Evaluating the East African Point-of-Care Ultrasound (E-POCUS) Training Program Pilot: Lessons Learned and Best Practices

Evaluating the East African Point-of-Care Ultrasound (E-POCUS) Training Program Pilot: Lessons Learned and Best Practices | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Evaluating the East African Point-of-Care Ultrasound (E-POCUS) Training Program Pilot: Lessons Learned and Best Practices Hannah Girdler, Inaya Yousaf, Tigist Worku, Anne Aspler, Temesgen Beyene, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8621713/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background: There is a pressing need for a sustainable, longitudinal point-of-care ultrasound (POCUS) education model that is contextually relevant, locally led, and systematically evaluated in East Africa. The Toronto Addis Ababa Academic Collaboration in Emergency Medicine (TAAAC-EM), a long-standing partnership between the University of Toronto and Addis Ababa University, developed the East African POCUS (E-POCUS) Training Program Pilot. This was a one-year, longitudinal, hybrid advanced training program tailored to local needs and interests. Methods: We used reflexive thematic analysis to conduct a qualitative program evaluation of the E-POCUS training program pilot. E-POCUS participants, staff involved with the execution of the training program, and those participants who had to leave the program were all invited to participate in a semi-structured virtual interview, exploring their perceived impact and opinion of the E-POCUS program. Interview transcripts were analyzed using Braun and Clarke’s reflexive thematic analysis framework. Results: A total of 13 interviews were conducted, representing participants in the E-POCUS program (n = 2), former participants of the E-POCUS program (n = 3), and staff involved in the teaching of the program (n = 8). The analysis highlighted three main themes: 1) time as a limiting factor, 2) expectations versus reality in program delivery, and 3) motivations for participation and the role of accreditation. Conclusion: This study highlighted the value of flexible, longitudinal, and hybrid curriculums in POCUS education. The E-POCUS pilot also illustrated that the hybrid model of education allowed participants to prioritize hands-on skill development teaching during in-person months. Advancing POCUS education in resource-limited settings is critical to improving patient care, and it is important to evaluate efforts at increasing access and education on the topics that are most relevant to their patient population. POCUS ultrasound global health program evaluation training program hybrid partnership Background There is a growing need for accessible imaging modalities in acute care settings. Globally, the World Health Organization estimates that 80–90% of diagnostic problems requiring imaging could be addressed using basic radiography equipment ( 1 , 2 ). Point-of-care ultrasound (POCUS) has emerged as a valuable diagnostic and resuscitative tool to bridge existing gaps in healthcare delivery ( 5 ). Its use has grown in both high- and low-resource settings, with demonstrated benefits including improved diagnostic accuracy, expedited decision-making, improved management of critically ill patients, and earlier diagnosis of conditions such as rheumatic heart disease ( 6 , 7 ). In low-resource settings where formal imaging is limited, POCUS plays an even greater role in emergency medicine (EM) ( 3 , 4 ). One barrier to effective and sustainable adoption of POCUS across low and middle income countries (LMICs) is a lack of standardized training programs ( 5 ). While there has been an increase in medical education programs that offer POCUS training across East Africa over the past decade, there is currently no formalized model for POCUS education delivery. Most programs remain short-term, typically lasting one to two weeks, and are primarily led by visiting international instructors ( 5 , 8 ). Only a handful of longitudinal programs have spanned more than one year ( 5 , 9 – 12 ). Program evaluation is also not standardized. Most existing POCUS programs across East Africa evaluate their outcomes using short-term educational metrics, such as pre- and post-training knowledge tests. Few studies have measured trainees’ confidence or satisfaction, and fewer have assessed long-term knowledge retention or the impact on patient-centered outcomes. The Toronto Addis Ababa Academic Collaboration in EM (TAAAC-EM) is a long-standing partnership between the University of Toronto and Addis Ababa University that has supported EM capacity building in Ethiopia for over a decade, including the establishment of the country’s first EM and Critical Care residency at Tikur Anbessa Specialized Hospital ( 4 , 13 ). Building on this foundation, TAAAC-EM launched the East African POCUS (E-POCUS) program in 2022 to train local staff emergency physicians ( 13 ). The program was originally designed as a one-year longitudinal fellowship with four consecutive months of in-person training followed by eight months of hybrid education incorporating mentorship, journal clubs, research, and quality assurance (QA). In early 2023, regional instability and institutional risk-management decisions necessitated suspension of planned in-person activities and discontinuation of the original structure. To preserve core educational objectives while addressing feasibility and safety constraints, the program was redesigned as a flexible hybrid model consisting of four non-consecutive in-person scanning intensive months (IPSIMs) held in February 2024, May 2024, November 2024, and February 2025, during which Canadian POCUS faculty travelled to Addis Ababa to deliver new curricular content and provide supervised hands-on scanning. Between IPSIM, participants were encouraged to continue independent scanning and upload studies for QA review. These off-site periods focused on skill consolidation and included virtual academic sessions, journal clubs, remote QA review, and tele-mentorship. A detailed description of the final program design is provided in Appendix 1. Delivery of this training program required the recruitment of eight Canadian POCUS experts who travelled to Addis Ababa to deliver the hands-on component of the curriculum. During these trips, we were able to provide 75 hours of dedicated one-on-one supervised scanning and teaching for our learners. Learners were required to keep detailed logs including the types of scans they recorded during these sessions, which have been categorized into common POCUS domains as defined by the International Federation on Emergency Medicine, and can be found in Table 1 ( 14 ). Table 1 Total Combined Scans Logged During the E-POCUS Pilot POCUS Domain Examples included n % Focused Cardiac Ultrasound TTE views, RV/LV function, TAPSE, MAPSE, EPSS, VTI, LVCO, Simpson’s biplane, valvular assessment (MR/TR/AR), colour Doppler, tamponade, CHF 185 43.0 Thoracic Ultrasound Pleural effusion, pulmonary edema, consolidation, pneumothorax, BLUE protocol 78 18.1 Inferior Vena Cava / Hemodynamic Assessment IVC assessment (standalone or integrated), VEXUS components 52 12.1 Abdominal & FAST Ultrasound FAST, ascites, appendicitis, bowel obstruction, gallbladder, CBD, renal, bladder, aorta, spleen, hepatic 64 14.9 Vascular Ultrasound Upper/lower extremity DVT, arterial Doppler, augmentation 19 4.4 Musculoskeletal & Soft Tissue Ultrasound Fractures, joint effusions, tendon injuries, abscess vs soft tissue infection, cellulitis, peripheral nerve, nerve blocks 32 7.4 Ocular Ultrasound Optic nerve sheath diameter, retinal pathology, globe pathology 11 2.6 Obstetric & Genitourinary Ultrasound Pregnancy, ectopic pregnancy, fetal heart rate, placenta position, testes 6 1.4 Procedural Ultrasound LP landmarking, intubation confirmation 3 0.7 Total 430 While several components of the program were successfully implemented, certain components, such as journal club and QA sessions, were more difficult to implement as planned. Ultimately, the E-POCUS pilot evolved and adapted in response to unprecedented systemic challenges and changing local needs, while working towards its larger program objectives of providing advanced POCUS training. The E-POCUS program sought to build a curriculum rooted in relational principles of partnership through co-development with Ethiopian faculty. These principles led to a qualitative review of the pilot program. Methods Study design This qualitative program evaluation utilized inductive thematic analysis to understand the perceived impact of the E-POCUS pilot training program by those involved in the program. As a hybrid training program, participants were located in Addis Ababa, Ethiopia, and across Canada. Ethics approval was obtained through the University of Toronto’s Review Ethics Board (RIS Human Protocol Number 48160) and Addis Ababa University’s Institutional Review Board (006/25/EM). The study was conducted in accordance with the Declaration of Helsinki. Participant recruitment Participants were recruited from the three distinct populations involved in the E-POCUS training program. Group one (G1) represents those who are involved in the E-POCUS training program as participants, working towards completing the program. Group two (G2) is the staff involved in the execution and teaching within the program (e.g., physicians and residents). Group three (G3) is those who had originally committed to participating in the E-POCUS program but left the program. Interviews were conducted until saturation was reached. Data collection Participants were contacted via email and invited to participate in a semi-structured interview. A consent information sheet was shared in advance via email, and then informed verbal consent was confirmed at the start of each interview. Interview guides and the timing of when participants were invited to interview varied slightly depending on which group the participant represented (Appendix 2). G1 participants were invited to complete an interview after they completed the program. The interviews collected information on self-perceived POCUS knowledge and comfort over time, as well as solicited feedback on the program. G2 participants were invited to participate in an interview following the completion of their core work with the E-POCUS program (e.g., traveling to Ethiopia to teach the E-POCUS participants). The interview questions addressed the design of the program content and the perceived value of the program. G3 participants were invited to participate in an interview to better understand barriers to participation, perceived benefits of participating, and questions related to the content, structure, and local relevance of the curriculum. These interviews took place towards the end of the E-POCUS pilot program. All interviews were completed virtually using Zoom by a program manager involved with the E-POCUS program (HG). They were recorded with permission and transcribed verbatim using an AI-transcription software (Sonix AI). Data analysis Braun and Clarke’s six-step reflexive thematic analysis framework was used in this study ( 15 , 16 ). Before coding, transcripts were reviewed for accuracy and then anonymised. Inductive coding was undertaken by the lead reviewer (IY), who was able to iteratively develop initial codes. The transcripts were then coded by a second reviewer (HG), who, with their experience involved in the E-POCUS program, worked with the lead reviewer to develop initial themes. Frequent discussions with the larger research team were important in refining preliminary themes, as well as in practicing reflexivity throughout the process to ensure the perspectives of both reviewers were captured. Results A total of 13 interviews were conducted. This included two (out of a possible two) participants from G1, eight (out of a possible nine participants) from G2, and three (out of a possible five) participants from G3. Interviews ranged from 18 to 35 minutes in length. The analysis highlighted three main themes: 1) time as a limiting factor, 2) expectations versus reality in program delivery, and 3) motivations for participation and the potential value of accreditation. Theme 1: Time as a limiting factor to meeting program objectives This theme was first expressed in terms of time commitment for E-POCUS program participants. The impact of competing priorities was clear across all interviews. With no protected time allocated to complete the requirements of the training program, it became difficult to meet the agreed-upon curriculum expectations. One participant stated (G2-2), “there is a time imbalance to do all the skills … like there was a target number of scans that we were supposed to do, but most of us, me and [other participant] were not able to achieve that [original] target number of scans." It was also clear across all interviews that this was not for a lack of trying, but the realities of participants and former participants having multiple roles (clinical, educational and administrative), working at multiple sites (public and private) and commitments outside of work. One former participant (G3-3) highlighted this, stating that “there were a lot of secondary mini reasons, like life changes, commitments in my life, like my kids and everything” that impacted participation in the program, especially when coupled with the change in the program timeline and structure. Time as a limiting factor was also discussed around the actual execution and teaching of the training program. IPSIM involved staff traveling to Addis Ababa for four weeks at a time. It was often identified that building rapport with trainees takes time; however, teaching staff had limited time to execute teaching goals impacting the experience and how much they were able to share. Similarly, the inconsistent and sometimes limited availability of E-POCUS participants made it challenging to schedule sessions in advance, affecting the ability to progress through the curriculum. One teaching staff (G1-4) highlighted this by stating, “it's hard to get time dedicated to just scanning... just like working around the schedules where it was difficult and then, you know, you're only there for four weeks and so, of the four weeks, five days of the week, that's only like 20 days." This structure also made it more difficult for the teaching staff to appreciate much of an impact they were making. Theme 2: Expectations versus reality - Operationalizing hybrid curriculum delivery in limited resource settings While the E-POCUS training program pilot was co-developed and co-designed, the interviews highlighted multiple areas in which expectations were different compared to how the program evolved. The first area where this was evident was around technology. An identified positive of the E-POCUS pilot was the ability to purchase portable ultrasounds to facilitate scanning. An ultrasound specific to E-POCUS is important because access to ultrasounds in the clinical space is limited by demand, availability, and if devices are working properly. However, potential benefits were complicated by local realities. For example, one participant identified “the [portable ultrasound] was very selective with the cell phone type, which I didn’t have anymore,” limiting the ability of participants to complete their scans independently. With inconsistent scanning taking place outside of IPSIM, this also limited the uptake of QA for unsupervised scans. One participant identified (G1-1), “ from a QA component, we were hoping to set up a remote system, and it never really materialized, despite there being a fair bit of work to see if we could set up systems in the country and in the hospital setting." Another area identified by interview participants was the ways in which the expectations around the training program changed over time, specifically the prioritization of certain components. The importance of maximizing time in-person was invaluable, emphasized by this quote from a teaching staff (G1-2), “... and so like much of that, like the didactic teaching and in-person scanning just fit so well culturally with academic emergency medicine there.” However, even the successes were limited by patient availability within the emergency department. For example, another teaching staff member highlighted this limitation (G1-4): “Because we were really only scanning during rounds, it was dependent on which patients were in the department for what kind of scans they would get. In terms of them being able to get a certain number of scans, it wasn't always guaranteed.” Additionally, while in-person activities were identified as successes, other components were less so. One participant (G2-1) identified that, “the journal club aspect often had conflicts due to overlapping schedules, that’s again one area we have faced difficulty, but at least the two journals I have presented really helped me.” Many participants felt different components, such as journal club and QA were important. However, with limited time for both residents and teaching staff, the supervised scanning was consciously prioritized and was emphasized by all participants as the most valuable part of the training program. Theme 3: Skill development and the impact of no accreditation Another theme that emerged through the interviews revolved around the motivations for advanced POCUS teaching and learning. For all interviewees, the importance of POCUS skill development was the driving factor to participate. The importance of advancing POCUS skills was multifaceted, and included 1) wanting to have greater POCUS skills to teach trainees, 2) improving patient care within low-resource settings, and 3) for ongoing continuing professional development as a staff. This idea is captured by an E-POCUS participant (G2-1), who stated, “ultimately, I joined the E-POCUS training program as a faculty to advance the teaching in POCUS for our specialty trainees as well as for the faculty and also for the patient benefit." The importance of POCUS within Ethiopia was also emphasized by participants. For example, one participant (G2-2) stated, "[The E-POCUS program is] going to have a big impact on patient outcomes because we're working in a resource-limited setup, where we cannot have portable X-ray, where we cannot have cardiologists at hand." Participants and former participants were also asked whether this program being an accredited POCUS fellowship would have impacted their participation. For the vast majority, accreditation, or the lack thereof, did not impact their participation. However, what accreditation could offer was consistently emphasized, whether it was identified through direct questions regarding accreditation or indirectly when discussing other barriers. There were many advantages of accreditation of a formal POCUS program that were discussed, which include: protected time to undertake the different components of the program, recognition for career advancement, interdisciplinary collaboration, and the perceived benefits of accreditation for future learning. "There should be dedicated time for the trainee, as well as for the trainer to have a more focused training, free of time, to have more skill to do more skill, to have more time to scan, and then organized curriculum" was shared by a participant (G2-2), which emphasized that while participants identified that they would participate in the E-POCUS training program regardless of whether it was accredited, being accredited would help alleviate many of the issues around program execution raised across interviews. Discussion This study explored the implementation of the E-POCUS training program, the first hybrid advanced POCUS training program in Ethiopia. Three primary themes were identified. First, time was the fundamental limiting factor for both learners and faculty. Second, there was a disparity between the program’s design and its execution in a resource-limited setting. Both of these themes connect to the third theme, which identified that participants were primarily motivated by the desire for skill development and improved patient care rather than formal credentials. These findings have multiple implications within the context of existing research. For one, there is a lack of reporting on both longitudinal and hybrid POCUS education initiatives. While the literature illustrated that shorter drop-in style POCUS workshops were the norm, we believed that a full-year program could help fill the identified gaps that emerged in evaluations of these programs ( 5 , 8 , 17 , 18 ). Leveraging the TAAAC-EM partnership, we felt that it would be possible to co-develop a longitudinal, hybrid training program, and we were successful in launching this pilot in practice. What we learned throughout this pilot was that longitudinal programs are valuable for enhancing POCUS skills and leadership amongst physicians. However, to fully benefit from this longitudinal E-POCUS pilot, future program development should focus on additional flexibility for participants. This is especially important in the context of programs that are not institutionally approved programs, but rather exist within global health partnerships. Having a long-standing relationship was critical in being able to iteratively adjust the curriculum to ensure needs were being met and the training program was beneficial to all who participated (teachers and participants). Future research comparing longitudinal and short-term POCUS teaching, specifically research focused on skill acquisition, will help guide the development of future POCUS education programs in LMICs. Current literature consistently highlights a tension between the clinical value of POCUS education and significant structural barriers in low-resource settings ( 5 ). In our study, the motivation for skill development, driven by the desire to improve patient care, mirrors findings from a longitudinal program in Zambia, where residents perceived POCUS as a meaningful adjunctive tool in narrowing differential diagnoses and altering medical management ( 11 ). Time was also a limiting factor for learners across various POCUS programs. A program in Kenya found that despite a well-designed longitudinal curriculum, participants fell short of scan targets due to an already full medical education curriculum ( 9 ). The impact of competing administrative and clinical roles was also apparent in Uganda, where high patient volumes and staffing shortages affected the advancement of nearly half of the trainees ( 8 ). These similarities suggest that barriers to POCUS education in Ethiopia reflect a broader implementation gap in global health medical education, often due to a lack of protected academic time ( 5 , 19 ). The difficulty in establishing a remote QA system in our study reflects another systemic challenge in low-resource settings, where infrastructure often prevents longitudinal evaluation ( 5 ). Our findings, alongside others, demonstrated that even with access to portable technology, infrastructure barriers such as inconsistent internet and incompatible technology create an operational gap that limits virtual hybrid education delivery, especially for skills-based education such as POCUS ( 9 ). These findings also illustrated that the consistency of learning opportunities was important and that program participants prioritized longitudinal hands-on training over accreditation ( 5 , 9 , 20 ). Having the teaching staff join participants during their shifts so that they could learn while working was critical to relationship building and cross-cultural knowledge sharing ( 5 ). Throughout the program, the emphasis was on more time for ultrasound scanning, and, in response to participant feedback, that is what was provided. They were able to ask about types of scans that were taught by previous instructors and were able to continually refine their skills without needing to take time off work or spend large amounts of money to access specialized training, which is difficult to obtain locally. While a formal accredited POCUS fellowship would have allowed protected time, participants chose to take on this additional unaccredited POCUS training, demonstrating their commitment to improving teaching and patient outcomes. However, the role and impact that a formal EM POCUS fellowship in Ethiopia could have on developing future POCUS leaders within the region, cannot be understated. This program evaluation was done internally, and so many members of the E-POCUS administrative team were also involved in the research activities (as researchers and participants). While this is in line with the ethos of the TAAAC-EM collaboration, it does introduce the possibility that participants may not have felt comfortable disclosing their feelings in the interviews. Additionally, while the coders worked together with an emphasis on reflexivity, there was a risk of bias. We chose a qualitative approach to program evaluation to understand and contextualize participants’ expectations and concerns about the E-POCUS pilot. Open-ended interviews ensured that we, as program evaluators in Canada, provide space for participants to speak to local and region-specific needs. During the E-POCUS pilot, while faculty in Addis co-developed a locally-relevant curriculum, it is important to be cognizant of how Canadian and institution-specific practices may influence curriculum development. Other limitations include that the evaluation focused only on perceptions, and not actually on POCUS skills acquisition or maintenance, and these interviews were conducted at the end of the interview participants' involvement in the program. Finally, while all participants are proficient in English, it is not their first language, and they would have had to translate their opinions in order to answer the questions. Conclusions This research illustrates that longitudinal POCUS training that utilizes hybrid learning is difficult to execute, but with time and a tailored curriculum that meets participants where they are (time, schedule, specific wants and needs), it can be beneficial to ensuring participants meet their goals. While accreditation is not a requirement for teaching POCUS, it does have the potential to alleviate multiple barriers faced by participants and former participants. Advancing POCUS education in resource-limited settings is essential to improving patient outcomes, and systematic evaluation of initiatives designed to expand access and training in areas most relevant to local patient populations is critical. In our experience, the E-POCUS program illustrated the value of flexible, longitudinal, and hybrid curricula in POCUS education, and underscores the importance of adaptability in global health partnership-based curricula. Abbreviations East African Point-of-Care Ultrasound (E-POCUS) Emergency Medicine (EM) In-person scanning intensive months (IPSIM) Low and middle income countries (LMICs) Point-of-Care Ultrasound (POCUS) TAAAC: Toronto Addis Ababa Academic Collaboration TAAAC-EM: Toronto Addis Ababa Academic Collaboration in Emergency Medicine Declarations Ethics approval and consent to participate: This study received Research Ethics Board approval from the University of Toronto (RIS Human Protocol Number 48160) and received Institutional Review Board approval from Addis Ababa University (006/25/EM). Consent for publication: N/A Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests: The authors declare no conflicts of interest. Funding: This E-POCUS Training Program Pilot was funded by the Royal College of Physicians and Surgeons of Canada International Development, Aid and Collaboration Grant, however the evaluation was funded through core TAAAC-EM funding. Authors' contributions: HG, TZ, TB and IS conceptualized and designed the study. HG collected the data. HG and IY analyzed and interpreted the data. HG and IY drafted the manuscript and all authors critically reviewed it. All authors approved the final manuscript. Acknowledgements: The authors would like to thank the leadership team at TAAAC-EM in Toronto, as well as the leadership at Addis Ababa University, for their work in maintaining this longitudinal collaboration. The authors would also like to thank all of those who volunteered their time to support the development and execution of the E-POCUS training program, including Dr. Michelle Lee, Dr. Alexandra Stefan and Dr. Julia Wytsma. References Omofoye TS. 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Supplementary Files Appendix1EPOCUSTrainingProgramOrientationManual.docx Appendix2EPOCUSInterviewGuides.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 07 May, 2026 Reviewers agreed at journal 23 Apr, 2026 Reviews received at journal 12 Mar, 2026 Reviewers agreed at journal 28 Feb, 2026 Reviewers agreed at journal 26 Feb, 2026 Reviewers invited by journal 09 Feb, 2026 Editor assigned by journal 21 Jan, 2026 Submission checks completed at journal 21 Jan, 2026 First submitted to journal 16 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8621713","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":588624455,"identity":"2f01afa8-df71-44bb-8b82-6742b40f927e","order_by":0,"name":"Hannah Girdler","email":"","orcid":"","institution":"The Centre for Global Equity in Emergency Medicine","correspondingAuthor":false,"prefix":"","firstName":"Hannah","middleName":"","lastName":"Girdler","suffix":""},{"id":588624458,"identity":"bebc91a6-9eb5-4cd4-a34d-fb4c16eab03e","order_by":1,"name":"Inaya Yousaf","email":"","orcid":"","institution":"University of Toronto","correspondingAuthor":false,"prefix":"","firstName":"Inaya","middleName":"","lastName":"Yousaf","suffix":""},{"id":588624465,"identity":"f5f047f9-74e9-48c0-a1e2-4b57b81ee575","order_by":2,"name":"Tigist Worku","email":"","orcid":"","institution":"Addis Ababa University","correspondingAuthor":false,"prefix":"","firstName":"Tigist","middleName":"","lastName":"Worku","suffix":""},{"id":588624472,"identity":"a9a71006-0832-479e-85f2-651294e9669e","order_by":3,"name":"Anne Aspler","email":"","orcid":"","institution":"University of Toronto","correspondingAuthor":false,"prefix":"","firstName":"Anne","middleName":"","lastName":"Aspler","suffix":""},{"id":588624473,"identity":"b1e47b68-53ec-4f15-bfc0-0c117e27bcff","order_by":4,"name":"Temesgen Beyene","email":"","orcid":"","institution":"Addis Ababa University","correspondingAuthor":false,"prefix":"","firstName":"Temesgen","middleName":"","lastName":"Beyene","suffix":""},{"id":588624475,"identity":"006a8003-141d-4c4c-a6d1-b555a6bbe66b","order_by":5,"name":"Tigist Zewdu","email":"","orcid":"","institution":"Addis Ababa University","correspondingAuthor":false,"prefix":"","firstName":"Tigist","middleName":"","lastName":"Zewdu","suffix":""},{"id":588624485,"identity":"6cd79d21-4761-4a1e-b9af-cc32d26ecb89","order_by":6,"name":"Inderjeet Sahota","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0ElEQVRIiWNgGAWjYBACNiBmBjH4SdViwCDZANbJIEGUNrAWgwPEauFjYH/4uaDij7zxjfyDjysq7tTxMzA//IDfYTzG0jPOGBhuu5HMbHjmzDMJyQY2Y7xWAbUwSPO2GTACtbBJNrYdljA4wIPfdWwM7I9/A7XYb56B0ML8A78WBjOQLYkbJBBa2PDbwsxjZs1zxjh5xpnHxoYNZw5LzmxmM7PAp0W+vf3xbZ4KOdv+9sSHDxsqDvPzszc/voFPCyTqCYiMglEwCkbBKCAVAADBoj0OnkZIBwAAAABJRU5ErkJggg==","orcid":"","institution":"University of Toronto","correspondingAuthor":true,"prefix":"","firstName":"Inderjeet","middleName":"","lastName":"Sahota","suffix":""}],"badges":[],"createdAt":"2026-01-16 19:08:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8621713/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8621713/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102397910,"identity":"5b775568-6a80-4e71-a48e-41521ecc6b95","added_by":"auto","created_at":"2026-02-11 10:20:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":670686,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8621713/v1/39a0093a-78df-445d-bae9-5d24fa03d4d7.pdf"},{"id":102391283,"identity":"016e6f3a-73d4-4b11-bb08-ea291f25c2e9","added_by":"auto","created_at":"2026-02-11 08:49:05","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":387345,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix1EPOCUSTrainingProgramOrientationManual.docx","url":"https://assets-eu.researchsquare.com/files/rs-8621713/v1/3643b015ff8612ba974d7c1e.docx"},{"id":102391281,"identity":"0e9d9b11-4fa1-4c8b-9fde-2efcee9ad861","added_by":"auto","created_at":"2026-02-11 08:49:05","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":9982,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix2EPOCUSInterviewGuides.docx","url":"https://assets-eu.researchsquare.com/files/rs-8621713/v1/e343a1ddf63e2fe34833a453.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Evaluating the East African Point-of-Care Ultrasound (E-POCUS) Training Program Pilot: Lessons Learned and Best Practices","fulltext":[{"header":"Background","content":"\u003cp\u003eThere is a growing need for accessible imaging modalities in acute care settings. Globally, the World Health Organization estimates that 80\u0026ndash;90% of diagnostic problems requiring imaging could be addressed using basic radiography equipment (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Point-of-care ultrasound (POCUS) has emerged as a valuable diagnostic and resuscitative tool to bridge existing gaps in healthcare delivery (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Its use has grown in both high- and low-resource settings, with demonstrated benefits including improved diagnostic accuracy, expedited decision-making, improved management of critically ill patients, and earlier diagnosis of conditions such as rheumatic heart disease (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). In low-resource settings where formal imaging is limited, POCUS plays an even greater role in emergency medicine (EM) (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOne barrier to effective and sustainable adoption of POCUS across low and middle income countries (LMICs) is a lack of standardized training programs (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). While there has been an increase in medical education programs that offer POCUS training across East Africa over the past decade, there is currently no formalized model for POCUS education delivery. Most programs remain short-term, typically lasting one to two weeks, and are primarily led by visiting international instructors (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Only a handful of longitudinal programs have spanned more than one year (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan additionalcitationids=\"CR10 CR11\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Program evaluation is also not standardized. Most existing POCUS programs across East Africa evaluate their outcomes using short-term educational metrics, such as pre- and post-training knowledge tests. Few studies have measured trainees\u0026rsquo; confidence or satisfaction, and fewer have assessed long-term knowledge retention or the impact on patient-centered outcomes.\u003c/p\u003e \u003cp\u003eThe Toronto Addis Ababa Academic Collaboration in EM (TAAAC-EM) is a long-standing partnership between the University of Toronto and Addis Ababa University that has supported EM capacity building in Ethiopia for over a decade, including the establishment of the country\u0026rsquo;s first EM and Critical Care residency at Tikur Anbessa Specialized Hospital (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Building on this foundation, TAAAC-EM launched the East African POCUS (E-POCUS) program in 2022 to train local staff emergency physicians (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The program was originally designed as a one-year longitudinal fellowship with four consecutive months of in-person training followed by eight months of hybrid education incorporating mentorship, journal clubs, research, and quality assurance (QA). In early 2023, regional instability and institutional risk-management decisions necessitated suspension of planned in-person activities and discontinuation of the original structure. To preserve core educational objectives while addressing feasibility and safety constraints, the program was redesigned as a flexible hybrid model consisting of four non-consecutive in-person scanning intensive months (IPSIMs) held in February 2024, May 2024, November 2024, and February 2025, during which Canadian POCUS faculty travelled to Addis Ababa to deliver new curricular content and provide supervised hands-on scanning. Between IPSIM, participants were encouraged to continue independent scanning and upload studies for QA review. These off-site periods focused on skill consolidation and included virtual academic sessions, journal clubs, remote QA review, and tele-mentorship. A detailed description of the final program design is provided in Appendix 1.\u003c/p\u003e \u003cp\u003eDelivery of this training program required the recruitment of eight Canadian POCUS experts who travelled to Addis Ababa to deliver the hands-on component of the curriculum. During these trips, we were able to provide 75 hours of dedicated one-on-one supervised scanning and teaching for our learners. Learners were required to keep detailed logs including the types of scans they recorded during these sessions, which have been categorized into common POCUS domains as defined by the International Federation on Emergency Medicine, and can be found in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTotal Combined Scans Logged During the E-POCUS Pilot\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePOCUS Domain\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eExamples included\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e%\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFocused Cardiac Ultrasound\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eTTE views, RV/LV function, TAPSE, MAPSE, EPSS, VTI, LVCO, Simpson\u0026rsquo;s biplane, valvular assessment (MR/TR/AR), colour Doppler, tamponade, CHF\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e185\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e43.0\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eThoracic Ultrasound\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003ePleural effusion, pulmonary edema, consolidation, pneumothorax, BLUE protocol\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e78\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e18.1\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInferior Vena Cava / Hemodynamic Assessment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eIVC assessment (standalone or integrated), VEXUS components\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e52\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e12.1\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAbdominal \u0026amp; FAST Ultrasound\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eFAST, ascites, appendicitis, bowel obstruction, gallbladder, CBD, renal, bladder, aorta, spleen, hepatic\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e64\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e14.9\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVascular Ultrasound\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eUpper/lower extremity DVT, arterial Doppler, augmentation\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e19\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e4.4\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMusculoskeletal \u0026amp; Soft Tissue Ultrasound\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eFractures, joint effusions, tendon injuries, abscess vs soft tissue infection, cellulitis, peripheral nerve, nerve blocks\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e32\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e7.4\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOcular Ultrasound\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eOptic nerve sheath diameter, retinal pathology, globe pathology\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e11\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e2.6\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eObstetric \u0026amp; Genitourinary Ultrasound\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003ePregnancy, ectopic pregnancy, fetal heart rate, placenta position, testes\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e6\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e1.4\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProcedural Ultrasound\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eLP landmarking, intubation confirmation\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e3\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0.7\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e430\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWhile several components of the program were successfully implemented, certain components, such as journal club and QA sessions, were more difficult to implement as planned. Ultimately, the E-POCUS pilot evolved and adapted in response to unprecedented systemic challenges and changing local needs, while working towards its larger program objectives of providing advanced POCUS training. The E-POCUS program sought to build a curriculum rooted in relational principles of partnership through co-development with Ethiopian faculty. These principles led to a qualitative review of the pilot program.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eThis qualitative program evaluation utilized inductive thematic analysis to understand the perceived impact of the E-POCUS pilot training program by those involved in the program. As a hybrid training program, participants were located in Addis Ababa, Ethiopia, and across Canada. Ethics approval was obtained through the University of Toronto\u0026rsquo;s Review Ethics Board (RIS Human Protocol Number 48160) and Addis Ababa University\u0026rsquo;s Institutional Review Board (006/25/EM). The study was conducted in accordance with the Declaration of Helsinki.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipant recruitment\u003c/h3\u003e\n\u003cp\u003eParticipants were recruited from the three distinct populations involved in the E-POCUS training program. Group one (G1) represents those who are involved in the E-POCUS training program as participants, working towards completing the program. Group two (G2) is the staff involved in the execution and teaching within the program (e.g., physicians and residents). Group three (G3) is those who had originally committed to participating in the E-POCUS program but left the program. Interviews were conducted until saturation was reached.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003e Participants were contacted via email and invited to participate in a semi-structured interview. A consent information sheet was shared in advance via email, and then informed verbal consent was confirmed at the start of each interview. Interview guides and the timing of when participants were invited to interview varied slightly depending on which group the participant represented (Appendix 2).\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eG1 participants were invited to complete an interview after they completed the program. The interviews collected information on self-perceived POCUS knowledge and comfort over time, as well as solicited feedback on the program.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eG2 participants were invited to participate in an interview following the completion of their core work with the E-POCUS program (e.g., traveling to Ethiopia to teach the E-POCUS participants). The interview questions addressed the design of the program content and the perceived value of the program.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eG3 participants were invited to participate in an interview to better understand barriers to participation, perceived benefits of participating, and questions related to the content, structure, and local relevance of the curriculum. These interviews took place towards the end of the E-POCUS pilot program.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eAll interviews were completed virtually using Zoom by a program manager involved with the E-POCUS program (HG). They were recorded with permission and transcribed verbatim using an AI-transcription software (Sonix AI).\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eBraun and Clarke\u0026rsquo;s six-step reflexive thematic analysis framework was used in this study (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Before coding, transcripts were reviewed for accuracy and then anonymised. Inductive coding was undertaken by the lead reviewer (IY), who was able to iteratively develop initial codes. The transcripts were then coded by a second reviewer (HG), who, with their experience involved in the E-POCUS program, worked with the lead reviewer to develop initial themes. Frequent discussions with the larger research team were important in refining preliminary themes, as well as in practicing reflexivity throughout the process to ensure the perspectives of both reviewers were captured.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 13 interviews were conducted. This included two (out of a possible two) participants from G1, eight (out of a possible nine participants) from G2, and three (out of a possible five) participants from G3. Interviews ranged from 18 to 35 minutes in length. The analysis highlighted three main themes: 1) time as a limiting factor, 2) expectations versus reality in program delivery, and 3) motivations for participation and the potential value of accreditation.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eTheme 1: Time as a limiting factor to meeting program objectives\u003c/h2\u003e \u003cp\u003eThis theme was first expressed in terms of time commitment for E-POCUS program participants. The impact of competing priorities was clear across all interviews. With no protected time allocated to complete the requirements of the training program, it became difficult to meet the agreed-upon curriculum expectations. One participant stated (G2-2), \u003cem\u003e\u0026ldquo;there is a time imbalance to do all the skills \u0026hellip; like there was a target number of scans that we were supposed to do, but most of us, me and [other participant] were not able to achieve that [original] target number of scans.\"\u003c/em\u003e It was also clear across all interviews that this was not for a lack of trying, but the realities of participants and former participants having multiple roles (clinical, educational and administrative), working at multiple sites (public and private) and commitments outside of work. One former participant (G3-3) highlighted this, stating that \u003cem\u003e\u0026ldquo;there were a lot of secondary mini reasons, like life changes, commitments in my life, like my kids and everything\u0026rdquo;\u003c/em\u003e that impacted participation in the program, especially when coupled with the change in the program timeline and structure.\u003c/p\u003e \u003cp\u003eTime as a limiting factor was also discussed around the actual execution and teaching of the training program. IPSIM involved staff traveling to Addis Ababa for four weeks at a time. It was often identified that building rapport with trainees takes time; however, teaching staff had limited time to execute teaching goals impacting the experience and how much they were able to share. Similarly, the inconsistent and sometimes limited availability of E-POCUS participants made it challenging to schedule sessions in advance, affecting the ability to progress through the curriculum. One teaching staff (G1-4) highlighted this by stating, \u003cem\u003e\u0026ldquo;it's hard to get time dedicated to just scanning... just like working around the schedules where it was difficult and then, you know, you're only there for four weeks and so, of the four weeks, five days of the week, that's only like 20 days.\"\u003c/em\u003e This structure also made it more difficult for the teaching staff to appreciate much of an impact they were making.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eTheme 2: Expectations versus reality - Operationalizing hybrid curriculum delivery in limited resource settings\u003c/h3\u003e\n\u003cp\u003eWhile the E-POCUS training program pilot was co-developed and co-designed, the interviews highlighted multiple areas in which expectations were different compared to how the program evolved. The first area where this was evident was around technology. An identified positive of the E-POCUS pilot was the ability to purchase portable ultrasounds to facilitate scanning. An ultrasound specific to E-POCUS is important because access to ultrasounds in the clinical space is limited by demand, availability, and if devices are working properly. However, potential benefits were complicated by local realities. For example, one participant identified \u003cem\u003e\u0026ldquo;the [portable ultrasound] was very selective with the cell phone type, which I didn\u0026rsquo;t have anymore,\u0026rdquo;\u003c/em\u003e limiting the ability of participants to complete their scans independently. With inconsistent scanning taking place outside of IPSIM, this also limited the uptake of QA for unsupervised scans. One participant identified (G1-1), \u0026ldquo;\u003cem\u003efrom a QA component, we were hoping to set up a remote system, and it never really materialized, despite there being a fair bit of work to see if we could set up systems in the country and in the hospital setting.\"\u003c/em\u003e\u003c/p\u003e \u003cp\u003e Another area identified by interview participants was the ways in which the expectations around the training program changed over time, specifically the prioritization of certain components. The importance of maximizing time in-person was invaluable, emphasized by this quote from a teaching staff (G1-2), \u0026ldquo;...\u003cem\u003eand so like much of that, like the didactic teaching and in-person scanning just fit so well culturally with academic emergency medicine there.\u0026rdquo;\u003c/em\u003e However, even the successes were limited by patient availability within the emergency department. For example, another teaching staff member highlighted this limitation (G1-4): \u003cem\u003e\u0026ldquo;Because we were really only scanning during rounds, it was dependent on which patients were in the department for what kind of scans they would get. In terms of them being able to get a certain number of scans, it wasn't always guaranteed.\u0026rdquo;\u003c/em\u003e Additionally, while in-person activities were identified as successes, other components were less so. One participant (G2-1) identified that, \u003cem\u003e\u0026ldquo;the journal club aspect often had conflicts due to overlapping schedules, that\u0026rsquo;s again one area we have faced difficulty, but at least the two journals I have presented really helped me.\u0026rdquo;\u003c/em\u003e Many participants felt different components, such as journal club and QA were important. However, with limited time for both residents and teaching staff, the supervised scanning was consciously prioritized and was emphasized by all participants as the most valuable part of the training program.\u003c/p\u003e\n\u003ch3\u003eTheme 3: Skill development and the impact of no accreditation\u003c/h3\u003e\n\u003cp\u003eAnother theme that emerged through the interviews revolved around the motivations for advanced POCUS teaching and learning. For all interviewees, the importance of POCUS skill development was the driving factor to participate. The importance of advancing POCUS skills was multifaceted, and included 1) wanting to have greater POCUS skills to teach trainees, 2) improving patient care within low-resource settings, and 3) for ongoing continuing professional development as a staff. This idea is captured by an E-POCUS participant (G2-1), who stated, \u003cem\u003e\u0026ldquo;ultimately, I joined the E-POCUS training program as a faculty to advance the teaching in POCUS for our specialty trainees as well as for the faculty and also for the patient benefit.\"\u003c/em\u003e The importance of POCUS within Ethiopia was also emphasized by participants. For example, one participant (G2-2) stated, \u003cem\u003e\"[The E-POCUS program is] going to have a big impact on patient outcomes because we're working in a resource-limited setup, where we cannot have portable X-ray, where we cannot have cardiologists at hand.\"\u003c/em\u003e\u003c/p\u003e \u003cp\u003eParticipants and former participants were also asked whether this program being an accredited POCUS fellowship would have impacted their participation. For the vast majority, accreditation, or the lack thereof, did not impact their participation. However, what accreditation could offer was consistently emphasized, whether it was identified through direct questions regarding accreditation or indirectly when discussing other barriers. There were many advantages of accreditation of a formal POCUS program that were discussed, which include: protected time to undertake the different components of the program, recognition for career advancement, interdisciplinary collaboration, and the perceived benefits of accreditation for future learning. \u003cem\u003e\"There should be dedicated time for the trainee, as well as for the trainer to have a more focused training, free of time, to have more skill to do more skill, to have more time to scan, and then organized curriculum\"\u003c/em\u003e was shared by a participant (G2-2), which emphasized that while participants identified that they would participate in the E-POCUS training program regardless of whether it was accredited, being accredited would help alleviate many of the issues around program execution raised across interviews.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study explored the implementation of the E-POCUS training program, the first hybrid advanced POCUS training program in Ethiopia. Three primary themes were identified. First, time was the fundamental limiting factor for both learners and faculty. Second, there was a disparity between the program\u0026rsquo;s design and its execution in a resource-limited setting. Both of these themes connect to the third theme, which identified that participants were primarily motivated by the desire for skill development and improved patient care rather than formal credentials.\u003c/p\u003e \u003cp\u003eThese findings have multiple implications within the context of existing research. For one, there is a lack of reporting on both longitudinal and hybrid POCUS education initiatives. While the literature illustrated that shorter drop-in style POCUS workshops were the norm, we believed that a full-year program could help fill the identified gaps that emerged in evaluations of these programs (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Leveraging the TAAAC-EM partnership, we felt that it would be possible to co-develop a longitudinal, hybrid training program, and we were successful in launching this pilot in practice. What we learned throughout this pilot was that longitudinal programs are valuable for enhancing POCUS skills and leadership amongst physicians. However, to fully benefit from this longitudinal E-POCUS pilot, future program development should focus on additional flexibility for participants. This is especially important in the context of programs that are not institutionally approved programs, but rather exist within global health partnerships. Having a long-standing relationship was critical in being able to iteratively adjust the curriculum to ensure needs were being met and the training program was beneficial to all who participated (teachers and participants). Future research comparing longitudinal and short-term POCUS teaching, specifically research focused on skill acquisition, will help guide the development of future POCUS education programs in LMICs.\u003c/p\u003e \u003cp\u003eCurrent literature consistently highlights a tension between the clinical value of POCUS education and significant structural barriers in low-resource settings (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). In our study, the motivation for skill development, driven by the desire to improve patient care, mirrors findings from a longitudinal program in Zambia, where residents perceived POCUS as a meaningful adjunctive tool in narrowing differential diagnoses and altering medical management (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Time was also a limiting factor for learners across various POCUS programs. A program in Kenya found that despite a well-designed longitudinal curriculum, participants fell short of scan targets due to an already full medical education curriculum (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). The impact of competing administrative and clinical roles was also apparent in Uganda, where high patient volumes and staffing shortages affected the advancement of nearly half of the trainees (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). These similarities suggest that barriers to POCUS education in Ethiopia reflect a broader implementation gap in global health medical education, often due to a lack of protected academic time (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). The difficulty in establishing a remote QA system in our study reflects another systemic challenge in low-resource settings, where infrastructure often prevents longitudinal evaluation (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Our findings, alongside others, demonstrated that even with access to portable technology, infrastructure barriers such as inconsistent internet and incompatible technology create an operational gap that limits virtual hybrid education delivery, especially for skills-based education such as POCUS (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThese findings also illustrated that the consistency of learning opportunities was important and that program participants prioritized longitudinal hands-on training over accreditation (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Having the teaching staff join participants during their shifts so that they could learn while working was critical to relationship building and cross-cultural knowledge sharing (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Throughout the program, the emphasis was on more time for ultrasound scanning, and, in response to participant feedback, that is what was provided. They were able to ask about types of scans that were taught by previous instructors and were able to continually refine their skills without needing to take time off work or spend large amounts of money to access specialized training, which is difficult to obtain locally. While a formal accredited POCUS fellowship would have allowed protected time, participants chose to take on this additional unaccredited POCUS training, demonstrating their commitment to improving teaching and patient outcomes. However, the role and impact that a formal EM POCUS fellowship in Ethiopia could have on developing future POCUS leaders within the region, cannot be understated.\u003c/p\u003e \u003cp\u003e This program evaluation was done internally, and so many members of the E-POCUS administrative team were also involved in the research activities (as researchers and participants). While this is in line with the ethos of the TAAAC-EM collaboration, it does introduce the possibility that participants may not have felt comfortable disclosing their feelings in the interviews. Additionally, while the coders worked together with an emphasis on reflexivity, there was a risk of bias. We chose a qualitative approach to program evaluation to understand and contextualize participants\u0026rsquo; expectations and concerns about the E-POCUS pilot. Open-ended interviews ensured that we, as program evaluators in Canada, provide space for participants to speak to local and region-specific needs. During the E-POCUS pilot, while faculty in Addis co-developed a locally-relevant curriculum, it is important to be cognizant of how Canadian and institution-specific practices may influence curriculum development. Other limitations include that the evaluation focused only on perceptions, and not actually on POCUS skills acquisition or maintenance, and these interviews were conducted at the end of the interview participants' involvement in the program. Finally, while all participants are proficient in English, it is not their first language, and they would have had to translate their opinions in order to answer the questions.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis research illustrates that longitudinal POCUS training that utilizes hybrid learning is difficult to execute, but with time and a tailored curriculum that meets participants where they are (time, schedule, specific wants and needs), it can be beneficial to ensuring participants meet their goals. While accreditation is not a requirement for teaching POCUS, it does have the potential to alleviate multiple barriers faced by participants and former participants. Advancing POCUS education in resource-limited settings is essential to improving patient outcomes, and systematic evaluation of initiatives designed to expand access and training in areas most relevant to local patient populations is critical. In our experience, the E-POCUS program illustrated the value of flexible, longitudinal, and hybrid curricula in POCUS education, and underscores the importance of adaptability in global health partnership-based curricula.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eEast African Point-of-Care Ultrasound (E-POCUS)\u003c/p\u003e\n\u003cp\u003eEmergency Medicine (EM)\u003c/p\u003e\n\u003cp\u003eIn-person scanning intensive months (IPSIM)\u003c/p\u003e\n\u003cp\u003eLow and middle income countries (LMICs)\u003c/p\u003e\n\u003cp\u003ePoint-of-Care Ultrasound (POCUS)\u003c/p\u003e\n\u003cp\u003eTAAAC: Toronto Addis Ababa Academic Collaboration\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTAAAC-EM: Toronto Addis Ababa Academic Collaboration in Emergency Medicine\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthics approval and consent to participate:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis study received Research Ethics Board approval from the University of Toronto (RIS Human Protocol Number 48160) and received Institutional Review Board approval from Addis Ababa University (006/25/EM).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for publication:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eN/A\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eAvailability of data and materials:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting interests:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflicts of interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis E-POCUS Training Program Pilot was funded by the Royal College of Physicians and Surgeons of Canada International Development, Aid and Collaboration Grant, however the evaluation was funded through core TAAAC-EM funding. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthors\u0026apos; contributions:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHG, TZ, TB and IS conceptualized and designed the study. HG collected the data. HG and IY analyzed and interpreted the data. HG and IY drafted the manuscript and all authors critically reviewed it. All authors approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAcknowledgements:\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank the leadership team at TAAAC-EM in Toronto, as well as the leadership at Addis Ababa University, for their work in maintaining this longitudinal collaboration. The authors would also like to thank all of those who volunteered their time to support the development and execution of the E-POCUS training program, including Dr. Michelle Lee, Dr. Alexandra Stefan and Dr. Julia Wytsma. \u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eOmofoye TS. Radiology education as a global health service vehicle. 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Qual Res Psychol. 2006;3(2):77\u0026ndash;101.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBraun V, Clarke V. One size fits all? What counts as quality practice in (reflexive) thematic analysis? Qual Res Psychol. 2021;18(3):328\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHenwood PC, Mackenzie DC, Liteplo AS, Rempell JS, Murray AF, Leo MM, et al. Point-of-care ultrasound use, accuracy, and impact on clinical decision making in Rwanda hospitals. J Ultrasound Med. 2017;36(6):1189\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJones L, Gathu C, Szkwarko D, Mucheru S, Amin N, Amisi JA, et al. Expanding point-of-care ultrasound training in a low- and middle-income country: Experiences from a collaborative short-training workshop in Kenya. Fam Med. 2020;52(1):38\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeshkat N, Teklu S, Hunchak C, TAAAC-EM and the Global Health Emergency. Medicine (GHEM) organization at the Division of Emergency Medicine, University of Toronto. Design and Implementation of a postgraduate curriculum to support Ethiopia\u0026rsquo;s first emergency medicine residency training program: the Toronto Addis Ababa Academic Collaboration in Emergency Medicine (TAAAC-EM). BMC Med Educ. 2018;18(1):71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKelm DJ, Ratelle JT, Azeem N, Bonnes SL, Halvorsen AJ, Oxentenko AS, et al. Longitudinal ultrasound curriculum improves long-term retention among internal medicine residents. J Grad Med Educ. 2015;7(3):454\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijem","sideBox":"Learn more about [International Journal of Emergency Medicine](https://intjem.biomedcentral.com/)","snPcode":"12245","submissionUrl":"https://submission.nature.com/new-submission/12245/3","title":"International Journal of Emergency Medicine","twitterHandle":"@IntJEmergMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"POCUS, ultrasound, global health, program evaluation, training program, hybrid, partnership","lastPublishedDoi":"10.21203/rs.3.rs-8621713/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8621713/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eThere is a pressing need for a sustainable, longitudinal point-of-care ultrasound (POCUS) education model that is contextually relevant, locally led, and systematically evaluated in East Africa. The Toronto Addis Ababa Academic Collaboration in Emergency Medicine (TAAAC-EM), a long-standing partnership between the University of Toronto and Addis Ababa University, developed the East African POCUS (E-POCUS) Training Program Pilot. This was a one-year, longitudinal, hybrid advanced training program tailored to local needs and interests.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eWe used reflexive thematic analysis to conduct a qualitative program evaluation of the E-POCUS training program pilot. E-POCUS participants, staff involved with the execution of the training program, and those participants who had to leave the program were all invited to participate in a semi-structured virtual interview, exploring their perceived impact and opinion of the E-POCUS program. Interview transcripts were analyzed using Braun and Clarke\u0026rsquo;s reflexive thematic analysis framework.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eA total of 13 interviews were conducted, representing participants in the E-POCUS program (n\u0026thinsp;=\u0026thinsp;2), former participants of the E-POCUS program (n\u0026thinsp;=\u0026thinsp;3), and staff involved in the teaching of the program (n\u0026thinsp;=\u0026thinsp;8). The analysis highlighted three main themes: 1) time as a limiting factor, 2) expectations versus reality in program delivery, and 3) motivations for participation and the role of accreditation.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e \u003cp\u003eThis study highlighted the value of flexible, longitudinal, and hybrid curriculums in POCUS education. The E-POCUS pilot also illustrated that the hybrid model of education allowed participants to prioritize hands-on skill development teaching during in-person months. Advancing POCUS education in resource-limited settings is critical to improving patient care, and it is important to evaluate efforts at increasing access and education on the topics that are most relevant to their patient population.\u003c/p\u003e","manuscriptTitle":"Evaluating the East African Point-of-Care Ultrasound (E-POCUS) Training Program Pilot: Lessons Learned and Best Practices","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-11 08:49:00","doi":"10.21203/rs.3.rs-8621713/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"221020860628259760418824801719488468682","date":"2026-05-07T13:50:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"59389428354786258361596336232068183505","date":"2026-04-23T12:32:05+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-12T13:29:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"185348871726306664396113047764640610297","date":"2026-02-28T11:37:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"138826520041086888696366784374834491021","date":"2026-02-26T16:34:53+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-09T09:40:32+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-21T05:35:58+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-21T05:34:03+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal of Emergency Medicine","date":"2026-01-16T18:54:17+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijem","sideBox":"Learn more about [International Journal of Emergency Medicine](https://intjem.biomedcentral.com/)","snPcode":"12245","submissionUrl":"https://submission.nature.com/new-submission/12245/3","title":"International Journal of Emergency Medicine","twitterHandle":"@IntJEmergMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3a5ece58-a780-4d53-bff0-a6e2afef7d0e","owner":[],"postedDate":"February 11th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"221020860628259760418824801719488468682","date":"2026-05-07T13:50:47+00:00","index":80,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-11T08:49:00+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-11 08:49:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8621713","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8621713","identity":"rs-8621713","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}