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Knowledge Translation in International Emergency Medical Care L. Kristian Arnold, MD, MPH, Hisham Alomran, MD, MPH, V. Anantharaman, MBBS, FRCP (Edin), FRCS Ed (A&E), FAMS, Pinchas Halpern, MD, Mark Hauswald, MD, Pia Malmquist, MBBS, FRCP, FRCPCH, FCEM, OBE, Elizabeth Molyneux, MRCPCH, FFAEM, Bishan Rajapakse, MBChB, Megan Ranney, MD, Junaid Razzak, MD, PhD, MPH

Abstract More than 90% of the world population receives emergency medical care from different types of practitioners with little or no specific training in the field and with variable guidance and oversight. Emergency medical care is being recognized by actively practicing physicians around the world as an increasingly important domain in the overall health services package for a community. The know-do gap is well recognized as a major impediment to high-quality health care in much of the world. Knowledge translation principles for application in this highly varied young domain will require investigation of numerous aspects of the knowledge synthesis, exchange, and application domains in order to bring the greatest benefit of both explicit and tacit knowledge to increasing numbers of the world’s population. This article reviews some of the issues particular to knowledge development and transfer in the international domain. The authors present a set of research proposals developed from a several-month online discussion among practitioners and teachers of emergency medical care in 16 countries from around the globe and from all economic strata, aimed at improving the flow of knowledge from developers and repositories of knowledge to the front lines of clinical care. ACADEMIC EMERGENCY MEDICINE 2007; 14:1047–1051 ª 2007 by the Society for Academic Emergency Medicine Keywords: developing countries, diffusion of innovation, evidence-based medicine, health policy information, dissemination, knowledge

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developed by the Canadian Institutes for Health Research, and incorporated it as a part of an initiative on ‘‘knowledge management.’’1

nowledge translation (KT) in international emergency medical care involves essentially all of the domains covered by the other theme topics of the consensus conference but with some aspects peculiar to the international domain. Issues from limited health budgets to the varied educational backgrounds of emergency medical care givers add complexity to this endeavor. It is useful to explicitly specify the terminology as it will be used in this article. The term ‘‘knowledge translation’’ is still under discussion in the literature. The World Health Organization (WHO) has refined the term, initially

The discussion of KT in this article is based on this somewhat broader definition, because it implies a more

From ArLac Health Services (LKA), Lexington, MA; Emergency Medicine, King Faisal Hospital (HA), Riyaad, Saudi Arabia; Emergency Medicine, Singapore General Hospital (VA), Singapore; Emergency Medicine, Tel Aviv University Hospital (PH), Tel Aviv, Israel; Emergency Medicine, University of New Mexico (MH), Albuquerque, NM; Department of Emergency Medicine, South Stockholm General Hospital (PM), Stockholm, Sweden; Department of Pediatrics, College of Medicine, Queen Elizabeth Central Hospital (EM), Blantyre, Malawi; South Asian Clinical Toxicology Research Collaboration (SACTRC) (BR), Kandy, Sri Lanka; Emergency Medicine, Brown University (MR), Providence, RI; and Section of Emergency Medicine, Aga Khan University (JR), Karachi, Pakistan.

Received June 9, 2007; revision received July 13, 2007; accepted July 13, 2007. This is a proceeding from a workshop session of the 2007 Academic Emergency Medicine Consensus Conference, ‘‘Knowledge Translation in Emergency Medicine: Establishing a Research Agenda and Guide Map for Evidence Uptake,’’ Chicago, IL, May 15, 2007. Workshop participants included John Allegra, David Bouslough, Ted Christopher, Eleanor Fitzpatrick, Mark Hauswald, Sue Huckson, Nancy Kerr, Heidi Ladner, Mary Ann McNeil, and Robert Shafermeyer. Contact for correspondence and reprints: L. Kristian Arnold, MD, MPH; e-mail: [email protected].

ª 2007 by the Society for Academic Emergency Medicine doi: 10.1197/j.aem.2007.07.013

[Knowledge Translation is:] the synthesis, exchange, and application of knowledge by relevant stakeholders to accelerate the benefits of global and local innovation in strengthening health systems and improving people’s health.2

ISSN 1069-6563 PII ISSN 1069-6563583

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global participation in both the generation of knowledge and the importance of contextual relevance. This article also uses the more generic term of ‘‘emergency medical care,’’ as opposed to ‘‘emergency medicine’’ (EM), for two reasons. First, the medical practice domain referred to as ‘‘emergency medicine’’ has different connotations around the globe. Second, emergent care of medical conditions is the clinical care being addressed in this discussion of KT. It is also useful to consider knowledge as a commodity, not much different from any other commodity that would be manufactured in response to market factors and feedback, packaged to attract potential purchasers, marketed to consumers of different ethnic and socioeconomic groups, and for which postmarketing analysis of sales, customer satisfaction assessment, and feedback would be performed. This analogy does not imply a call for commercialization of knowledge. We searched MEDLINE from 1996 to 2007 using several terms to capture publications related to KT, developing countries, and EM. Fewer than ten articles were found, most of which concerned the UN Millennium Development Goals (http://www.un.org/millenniumgoals/) (Table 1); none addressed EM specifically. It was appreciated very early on in the consensusseeking process that, except for pockets of knowledgeable persons, much of the international EM community is ignorant of KT, its meaning, and its relevance to the day-to-day management of emergency patients. This article will hopefully start a process of research focused on understanding and improving the flow of knowledge in international emergency medical care. DISCUSSION GROUP This article represents a consensus of international physician participants arrived at through an electronic discussion via a Google Group and additional discussion at the 2007 Academic Emergency Medicine Consensus Conference (Chicago, IL, May 15, 2007). There were 27 discussants representing 16 countries from all economic strata (see the list of participants in Appendix A). A number of the participants had extensive emergency care experience in multiple countries. Most of the Google postings came from participants in countries in which the emergency medical care system would be classified as ‘‘underdeveloped’’ or ‘‘developing,’’ using published criteria.3 RESEARCH AGENDAS Following the lead of the WHO statement on KT, research into improved application of KT on an interTable 1 Publications on Knowledge Translation in Emergency Medical Care and in Developing Countries Search Term Knowledge translation Emergency medicine/ knowledge translation Knowledge translation/ developing countries

Type of Search Title word (not a MeSH term) ‘‘Emergency medicine’’ as title and MeSH term ‘‘Developing countries’’ as title and MeSH term

MeSH = Medical Subject Heading.

Results 94 0 4



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national scale can be divided into three broad themes regarding the management of knowledge: synthesis, exchange, and application. These themes do not directly replicate the other theme topics of this consensus conference, although the WHO domains do cover most of the consensus conference themes. To avoid redundancy in suggested research agendas, we focus on agendas particularly problematic in addressing improvement of emergency medical care on a global scale.

Knowledge Synthesis Synthesized knowledge, as exemplified by systematic reviews of experimental design research projects, is held as an ideal for advancing health care.4 However, even the best of systematic reviews may have limited validity in many resource-limited settings, because the majority of studies underlying the reviews have been performed in countries with sophisticated health care systems, thus not necessarily reflecting the burden of disease or resources available in developing economies.5,6 Evidence suggests that high-quality, locally-produced, and published research is likely to have a greater impact on practice.7 Improving research capacity in countries at lower levels of economic development is fundamental in attempts to narrow the ‘‘10/90’’ gap (10% of medical research funds are devoted to diseases that account for 90% of the global burden of disease8,9). Currently, funding for local researchers is often limited. Additionally, mechanisms must be found to provide more venues for publication of locally-produced data, both positive and negative. As much as developing evidence-based foundations for clinical practice may be an ideal, the vast majority of activities undertaken in the practice of medicine are not presently based on well-designed, highly powered research. A significant portion of the activities undertaken to diagnose and treat patients have been developed over the ages through diligent observation and rational deduction and passed on via observation and integration rather than didactic methods. This knowledge gained through experience, referred to as tacit knowledge, is considered of fundamental importance in many settings outside medicine, such as business, where it is impractical or impossible to conduct experimental studies.10 Tacit knowledge is also a fundamental basis for development of heuristic, or ruleof-thumb, decision-making processes found to be frequently used by physicians.11 While this should not be construed as embracing ‘‘eminence-based medicine,’’ it implies the need to understand the constraints that currently exist in the generation and application of knowledge. Since emergency medical care covers the breadth of medical care, much published information of value is dispersed in specialty and policy literature. Immense amounts of time and money have been invested into projects and redacted into guidelines and protocols by organizations such as the WHO, the American Heart Association, and the European Resuscitation Council. Without a centralized source, these guidelines can be difficult to access and apply. The plethora of guidelines available on the Internet on the same topics from different geographic regions suggests some degree of local and regional reanalysis and editing of many guidelines.

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Literature on international KT highlights a need for communication between researchers and end-users in order to generate research that is relevant to the issues most affecting a population.12 Lack of prestudy communication between researchers and end-users serves as a barrier to the actual use of research results for clinical care or policy decisions regardless of the level of development.13 KT should be viewed as an integral part of locally-owned, egalitarian networks and knowledge management systems.14 It is also essential that researchers and policy makers agree on terminology, especially when discussing concepts such as emergency medical care or EM. Endeavors are currently under way to develop a common terminology.15 Based on this analysis, several agendas for improving the quality and relevance of knowledge useful in emergency medical care in differently resourced settings follow. Some of the research proposals are not typical of medical research, as they are more representative of sociologic, anthropologic, or psychological studies because the KT domain is itself more of a sociologic than medical concept. Knowledge Synthesis Agenda 1. Much guidance regarding best practices in the emergency medical care of various conditions has been documented in the form of guidelines from a variety of different organizations, not always in their entirety directed specifically at emergency medical care. Because much of the guideline development has occurred in countries with advanced health care systems, their relevance to many clinical settings around the world may be questionable, particularly in settings where acute health care is delivered by persons with minimal training and guided by protocols. A repository of generic guidelines relevant to emergency medical care derived from existing guidelines related to the major health burden conditions could serve as a valuable resource for developing high-quality, locally-relevant protocols. Research Questions 1. What are the similarities and differences among various published, well-founded medical guidelines as regards recommendations for emergency management? 2. Are there core principles embedded in various published guidelines for emergency management that can be redacted into broadly applicable principles for constructing locally-relevant protocols? 3. Does revising established clinical guidelines to local conditions lead to improved implementation of guideline recommendations? Knowledge Synthesis Agenda 2. To develop locallyrelevant research, practitioners and scientists with an interest in developing emergency medical care services will need appropriate skill sets. Education in principles of research methodology and critical literature appraisal should be introduced internationally during medical school, led by initiatives from groups such as the World Medical Association and the Association of Academic Chairs and University Presidents. Research Questions 1. What differences exist in research skills between international emergency medical care physician pro-

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viders and those trained in developed EM residency programs? 2. Does participation in an online, distance learning research skills course affect participant research activity? Does it improve the publication rate? 3. Do academic mentoring services from professional societies in regions with well-developed research capacities in emergency medical care increase the research activity and publication rate for colleagues in regions with developing emergency medical care systems? Knowledge Synthesis Agenda 3. Epidemiologic assessment is critical to appropriately adapt existing care guidelines and to develop locale-appropriate protocols to address the range of variations across different communities needing emergency care. Epidemiologic research in resource-constrained environments often relies on different techniques from those most frequently used in developed country settings. The performance of many of these techniques in the domain of emergency medical care is not known. In many countries, epidemiologic assessments relevant to emergency medical care have been undertaken by agencies and nongovernmental organizations not focused on emergency medical care. Additionally, due to lack of central coordination of such efforts, information gathered is often not easily accessed or well applied. Research Questions 1. How well do low resource research methodologies perform in variably resourced emergency medical care settings? 2. What are major transnational similarities and differences in emergency medical care needs and interventions? 3. What epidemiologic databases pertaining to emergency medical care currently exist in the developing world, and do any have broader applicability? Knowledge Synthesis Agenda 4. It is also inherent in the KT model that knowledge development occurs in any setting where questions are being asked and studied. This highlights the importance of developing improved lines of communication among developers of emergency medical care capacity in order to both share knowledge and avoid ‘‘reinventing the wheel.’’ Such sharing is likely to be of particular utility in the area of influencing decision- and policy-makers since there is little communication of these experiences in the published literature. Research Questions 1. Will development of an Internet-based forum for emergency medical care lead to international sharing of experiences? Knowledge Exchange Knowledge exchange is critical to the generation and synthesis of knowledge, as well as to its dissemination.

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Concepts of KT are evolving away from the one-way model of knowledge brokers deciding on methods to get existing validated ‘‘knowledge’’ out to the front lines of clinical practice without input from the recipients. As with marketing of any goods, marketers of knowledge must listen to their target audience in order to develop effective packaging and dissemination tactics. The actual techniques of dissemination, such as ‘‘academic detailing,’’16 will not be addressed here; rather, we will discuss issues that seem of particular relevance to the international domain. Assessment of physician learning and informationgathering styles and decision-making patterns is important in order to assess mechanisms for disseminating knowledge. Physicians have been found to rely much more on information gathered informally from a variety of resources, including colleagues, patients, and pharmaceutical representatives.17 This information is frequently integrated in developing personal rules of thumb, particularly in situations of uncertainty and time constraint.11 An understanding of learning and decision-making theory will be helpful. A number of participants in the discussion group believed that practice protocols should be assessed as a possible vehicle to disseminate clinical knowledge. Participants with experience in severely resource-restricted settings, in which health care providers often have very limited education, related appreciation of simplicity on the part of the target practitioners. As recently as 2005, a review of the literature addressing the effectiveness of interventions intended to change practitioner behavior in developing countries found 44 articles, only one of which was a systematic review.18 The conclusion in this review, limited to medication use, was that, despite most studies of interventions being of poor design, they did demonstrate beneficial effects of the strategies. The authors noted a strong influence of cultural parameters on the effectiveness of different interventions. Implicit in the discussion of designing the vehicle and the delivery technique for passing on knowledge is an analysis of the learning styles of the target audience. Issues raised in the online discussion reflect those brought forward in the above literature and lead to the following global agenda in this domain. Knowledge Exchange Agenda 1. Emergency medical care developers in a number of countries have had success in influencing policy makers. Developing an understanding of effective strategies to affect policy making in different settings will help facilitate emergency medical care capacity development in more locations. Research Questions 1. What similarities and differences exist in methodologies utilized in different countries and cultures to influence policy and decision-makers?

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One discussion member created an e-mail newsletter of advances and best practices in emergency medical care that evolved into a regularly published journal feature. Research Questions 1. What local initiatives exist for disseminating knowledge and best practices in different settings around the world? 2. What are common characteristics among successful existing information dissemination initiatives? Knowledge Application (Implementation) Application of the knowledge that has been developed will be affected by many of the same factors mentioned previously. The most important aspect of this step is to ensure evaluation of both appropriate utilization of the knowledge and outcomes in terms of the effect on health of the affected population. A review of studies in developed countries that assessed attempts at changing clinician behavior in ‘‘developing countries’’ concluded that despite the demonstrated value of tactics such as ‘‘audit and feedback, educational strategies, opinion leaders, educational outreach, and local consensus development,’’ there was not adequate evidence to arrive at recommendations other than that more high-quality research is needed.17 This underscores the need to apply common strategies in different communities so as to better learn those factors that portend success in implementing evidencebased interventions. Knowledge Application Agenda 1. Evaluation of changes in procedures is a source of new knowledge to improve services in a continuous quality improvement model, but monitoring clinical activities is often a burden on health systems that may already be overwhelmed. Note this description of evaluation of pediatric care at first referral level (district) hospitals in Kenya: .three teams of three to four people working in parallel at separate hospitals conducted the survey. All survey staff were skilled Kenyan health workers trained for 3 weeks in survey procedures, including pilot exercises in one district and one provincial hospital. Surveys took 10 continuous days at every site, spanned a weekend, and included supervision visits by the principal investigator.19 Research Questions 1. What are characteristics of low resource utilization implementation monitoring techniques? 2. Are low resource utilization implementation monitoring techniques valid in the assessment of changes in the emergency care setting?

CONCLUSIONS Knowledge Exchange Agenda 2. Physician groups in some developing settings have developed means of disseminating up-to-date information among themselves.

An international discussion group of experienced physician educators, representing countries at all levels of economic and emergency medical care system development,

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addressed the topic of KT in international emergency medical care. From this discussion, several research agendas were developed that reflect the published literature in the application of KT to general international health development. We present key concepts as a stimulus and introductory guide for further research in the increasingly important agenda of improving international emergency medical care capacity. The recommendations presented are primarily in the domain of knowledge synthesis. This is fitting, in that international emergency medical care is only beginning to develop. While the issue of multicultural variability will apply, the other theme discussions in this consensus document address many of the technical aspects of knowledge exchange and application.

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12. 13.

14. 15. 16.

17. References 1. Knowledge Management and Health. World Health Organization Internet Web Site. Available at: http:// www.who.int/kms/en/. Accessed Apr 28, 2007. 2. Shademani R. The know-do gap: knowledge translation in global health. Paper presented at: Informal Consultation on a Global Network and Database of Public Health Partners. WHO 7-8 Dec 2005, Geneva. Available at: http://www.who.int/kms/events/ ShademaniR_KT-NIPH_PH%20Consultation_8Dec05. pdf. Accessed Mar 23, 2007. 3. Alagappan K, Holliman CJ. History of the development of international emergency medicine. Emerg Med Clin North Am. 2005; 23:1–10. 4. Mulrow CD, Cook DJ, Davidoff F. Systematic reviews: critical links in the great chain of evidence. Ann Intern Med. 1997; 126:389–91. 5. Swingler GH, Volmink J, Ioannidis JPA. Number of published systematic reviews and global burden of disease: database analysis. BMJ. 2003; 327:1083–4. 6. Trouiller P, Olliaro P, Torreele E, Orbinski J, Laing R, Ford N. Drug development for neglected diseases: a deficient market and a public-health policy failure. Lancet. 2002; 359:2188–94. 7. Page J, Heller RF, Kinlay S, et al. Attitudes of developing world physicians to where medical research is performed and reported. BMC Public Health. 2003; 3:6. 8. Global Forum for Health Research. 10/90 Report on Health Research 2001-2002. Geneva: Global Forum for Health Research, 2002. Available at: http:// www.globalforumhealth.org/Site/002__What%20we% 20do/005__Publications/001__10%2090%20reports.php. Accessed Apr 24, 2007. 9. Pang T, Sadana R, Hanney S, Bhutta ZA, Hyder AA, Simon J. Knowledge for better health: a conceptual framework and foundation for health research systems. Bull World Health Org. 2003; 81:815–20. 10. Palmer NA. Polanyi’s concept of tacit knowledge. In: Perkins D, ed. The Tacit Knowledge and Intuition Website. Cambridge Harvard University. Sept 2001. Available at: http://www.gse.harvard.edu/wt656_web/ From_2000-2001_students/Polanyi_Nina.htm. Accessed Apr 12, 2007. 11. Andre M, Borgquist L, Molstad S. Use of rules of thumb in the consultation in general practice—an

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act of balance between the individual and the general perspective. Fam Pract. 2003; 20:514–9. Straus SE, Sackett DL. Using research findings in clinical practice. BMJ. 1998; 317:339–42. Innvaer S, Vist G, Trommald M, Oxman A. Health policy-makers’ perceptions of their use of evidence: a systematic review. J Health Serv Res Policy. 2002; 7:239–44. Bailey C, Pang T. Health information for all by 2015? Lancet. 2004; 364:223–4. Tintinalli J. Personal communication (e-mail). Chapel Hill, NC: May 23, 2007. Garner P, Kale R, Dickson R, Dans T, Salinas R. Getting research findings into practice: implementing research findings in developing countries. BMJ. 1998; 317:531–5. Gabbay J, le May A. Evidence based guidelines or collectively constructed ‘‘mindlines?’’ Ethnographic study of knowledge management in primary care. BMJ. 2004; 329:1013. Siddiqi K, Newell J, Robinson M. Getting evidence into practice: what works in developing countries? Int J Quality Health Care. 2005; 17:447–54. English M, Esamai F, Wasunna A, et al. Delivery of paediatric care at the first-referral level in Kenya. Lancet. 2004; 364:1622–9.

APPENDIX A Members of the International Aspects of Knowledge Translation Discussion Group, Presented in Alphabetical Order, Including Online and Workshop Participants Last Name Al Ansari Allegra Alomran Anantharaman Arnold Bouslough Christopher Corder Fitzpatrick Godoy Hall Halpern Hauswald Huckson Kerr Kobusingye

First Name Nabeel John Hisham V. Kris David Ted Bob Eleanor Daniel Haywood Pinny Mark Sue Nancy L. Olive

Ladner Lewis Malmquist

Heidi Owen Pia

McNeil Molyneux Morabito Rajapakse Ranney Razzak Schafermeyer Venughopal

Mary Ann Elizabeth Gemma Bishan Megan Junaid Bob Raghu

Degrees MD MD MD, MPH MBBS MD, MPH MD MD MD MD MD MD MD MD MD MBChB, MSc, MMed, MPH MD MD MBBS, FRCP, FRCPCH, FCEM, OBE MD MRCPCH, FFAEM MD MB, ChB MD MD, MPH MD MD

Country Bahrain USA Saudi Arabia Singapore USA USA USA USA USA Argentina Mexico Israel USA Australia USA Uganda USA Nepal Sweden

USA Malawi Italy Sri Lanka USA Pakistan USA Canada