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Introduction: The indications for cardiac point of care ultrasound (PoCUS) vary somewhat in different parts of the world, and training programs may also differ. We set out to describe the self-reported cardiac PoCUS indications and imaging windows used at a selection of secondary-level, public hospital emergency centres in Cape Town. Methods: A descriptive study with prospective data collected from emergency centres of Mitchells Plain District, Victoria and New Somerset Hospitals in Cape Town were used. Data were collected over a three-month period by providers who have completed a basic emergency ultrasound course, using a purpose-designed data collection tool for all cardiac PoCUS scans. Results: Fifteen PoCUS providers recorded 267 data entries over the three-month study period; there were 17 exclusions, leaving 250 entries for analysis. The most common indication for performing cardiac PoCUS was electrocardiogram abnormalities, 27% (n = 112); dyspnoea, 25% (n = 102); chest pain, 16% (n = 65); cardiomegaly on chest x-ray, 12% (n = 51); new murmur, 6% (n = 23); and chest trauma, 5% (n = 22). Other indications made up the remaining 10% (n = 40). Parasternal long and short axis were the predominantly used views. Conclusion: Cardiac PoCUS is used for a wide range of indications beyond the recommended training guidelines. Some indications may be more useful in low- to middle-income settings. Further research needs to be done to ascertain the extent of the use of cardiac PoCUS, and possibly the need for a more comprehensive training program with adequate training in these clinical conditions, to ensure safe practice.

Abstract Background Methods on developing new (de novo) clinical practice guidelines (CPGs) have received substantial attention. However, research into alternative methods of CPG development using existing CPG documents (CPG adaptation) — a specific issue for guideline development groups in low- and middle-income countries — is sparse. There are only a few examples showcasing the pragmatic application of such alternative approaches in settings with time and budget constraints, especially in the prehospital setting. This paper aims to describe and strengthen the methods of developing prehospital CPGs using alternative guideline development methods through a case study design. Methods We qualitatively explored a CPG development project conducted in 2016 for prehospital providers in South Africa as a case study. Key stakeholders, involved in various processes of the guideline project, were purposefully sampled. Data were collected from one focus group and six in-depth interviews and analysed using thematic analysis. Overarching themes and sub-themes were inductively developed and categorised as challenges and recommendations and further transformed into action points. Results Key challenges revolved around guideline implementation as opposed to development. These included the unavoidable effect of interest and beliefs on implementing recommendations, the local evidence void, a shifting implementation context, and opposing end-user needs. Guideline development and implementation strengthening priority actions included: i) developing a national end-user document; ii) aligning recommendations with local practice; iii) communicating a clear and consistent message; iv) addressing controversial recommendations; v) managing the impact of interests, beliefs and intellectual conflicts; and vi) transparently reporting implementation decisions. Conclusion The cornerstone of a successful guideline development process is the translation and implementation of CPG recommendations into clinical practice. We highlight key priority actions for prehospital guideline development teams with limited resources to strengthen guideline development, dissemination, and implementation by drawing from lessons learnt from a prehospital guideline project conducted in South Africa.

Background: Better access for clinicians from low- and middle-income countries to international conferences can improve collaborative opportunities and subsequently address the knowledge gap between the weaker and stronger knowledge economies. A better understanding of the cost of international conferences may help conference organisers improve access to their conferences. This study aimed to describe the expense-associated barriers to a selection of international emergency medicine and critical care conferences, in terms of registration cost and out-of-pocket expense. Methods: A cross sectional, retrospective design was used. Registration cost variables (cost, waivers, discounts and scholarships) were collected from a cohort of international emergency medicine and critical care conferences held during 2016. The World Health Organization Purchasing Power Parity index was then applied to calculate an equitable registration cost for delegates from South Africa, Brazil, Turkey, China, Australia, Germany and the United States for each conference. Results: Twenty conferences were included. Eight conferences (36%) offered discounted rates, and another eight offered scholarships for low- and middle-income country delegates. Calculated, equitable registration rates were 2.6, 1.9, 1.9, 1.7, 0.9, 1.1 times lower than quoted respectively for South Africa, Brazil, Turkey, China, Australia and Germany compared to the rate in United States dollar. Only one conference provided equitable registration rates for all test-countries. Discussion: Current international conference registration costs (despite discounts, waivers and scholarships) are likely a barrier to including low- and middle-income delegates in the educational, networking and promotional opportunities that conferences provide. Conference organisers should consider restructuring registration costs to encourage more representative international audiences. Keywords: Parity, Health expenditures, Critical care, Emergency medicine, Fellowships and scholarships, Conference

Introduction: Finding journal open access information alongside its global impact requires access to multiple databases. We describe a single, searchable database of all emergency medicine and critical care journals that include their open access policies, publication costs, and impact metrics. Methods: A list of emergency medicine and critical care journals (including citation metrics) was created using Scopus (Citescore) and the Web of Science (Impact Factor). Cost of gold/hybrid open access and article process charges (open access fees) were collected from journal websites. Self-archiving policies were collected from the Sherpa/RoMEO database. Relative cost of access in different regions were calculated using the World Bank Purchasing Power Parity index for authors from the United States, Germany, Turkey, China, Brazil, South Africa and Australia. Results: We identified 78 emergency medicine and 82 critical care journals. Median Citescore for emergency medicine was 0.73 (interquartile range, IQR 0.32–1.27). Median impact factor was 1.68 (IQR 1.00–2.39). Median Citescore for critical care was 0.95 (IQR 0.25–2.06). Median impact factor was 2.18 (IQR 1.73–3.50). Mean article process charge for emergency medicine was $2243.04, SD = $1136.16 and for critical care $2201.64, SD = $1174.38. Article process charges were 2.24, 1.75, 2.28 and 1.56 times more expensive for South African, Chinese, Turkish and Brazilian authors respectively than United States authors, but neutral for German and Australian authors (1.02 and 0.81 respectively). The database can be accessed here: http://www.emct.info/publication-search.html. Conclusions: We present a single database that captures emergency medicine and critical care journal impact rankings alongside its respective open access cost and green open access policies. Keywords: Open access, Impact, Emergency medicine, Critical care

Introduction: Evidence based medicine is the standard of modern health care practices. Ongoing biomedical research is needed to expand existing knowledge and improve quality of care, but it needs to reach clinicians to drive change. Journal articles and conference presentations are dissemination tools. The aim of the study was to establish the publication rate of scientific abstracts presented at the first and second African Conference of Emergency Medicine. The secondary objectives were establishing non-publication dissemination and the factors associated with publication and non-publication. Determining non-publication dissemination patterns and the factors associated with reasons for publishing or non-publication were also investigated. Methods: Presenters of the 129 scientific abstracts from the first and second African Conference of Emergency Medicine were invited to participate in an online survey. The survey was followed by a manual literature search to identify published manuscripts of authors that did not complete the survey, to determine the most accurate publication rate. Results: Thirty-one presenters responded (24%), of which 18 published in a peer-reviewed journal. An additional 25 publications were identified by the literature search. The overall publication rate was 33.3% (26.9% from 2012 and 40.3% from 2014). Oral presentations were more likely to be published (p = 0.09). Sixteen manuscripts (37.2%) were published in the African Journal of Emergency Medicine. Presentations at local academic meetings were the most used platform beyond publication (43%). The main reason to publish was to add to the body of knowledge (100%), while lack of time (57%) was the major obstacle for not publishing. Conclusion: The overall publication rate for the first and second Africa Conferences of Emergency Medicine is comparable to other non-African Emergency Medicine conferences. The increasing publication trend between conferences might reflect the development of regional research capacity. Emergency Medicine providers in Africa need to be encouraged to participate in high quality, locally relevant research and to distribute those findings through accessible formats. Keywords: Conference, Africa, Publication, Barriers, Dissemination

Introduction: Stroke affects 15 million people annually and is responsible for 5 million deaths per annum globally. In contrast to the trend in low- and middle-income countries (LMICs), stroke mortality is on the decline in high-income countries (HICs). Even though the availability of resources varies considerably by geographic region and across LMICs and HICs, evidence suggests that material resources in LMICs to implement recommendations from international guidelines are largely unmet. This study describes and compares the availability of resources to treat new-onset stroke in countries based on the World Bank’s gross national incomes, using recommendations of the American Heart Association and the American Stroke Association 2013 update. Methods: A self-reported cross-sectional survey was conducted of delegates that attended the April 2016 International Conference on Emergency Medicine using the web-based e-Survey client, Survey Monkey Inc. The survey assessed both pre-hospital and in-hospital settings and was piloted before implementation. Results: The survey was distributed and opened by 955 delegates and 382 (40%) responded. Respondents from LMICs reported significantly less access to a prehospital service (p

Introduction: An adaptive guideline development method, as opposed to a de novo guideline development, is dependent on access to existing high-quality up-to-date clinical practice guidelines (CPGs). We described the characteristics and quality of CPGs relevant to prehospital care worldwide, in order to strengthen guideline development in low-resource settings for emergency care. Methods: We conducted a descriptive study of a database of international CPGs relevant to emergency care produced by the African Federation for Emergency Medicine (AFEM) CPG project in 2016. Guideline quality was assessed with the AGREE II tool, independently and in duplicate. End-user documents such as protocols, care pathways, and algorithms were excluded. Data were imported, managed, and analysed in STATA 14 and R. Results: In total, 276 guidelines were included. Less than 2% of CPGs originated from low- and middle income-countries (LMICs); only 15% (n = 38) of guidelines were prehospital specific, and there were no CPGs directly applicable to prehospital care in LMICs. Most guidelines used de novo methods (58%, n = 150) and were produced by professional societies or associations (63%, n = 164), with the minority developed by international bodies (3%, n = 7). National bodies, such as the National Institute for Health and Care Excellence (NICE) and the Scottish Intercollegiate Guidelines Network (SIGN), produced higher quality guidelines when compared to international guidelines, professional societies, and clinician/academic-produced guidelines. Guideline quality varied across topics, subpopulations and producers. Resource-constrained guideline developers that cannot afford de novo guideline development have access to an expanding pool of high-quality prehospital guidelines to translate to their local setting. Discussion: Although some high-quality CPGs exist relevant to emergency care, none directly address the needs of prehospital care in LMICs, especially in Africa. Strengthening guideline development capacity, including adaptive guideline development methods that use existing high-quality CPGs, is a priority. Keywords: Emergency care, Prehospital, Guideline development, Scoping, Guideline quality

Introduction: International guidance suggests that injury-associated haemorrhagic shock should be resuscitated using blood products. However, in low- and middle-income countries resuscitation emphasises the use of crystalloids – mainly due to poor access to blood products. This study aimed to estimate the amount of blood loss from serious injury in relation to available emergency blood products at a secondary-level, public Cape Town hospital. Methods: This retrospective, cross-sectional study included all injured patients cared for in the resuscitation area of Khayelitsha Hospital’s emergency centre over a fourteen-week period. Injuries were coded using the Abbreviated Injury Scale, which was then used to estimate blood loss for each patient using an algorithm from the Trauma Audit Research Network. Descriptive statistics were used to describe blood volume lost and blood units required to replace losses greater than 15% circulating blood volume. Four units of emergency blood are stored in a dedicated blood fridge in the emergency centre. Platelets and fresh plasma are not available. Results: A total of 389 injury events were enrolled of which 93 were excluded due to absent clinic data. The mean age was 29 (±10) years. We estimated a median of one unit of blood requirement per week or weekend, up to a maximum of eight or six units, respectively. Most patients (n = 275, 94%) did not have sufficient injury to warrant transfusion. Overall, one person would require a transfusion for every 15 persons with a moderate to serious injury. Conclusion: The volume of available emergency blood appears inadequate for injury care, and doesn’t consider the need for other causes of acute haemorrhage (e.g. gastric, gynaecological, etc.). Furthermore, lack of other blood components (i.e. plasma and platelets) presents a challenge in this low-resourced setting. Further research is required to determine the appropriate management of injury-associated haemorrhage from a resource and budget perspective. Keywords: Injury, Low resource, Blood products

Introduction: In South Africa’s high injury prevalent setting, it is imperative that injury mortality is kept to a minimum. The CRASH-2 trial showed that Tranexamic acid (TXA) in severe injury reduces mortality. Implementation of this into injury protocols has been slow despite the evidence. The 2013 Western Cape Emergency Medicine Guidelines adopted the use of TXA. This study aims to describe compliance. Methods: A retrospective study of TXA use in adult injury patients presenting to Khayelitsha Hospital was done. A sample of 301 patients was randomly selected from Khayelitsha’s resuscitation database and data were supplemented through chart review. The primary endpoint was compliance with local guidance: systolic blood pressure 110 or a significant risk of haemorrhage. Injury Severity Score (ISS) was used as a proxy for the latter. ISS >16 was interpreted as high risk of haemorrhage and ISS 15 (p

Introduction: Unrestricted access to journal publications speeds research progress, productivity, and knowledge translation, which in turn develops and promotes the efficient dissemination of content. We describe access to the 500 most-cited emergency medicine (EM) articles (published between 2012 and 2016) in terms of publisher-based access (open access or subscription), alternate access routes (self-archived or author provided), and relative cost of access. Methods: We used the Scopus database to identify the 500 most-cited EM articles published between 2012 and 2016. Access status was collected from the journal publisher. For studies not available via open access, we searched on Google, Google Scholar, Researchgate, Academia.edu, and the Unpaywall and Open Access Button browser plugins to locate self-archived copies. We contacted corresponding authors of the remaining inaccessible studies for a copy of each of their articles. We collected article processing and access costs from the journal publishers, and then calculated relative cost differences using the World Bank purchasing power parity index for the United States (U.S.), Germany, Turkey, China, Brazil, South Africa, and Australia. This allows costs to be understood relative to the economic context of the countries from which they originated. Results: We identified 500 articles for inclusion in the study. Of these, 167 (33%) were published in an open access format. Of the remaining 333 (67%), 204 (61%) were available elsewhere on the internet, 18 (4%) were provided by the authors, and 111 (22%) were accessible by subscription only. The mean article processing and access charges were $2,518.62 and $44.78, respectively. These costs were 2.24, 1.75, 2.28 and 1.56 times more expensive for South African, Chinese, Turkish, and Brazilian authors, respectively, than for U.S. authors (p

Introduction: Injury and violence are neglected global health concerns, despite being largely predictable and therefor preventable. We conducted a small study to indirectly describe and compare the perception of availability of resources to manage major trauma in high-income, and low- and middle-income countries using evidence-based guidance (as per the 2016 National Institute of Clinical Excellence guidelines), as self-reported by delegates attending the 2016 International Conference on Emergency Medicine held in South Africa. Methods: A survey was distributed to delegates at the International Conference on Emergency Medicine 2016. The survey instrument captured responses from participants working in both pre- and in-hospital settings. Responses were grouped according to income group (either high-income, or low- and middle-income) based on the respondent’s nationality (using the World Bank definition for income group). A Fisher’s Exact test was conducted to compare responses between different income groups. Results: The survey was distributed to 980 delegates, and 392 (40%) responded. A total of 206 (53%) respondents were from high-income countries and 186 (47%) were from low- to middle-income countries. Respondents described significantly less access to resources and services for low- and middle-income countries to adequately care for major trauma patients both pre- and in-hospital when compared to high-income countries. Shortages ranged from consumables to analgesia, imaging to specialist services, and pre-hospital to in-hospital care. Conclusion: Major trauma care requires a chain of successful, evidence-based events for outcomes to benefit. This small study suggests that many of the links of this chain are either missing or broken within low- and middle-income countries. These settings simply do not benefit from the currently available evidence-base in major trauma care. It is important that this evidence-base also be evaluated within low- and middle-income countries. The capacity of low- and middle-income country emergency care systems also needs better describing. Keywords: Self-report, Specialization, Global health, Income, Emergency medicine, Developed countries

Introduction: Based on relative population size and burden of disease, emergency care publication outputs from low- and middle-income regions are disproportionately lower than those of high-income regions. Ironically, outputs from regions with higher publication rates are often less relevant in the African context. As a result, the dissemination of and access to local research is essential to local researchers, but the cost of this access (actual and cost-wise) remains unknown. The aim of this study was to describe access to African emergency care publications in terms of publisher-based access (open access or subscription) and alternate access (self-archived or author provided), as well as the cost of access. Methods: We conducted a retrospective, cross-sectional study using all emergency medicine publications included in Scopus between 2011 and 2015. A sequential search strategy described access to each article, and we calculated mean article charges against the purchasing power parity index (used to describe out-of-pocket expense). Results: We included 666 publications from 49 journals, of which 395 (59.3%) were open access. For subscription-based articles, 106 (39.1%) were self-archived, 60 (22.1%) were author-provided, and 105 (38.8%) were inaccessible. Mean article access cost was $36.44, and mean processing charge was $2,319.34. Using the purchasing power parity index it was calculated that equivalent out-of-pocket expenditure for South African, Ghanaian and Tanzanian authors would respectively be $15.77, $10.44 and $13.04 for access, and $1,004.02, $664.36 and $830.27 for processing. Based on this, the corrected cost of a single-unit article access or process charge for South African, Ghanaian and Tanzanian authors, respectively, was 2.3, 3.5 and 2.8 times higher than the standard rate. Conclusion: One in six African emergency care publications are inaccessible outside institutional library subscriptions; additionally, the cost of access to publications in low- and middle-income countries appears prohibitive. Publishers should strongly consider revising pricing for more equitable access for researchers from low- and middle-income countries.