets of SDG 3 Good Health and Well Being associated with emergency care 15 2 East African healthcare workforce by country 27 3 Barriers to emergency care in Kenya identified by community focus groups, and 46 proposed interventions

Glossary

Emergency condition: illness or injury that could lead to serious harm, disability or death if not addressed within hours to days of onset Emergency care: efforts to address and reverse time-sensitive conditions which threaten death, further harm or disability, including clinical and non-clinical efforts Emergency medical services (EMS): professional efforts to deliver emergency care to patients outside of a healthcare facility, including care delivered on scene, activation of a response, transport or movement of the victim, and coordination with response personnel and health facilities Emergency medical services system: coordinated delivery of emergency medical services within a geographic area Emergency care provider: designated professional who delivers emergency medical care to a patient, including trained first responders, emergency medical technicians and paramedics, nurses, clinical officers or advanced practice practitioners, and physicians Emergency medicine: specialized field defined by knowledge and skills dedicated to the clinical care of time-sensitive conditions Stabilization: emergency medical care delivered to prevent deterioration of an acute condition Definitive care: emergency medical care delivered to stop or reverse an ongoing underlying threat to health or life in a patient with an emergency condition, such as surgery to identify and stop a source of bleeding Triage: process of identifying and prioritizing patients who will benefit most from available resources or will suffer the greatest harm if care is delayed Low-Income Country (LIC): Country with gross national income per capita of $995 or less as defined by the World Bank1 High-Income Country (HIC): Country with gross national income per capita of $12.056 or more as defined by the World Bank1 Low- and Middle-Income Countries (LMICs): All countries excluding high income countries, including low-income, lower-middle-income and upper-middle-income countries as classified by the World Bank, with gross national income per capita less than $12,0561

Abbreviations

ACGME Accreditation Council for Graduate Medical Education (United States) ACLS® Advanced Cardiac Life Support® (American Heart Association) AFEM African Federation for Emergency Medicine ATLS ® Advanced Trauma Life Support® (American College of Surgeons) BEC Basic Emergency Care CHW Community Health Worker DALY Disability Adjusted Life Years EAC East African Community ECG Electrocardiogram EmONC Emergency Obstetric and Newborn Care EMS Emergency Medical Services EMT Emergency Medical Technician FAME Freely Accessible Medical Education FOAMed Free Open Access Medical Education GDP Gross Domestic Product GIS Geographic Information System HIC High Income Country IFEM International Federation for Emergency Medicine IOM Institute of Medicine LIC Low Income Country LMICs Low- and Middle- Income Countries MMed Master of Medicine NHIF National Health Insurance Fund (Kenya) NHTSA National Highway Traffic Safety Administration (United States) SDG Sustainable Development Goal TIPSI© The Injury Prevention & Safety Initiative UHC Universal Health Care UN United Nations UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund US United States USD United States Dollar WHO World Health Organization

Executive Summary

East Africa is a vibrant, growing community made up of the nations of Burundi, Kenya,

Rwanda, Tanzania, Uganda and South Sudan. These countries and their neighbors face the highest burden of death and disability from emergencies in the world coupled with poor access to emergency care. As a hub of innovation, technology, and investment, the East African community should prioritize emergency care to protect health and promote prosperity.

The past decade has witnessed the debut of a bright and talented generation of young professionals eager to improve emergency care in East Africa. They face unique challenges and opportunities ahead. Their communities are affected by a growing “triple” burden of disease including communicable disease, non-communicable disease, and injuries. Emergency care can address these burdens to save lives, prevent disability, and shape determinants of health.

These emergency care providers will be called upon to define the role and limits of their profession, lead teams and departments, apply innovation and technology to accelerate change, develop and disseminate evidence-based practices, ensure accountability and quality of care, align stakeholders across fragmented sectors, shape health policy, and build systems to extend the reach of timely, effective emergency care to all who need it.

East African emergency care providers depend not only on expert clinical knowledge and technical skills, but even more so on their capabilities as public health leaders and health strategists in their community. This paper outlines the challenges and opportunities they face and provides recommendations for ensuring they have the support necessary to be successful.

1. Introduction

Low- and middle-income countries face the largest burden of emergency conditions

The World Health Organization (WHO) defines an emergency condition as an illness or injury that can lead to disability or death if not addressed in hours to days of onset. This description includes the top causes of death in low- and middle-income countries (LMICs). The burden of emergency conditions accounts for 90% of deaths and 84% of disability around the world.2,3

Emergency care is effective in terms of lives saved, disability averted, and cost to society

Timely, effective emergency care can address 45% of deaths and 36% of disease burden in low- income countries (LICs).4 The impact of emergency care on society and economic development in LICs is higher than high-income countries (HICs), because emergency patients in LICs are younger and healthier at the peak of their economically productive years.5 Their loss is a blow to families, communities, economies and society.6

East Africa depends on public health leaders to develop effective emergency systems

The East African Community (EAC) includes Burundi, Kenya, Rwanda, Tanzania, Uganda and

South Sudan.7 Neighboring Zambia, Malawi and Ethiopia are also key players in regional emergency care development. The region is a growing hub of investment and development.8

However, these countries face the highest burden of death and disability from emergency conditions in the world, up to three times higher than LMICs in the rest of the world.3 There is a new generation of emergency care leaders, and growing interest in policies and programs are focused on building emergency care systems.9–14 A strategic approach to improving emergency care systems will be a critical public health consideration in the coming years.

2. Defining Emergency Care

A broad range of illnesses and injuries can be considered emergencies, including communicable diseases such as acute infections or exacerbations of chronic infections, new onset non-communicable diseases, acute or end-state complications of chronic non- communicable diseases, traumatic injuries, surgical diseases, obstetric and gynecological emergencies, acquired and congenital pediatric conditions, mental health crises, environmental injuries and poisonings.15,16 These affect all age groups, all societal groups and cross all medical specialties. Emergency conditions are united only by the timeliness with which they must be addressed and the ability of emergency care to influence their outcomes.

All of the top causes of death and disability in low- and middle-income countries present as emergency conditions. (Figure 1) This differs from high-income countries where many top causes of death are chronic diseases characterized by gradual decline, such as cancer, dementia or chronic kidney disease. Low-income countries instead face a variety of acute conditions which are often reversible or preventable with access to timely high-quality emergency care.17

Figure 1. The top ten causes of death in low-income countries (left) compared to high- income countries (right).17

Emergency care is defined by efforts to address and reverse time-sensitive conditions which threaten death, further harm or permanent disability. The term encompasses multiple professional fields and concepts beyond emergency medicine as a medical specialty. The

Institute of Medicine (IOM) defines emergency care as the “full continuum of services involved in emergency medical care, including EMS, hospital-based emergency and trauma care, on-call specialty care, bystander care, and injury prevention and control.” An organized system that delivers these services within a geographic area is an emergency care system.18

The IOM definition does not entirely capture the broad role of emergency care systems outside of direct medical care. Components of emergency care systems engage in data collection, reporting, and advocacy focused on multiple conditions, such reporting and surveillance of communicable diseases, identifying gaps in existing care systems, and reporting on emerging health threats in the community. In the United States (US), systems designed to deliver emergency care for acute illnesses are also frequently involved in management of non- emergency conditions, including care of minor ailments or chronic diseases, preventative efforts such as screening, linkage to community resources, and social problems.19

The definition of emergency care systems does not depend on the location of care, such as an emergency department or an ambulance. Emergency care systems in high-income countries increasingly bypass emergency departments, for example delivering patients directly to trauma surgeons or cardiologists.19,20 However, there is often a distinction between systems designed to provide emergency care outside of the hospital and in-hospital care. For example, the Institute of Medicine defines Emergency Medical Services (EMS) based on a set of prehospital services which include centralized emergency number and dispatch, field triage and

9 stabilization by first responders or trained emergency professionals such as EMTs or paramedics, and transport to a facility typically by ambulance. The United States National

Highway Traffic Safety Administration (NHTSA) defines emergency medical services more broadly as a system that operates at the crossroads between health care, public health and public safety and includes private and public agencies and organizations, communication and transportation networks, hospitals, trauma centers and specialty care centers, rehabilitation facilities, prehospital personnel, physicians, nurses, therapists, administrators, government officials and an informed public.21

Figure 2. Emergency medical services as depicted by the NHTSA, which includes not only prehospital care, but also in-hospital care, prevention and public education directed at addressing emergency conditions.21

Figure 3. The World Health Organization conceptualization of an emergency care system framework includes many different components from onset of the condition to delivery of inpatient hospital care and disposition of patients, focused largely on injuries.22 There are some flaws in the IOM and NHTSA definitions of EMS when applied to LMICs.

While in the US and other HICs pre-hospital care is synonymous with a professional EMS system defined by a centralized emergency number, professional ambulances and regional referral systems with designated tiers of care, in low- and middle-income countries the boundaries and scope of pre-hospital care and EMS are less clear. Even the WHO framework for emergency care systems assumes a linear, centralized process which does not exist in many East African countries. The role of small health centers or dispensaries, midwives and community health workers as initial points of contact with the health system are not depicted. Nor are decentralized, private emergency response structures which have arisen in the absence of a

11 centralized phone number or dispatch system. The definitions and graphics focus heavily on the role of an ambulance, while models of EMS in LMICs often depend on non-ambulance transport. The route by which emergency patients arrive at the necessary level of care may be less linear and more variable in LMIC settings than in HIC settings. These models do not address the concept of dissemination of emergency care practices through non-emergency providers and systems, such as training providers in rural areas to recognize and treat emergency conditions that occur within their clinic or hospital ward. Finally, existing definitions of emergency care systems do not address the potential for emergency care providers to play a role in addressing non-emergent conditions in the community. The definition of emergency care systems and emergency medical services systems in LMICs may ultimately evolve into something very different than their Western counterparts.

For the purpose of this paper, emergency care system refers to a systematic, coordinated effort to address the public health threat of emergency conditions, while emergency medical service or EMS refers specifically to professional efforts directed at out-of- hospital services aimed at managing emergency conditions. Emergency care represents something even broader, including efforts to address emergency conditions and prevent further harm, death or disability even in the absence of a functioning system.

3. Defining Public Health

To discuss emergency care from the public health perspective, it is helpful to review perceptions and definitions of public health. The World Health Organization (WHO) constitution defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”23 Public health refers both to the state of health within the population or society, and to the professional field or coordinated efforts focused on achieving better health for the community.24

The 1988 IOM report The Future of Public Health defined the mission of public health as

“the fulfillment of society’s interest in assuring the conditions in which people can be healthy.”24 Public health as a profession focuses on the needs of the population, with an emphasis on prevention of disease and injury and the promotion of overall well-being in communities. The public health profession has evolved over the last few decades with professionalization and strategic organization of public health agencies, guided by clearly defined standards, core functions and essential services. Over time it has become clear that the health of the community is shaped largely by upstream factors including socioeconomic disparities, environmental conditions, behavioral influences and policies. “Public Health 3.0” challenges public health professionals to become “Chief Health Strategists” for their communities, responsible for working strategically with stakeholders across sectors and disciplines in pursuit of better health outcomes for the community.25

Discussion of public health objectives cannot be complete without a discussion of prevention, which is often described in three categories or stages. Primary prevention focuses

13 on addressing risk factors and exposures to avoid an injury or illness. Secondary prevention focuses on limiting damage once an injury or illness has occurred. Tertiary prevention mitigates the consequences of the event, including rehabilitation and management of long-term disability.24 These definitions shift depending on their context and the problem of focus. The discussion of emergency care typically focuses on secondary prevention, or the rapid treatment of acute conditions to prevent death, worsening condition, or permanent disability.

The growth of health care delivery systems has blurred the separation between healthcare and public health. Classically healthcare focuses on the relationship between a medical provider and an individual patient with an emphasis on curative clinical care for the treatment of disease. In contrast, public health focuses on prevention of disease and promoting overall well-being.24 Nevertheless, modern healthcare is comprised of complex systems rather than individual providers. These systems address complex needs in the community, including multiple levels of prevention. Just as public health depends on policies and determinants of health outside of the traditional scope of health practitioners, the effectiveness of healthcare providers and systems also depend on factors outside of clinical care alone. The delivery of quality emergency care depends as much on communication, transportation, community awareness, policy, management, finance and cultural factors as it does on clinical care.

Emergency care providers are often pushed beyond their clinical expertise and practice to build systems, advocate for health gaps in the community and contribute to better health policies.

As part of strategic health leadership, it is important to understand the larger strategic framework in place for policy and development of which health is only one part. Global development strategy is driven by the United Nation (UN) Sustainable Development Goals

(SDGs), focused on targets to be achieved in all countries by 2030. The SDGs emphasize whole- of-government approaches, engagement across multiple sectors, clear goals and accountability measures. Many of the goals associated with the SDG are influenced by the presence or absence of effective emergency care systems. These include reducing maternal mortality, ending preventable neonatal and pediatric deaths, managing infectious disease epidemics, treating substance abuse, reducing deaths from road traffic accidents, providing sexual and reproductive health services, ensuring access to medicines and safe medical care, managing environmental hazards, strengthening the health workforce, and developing systems for early detection and response to global health threats such as major outbreaks of disease.26,27

3.1 Reduce the global maternal mortality ratio to less than 70 per 100,000 live births 3.2 End preventable deaths of newborns and children under 5 years of age 3.3 End the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases 3.4 Reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being. 3.5 Prevention and treatment of substance abuse 3.6 Halve the number of global deaths and injuries from road traffic accidents 3.7 Ensure universal access to sexual and reproductive health-care services 3.8 Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all 3.9 Substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water and soil pollution and contamination 3.C Increase health financing and the recruitment, development, training and retention of the health workforce 3.D Strengthen the capacity of all countries, in particular developing countries, for early warning, risk reduction and management of national and global health risks. Table 1. Targets of SDG 3 Good Health and Well Being associated with emergency care systems 26,27

Particularly in the setting of a developing low- or middle-income country, the presence of effective emergency care does not only serve the purpose of secondary prevention of death

15 due to trauma or disease. It serves to protect investments in prevention and primary care by ensuring that individuals who have benefitted from public health interventions are not lost to an unexpected, isolated emergency incident. Emergency departments can serve as a powerful vantage point for identifying and advocating against gaps and failures in the rest of the health system.19 In regions where emergency conditions threaten the well-being and prosperity of entire countries, effective emergency care promotes development. Emergency care returns individuals who would be otherwise lost back to their families, communities, economies and schools, influencing the very determinants that shape the overall health of the population.

4. Emergency Care in East Africa

For the discussion of emergency care development, East Africa refers generally to the East

African Community (EAC) which includes the countries of Tanzania, Kenya, Uganda, Rwanda,

Burundi and recently South Sudan.7 Neighboring Ethiopia, Malawi and Zambia have close ties to the emergency medicine development communities in EAC countries (see figure 4).

Figure 4. Geographic boundaries of the East African emergency medicine community, composed of the core East African Community economic bloc with additional support from neighboring Ethiopia, Malawi and Zambia.

As discussed previously, low- and middle-income countries face the largest burden of death and disability from emergency conditions, particularly in Africa (Figure 5).3 Emergency department mortality in East African countries averages 4.8% in existing studies, compared to

1.8% overall in emergency departments in other low and middle income countries and 0.04% in high income countries.5 East African countries including Kenya, Uganda and neighboring

Ethiopia have some of the lowest emergency care utilization rates in the world, coupled with a high burden of death and disability from emergency conditions (Figure 6).3

Figure 5. The burden of disability from emergency conditions is greatest in low- and middle- income countries, particularly in Africa, which face a “triple burden” of death and disability caused by communicable disease, non-communicable disease and trauma.3

Figure 6. Uganda (yellow), Kenya (red) and Ethiopia (orange) have low emergency utilization rates and high rates of death and disability compared to other countries. 3

The impact of emergency care has often been neglected in global health research and funding.28 Emergency care is perceived as an expensive approach that takes resources away from more cost-effective measures such as preventative medicine and population health initiatives. However, it is increasingly recognized that emergency care as an essential part of basic health services. There is growing evidence of the cost effectiveness of emergency care interventions.29 The World Bank has highlighted emergency care as one of six basic, cost- effective health services as part of a minimum package of care since 1993. In 2007, the World

Health Assembly passed Resolution 60.22, which emphasized the role of emergency care systems in reducing the burden of acute illness and injuries.29,30 The WHO has identified emergency care among the most cost effective interventions for public health.31

The broad nature of emergency conditions makes them difficult to define for research purposes. One way to evaluate the cost and benefit of healthcare associated costs is to analyze

“amenable” mortality. This refers to deaths which were not unavoidable altogether or preventable by public health and primary preventative measures, but could have been addressed by delivery of effective high-quality medical care. Of amenable deaths, 96.3% occur in LMICs and are expected to cost USD $11.2 trillion in lost Gross Domestic Product (GDP) by

2030. This represents 2.7% of potential GDP in Sub-Saharan Africa.6 Similar studies looking at conditions amenable to surgical intervention suggest that low and middle income countries will lose USD $12.3 trillion in GDP over the same time frame from mortality due to unaddressed surgical conditions, many of which occur as emergencies.6 Surgical treatment of appendicitis costs approximately USD $36 per year of life saved, well within the cost limits of other clinical interventions, such as HIV treatment which costs $1,282 USD per year of life saved.28

Emergency conditions should not be left out of global health programming based on the assumption that their treatment is not cost-effective.

Road traffic accidents represent a form of amenable mortality that presents a rising threat to the health and economic development of low- and middle-income countries. These countries already face a “double” burden of disease including communicable disease, malnutrition, child mortality and maternal mortality on one hand, and a rising burden of chronic lifestyle-related non-communicable diseases on the other.32 Injuries can now be considered a kind of “triple” burden which also disproportionately affect low and income countries, where 90% of death and disability from road accidents occurs. 33 Much of the disparity in trauma outcomes can be attributed to gaps in emergency and trauma care systems, with the result that victims in low income settings are twice as likely to die compared to victims with comparable injuries in high income settings. 31,34

The impact of road traffic accidents on economic development is of particular concern because these injuries tend to disproportionately affect the young and most productive members of society. The majority of Kenyans killed in road accidents are young men between the ages of 15 and 45 years old. A 1991 study suggested that road traffic accidents cost the country 5% of annual gross national product per year. Since then, mortality from traffic accidents has continued to rise.35 This pattern of loss is observed across West, East and Central

Africa and can be seen as an indicator for the state of emergency care and the impact of its absence in those regions (Figure 7).

Figure 7. Burden of mortality by country from road traffic injuries among men aged 15-44 years per 100,000 population.36

All of these cost effectiveness analyses are flawed in their assessment of emergency systems because they focused on a single intervention and disease process at a time. This reflects the way global health has been funded and directed in the past. There is a need for a shift to horizontal approaches which focus on strengthening healthcare systems capable of targeting more than one health threat using the same resources.37 As a system which addresses multiple conditions and improves morbidity and mortality at more than one level of prevention, emergency care represents an opportunity to invest in multiple health priorities at once. These interventions can often be built into existing programs using existing resources. For example, emergency care principles are increasingly included as a component of other horizontal health

21 interventions, such as the emphasis on triage and emergency care that can be seen in the WHO and USAID Integrated Management of Childhood Illness program.38

The impact of emergency care on the economies and development of LMICs is greater than in HICs, because patients seeking emergency care in LMICs are younger and healthier, with an average age of 35 years old.5 This differs from the United States, where emergency care users are more often elderly patients with complex co-morbidities and poor baseline health.39

Emergency care systems can also act as an important point of access for the healthcare system for non-emergency conditions among patients who might otherwise not seek care.28,29,38 Emergency departments in LMICs also carry much of the burden of clinical care within the community, with emergency facilities seeing an average of ten times the caseload of primary care facilities.5 Community surveys in Nigeria, Nepal and Sri Lanka have suggested than in many LMIC settings, community members do not trust or seek out facilities for primary care and preventative services, preferring to utilize health facilities only when they have emergencies.38 Interventions which reduce mortality and disability in this otherwise under- accessed population are likely to have a greater impact on the economies and development of rising LMICs than they would in HICs.6

5. Understanding the problem: regional considerations

There are unique considerations facing the East African emergency care community that present both challenges and opportunities. These include yet undefined boundaries of the scope and responsibilities of emergency care providers, the composition of the healthcare workforce, complex and often fragmented systems spread across private and public sectors, financing considerations, the risk of corruption and mismanagement, barriers to accessing care including geographic and environmental considerations, innovative technologies and new models of delivering care, special concerns regarding the availability and accessibility of regionally applicable references and resources, and the need for a unique set of skills regarding leadership and management outside of clinical practice alone.

5.1 Defining the scope of emergency care systems and providers

Much like the profession of public health, which over time has come to encompass a larger scope of considerations and responsibilities, it is difficult to define the limits of what constitutes emergency care. Emergency care providers struggle to define exactly where the limits of their expertise and responsibility lie, with differing perceptions between individuals, institutions, countries and regions. In some countries, emergency medicine as a physician specialty emerged from the field of anesthesia and critical care, with a scope of practice defined by airway management and resuscitation. In other countries such as the United States, the specialty was developed by general practitioners and family medicine specialists, with a scope of practice that includes features of primary care. In countries without emergency specialists, emergency conditions are often divided between different specialties. Hospitals may have separate receiving areas for surgical, medical, obstetric and pediatric emergency cases.

Development of a common operational picture, or consensus on the definitions of emergency care, will be important to help focus and implement achievable, measurable strategic goals.

African emergency providers are facing the challenge of defining the scope of their practice and responsibility, as well as the role of the emergency department. In the US, emergency departments are one of the few parts of the healthcare system obligated to provide care regardless of ability of pay, earning them the title of the “safety net of the safety net.”39

Tintinalli’s Emergency Medicine, a classic textbook reference for providers in the US, introduces emergency medicine as “the only population based specialty” and “the only specialty that serves as a safety net for those with illnesses, injuries, socioeconomic barriers to care, and conditions that require mobilization of resources for care on a 24/7 basis.”15 While emergency medicine specialists in North America typically envision themselves as specialists in the clinical treatment of critically ill patients, day to day practice involves addressing many non-emergent conditions and sometimes even non-medical issues altogether.

Recently at the 2018 African Conference on Emergency Medicine, Dr. James Ducharme, the president of the International Federation for Emergency Medicine addressed African emergency physicians and encouraged them to clearly define the limits of their role as emergency providers. “We should consistently state from the start what we will NOT provide,” he proposed, rather than to allow the emergency medicine specialty to be defined by the gaps which society or other specialties fail to address. “Advocate for the emergency patient, not all patients…Patients will inevitably come to the ED when solutions are not available elsewhere.”20

Emergency Medicine providers in Africa have distinguished themselves as a community committed to service, with a willingness to accept responsibility for a very broad range of problems. Nevertheless, as the field of emergency care moves forward in Africa, it will not be feasible to assume the role as the “safety net of the safety net” alone. A critical skillset of emergency providers will be to reach out to their colleagues in other specialties, administrators, and those outside of healthcare. It will not be enough to accept responsibility for gaps without addressing their source or identifying alternative solutions. In order to maintain their role as a safety net without exhausting themselves and their resources, and to obtain the best outcomes for their patients or potential future patients, emergency physicians must be prepared to become advocates, focused on building partnerships that can address the underlying causes of the societal burdens witnessed in emergency departments.

There is also a struggle to define the scope of emergency care as a field and as a system.

Although emergency care has been traditionally associated with emergency departments staffed by emergency physicians with clearly defined levels of capabilities, in LMIC settings, emergency care is often delivered in numerous settings by all different levels of providers.28

Emergency care principles such as triage and initial resuscitation can be included in community health worker and health center practices as a way of extending care beyond the reach of a very limited number of specialist-staffed health facilities clustered in major urban areas. Thus, the definition of emergency care systems may depend less on the type of facility or provider and more on the conditions they work to address.

Given the range of facilities which may be involved in emergency care, it is important to define levels or tiers of capability to facilitate referral and communication systems, a process

25 known as “regionalization”. This approach ensures that ambulance providers, low-level clinics, primary hospitals, and the general public know which facilities are capable of providing the necessary level of intervention for a given condition.18 For example, a patient suffering a heart attack requires specialized intervention within minutes to hours to prevent death or permanent disability.40 The recognition of this condition requires an electrocardiogram (ECG). Knowing which facilities have an ECG machine and which facilities have the medications or specialists needed to deliver definitive care could ensure that patients do not waste precious time being referred or transported to facilities that can neither diagnose nor treat their condition.

Emergency care in East Africa will have a different definition than emergency care in other regions. It will be up to East African emergency medicine physicians to define their scope of practice relative to other specialties. As a common point of entry into the healthcare system and a safety net for gaps in public health, prevention and primary care, emergency departments and emergency providers should be prepared to communicate with other sectors and specialties to avoid becoming overburdened. Levels of emergency care capability at different facilities should be clearly distinguished with common definitions to enable efficient movement of patients to sites with appropriate resources. However, emergency care should not be defined in terms of emergency departments or the availability of emergency specialists alone, but should include consideration of time-sensitive interventions for emergency conditions that occur within other specialties and programs, outside of the hospital, and at the community level.

5.2 Shifting attention to the non-physician health work force

There are few physicians in East Africa, and even fewer emergency medicine specialists. The country with the largest health worker cohort in the region, Kenya, had 18 physicians per

100,000 population in 2007. Most healthcare is provided by nurses, community health workers and mid-level providers such as clinical officers.41–43 Community health workers are often not included in official estimates of the healthcare workforce (Table 2). Just prior to the start of an emergency physician specialty training program, Rwanda had a total of 172 specialist physicians in any specialty, 684 general practitioners, 8,985 nurses and 45 thousand community health workers serving a population of almost 11 million people.42 The growth of emergency care systems will depend on support and professional development of non-physicians, many of whom are already treating emergency conditions on a daily basis.

East African Health Care Work Force 18 15.8 16 14 12 12 10 8 8 6.7 6.5 6 4.3 4 2 2 0.5 0.9 Number per 10,000 population 0.15 0.3 0.3 0 South Sudan Burundi Tanzania Rwanda Uganda Kenya

Physicians Nurses

Table 2. There are very few physicians in East Africa, with nurses making up a much larger portion of the workforce. Overlooked in this table are the roles of other providers such as clinical officers, midwives and community health workers.44–46

There has been a rapid growth in emergency medicine education and professional training pathways available in East African countries. Emergency medicine specialty training programs for physicians, or Masters in Medicine (MMed), have sprung up over the last decade in Ethiopia, Rwanda, Tanzania and Uganda, along with shorter diploma programs.9–12,47,48

Likewise, there are diploma and professional certificate programs available for clinical officers and nurses. Emergency Medical Technician training for pre-hospital providers exists, although standards of training vary by country.43,49 Other advanced degrees in research or emergency management are available but often require overseas travel. There are also emerging fellowship programs in emergency and critical care for non-emergency specialists, such as the

Pediatric Emergency and Critical Care Fellowship in Kenya.50 These programs reflect a growing professionalization of emergency care across multiple components of the healthcare workforce.

Although implementation of a physician emergency medicine specialist training program in

Kigali, Rwanda, resulted in dramatic improvements in hospital mortality at the tertiary teaching and referral hospital, it required five years of investment to produce just a handful of specialists.9 A new MMed program in Emergency Medicine is anticipated to start in Kenya in

2020; however, each class is expected to include only 3 graduates, with the first class expected to graduate in 2025. It is unlikely that this small handful of specialists can answer the emergency care needs of a country of almost 50 million people with clinical knowledge and training alone.

Nurses are often the only health professionals available to provide care to a critically ill or severely injured patient in Sub-Saharan Africa.51,52 Due to the shortage of doctors in many

African settings, nurses often face responsibilities and expectations which exceed the scope of

28 their training. There are limited opportunities for specialist training and lack of professional recognition or compensation for having specialized skills.53 Among South African emergency nurses, a survey revealed that less than half felt comfortable administering medications during cardiac arrest or interpreting electrocardiograms, suggesting that gaps in training and clinical practice exist even in countries where specialized nursing programs exist.51,54

One way to expand the role of nurses and increase opportunities for professional development in their field is to create career pathways for advanced practice nurse practitioners, or nurses with advanced training through either a masters or doctoral degree.

These practitioners, including family nurse practitioners, nurse anesthetists and nurse midwives, were introduced in the US to provide emergency care in rural areas in the 1970s. The introduction of advanced nurse career pathways may represent a critical opportunity to expand the emergency care workforce in Africa by empowering nurses who are already providing emergency care and would benefit from additional professional development and training.55

For many emergency medicine professionals, training does not guarantee career progression. Physicians, nurses and other members of the health care workforce who complete advanced training in emergency care should be recognized for their skills, with dedicated positions that utilize their unique skill set and financial compensation to reflect their expertise.

Many healthcare workers in Kenya emigrate to other countries in pursuit of better career opportunities.41 Retention of skilled emergency care providers in positions that empower them to use their skills will be important for ensuring effective, long term leadership in developing emergency care systems.

5.3 Integrating fragmented systems across the healthcare sector

Fragmentation of the healthcare sector has been identified as a barrier to achieving development goals, particularly strengthening of healthcare systems. A World Bank analysis of the private healthcare sector in Kenya in 2010 identified that the private sector had inadequate regulation and oversight to ensure quality of care and adequate training of workers. A surplus, rather than shortage, of suppliers in the marketplace resulted in low prices and low quality, with duplication of public, private and not-for-profit supply chains. Quality of care was limited by large quantities of substandard and counterfeit drugs. Many facilities were operating without licenses.56 In Kenya, half of all healthcare workers are employed by the private rather than public sector, not including those employed by faith based organizations.41 Emergency care leaders operating in mixed public-private systems will need to be able to communicate across sectors and build professional bodies capable of ensuring that standards are enforced regardless of where emergency patients seek care.

Within the public sector, most health systems in East Africa are based on a tiered structure, with several levels of care facilities. In Kenya, 80% of the healthcare system is focused on the lowest level of care (dispensaries and clinics), 15% of health facilities fall at the second lowest level (health centers, maternities and nursing homes), while the remaining 5% of facilities include primary hospitals, secondary referral centers and tertiary referral centers. This system does not include the private sector, which compromises almost half of all healthcare services in the country.10

Although current efforts to train emergency specialists occur in major urban centers, tertiary referral center hospitals and teaching hospitals, recent analysis of the health system in

Rwanda suggest that 80% of the burden of mortality occurs at levels below a provincial referral hospital, with most patients dying either in the community, outpatient clinics or lower level hospitals.42 Current research and training efforts focused on delivery of emergency care in the setting of large, specialized, urban referral centers does not adequately capture the emergency care needs of the population outside of those cities and major hospitals.

Figure 8. Analysis of Rwanda’s healthcare system shows that the majority of death and disability occurs below provincial or tertiary referral center level, indicating the greatest need for emergency care services is at the district hospital level and below.42

5.4 Financing of healthcare and the burden of corruption and mismanagement

The variety of healthcare financing models in East Africa and the role of out-of-pocket spending should be an issue of concern for emergency care development leaders, because

31 delays in care have been associated with the need for individuals to pay up-front for emergency services prior to receiving care.57 Emergency providers should work with insurers, hospital administrators and policymakers to ensure that emergency care is included in essential covered services, and identify ways in which billing or financing of health services can be implemented sustainably without creating delays in care.

In most of East Africa, there are very low rates of insurance coverage within the population and high rates of out-of-pocket financing of healthcare. In Kenya, for example, more than half of health expenditures are financed by individual out-of-pocket payments.58 Of the government funding for health that exists, a large proportion of funds originate from donors, mostly targeted at supply subsidies for in-hospital curative care. Only 7 percent of the population has access to national health insurance (NHIF) which offers weak protection against healthcare costs. Less than 2% of the population has private health insurance.58

Universal Health Care (UHC) has been identified as a WHO priority and is increasingly being implemented in East Africa as a means of ensuring access to essential services, including emergency care.59,60 Rwanda, which relies mostly on public delivery of health services, has implemented a community based health insurance program which covered 74% of the population in 2013. The system is based on sliding-scale payments for healthcare which vary based on an individual’s annual income. It replaced an earlier model in which health services were free. This, coupled with significant government investments in facilities, staffing, equipment and models of performance-based reimbursement, has reduced disparities in access to care throughout the population and increased utilization of healthcare services.61

The gap in healthcare financing has been filled in many occasions by privately funded services. In Nairobi, for example, there are several different private for-profit services which offer a combination of ambulance services and access to clinics or hospital care in exchange for a monthly subscription fee. Some non-profit organizations have sister for-profit ambulance services which provide non-emergency services, such as contracting with venues to provide an ambulance on scene during events, in order to raise funds to support charity ambulance calls for the public. Emergency response companies also finance their operations by charging for training, such as community first aid, ACLS or EMT certification. This puts them at odds with foreign volunteer groups and organizations eager to provide community first aid training at no cost. Most recently, there has been development of private dispatch systems which charge a subscription fee and contract calls to smaller private ambulance companies, including Rescue by Flare or the so-called “Uber for Ambulances.”62

Corruption and mismanagement of healthcare programs has been a major barrier to public support and the success of interventions. The collapse of several managed care schemes in

Kenya has reduced public trust in insurance companies.56 Public investment in emergency services has also been marred with controversy due to corruption, such as incident in 2001 when government health officials were removed from their posts after taking bribes and falsifying purchases of public ambulance vehicles.63 It is not enough for emergency care leaders to advocate for effective, evidence-based policies and financing mechanisms for emergency care based on technical expertise. There is also a need to ensure accountability and transparency to ensure that these policies and programs, once approved, are not misdirected

33 or abused. Emergency care professional societies will have to work hard to win public trust and influence the successful implementation of new programs.

Emergency medicine leaders are also likely to encounter issues of management within their workplace. Absenteeism has been identified as a major problem in public health facilities.

During one country-wide health sector service delivery analysis, data collectors found that one third of public healthcare workers were absent from their posts. Eighty percent had an approved absence, suggesting that the problem of absenteeism rests on the management and structure of healthcare facility staffing rather than on individual worker choices alone.64 Future emergency care leaders will have to understand the management and staffing structures that exist, communicate effectively with administrators, and develop their own management skills to ensure that their coworkers are present when they need them and that the quality of care delivered is adequate.

5.5 Identifying barriers to accessing care

As already discussed, East African countries have some of the lowest emergency care utilization rates in the world.3 The reasons for this lack of utilization are complex, and have been explored in several qualitative studies.57,65 A study of road traffic accident victims in Kenya described what they experienced from the point of injury to delivery of medical care in a district hospital. The participants reported that victims were most often rescued by community laypersons with good intentions but inadequate training in first aid and safe transport. Those willing to provide first aid and trained in first aid skills lacked basic equipment such as gloves.

Most of the participants reported an absence of trained medical personnel on scene, with the role of medical provider often assumed by police. In some cases victims did not seek care at a

34 hospital because they could not afford transport or the hospital fee, or did not have access to transport. For most of them, distance itself was not an issue. Most victims did not dial an emergency number. The public emergency number, 999, when dialed, was directed to police who often did not have transport, or the call went unanswered. Many victims knew of the existence of private companies with emergency numbers, but did not know the numbers to call.

Ambulances belonging to the district hospitals were available only for facility-to-facility transport at out-of-pocket cost, and generally described as unreliable. There was only one ambulance per hospital, while most accidents had more than one victim requiring transport.

Lack of communication between the community, police and health care providers were highlighted as common problems.

Once at the hospital, the facilities lacked capacity to provide organized response to multiple casualties. The surgeons and medical officers at night were at home and had to be retrieved by ambulance, with concerns for safety and risk of hijacking on the way. The hospitals lacked basic equipment including oxygen and suction. Victims reported long wait times, lack of beds and equipment, medication shortages, and reluctance of health providers to provide care unless it was someone they knew. Interestingly, despite a lack of formal trauma training such as

Advanced Trauma Life Support (ATLS), it was perceived that the providers generally knew how to manage trauma because they had significant on the job training and exposure. The facilities reported lack of space for victims and a desire to have a data collection system.65 Altogether, it is clear that barriers to effective care exist at every step from the point of injury or illness to facilities themselves. The fact that the knowledge and skills of clinical providers within facilities were not identified as a major barriers is an important consideration, as many outside

35 organizations and charity groups focused on training as the focus of interventions and programs. It suggests that programs focused on training of healthcare workers alone will not be effective at addressing significant barriers to care.

5.6 Utilizing emerging technology and innovative approaches

East Africa is a hub for emerging mobile phone technologies, sometimes referred to as the “Silicon Savannah” due to an explosion of successful technological developments over the last two decades. The most famous is M-Pesa mobile banking which was started in 2007 and currently moves half of Kenya’s GDP.66,67 As many as 80% of Kenyans and 75% of Tanzanians have a mobile phone.67 Because emergency medical systems rely heavily on communication, it is no wonder that the East African emergency medical community has embraced mobile technologies and bypassed many of the infrastructure-heavy approaches taken by Western countries in developing emergency care infrastructure and centralized systems.

Many novel approaches to delivery of emergency services have focused on utilization of community networks and community layperson first responders. A start-up nonprofit company called Beacon in Tanzania provides SMS-based EMS activation and automated, mobile-phone based dispatch for communities that lack a centralized dispatch and coordination system. It allows small-scale immediate implementation of prehospital care dispatch and coordination without the oversight and costs required to build infrastructure for a centralized, professional dispatch center.68 An initiative called TIPSI in Kenya is exploring use of bystanders such as motorcycle drivers as community first responders capable of recognizing emergencies, activating an emergency response system and providing first aid. The program also collects information about accidents to advocate for road safety, injury prevention and improved

36 trauma care.69 These programs have the potential to develop small but scalable community networks for activation of first responders as an alternative to large, centralized systems.

Telemedicine and artificial intelligence technologies have also been a target for improving emergency care in LMIC settings. Medtronic, a private for-profit medical equipment corporation, is currently investigating a program to introduce advanced cardiac diagnostic capabilities to rural areas in Kenya. This follows implementation of a “hub and spoke” system in

Latin America which allowed local providers in remote, impoverished areas to submit electrocardiograms electronically to cardiology specialists in urban areas for interpretation. The system works in coordination with local EMS including non-profit organizations to deliver patients with heart attacks directly to a cardiac center for intervention, with follow up data collection and review processes to ensure quality. One hospital in Colombia saw a 71% reduction in mortality from heart attacks, and reduced time to intervention from symptom onset from 384 minutes to 167 minutes. Future efforts may incorporate machine interpretation of ECGs to assist prehospital providers where cardiologists are not available.70

Kenya benefits from a relatively large number of health facilities relative to neighboring countries. As many as 90% of Kenyans are geographically located within 2 hours driving time from a public hospital, above the suggested target of 80% for developing countries.59 These data coupled with knowledge that Kenyans rarely access emergency care services suggest that distance alone is not the only barrier. Meanwhile, in other areas of East Africa, distance to facilities remains a recognized problem which is increasingly addressed through the use of innovative technologies.

There have been several examples of the use of Geographic Information Systems (GIS) in combination with Google maps data and mobile phone technology, to analyze barriers to emergency care, identify targets for ambulance staging, or to locate hospitals which would benefit from additional equipment or training to ensure emergency care capability.59,62,71–75

Large-scale attempts to map access to emergency care in Sub-Saharan Africa have not yet included private hospitals nor data on specific capabilities of various facilities or EMS services, such as emergency obstetric care, surgical subspecialties, thrombolytic medications for heart attacks and strokes, radiology or other diagnostic capabilities. There have been proposals to develop an open access resource that includes this information and allows input from multiple sources to develop a more accurate picture of emergency care access barriers.76

Leaders in emergency care development in East Africa should be prepared to embrace and effectively utilize existing and emerging technological resources, novel approaches to problems, and innovative partnerships across public and private sectors as ways to avoid duplicate efforts and catalyze rapid progress towards improved emergency care systems.

5.7 Accessing and appraising guidelines and resources

It is important to note that many existing clinical resources and guidelines from outside the African content are not accurate when applied to East African settings. For example, while much of the world has embraced and promoted the “Surviving Sepsis” Campaign which includes strict protocols focused on early antibiotics and aggressive fluid resuscitation in patients with severe infections, recent studies in Zambia, Uganda and Tanzania suggest that this bundle of care increases mortality in children and adults in these settings and may not address needs of patients infected with HIV, malaria or tuberculosis.77–79

Resources and references from high-income settings often fail to provide African emergency care providers with actionable recommendations. One speaker at the recent African

Conference on Emergency Medicine conference in Rwanda noted that when faced with the dilemma of two patients who both require mechanical ventilation and only one available ventilation machine, UptoDate (a common online medical reference tool used by American providers) and classic textbooks published in the US offered no guidance for how to decide which one would be more likely to benefit.80 There is a need for training and reference materials based on evidence from African and LMIC settings, with recommendations that are practical, feasible, and adaptable to different practice environments with different levels of resources.

Cost effectiveness of emergency interventions is also important in determining which approaches and treatments to prioritize in resource-poor settings. For example, out of hospital cardiac arrest is associated with low rates of survival and a high risk of poor neurologic outcomes among survivors. Treatment of these patients with adrenaline has not been found to improve survival to hospital discharge or result in good neurologic outcomes.81 Nevertheless, adrenaline is considered a standard of care and is carried by most ambulances in the US. As East

African providers develop EMS and resuscitation standards and guidelines, they will have to consider whether the cost of stocking adrenaline on ambulances or training providers according to US protocols is worthwhile.

There is also an effort underway to develop guidelines for when to initiate or terminate resuscitation efforts in cardiac arrest patients in Africa. For example, a patient who is in cardiac arrest as the end state of a severe infection in a remote area will have virtually no chance of

39 survival with or without Advanced Cardiac Life Support (ACLS) interventions, while a patient with cardiac arrest from a heart attack located in an urban area within minutes of a hospital with advanced cardiac critical care capabilities may have relatively high chance of survival with

ACLS similar to patients in urban areas of the United States, albeit they will require costly interventions and face a high risk of severe permanent neurologic and cardiac disability.

In the absence of regional guidelines, African providers who discontinue resuscitation are at risk of being targeted by media scandals or taken to court, even if they judge that there was no change of survival. They may be judged based on the premise that they should have been following US based guidelines as “standard of care,” even if those standards are not truly applicable to or feasible in their setting. African providers could benefit from clear evidence and guidance for when it is acceptable to discontinue resuscitation efforts and avoid using precious resources on patients who will not benefit, while identifying patients and circumstances in which interventions can actually make a difference. These also serve to show that East African providers are providing a high level of care driven by evidence, experience and pursuit of the best patient outcomes, not care inferior to that provided by Western physicians as is often assumed.

Much of modern medical education involves use of online resources and dissemination of ideas through social media or websites. “Free Open Access Medical Education” or FOAMed is an initiative to expand access to free medical education through online resources such as instructional videos, recorded lectures, blogs, podcasts and infographics shared mostly through online or social media sources. The vast majority of FOAMed users are from high income countries, with only 8.5% from LMICs and 0.3% from LICs.82 The African emergency medicine

40 community has recognized that despite its name, FOAMed is not truly freely accessible to

African providers.83

Although more than three quarters of people in Sub Saharan Africa have mobile phones, few have access to internet.67 Internet and mobile phone data services charge by the megabyte, which makes many modes of online education inaccessible to East Africans trying to learn more about emergency care. Communications and technology companies have modified services to accommodate this market. For example, Facebook has launched low-data models of its popular apps in many countries and established its messaging service, Whatsapp, as zero- data service which costs users nothing to send messages or media files.84

In an effort to improve the accessibility of emergency medicine training materials the

African Federation for Emergency Medicine (AFEM) has launched a campaign to create “FAME” or “freely accessible medical education” for African providers. This approach focuses on availability, appropriateness and affordability. It uses a combination of traditional and newer educational approaches including open access scientific journals, use of low-data services such as Whatsapp, sharing materials on flashdrives or in-person through conferences and social networks, use of low-fidelity or low-cost simulation models, and online materials that can be downloaded when internet is available but accessed later. The approach also emphasizes peer review of materials by experienced African providers to ensure their quality and applicability in

African settings.83

Going forward, leaders and educators in East African emergency care must be prepared to appraise the literature and existing guidelines based on evidence and experience applicable

41 to their setting. They should continue to develop and implement regional guidelines and standards. To extend their expertise to colleagues across the field, emergency care providers and educators must use methods of dissemination which are most effective in resource-limited settings. Many care providers in East Africa who are currently managing patients with emergency conditions have little support to guide their practice. They depend on African emergency medicine leaders to continue to redesign guidelines and develop learning networks which reflect what African providers actually face and actually do in the settings where they work, not what emergency providers in other regions tell them they ought to do based on a different set of challenges and resources.

5.8 Demand for skills beyond technical medical care

New emergency care specialists in East Africa are likely to find themselves faced with leadership responsibilities their training and experience may not have prepared them for.

Graduates of emergency medicine physician specialty programs are likely to find themselves as the Head of Department.85,86 Health care providers in East African countries are often promoted to leadership roles without adequate preparation and training to be effective or successful.87 Even in the absence of a formal leadership role, emergency care professionals, like all health professionals, rely on more than clinical skills to be effective. Delivery of quality healthcare requires a set of non-clinical “soft” leadership skills, including problem solving abilities and the ability to communicate effectively within a team.85,86

A 2016 survey of recent African emergency medicine specialist graduates in Ghana,

Tanzania, Ethiopia and South Africa suggested that while they felt confident in their clinical skills and knowledge, they were least confident in their management and academic skills. They

42 requested support for advocacy programs, leadership development, mentorship and access to educational materials, especially online.47 These graduates were facing leadership challenges for which their clinical training had not adequately prepared them.

Figure 9. African emergency medicine specialists feel confident as health professionals, but under-equipped as managers, scholars and system developers.47

Figure 10. Newly graduated African emergency medicine specialists listed leadership training as their highest priority in development needs. 4 = extremely important, 3 = very important, 2 = important, 1 = somewhat important, 0 = not important47

Teamwork is a critical component of effective emergency care. A study on “failure to rescue” or factors which contributed to preventable deaths from major surgical complications found that successful rescue of surgical patients depended largely on interpersonal and team dynamics rather than surgical technique or technical skill. Success depends on the ability of the team to work together in crisis, take initiative to implement swift action when a problem is identified, feel safe to express concerns, recognize an emergency, and communicate effectively.88 Emergency providers facing similar high-risk patient situations rely on more than technical knowledge. The development of curricula to develop critical thinking, emotionally developed, empathetic and reflective health leaders has been identified as a priority for future emergency care education in Africa.51,89,90 Promoting a culture of effective teamwork, action taking, open and effective communication will be critical skills for future EM providers.

6. Lessons from evidence based interventions

6.1 Education and training initiatives

There is some evidence that emergency medical training can impact emergency condition outcomes. Some of the most impactful training has been focused on improving recognition of emergencies, triage, and basic interventions by community health workers, laypersons and prehospital providers.91,92 Interventions to improve recognition and triage of childhood emergencies in Zimbabwe reduced infant mortality from diarrhea by 39% and from respiratory illness by 43%.38 There are several examples in LMICs of programs focused on training layperson first responders and community members such as police officers, commercial drivers, mothers, and other community members to respond to trauma, although data on patient-

44 centered outcomes and long-term follow up once these programs are completed is often limited.92

Higher level professional training programs also have significant impact, particularly within the facilities or departments where they occur. Historically, professional medical training often focuses on clinical knowledge and diagnosis but falls short on developing providers’ ability to recognize emergencies and take critical life-saving actions. Certificate and degree programs designed to enhance this skill set can improve outcomes. For example, a faith based hospital in

Kenya found that implementation of an emergency and critical care training certificate program for clinical officers resulted in a 50% reduction in mortality within the department.93

One of the problems with gleaning lessons learned from the literature is that researchers and programs tend to publish positive reports rather than failures. Short term global health interventions often claim to offer sustainable models, but rarely publish data on long term health outcomes or social, economic and diplomatic impacts.94,95 One year after a large-scale emergency medicine train-the-trainers program was conducted in Haiti, a follow up training program found that none of the physicians trained were still working at the facility, those who could be located were not involved in training activities, and most of the equipment donated during the training was missing or unused, suggesting that clinical knowledge and equipment alone were not enough to address barriers to successful implementation of emergency care in that setting.96,97

Community focus groups in Kenya have noted that provider training is only one small part of many factors that determine whether a patient with an emergency condition receives timely,

45 effective care. Access is complicated by cost, lack of community first responders, transport, lack of emergency numbers, hesitation by bystanders to intervene, road conditions, prioritization of administrative tasks and fee payment prior to delivery of services, lack of equipment and medications at receiving facilities, lack of training or motivation by healthcare providers, absenteeism, corruption, long queues without triage mechanisms, and ineffective approaches to department operations and patient flow.57 To maximize effectiveness, training and education interventions should be coupled with approaches that address multiple barriers to effective care.

Barriers to Care Proposed Solutions Non-functioning emergency numbers Establish a centralized emergency number Distance from facilities Increase number of facilities or mobile clinics Geographic barriers Fix impassable roads Difficulty locating patietns Number houses to help direct ambulances Transportation Increase access to emergency transportation Bystanders untrained Train community first responders Long queues and lack of triage Make gloves and first aid kits available Lack of medicines or equipment Improve patient flow practices Poor quality of care Stock adequate equipment at facilities Poor leadership Improve leadership of healthcare providers Lack of healthcare provider motivation Improve accountability of healthcare providers Corruption Penalize corruption and bribes Police delays Prioritize delivering care before instead of after Administrative delays before care administrative tasks (registration forms, bills, Cost of care police reporting) Reduce costs of care Table 3. Barriers to emergency care in Kenya identified by community focus groups, and proposed interventions.57

6.2 Focusing on department operations and nurse leadership

Many effective interventions have focused on in-hospital or clinic operational processes, with interventions designed to improve prioritization and flow of patient care. They utilize business and engineering principles focused on quality improvement, team work, management

46 and department structures. Some of the most effective interventions are those that have combined education or professional training with other operational and process based changes.

Operational changes, staff training, and improved communication initiatives over 15 years in a pediatric emergency department in Malawi resulted in reduced delays and mortality, with improved staff morale and better quality of care.98 Interventions focused on staff training, hospital layout, staff allocation, medical equipment, and medical record keeping at a children’s hospital in Sierra Leone halved the rate of pediatric deaths from 15% to 6% within 6 months.99

A new emergency medicine residency at the tertiary referral hospital in Rwanda was associated with a drop in hospital mortality from 6% to 1%.9 Some of this may be attributable to improved clinical care, but was also likely influenced by a variety of interventions that occurred at the same time through the presence of emergency medicine specialists and a new focus on emergency care improvement.

Some of the most impressive interventions have been generated by nurse leadership in emergency care. For example, a nurse-led intervention in Rwanda to utilize smart locks on resuscitation carts as a mechanism for ensuring accountability for inventory and restocking of carts, as well as changing shifts to ensure that there was a trained resuscitation team available on every shift doubled the survival rate for patients in cardiac arrest.100,101 A similar approach in

Uganda showed that training nurses in Basic Emergency Care (BEC), developing an emergency response team, and improving hand-over practices reduced death rates and length of stay, increased completion of basic nursing tasks, and improved availability of equipment and medicines in the hospital.102 Nursing leadership development has been repeatedly been demonstrated to have a significant impact on the delivery of effective, high quality care across

East African settings. Nurses provide valuable insight to in committees, utilize continuing medical education, act as patient advocates, improve patient safety and quality assurance systems, and expand emergency care skills to other providers.51,100–103

Effective training programs have also focused on expanding interventions outward in the context of much larger country-wide changes. For example in Ethiopia, graduates of an emergency medicine residency program went on to implement research initiatives, develop an ambulance system, and implement training centers which went on to train thousands of additional providers in emergency care.104 Emergency nurse trainers in Tanzania have delivered

Emergency Care training throughout the country and to other countries, including Uganda,

Ethiopia, Malawi and Congo.103 The ability of trainees to extend influence beyond their own clinical practice may be one of the most important considerations for those who wish to design effective emergency care education programs.

6.3 Pre-hospital care: alternative transport and communication systems

While the majority of the population in East African countries (with the exception of

South Sudan) are within 2 hours of a public hospital,59 emergency care utilization rates remain exceptionally low and mortality and morbidity from emergency conditions remains high3, which suggests that distance alone is not enough to predict whether victims can access care when they need it. Case studies of referral system interventions in remote Uganda and Burundi hint at some of the challenges and potential solutions for ongoing gaps in access to timely care.

Many of the studies providing evidence for emergency care interventions in East Africa have come from pre-hospital approaches focused on reducing maternal mortality. An estimated

45% of stillbirths, 38%–68% of neonatal deaths, and 75% of maternal deaths could be averted by basic intervention packages including emergency obstetric and newborn care (EmONC).71

WHO, United Nations Populations Fund (UNFPA), and United Nations Children’s Fund (UNICEF) consensus recommendations in 2009 suggested that all people should have access to emergency obstetric care within 2 hours,71 a time parameter that brings access to obstetric care in line with broader emergency care objectives.

Uganda is one of the poorest countries in East Africa, with low life expectancy, high rates of infant and maternal mortality, poor transportation and communication systems. Less than one third of people in the country have access to a telephone, and private vehicles are rare.105 Cost analysis for a single ambulance located at an obstetric hospital in Northern Uganda for 3 months showed that the transport and communication service saved 10 mothers and 5 children, with an additional 20 mothers and 16 infants who benefitted but could have potentially been saved by other means of transport. Based on the 15 lives attributed directly to the service, the estimated cost was 15.82 USD per year of life saved.106

Burundi faces a similar set of challenges to Uganda, with highly isolated, mountainous rural communities. Lack of adequate referral facilities and geographic barriers to access have been identified as key contributors to obstetric and neonatal mortality. Implementation of an ambulance referral system using three ambulances coupled with a 24/7 communications network and high quality emergency obstetric care was estimated to have saved the lives of

7.5-13.2% of women with acute obstetric complications, averting 74% of anticipated maternal deaths in a single district. The program overall cost approximately USD $4.41 per year per inhabitant of the district, compared to USD $275.56 GDP per capita in the country.107

In both of these studies, ambulances were located at a single referral hospital in a mountainous region, intended for obstetric cases. It might be reasonable to think that a larger system composed of many ambulances spread out over multiple facilities or staging areas, capable of transporting patients with a variety of conditions, could probably provide services to more patients at similar cost with the added benefit of shorter response times due to closer geographic proximity to the patient at the time of the call.

One of the barriers identified to accessing emergency care response systems is the absence of a centralized emergency number and dispatch system.57 There are several innovative approaches to system activation and dispatch which have been successfully implemented in East African countries. As discussed earlier, several private companies have attempted to develop dispatch systems that rely on machine learning, SMS or smart-phone based app technology.62,68,70 Other systems have used person-to-person networks, community health workers and health centers as entry points into the emergency system. One program in

Uganda focused on community health workers as emergency system activators, providing each of them with a phone and access to a toll-free dispatch center. The dispatch center would then dispatch an ambulance with a nurse or midwife to accompany the patient and provide care. The service transported 207 patients over 6 months, at an estimated cost of USD $89.95 per life saved according to the authors.105

Not all interventions require a traditional ambulance vehicle. The utility of non- traditional modes of transport is well known, for example in Tanzania, where emergency transport includes not only motorcycles, but tractors, bicycle trailers, tricycle platforms, canoes, motorboats and ox carts.37 Prehospital emergency care systems using motorcycle ambulances

50 have been implemented in Kenya, Malawi, Liberia, Southern Sudan, Afghanistan, Ethiopia,

Uganda and Sierra Leone.108 Data collected on three motorcycle ambulances placed at rural health centers in Malawi showed that the presence of the vehicles reduced delays in obstetric emergency transfer times to the district hospital by a median of 2 to 4.5 hours. Two of the health centers in the study were so remote that they lacked both transportation and communication. Previously, staff had to ride several hours to reach a telephone or radio in order to request an ambulance from the referral hospital. The cost of purchasing a motorcycle ambulance was 22 times less than a Toyota Land Cruiser ambulance, and annual operating costs were 23 times less. The motorcycle ambulances also transported non-obstetric emergencies, with twice as many non-obstetric emergencies transported compared to obstetric emergencies (126 versus 68 in one year).109

Figure 11. Motorcycle ambulance in Malawi driven by community health workers.109

Implementation of accessible transportation combined with communication networks in these interventions frequently improved emergency response times and survival not only from obstetric complications, but often from other emergency conditions as well, reflecting the horizontal nature of emergency systems.38 Prehospital ambulances can serve two purposes in the pursuit of timely emergency care; either to deliver a patient quickly and safely to a higher level of care, or to deliver skilled emergency medical personnel and resources earlier to the patient. East African emergency care systems developers attempting to design effective prehospital programs in remote areas must weigh the benefits and costs of having trained medical providers capable of delivering care on scene or in route using a traditional ambulance vehicle against the ease and feasibility of systems which focus on low-cost rapid transport and community health workers or layperson responders.

6.4 Use of GIS technology for development of regionalized referral networks

The role of mapping and communications technologies in emergency care delivery shows the importance of a systems-level approach to developing emergency care systems. A program in Ethiopia focused on improving maternal-fetal outcomes in obstetric emergencies utilized GIS software to measure the effect of facility location and transportation resources on time to care. Prior to the intervention, they estimated that 70% of the population in the area studied had access to emergency obstetric care within 2 hours. Adding vehicles and communication capability and upgrading seven strategically located facilities based on the GIS data expanded access to timely emergency obstetric care to 90% of the population and reduced average travel time to facilities from 121 to 64 minutes.71

Similar approaches to mapping facilities and identifying strategic geographic targets for improvement of emergency referral systems have taken place in Zambia and Ghana, and several are currently underway in Kenya.72,73 The Emergency Medicine Kenya Foundation has launched an initiative to map and perform site visits of county hospitals, identify targets for intervention and provide training and equipment to ensure all Kenyans are located within an hour of a facility capable of delivering emergency care.72 This overlaps with private sector efforts to utilize GIS mapping of facilities and real-time smart phone based tracking of ambulances to determine efficient referral and transport practices.62

There are also parallel efforts within academic institutions, such as a 2017 study by the

University of California San Francisco and Kenyatta National Hospital staff to analyze road traffic accident patterns in Nairobi, Kenya. The program utilized a local phone application which gathers user data on traffic patterns, informal bus routes, and accidents, including data from twitter and other social media sites.110 The researches combined the app data with transit data from Google Maps Distance Matrix API, site surveys and ArcGIS analysis to produce a map of road traffic accident hotspots in Nairobi, identify times of day when accidents were more likely, and quantify the location and capability of surgical facilities relative to hotspots (figure 12). The data showed that most road traffic accidents in the capital city occur within 7 minutes driving time to a health facility and within 20 minutes of the national referral center.73 Meanwhile, data from Nairobi health facilities suggest that road traffic accident victims do not arrive at the hospital from the scene of an accident until after a median of 162 minutes.75 Both studies suggested that lack of coordinated prehospital emergency care and communication was a major barrier to effective transport.73,75

Figure 12. Utilizing smartphone app user reported data, Google maps, and GIS to identify hotspots for road traffic accidents (heat map) relative to the location of facilities capable of providing emergency surgical care to victims (block dots). 73

Awareness of these technologies and scientific approaches, coupled with cross-sector collaboration and data sharing could improve the quality of data and planning, avoid duplicate systems, and meet the goals of a variety of programs, such as improving response times both for trauma resuscitation and obstetric emergencies utilizing the same mapping, transport and communication resources.

7. Applying public health leadership principles

Applying the competencies of public health professionals to emergency care development in East Africa, it is not difficult to find overlap. Emergency conditions have been recognized as a threat to public health. Establishing effective emergency care systems is part of the World

Health Association strategic agenda for global development and strengthening of healthcare systems. Like public health professionals, those tasked with leadership of emergency care systems must assess the state of emergency care, including the burden of emergency conditions and the current state of the system which serves those in the community at highest risk. They must implement measures to mitigate these injuries and illnesses, prevent secondary harm, and advocate for changes in policy or within the community to help prevent death and disability that threatens development and prosperity.

The 2014 Core Competencies for Public Health Professionals are divided into domains which encompass the scope of public health professional development. These include analytical skills, assessment, policy development, program planning, communication, cultural competency, financial planning, management, leadership and systems thinking skills. They also include

“community dimensions of public health” which include engaging with and communicating between a variety of stakeholders and partners, as well as “public health sciences skills” which includes understanding the history of public health and utilizing biostatistics and epidemiology to shape evidence-based practice.111

The mission of public health and emergency care systems are not very different. Emergency care providers play a key role in prevention and population health. They are uniquely

55 positioned to observe where public health and prevention policies and programs have failed, and to identify potential solutions for the future, while at the same time providing care to prevent secondary harms, disability and death to those who have slipped through the gaps. This advocacy can take the form of policy, community outreach and education, and coordination of stakeholders to build more effective systems. There is a need for emergency medicine leaders who can guide coalitions of multiple stakeholders across private and public sectors, both in and outside of the health field.

The ethics of emergency care are defined by a commitment to serving all people in a time of need, including those who otherwise have inadequate access to health services. This sentiment is reflected in the 2011 African Federation for Emergency Medicine definition of emergency medicine as “the provision of initial resuscitation, stabilization, and treatment to acutely ill and injured patients, and delivery of those patients to the best available definitive care, regardless of ability to pay."112 Emergency medicine as a global professional community has distinguished itself as the “safety net of the safety net” with a culture and set of values that mirrors the commitment of public health professionals to addressing disparities in health and protecting the health of all groups in society.39,113

Public Health 3.0 calls for public health professionals to act as the “Chief Health

Strategists” within their communities.25 As East African emergency providers embark as a new profession facing unique challenges within their respective countries, they too will have to act as strategists and leaders within their community to achieve the goal of disseminating timely, effective emergency care to those who need it most.

8. Redefining emergency medicine professionals as public health leaders in East Africa

The past president of the African Federation for Emergency Medicine aptly described the challenge ahead for emergency leaders in Africa; a task of servant leadership focused on development of others, the agency to act independently, make choices and develop an identity as African providers, and a revolutionary mindset focused on reaching out to broader viewpoints outside of the clinical scope of emergency medical healthcare specialists alone.85

Nevertheless, the training and preparation of East African emergency specialists does not yet reflect the leadership skills their mission demands.

The current African Federation of Emergency Medicine curriculum for emergency care specialists focuses on clinical care, with physician skills and competencies organized by anatomical systems or disease categories. The curriculum is organized in terms of physician clinical skills for management of individual or simultaneous multiple patients with acute illnesses or injuries. Although it includes some training on pre-hospital emergency care, referral systems and disaster preparedness, the core curriculum for African emergency providers does not include any specific mention of leadership or systems-based practice.114

Similar to the AFEM curriculum, the American Board of Emergency Medicine core competencies for emergency medicine physicians in the United States focuses almost exclusively at clinical care, with skill categories divided by disease class or anatomical system.

However, an increasing emphasis on non-clinical skills gained momentum when the ACGME, the regulatory body for physician professional education, released core competencies which

57 include practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice in addition to patient care and medical knowledge.115 Core competencies of American emergency physicians over time have expanded to include performance improvement and lifelong learning, quality improvement, advocacy, leadership and management principles, administration and operations, health care coordination, and public policy.16 Altogether, skills focused on professionalism, communication and systems-based practice make up 5% of the emergency medicine specialist competencies.

A handful of highly-trained, technically skilled specialist physicians or nurses in any given country in East Africa are unlikely to be able to meet the emergency needs of the population based on their clinical skills alone. The majority of patients with emergency conditions in East

Africa may never reach a tertiary referral hospital to be seen by a trained emergency specialist.42 Patient lives depend on the actions of many; community health workers, bystanders and first responders, EMTs, nurses, midwives, clinical officers, general practitioners, health administrators, policy makers, transporters, dispatchers, technology developers, equipment and medication suppliers, regulatory bodies, data collectors and researchers, blood banks, radiologists, technicians, quality improvement and patient safety teams, advocates and educators within the community. Access to timely, effective emergency care will depend on strategic implementation of emergency systems and dissemination of emergency care practices to every level of the community, using the human resources and systems already in place.

The success of this effort depends on effective leadership and management skills. The effectiveness of clinical care will depend on those who can critically appraise existing literature, conduct research, compare experiences and build consensus to produce regional or local

58 evidence based guidelines and protocols. The ability to implement a high standard of quality care depends not only on training and equipping of health providers, but also on improving the management and implementation of better operations and processes within departments and facilities. In order for patients to benefit from functioning facilities, there must be cross-sector collaboration and policies in place to ensure access to efficient networks of communication, transport and referral. These systems depend on a variety of cross-sector resources, policies, and regulatory bodies. Emerging leaders in the field must be prepared to act as researchers, teachers, managers and spokespersons capable of guiding the vision and progress of emergency systems in their communities.

The Lancet Commission on the future of health in sub-Saharan Africa in 2017 concluded that “failure of health achievements to date is more likely to be caused by inadequate and poor implementation of the most important ideas, an inadequate health workforce, and insufficient investment in health systems, rather than by a paucity of novel ideas.”32 Dissemination of even the best ideas relies on the qualities of leaders within the community, so-called adopters or opinion leaders, who translate that idea into their local community and environment, with consideration of competing priorities, timing and the constraints of the context in which that process occurs.116 This kind of change cannot come from the outside. People adopt ideas best from those most like themselves, whom they perceive as trustworthy and legitimate, firmly rooted within strong social networks defined by peer-to-peer interactions.117 The public burden of emergency conditions and development of emergency care systems in Africa will not be addressed through the efforts of foreign innovators, but by a generation of African leaders who are competent in both clinical care and public health leadership principles. East African

59 emergency care providers must act both as innovators capable of identifying new solutions to problems, and even more importantly as adaptors, capable of testing, implementing, modifying and improving innovations to change systems and improve outcomes.

The demand for emergency care is overwhelming and the need for changing practices is time sensitive. The East African emergency care community must continue to approach this problem strategically to catalyze the spread of emergency care as broadly, quickly, effectively and sustainably as possible. The key to this is investing in African leaders capable of implementing that change, ensuring they have the full support of their peers with access to professional development and mentorship focused on empowering their success.

9. Conclusions

Emergency conditions represent a threat to public health and development goals in East

Africa. Emergency care is an effective intervention for reducing morbidity and mortality, addressing failures and gaps in preventative or public health measures, and supporting regional development. The delivery of emergency care relies on complex systems of which clinical care is only one small component. There is a critical need for public health leadership in emergency care systems development. Future training of emergency medicine professionals must focus on the creation of emergency care leaders as public health strategists, advocates, educators, researchers, policy makers, mentors, managers, and ethical and visionary leaders.

10. Recommendations

1. Global health policymakers, donors, and program directors should include emergency care

in future programming as a horizontal approach to public health and development goals

2. Professional education and curriculum for East African emergency medicine physicians and

nurses should include public heath leadership principles as core competencies (Appendix A)

3. Employers, educators and system developers should expand professional development

opportunities for non-physicians working in emergency care including nurses, mid-level

providers, paramedics, EMTs, administrators, emergency managers and CHWs

4. The global emergency medicine community should redesign its approach to dissemination

of resources to ensure that African providers have access to training and tools designed,

developed and validated by African emergency care experts

5. Emergency medicine physicians and non-physician leaders in emergency care should

maintain a presence in cross-sector discussions to ensure that emergency care strategic

objectives are included in health and development programming

Appendix A: Competencies Proposed leadership competencies for East African emergency care professionals

Competency Skills Evidence based - Maintain expertise on existing guidelines and recommendations with practice the ability to discern what material is applicable locally - Collect and analyze data to assess the burden of emergency conditions and build evidence based practices - Build consensus for guidelines, definitions and standards of care - Plan effective emergency care interventions based on evidence Dissemination - Test, demonstrate and adapt new ideas to promote wide adoption of ideas and - Share lessons learned and expertise through accessible resources practices - Extend training opportunities and programs to many types of providers at all levels of the health system Systems-based - Establish effective communication, referral and transport systems approach - Implement and support programs that extend emergency care outside of tertiary referral centers and emergency departments - Identify problems in emergency departments that could be prevented or better addressed through outside resources and partners - Act as the chief emergency care strategist within the community - Communicate and coordinate with stakeholders across sectors Innovation - Maintain awareness of new technologies, ideas and approaches in the field of emergency medicine and other disciplines - Develop, test and share innovations in emergency care Accountability - Establish regulatory bodies capable of enforcing standards - Conduct measurement and evaluation of interventions and programs - Implement regulatory mechanisms to prevent and address corruption, mismanagement or ineffective practices - Share results and maintain transparent communication with the public Management - Guide the strategic vision, goals, ethics and culture of emergency care and team - Manage a team and communicate effectively with others leadership - Understand operational and quality improvement principles relevant to patient flow and safety within emergency departments - Build networks to mentor and support other emergency care professionals and future leaders Advocacy - Engage in community awareness and response to emergencies - Participate in policy development - Advocate for inclusion of emergency care considerations in health and development programming

References

1. World Bank Data Team. New country classifications by income level: 2017-2018 | The Data Blog. The World Bank Data Blog. https://blogs.worldbank.org/opendata/new-country-classifications-income-level-2017- 2018. Published 2017. Accessed August 8, 2018.

2. Mung’Ayi V, Sharif T, Odaba DS. Blood transfusion and oxygen extraction ratio in patients admitted to the general intensive care unit: A quasi experimental study. African J Emerg Med. 2014;4(2):66-70. doi:10.1016/j.afjem.2013.06.004.

3. Chang CY, Abujaber S, Reynolds TA, Camargo CA, Obermeyer Z, Obermeyer Z. Burden of emergency conditions and emergency care usage: new estimates from 40 countries. Emerg Med J. 2016;33(11):794- 800. doi:10.1136/emermed-2016-205709.

4. Kobusingye OC, Hyder AA, Bishai D. Emergency Medical Services. In: Jamison D, Breman J, Measham A, eds. Disease Control Priorities in Developing Countries. 2nd ed. New York: The International Bank for Reconstruction and Development / The World Bank; 2006:1261-1280. doi:10.1596/978-0-8213-6179- 5/chpt-68.

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(8):577-586G. doi:10.2471/BLT.14.148338.

6. Alkire BC, Peters AW, Shrime MG, Meara JG. The Economic Consequences Of Mortality Amenable To High- Quality Health Care In Low- And Middle-Income Countries. Health Aff. 2018;37(6):988-996. doi:10.1377/hlthaff.2017.1233.

7. Overview of EAC. East African Community. https://www.eac.int/overview-of-eac. Published 2018. Accessed March 17, 2019.

8. The new scramble for Africa. The Economist. March 9, 2019:9.

9. Aluisio AR, Barry MA, Martin KD, et al. Impact of emergency medicine training implementation on mortality outcomes in Kigali, Rwanda: An interrupted time-series study. African J Emerg Med. 2019;9(1):14-20. doi:10.1016/J.AFJEM.2018.10.002.

10. Wachira B, Martin IBK. The state of emergency care in the Republic of Kenya. African J Emerg Med. 2011;1(4):160-165. doi:10.1016/J.AFJEM.2011.10.008.

11. Teklu S, Azazh A, Seyoum N, et al. Development and implementation of an emergency medicine graduate training program at Addis Ababa University School of Medicine: challenges and successes. Ethiop Med J. 2014;Suppl 2:13-19. http://www.ncbi.nlm.nih.gov/pubmed/25546905. Accessed October 28, 2018.

12. W/Tsadik A, Azazh A, Teklu S, et al. Development of emergency medicine and critical care masters program for nurses at Addis Ababa University, School of Medicine. Ethiop Med J. 2014;Suppl 2:21-26. http://www.ncbi.nlm.nih.gov/pubmed/25546906. Accessed October 28, 2018.

13. Bisanzo M. The frontline of emergency cardiac care in Africa. African J Emerg Med. 2014;4(3):102-103. doi:10.1016/j.afjem.2014.07.001.

14. Carlson S, Duber HC, Achan J, et al. Capacity for diagnosis and treatment of heart failure in sub-Saharan Africa. Heart. 2017. doi:10.1136/heartjnl-2016-310913.

15. Tintinalli J, Stapczynaki J, Ma O, Cline D, Cydulka R, Meckler G, eds. Tintinalli’s Emergency Medicine; A Comprehensive Study Guide. 7th ed. McGraw Hill Medical; 2011.

16. Counselman FL, Babu K, Edens MA, et al. The 2016 Model of the Clinical Practice of Emergency Medicine. J Emerg Med. 2017;52(6):846-849. doi:10.1016/j.jemermed.2017.01.040.

17. World Health Organization. The top 10 causes of death. https://www.who.int/en/news-room/fact- sheets/detail/the-top-10-causes-of-death. Published 2018. Accessed March 23, 2019.

18. Institute of Medicine. Emergency Medical Services: At the Crossroads. Washington, D.C.: National Academies Press; 2007. doi:10.17226/11629.

19. Kellermann AL, Hsia RY, Yeh C, Morganti KG. Emergency Care: Then, Now, And Next. Health Aff. 2013;32(12):2069-2074. doi:10.1377/hlthaff.2013.0683.

20. Ducharme J. Defining and Building Emergency Medicine - A Moving Target. African Conf Emerg Med. 2018. https://www.dropbox.com/sh/jbsgif54lipo3pp/AADV7srE1A7g4vQ9RXSM2ZWda/Plenary - Day 1/AFCEM Plenary.pdf?dl=0. Accessed April 11, 2019.

21. National Highway Traffic Safety Administration. What is EMS? https://www.ems.gov/whatisems.html. Accessed April 7, 2019.

22. WHO Emergency Care System Framework Infographic. WHO. 2017. https://www.who.int/emergencycare/emergencycare_infographic/en/. Accessed April 7, 2019.

23. World Health Organization. Constitution of the World Health Organization. In: Basic Documents. 48th ed. Geneva: World Health Organization; 2014:1. http://apps.who.int/gb/bd. Accessed March 23, 2019.

24. Schneider M-J. Introduction to Public Health. 4th ed. Burlington, MA: Jones & Bartlett Learning; 2013.

25. DeSalvo KB, Wang YC, Harris A, Auerbach J, Koo D, O’Carroll P. Public Health 3.0: A Call to Action for Public Health to Meet the Challenges of the 21st Century. Prev Chronic Dis. 2017;14:170017. doi:10.5888/pcd14.170017.

26. Global Emergency Care. Emergency Care & the Sustainable Development Goals. https://www.globalemergencycare.org/blog/emergency-care-the-sdgs. Published 2016. Accessed March 23, 2019.

27. United Nations Development Programme. From the MDGs to Sustainable Development for All. New York; 2016. http://www.undp.org/content/dam/undp/library/SDGs/English/From the MDGs to SD4All.pdf. Accessed March 23, 2019.

28. Hsia R, Razzak J, Tsai AC, Hirshon JM. Placing Emergency Care on the Global Agenda. Ann Emerg Med. 2010;56(2):142-149. doi:10.1016/J.ANNEMERGMED.2010.01.013.

29. Yiadom MYAB, McWade CM, Awoonor-Williams K, Appiah-Denkyira E, Moresky RT. Public Health Rationale for Investments in Emergency Medicine in Developing Countries – Ghana as a Case Study. J Emerg Med. 2018;55(4):537-543. doi:10.1016/J.JEMERMED.2018.07.021.

30. World Health Organization. WHA60.22 Health Systems: Emergency-Care Systems.; 2007. http://www.wpro.who.int/mnh/A60_R22-en.pdf?ua=1. Accessed April 7, 2019.

31. World Health Organization. A60/21 Health Systems: Emergency Care Systems.; 2007. http://www.who.int/surgery/imeesc/en/index.html. Accessed April 7, 2019.

32. Agyepong IA, Sewankambo N, Binagwaho A, et al. The path to longer and healthier lives for all Africans by 2030: the Lancet Commission on the future of health in sub-Saharan Africa. Lancet. 2017;390(10114):2803- 2859. doi:10.1016/S0140-6736(17)31509-X.

33. World Health Organization. The Global Burden of Disease: 2004 Update. Geneva; 2008. https://www.who.int/healthinfo/global_burden_disease/GBD_report_2004update_full.pdf?ua=1. Accessed April 7, 2019.

34. Chandran A, Hyder AA, Peek-Asa C. The global burden of unintentional injuries and an agenda for progress.

Epidemiol Rev. 2010;32(1):110-120. doi:10.1093/epirev/mxq009.

35. Bachani AM, Koradia P, Herbert HK, et al. Road Traffic Injuries in Kenya: The Health Burden and Risk Factors in Two Districts. Traffic Inj Prev. 2012;13(sup1):24-30. doi:10.1080/15389588.2011.633136.

36. GBD Compare | IHME Viz Hub. https://vizhub.healthdata.org/gbd-compare/. Published 2017. Accessed April 7, 2019.

37. Siddharthan T, Ramaiya K, Yonga G, et al. Noncommunicable Diseases In East Africa: Assessing The Gaps In Care And Identifying Opportunities For Improvement. Health Aff. 2015;34(9):1506-1513. doi:10.1377/hlthaff.2015.0382.

38. Razzak JA, Kellermann AL. Emergency medical care in developing countries: is it worthwhile? Bull World Health Organ. 2002;80:900-905. doi:10.1590/S0042-96862002001100011.

39. Institute of Medicine. Hospital-Based Emergency Care; At The Breaking Point. Washington, D.C.: National Academies Press; 2007. doi:10.17226/11621.

40. Ibanez B, James S, Agewall S, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2018;39(2):119-177. doi:10.1093/eurheartj/ehx393.

41. MoH. National Human Resources for Health Strategic Plan 2009-2012. Minist Public Heal Sanit Repub Kenya. 2009;(April 2009).

42. Moresky R, Nzeyimana I. Rwanda Emergency Care Systems: Implementation Support to Implementation Science. African Conf Emerg Med. 2018. https://www.dropbox.com/sh/jbsgif54lipo3pp/AACxJgE98cdE7BczNMKG1iR0a/Plenary - Day 2?dl=0&preview=Moresky_AfCEM18_2018_11_7_10p.pptx&subfolder_nav_tracking=1. Accessed April 7, 2019.

43. Dushime T. Emergency Medical Services (Rwanda). African Conf Emerg Med. 2018.

44. Central Intelligence Agency. The World Factbook. https://www.cia.gov/library/publications/the-world- factbook/geos/od.html. Published 2019. Accessed March 17, 2019.

45. World Health Organization. South Sudan: Health Workforce Statistics. https://www.who.int/workforcealliance/countries/ssd_hrhdensity.pdf. Accessed March 17, 2019.

46. African Health Observatory:Health Workforce. World Health Organization. http://www.aho.afro.who.int/en/content/health-system. Published 2018. Accessed July 4, 2019.

47. Bae C, Geduld H, Wallis LA, Smit DV, Reynolds T. Professional needs of young Emergency Medicine specialists in Africa: Results of a South Africa, Ethiopia, Tanzania, and Ghana survey. African J Emerg Med Rev africaine la Med d’urgence. 2016;6(2):94-99. doi:10.1016/j.afjem.2016.02.005.

48. Call for Applications | Master of Medicine Emergency Medicine | Makerere University College Of Health Sciences | MakCHS. Makerere University College of Health Sciences. http://chs.mak.ac.ug/news/call- applications-master-medicine-emergency-medicine. Published 2019. Accessed April 7, 2019.

49. Nicholson B, Mccollough C, Wachira B, Mould-Millman N-K. Emergency medical services (EMS) training in Kenya: Findings and recommendations from an educational assessment. 2017. doi:10.1016/j.afjem.2017.06.002.

50. Pediatric Emergency and Critical Care. http://www.pecc-kenya.org/. Published 2019. Accessed July 4, 2019.

51. Brysiewicz P. Unpacking the essential elements of emergency nursing in Africa. African Conf Emerg Med. 2018. https://www.dropbox.com/sh/jbsgif54lipo3pp/AACEGeA-UWsjxnlGXqIIaAKpa/Plenary - Day

1?dl=0&preview=Rwanda+key+note+2018+for+distribution.pdf&subfolder_nav_tracking=1.

52. Brysiewicz P. Emergency nurses: An essential component of emergency care in Africa. African J Emerg Med. 2011;1(1):3-4. doi:10.1016/j.afjem.2011.05.003.

53. Calvello EJB, Tenner AG, Broccoli MC, et al. Operationalising emergency care delivery in sub-Saharan Africa: consensus-based recommendations for healthcare facilities. Emerg Med J. 2016;33(8):573-580. doi:10.1136/emermed-2015-204994.

54. Dulandas R, Brysiewicz P. A description of the self-perceived educational needs of emergency nurses in Durban, KwaZulu-Natal, South Africa. African J Emerg Med. 2018;8(3):84-88. doi:10.1016/j.afjem.2018.03.001.

55. DiFazio RL, Vessey J. Advanced practice registered nurses: Addressing emerging needs in emergency care. African J Emerg Med. 2014;4(1):43-49. doi:10.1016/J.AFJEM.2013.04.008.

56. Barnes J, O’Hanlon B, Feeley F, McKeon K, Gitonga N, Decker C. Private Health Sector Assessment in Kenya. Washington, D.C.: The World Bank; 2010. https://openknowledge.worldbank.org/bitstream/handle/10986/5932/552020PUB0Heal10Box349442B01 PUBLIC1.pdf?sequence=1&isAllowed=y. Accessed April 30, 2018.

57. Broccoli MC, Calvello E, Skog AP, Wachira BW, Wallis LA. COMMUNITY-BASED PERCEPTIONS OF EMERGENCY CARE IN KENYA Results of a Qualitative Research Study Conducted by the African Federation for Emergency Medicine.; 2015. http://ecommons.aku.edu/eastafrica_fhs_mc_emerg_med/1. Accessed March 11, 2019.

58. World Bank [institution]. Health Equity and Financial Protection Report - Kenya. Washington, D.C.; 2012. https://openknowledge.worldbank.org/bitstream/handle/10986/27066/712540WP00PUBL0Country0Repo rt0Kenya.pdf?sequence=1&isAllowed=y. Accessed April 30, 2018.

59. Ouma Paul O, Maina Joseph, Thuranira Pamela N, et al. Access to emergency hospital care provided by the public sector in sub-Saharan Africa in 2015: a geocoded inventory and spatial analysis. Lancet Glob Heal. 2018;(17):2214-109. doi:10.1016/S2214-109X(17)30488-6.

60. Hazel Miseda M, Odhiambo Were S, Anne Murianki C, Peter Mutuku M, Mutwiwa SN. The implication of the shortage of health workforce specialist on universal health coverage in Kenya. Hum Resour Health. 2017;15. doi:10.1186/s12960-017-0253-9.

61. Rwanda Improves Access to Care and Equity through Community-Based Health Insurance.; 2018. https://www.msh.org/news-events/stories/rwanda-improves-access-to-care-and-equity-through- community-based-health. Accessed April 7, 2019.

62. Kuo L. A startup in Kenya is launching “Uber for ambulances.” Yahoo Finance. https://finance.yahoo.com/news/startup-kenya-launching-uber-ambulances-095636901.html. Published 2016. Accessed March 31, 2019.

63. Ndichu L. Kenya: The Ambulance Saga That Cost Minister His Job - allAfrica.com. The Standard. https://allafrica.com/stories/200112310121.html. Published 2001. Accessed April 1, 2019.

64. Martin GH, Pimhidzai O. SERVICE DELIVERY INDICATORS: Kenya.; 2013. https://openknowledge.worldbank.org/bitstream/handle/10986/20136/903710WP0Box380IC00SDI0Repo rt0Kenya.pdf?sequence=1&isAllowed=y. Accessed April 30, 2018.

65. Wesson HKH, Stevens KA, Bachani AM, et al. Trauma Systems in Kenya: A Qualitative Analysis at the District Level. Qual Health Res. 2015;25(5):589-599. doi:10.1177/1049732314562890.

66. Bleach L. How Kenya’s Mobile Apps Are Changing the Face of Africa. Huffpost. https://www.huffpost.com/entry/how-kenyas-mobile-apps-ar_b_5577233. Published 2017. Accessed

March 31, 2019.

67. Silver L, Johnson C. Internet Seen as Having Positive Impact in Sub-Saharan Africa | Pew Research Center.; 2018. https://www.pewglobal.org/2018/10/09/internet-connectivity-seen-as-having-positive-impact-on- life-in-sub-saharan-africa/. Accessed March 31, 2019.

68. Trek Medics International. Beacon Emergency Dispatch Software. https://www.trekmedics.org/. Accessed April 7, 2019.

69. Emergency Medicine Kenya Foundation. The Injury Prevention and Safety Initiative (TIPSI©). https://www.emergencymedicinekenya.org/tipsi/. Accessed April 7, 2019.

70. Medtronic. Aligning Value - A Telemedicine Partnership Leads to Better Patient Outcomes in Latin America. https://www.medtronic.com/us-en/transforming-healthcare/aligning-value/perspective/case- studies/latin.html. Accessed March 31, 2019.

71. Bailey PE, Keyes EB, Parker C, Abdullah M, Kebede H, Freedman L. AVERTING MATERNAL DEATH AND DISABILITY Using a GIS to model interventions to strengthen the emergency referral system for maternal and newborn health in Ethiopia. Int J Gynecol Obstet. 2011;115:300-309. doi:10.1016/j.ijgo.2011.09.004.

72. Emergency Medicine Kenya Foundation. PROJECT 47: Emergency Departments in 47 Counties. https://www.emergencymedicinekenya.org/project47/. Accessed April 7, 2019.

73. Shaw BI, Wangara AA, Wambua GM, et al. Geospatial relationship of road traffic crashes and healthcare facilities with trauma surgical capabilities in Nairobi, Kenya: defining gaps in coverage. Trauma Surg Acute Care Open. 2017;2(1):e000130. doi:10.1136/tsaco-2017-000130.

74. Botchey IM, Hung YW, Bachani AM, et al. Epidemiology and outcomes of injuries in Kenya: A multisite surveillance study. 2017. doi:10.1016/j.surg.2017.01.030.

75. Botchey IM, Wai Hung Y, Bachani AM, Saidi H, Paruk F, Hyder AA. Understanding patterns of injury in Kenya: Analysis of a trauma registry data from a National Referral Hospital. 2017. doi:10.1016/j.surg.2017.02.016.

76. Marsh RH, Rouhani SA. Gaps in physical access to emergency care in sub-Saharan Africa. Lancet Glob Heal. 2018;6(3):e240-e241. doi:10.1016/S2214-109X(18)30026-3.

77. Andrews B, Muchemwa L, Kelly P, Lakhi S, Heimburger DC, Bernard GR. Simplified severe sepsis protocol: a randomized controlled trial of modified early goal-directed therapy in Zambia. Crit Care Med. 2014;42(11):2315-2324. doi:10.1097/CCM.0000000000000541.

78. Maitland K, Kiguli S, Opoka RO, et al. Mortality after Fluid Bolus in African Children with Severe Infection. N Engl J Med. 2011;364(26):2483-2495. doi:10.1056/NEJMoa1101549.

79. Shrestha GS, Kwizera A, Lundeg G, et al. International Surviving Sepsis Campaign guidelines 2016: the perspective from low-income and middle-income countries. www.thelancet.com/infection. 2017;17. doi:10.1016/S1473-3099(17)30325-0.

80. Umuhire OF. ABCDEFFF, a Primary survey adaptation. African Conf Emerg Med. 2018.

81. Shao H, Li C-S. Epinephrine in Out-of-hospital Cardiac Arrest. Chin Med J (Engl). 2017;130(17):2112-2116. doi:10.4103/0366-6999.213429.

82. Burkholder TW, Bellows JW, King RA. Free Open Access Medical Education (FOAM) in Emergency Medicine: The Global Distribution of Users in 2016. West J Emerg Med. 2018;19(3):600-605. doi:10.5811/westjem.2018.3.36825.

83. Cattermole GN, Manirafasha A, Aluisio AR, Mbanjumucyo G. Freely Accessible Medical Education (FAME)

for Africa. African J Emerg Med Rev africaine la Med d’urgence. 2018;8(2):41-42. doi:10.1016/j.afjem.2018.05.003.

84. Siegele L. Closing the “digital divide” in 2019. Econ. 2018. https://worldin2019.economist.com/digitaldivide. Accessed April 7, 2019.

85. Evans K. AfCEM 2018 - Day 1:Opening Plenaries & Education. Brave African Discussions in Emergency Medicine. https://badem.co.za/afcem-2018-day-1-opening-plenaries-education/. Published November 2018. Accessed April 8, 2019.

86. Cox M. Postgraduate EM education in Botswana. African Conf Emerg Med. 2018. https://www.dropbox.com/sh/jbsgif54lipo3pp/AADs-POPek_gXC6GYrq-auPya/Novel Education Methods?dl=0&preview=AFCEM_18_MC.pdf&subfolder_nav_tracking=1. Accessed April 8, 2019.

87. Musinguzi C, Namale L, Rutebemberwa E, Dahal A, Nahirya-Ntege P, Kekitiinwa A. The relationship between leadership style and health worker motivation, job satisfaction and teamwork in Uganda. J Healthc Leadersh. 2018;10:21-32. doi:10.2147/JHL.S147885.

88. Smith ME, Wells EE, Friese CR, Krein SL, Ghaferi AA. Interpersonal And Organizational Dynamics Are Key Drivers Of Failure To Rescue. Health Aff. 2018;37(11):1870-1876. doi:10.1377/hlthaff.2018.0704.

89. de la Croix A, Veen M. The reflective zombie: Problematizing the conceptual framework of reflection in medical education. Perspect Med Educ. 2018;7(6):394-400. doi:10.1007/s40037-018-0479-9.

90. Pentecost M, Gerber B, Wainwright M, Cousins T. Critical orientations for humanising health sciences education in South Africa. Med Humanit. 2018;44(4):221-229. doi:10.1136/medhum-2018-011472.

91. Husum H, Gilbert M, Wisborg T, Van Heng Y, Murad M. Rural Prehospital Trauma Systems Improve Trauma Outcome in Low-Income Countries. J Trauma Inj Infect Crit Care. 2003;54(6):1188-1196. doi:10.1097/01.TA.0000073609.12530.19.

92. Drake K. A Lay Training Program in Basic Emergency Care and Danger Sign Recognition in Rukungiri District, Uganda: Recommendations for Global Emergency Care Collaborative’s Prehospital Emergency Resources Project.; 2012. https://www.jhsph.edu/academics/degree-programs/master-of-public- health/curriculum/Kelsey Drake capstone paper 2012.pdf. Accessed April 8, 2019.

93. Okeyo V. All you need to know about emergency care in Kenya. Daily Nation. https://www.nation.co.ke/lifestyle/health/-Someone-call-911/1954202-4944050-vgnluqz/index.html. Published January 2019.

94. Sykes KJ. Short-Term Medical Service Trips: A Systematic Review of the Evidence. Am J Public Health. 2014;104(7):e38-e48. doi:10.2105/AJPH.2014.301983.

95. Caldron PH, Impens A, Pavlova M, Groot W. A systematic review of social, economic and diplomatic aspects of short-term medical missions. BMC Health Serv Res. 2015;15(1):380. doi:10.1186/s12913-015-0980-3.

96. Ashley S. International Emergency Medicine. In: ECU Global Health and Underserved Populations Conference. Greenville, NC; 2015.

97. Pettersen K, Ashley S, Edris M, Jhonson M, Salmon M, Miss J. Emergency Medicine Training for Haitian Senior Medical Students. Haile T Debas Acad Med Educ Acad Med Educ Educ Symp Abstr. 2013.

98. Molyneux EM, Quarm Goka B. Paediatric emergencies in sub-Saharan Africa. 2017. doi:10.1016/j.afjem.2017.11.005.

99. Clark M, Spry E, Daoh K, Baion D, Skordis-Worrall J. Reductions in inpatient mortality following interventions to improve emergency hospital care in Freetown, Sierra Leone. Morgan D, ed. PLoS One. 2012;7(9):e41458. doi:10.1371/journal.pone.0041458.

100. Uwineza C. Resuscitation practice during cardiac arrest in emergency department of CHUK. African Conf Emerg Med. 2018.

101. Delphine C. Resuscitation Trolley Checking at Accident and Emergency Department of Kigali University Teaching Hospital. African Conf Emerg Med. 2018. https://www.dropbox.com/sh/jbsgif54lipo3pp/AABMD- 4ygARH4nbNV183nzkea/Nursing I?dl=0&preview=TO+PRESENT+08-11-2018+AFCEM- 2.pptx&subfolder_nav_tracking=1. Accessed April 8, 2019.

102. Mirembe V. Continuity of BEC to Critical Patients on Surgical Ward. African Conf Emerg Med. 2018. https://www.dropbox.com/sh/jbsgif54lipo3pp/AABCDVWr2Ph3Nxerng8EJOyua/Nursing II?dl=0&preview=AFCEM+2018+MIREMBE+VIOLET.pptx&subfolder_nav_tracking=1#. Accessed April 8, 2019.

103. Sepeku A. Development of Emergency Nursing in Tanzania. African Conf Emerg Med. 2018. https://www.dropbox.com/sh/jbsgif54lipo3pp/AAAt14c9Sj1jkdPiKtrDrUNaa/Nursing I/ANGELINA SEPEKU.pdf?dl=0. Accessed April 8, 2019.

104. Azazh A, Teklu S, Woldetsadi A, et al. Emergency medicine and its development in Ethiopia with emphasis on the role of Addis Ababa University, School of Medicine, Emergency Medicine Department. Ethiop Med J. 2014;Suppl 2:1-12. http://www.ncbi.nlm.nih.gov/pubmed/25546904. Accessed October 28, 2018.

105. de Ramirez SS, Doll J, Carle S, et al. Emergency Response in Resource-poor Settings: A Review of a Newly- implemented EMS System in Rural Uganda. Prehosp Disaster Med. 2014;29(03):311-316. doi:10.1017/S1049023X14000363.

106. Somigliana E, Sabino A, Nkurunziza R, et al. Ambulance service within a comprehensive intervention for reproductive health in remote settings: a cost-effective intervention. Trop Med Int Heal. 2011;16(9):1151- 1158. doi:10.1111/j.1365-3156.2011.02819.x.

107. Tayler-Smith K, Zachariah R, Manzi M, et al. Achieving the Millennium Development Goal of reducing maternal mortality in rural Africa: an experience from Burundi. Trop Med Int Heal. 2013;18(2):166-174. doi:10.1111/tmi.12022.

108. eRanger Case Studies. http://www.eranger.com/Results.aspx. Accessed March 22, 2019.

109. Hofman JJ, Dzimadzi C, Lungu K, Ratsma EY, Hussein J. Motorcycle ambulances for referral of obstetric emergencies in rural Malawi: Do they reduce delay and what do they cost? Int J Gynecol Obstet. 2008;102(2):191-197. doi:10.1016/j.ijgo.2008.04.001.

110. Ma3Route. https://www.ma3route.com/traffic-updates. Accessed April 8, 2019.

111. Council on Linkages Between Academia and Public Health Practice. Core Competencies for Public Health Professionals.; 2014. http://www.phf.org/resourcestools/Documents/Core_Competencies_for_Public_Health_Professionals_20 14June.pdf. Accessed April 2, 2019.

112. Calvello E, Reynolds T, Hirshon JM, et al. Emergency care in sub-Saharan Africa: Results of a consensus conference. African J Emerg Med. 2013;3(1):42-48. doi:10.1016/j.afjem.2013.01.001.

113. Rowitz L. The Basics of Leadership. In: Public Health Leadership. . Jones & Bartlett Publishers; 2013:3-17. https://ares.lib.unc.edu/ares/ares.dll?SessionID=E042638320E&Action=10&Type=10&Value=109072907. Accessed September 5, 2018.

114. The African Federation for Emergency Medicine Emergency Care Curriculum Keystone Curriculum.; 2017. http://afem.co.za/wp-content/uploads/2017/10/AFEM-Curriculum.pdf. Accessed April 2, 2019.

115. Counselman FL, Beeson MS, Marco CA, Adsit SK, Harvey AL, Keehbauch JN. Evolution of the Model of the Clinical Practice of Emergency Medicine: 1979 to Present. Asher SL, ed. Acad Emerg Med. 2017;24(2):257-

264. doi:10.1111/acem.13137.

116. Dearing JW, Cox JG. Diffusion Of Innovations Theory, Principles, And Practice. Health Aff. 2018;37(2):183- 190. doi:10.1377/hlthaff.2017.1104.

117. Horton TJ, Illingworth JH, Warburton WHP. Overcoming Challenges In Codifying And Replicating Complex Health Care Interventions. Health Aff. 2018;37(2):191-197. doi:10.1377/hlthaff.2017.1161.