Challenges and Opportunities in Developing a Comprehensive, Rural, Trauma-Care Program: Experiences from Nepal.

Traumatic injury remains a significant public health problem, with the burden highest in low-middle income countries (LMICs) and rural areas.1,2 The far-western region of Nepal, which has the lowest human development index in the country, has a high burden of traumatic injuries.3-5 One hospital in the far-western district of Achham, Bayalpata Hospital, cares for the majority of patients with traumatic injuries - most of whom arrive without any pre-hospital care. The absence of a professionalized pre-hospital program, such as an established Emergency Medical Services (EMS) system, necessitates creative strategies to address this gap.6,7 In this context, implementing a trauma-training program for community health responders (CHRs) offers a promising solution, leveraging local resources to improve early-stage trauma care.

Establishment of the First Institution-Based Poison Information Center in Nepal Through a Multilateral International Partnership.

Toxicological emergencies present a significant health challenge in Nepal. Despite the high burden, the country has inadequate formal toxicology training, medical toxicology expertise, and adequate poison control infrastructure. In recognition of this need, the Nepal Poison Information Center (PIC) was established as a collaborative effort involving local and international partners. Through a comprehensive partnership framework, the Nepal PIC provides 24 hours a day, 7 days a week expert guidance to health care workers, conducts educational webinars, and engages in research. Initial data from the pilot phase indicate successful consultation delivery. Challenges include bureaucratic hurdles and the need for sustainable funding. Despite these challenges, the Nepal PIC demonstrates early feasibility and potential for expansion into a comprehensive toxicology center, contributing to the advancement of clinical toxicology in Nepal. Long-term sustainability relies on governmental support and continued advocacy efforts.

A tabletop exercise approach to global disaster preparedness: insights from Nepal's first international conference on disaster preparedness and management.

Considering recent earthquakes and the COVID-19 pandemic, disaster preparedness has come to the forefront of the public health agenda in Nepal. To strengthen the developing health system, many initiatives are being implemented at different levels of society to build resiliency, one of which is through training and education. The first International Conference on Disaster Preparedness and Management convened in Dhulikhel, Nepal on December 1-3, 2023. It brought together international teaching faculty to help deliver didactic and simulation-based sessions on various topics pertaining to disaster preparedness and management for over 140 Nepali healthcare professionals. This paper focuses on the tabletop exercise-based longitudinal workshop portion of the conference on disaster leadership and communication, delivered by United States-based faculty. It delves into the educational program and curriculum, delivery method, Nepali organizer and US facilitator reflections, and provides recommendations for such future conferences, and adaptation to other settings.

Emergency medical dispatch technologies: Addressing communication challenges and coordinating emergency response in low and middle-income countries.

A majority of emergency response in low and middle-income countries (LMICs) without formal emergency medical services (EMS) rely on uncoordinated layperson first responders (LFRs) to respond to emergencies using readily available mobile phones and private transport. Although formally trained LFRs are an important foundation for nascent emergency medical services (EMS) development, without coordination by standardized emergency medical dispatch (EMD) systems, LFR response is limited to witnessed emergencies, which provides significant but incomplete coverage. After training and equipping LFRs, EMD implementation using telecommunications technologies is the next step in formal EMS development and is essential to coordinate response, given the impact of timely prehospital response, intervention, and transportation on reducing morbidity/mortality. In this paper, we describe the current state of dispatch technologies used for emergency response in LMICs, focusing on the role of communication technologies, current approaches, and challenges in communication, and offer potential strategies for future development.

Pilot Training Program on Hands-Only CPR and Choking First Aid for Frontline Police Responders in Rural Nepal.

INTRODUCTION: Basic life support (BLS) is an emergency skill that includes performing appropriate cardiopulmonary resuscitation (CPR). Out-of-hospital cardiac arrest (OHCA) is a leading cause of mortality worldwide and is rising in Nepal. After an OHCA event, a bystander starting CPR quickly has been shown to increase the survival rate. While the Nepali police are generally the first responders to emergencies in rural parts, they are not trained in BLS. This program assesses a pilot training of hands-only CPR and choking first aid to the Nepal Police and Nepal Army participants in rural Nepal. METHODS: A community-based nonprofit organization, HAPSA-Nepal, coordinated with local government to pilot this program. The program included pre- and post-tests, lectures, videos, and small group hands-on exercises; facilitators included faculty emergency physicians, residents, and medical officers. Structured pre- andp post-test questionnaires, confidence surveys, and skills checklists were conducted. Descriptive analysis examined the respondent's characteristics, and paired t-test was used to compare pretest and post-test scores. RESULTS: A total of 126 participants received the training in this pilot phase. Prior to this training, 98.4% of the participants had not received any CPR training, and 100% of the participants had not received training on first aid for choking. The average pretest score was 4.4 with 95% CI ± 1.75, and the average post-test score was 8.06 with 95% CI ± 1.73 (out of a total of 11). All participants passed the skills assessment. CONCLUSIONS: Locally adapted BLS training programs that included hands-only CPR and choking first aid showed a significant knowledge gain and skills competence among the frontline participants.

Emergency unit assessment of seven tertiary hospitals in Nepal using the WHO tool: a cross-sectional study.

BACKGROUND: In 2021, the Nepal national emergency care system's assessment (ECSA) identified 39 activities and 11 facility-specific goals to improve care. To support implementation of the ECSA facility-based goals, this pilot study used the World Health Organization's (WHO) Hospital Emergency Unit Assessment Tool (HEAT) to evaluate key functions of emergency care at tertiary hospitals in Kathmandu, Nepal. METHODS: This cross-sectional study used the standardized HEAT assessment tool. Data on facility characteristics, human resources, clinical services, and signal functions were gathered via key informant interviews conducted by trained study personnel. Seven tertiary referral centers in the Kathmandu valley were selected for pilot evaluation including governmental, academic, and private hospitals. Descriptive statistics were generated, and comparative analyses were conducted. RESULTS: All facilities had continuous emergency care services but differed in the extent of availability of each item surveyed. Academic institutions had the highest rating with greater availability of consulting services and capacity to perform specific signal functions including breathing interventions and sepsis care. Private institutions had the highest infrastructure availability and diagnostic testing capacity. Across all facilities, common barriers included lack of training of key emergency procedures, written protocols, point-of-care testing, and ancillary patient services. CONCLUSION: This pilot assessment demonstrates that the current emergency care capacity at representative tertiary referral hospitals in Kathmandu, Nepal is variable with some consistent barriers which preclude meeting the ECSA goals. The results can be used to inform emergency care development within Nepal and demonstrate that the WHO HEAT assessment is feasible and may be instructive in systematically advancing emergency care delivery at the national level if implemented more broadly.

Training program for female community volunteers to combat COVID 19 in rural Nepal.

Female Community Health Volunteers (FCHV) in Nepal have identified lack of appropriate training as a barrier to involvement in the COVID 19 response. With more than 50,000 FCHVs serving rural areas of Nepal, they are instrumental in healthcare and are a major source of information delivery to those with the most limited health-care access in Nepal. This communication describes an innovative training programme to rapidly equip FCHVs with knowledge on COVID 19 response. The ongoing programme leverages partnerships between local municipalities and a local community-based organisation and has rapidly trained more than 300 FCHVs across four districts with a population of 1,000,000, and has plans to expand the training across the country. This training programme is a key example of how local partnerships can be utilised for digital training of FCHVs in remote parts of Nepal and leveraged to strengthen response capacity during the pandemic.

Establishment of a Rapid Phone Consultation Service for COVID-19 Public Health Support in Nepal.

Background The coronavirus disease 2019 (COVID-19) pandemic strained the already weak health system of Nepal, especially during the surge of the delta variant. A telephonic consultation service was rapidly established to provide free consultations to assist those in home isolation due to severe acute respiratory syndrome coronavirus 2 infection. In this study, we describe the process of establishing the hotline and share preliminary findings. During the peak of the delta wave in Nepal, the hotline was started by a local non-profit organization. Methodology We established the hotline with help of a private telecommunication company. The hotline was advertised on social media, radio, and newspapers. Healthcare workers were recruited and trained and the service was provided for free. Patient data were recorded and de-identified for analysis, monitoring, and evaluation. Results The majority of the callers were from Kathmandu valley, which includes three districts, Kathmandu, Lalitpur, and Bhaktapur. Overall, 44% of the callers inquired about the clinical manifestations of COVID-19. On average, there were 75 calls each day between May 2021 and February 2022. The average call duration was three minutes and 42 seconds. Trained healthcare workers answered the calls for 15.5 hours a day. Conclusions Our work established the feasibility of a rapid hotline service in response to the pandemic causing high strain on the health system. Lessons learned from this experience can be useful for future disasters in Nepal and other places with similar health system strains.

Comparative Effectiveness of an In-Person and a Virtual Basic Emergency Care Instructor Course.

Background: Resource limited settings have an ongoing need for access to quality emergency care. The World Health Organization - International Committee of the Red Cross Basic Emergency Care (BEC) course is one mechanism to address this need. Training of BEC trainers has been challenging due to barriers including cost, travel logistics, scheduling, and more recently, social distancing regulations related to the coronavirus pandemic. Objective: We seek to determine if an online virtual format is an effective way to train additional trainers while overcoming these barriers. Methods: The BEC Training-of-Trainers (ToT) course was adapted to a virtual format and delivered entirely online. Participants were assessed with a multiple choice pre- and post-test and completed a course feedback form upon completion. Results from the virtual course were then compared to the results from an in-person ToT course. Findings: The in-person course pre- and post-tests were completed by 121 participants with a pre-test mean of 87% (range 60-100%) and a post-test mean of 95% (range: 75-100; p < 0.05). Virtual course pre- and post-tests by 27 participants were analyzed with a pre-test mean of 89% (range 75-100%) and a post-test mean of 96% (range: 79-100; p < 0.05). No difference in test improvements between the courses was detected (z = -0.485; p = 0.627). The course feedback was completed by 93 in-person participants and 28 virtual participants. Feedback survey responses were similar for all questions except for course length, with in-person participant responses trending towards the course being too long. Conclusions: A virtual format BEC ToT course is effective, feasible, and acceptable. When compared to an in-person course, no difference was detected in nearly all metrics for the virtual format. Utilizing this format for future courses can assist in scaling both the BEC ToT and, by extension, the BEC course globally, particularly in regions facing barriers to in-person training.

Emergency Medicine Around the World: Analysis of the 2019 American College of Emergency Physicians International Ambassador Country Reports.

OBJECTIVE: The specialty of emergency medicine and recognition of the need for emergency care continue to grow globally. The specialty and emergency care systems vary according to context. This study characterizes the specialty of emergency medicine around the world, trends according to region and income level, and challenges for the specialty. METHODS: We distributed a 56-question electronic survey to all members of the American College of Emergency Physicians International Ambassador Program between March 2019 and January 2020. The Ambassador Program leadership designed the survey covering specialty recognition, workforce, system components, and emergency medicine training. We analyzed results by country and in aggregate using SAS software (SAS Institute Inc). We tested the associations between World Bank income group and number of emergency medicine residency-trained physicians (RTPs) and emergency medicine specialty recognition using non-parametric Fisher's exact testing. We performed inductive coding of qualitative data for themes. RESULTS: Sixty-three out of 78 countries' teams (80%) responded to the survey. Response countries represented roughly 67% of the world's population and included countries in all World Bank income groups. Fifty-four countries (86%) recognized emergency medicine as a specialty. Ten (16%) had no emergency medicine residency programs, and 19 (30%) had only one. Eight (11%) reported having no emergency medicine RTPs and 30 (48%) had <100. Fifty-seven (90%) had an emergency medical services (EMS) system, and 52 (83%) had an emergency access number. Higher country income was associated with a higher number of emergency medicine RTPs per capita (P = 0.02). Only 6 countries (8%) had >5 emergency medicine RTPs per 100,000 population, all high income. All 5 low-income countries in the sample had <2 emergency medicine RTPs per 100,000 population. Challenges in emergency medicine development included lack of resources (38%), burnout and poor working conditions (31%), and low salaries (23%). CONCLUSIONS: Most surveyed countries recognized emergency medicine as a specialty. However, numbers of emergency medicine RTPs were small, particularly in lower income countries. Most surveyed countries reported an EMS system and emergency access number. Lack of resources, burnout, and poor pay were major threats to emergency medicine growth.

Frameworks for Global Health Collaboration in Pandemic Disease.

Novel disease emergence with associated outbreaks and pandemics have become increasingly common in the last several decades. For centuries, people have utilized various forms of collaboration to control outbreaks. Modern global health frameworks now play a central role in guiding a targeted and coordinated international disease response; recent pandemics have shown that such systems have both strengths and vulnerabilities. This report assesses the existing global health infrastructure for pandemic response and discusses how the World Health Organization (WHO) and global health infrastructure has responded to recent public health threats.

The status and future of emergency care in the Republic of Kenya.

Kenya is a rapidly developing country with a growing economy and evolving health care system. In the decade since the last publication on the state of emergency care in Kenya, significant developments have occurred in the country's approach to emergency care. Importantly, the country decentralized most health care functions to county governments in 2013. Despite the triple burden of traumatic, communicable, and non-communicable diseases, the structure of the health care system in the Republic of Kenya is evolving to adapt to the important role for the care of emergent medical conditions. This report provides a ten-year interval update on the current state of the development of emergency medical care and training in Kenya, and looks ahead towards areas for growth and development. Of particular focus is the role emergency care plays in Universal Health Coverage, and adapting to challenges from the devolution of health care.

Development and assessment of novel virtual COVID-19 trainer-of trainers course implemented by an academic-humanitarian partnership.

BACKGROUND: In response to the coronavirus disease (COVID-19) pandemic, Project HOPE®, an international humanitarian organization, partnered with Brown University to develop and deploy a virtual training-of-trainers (TOT) program to provide practical knowledge to healthcare stakeholders. This study is designed to evaluate this TOT program. OBJECTIVE: The goal of this study is to assess the effectiveness of this educational intervention in enhancing knowledge on COVID-19 concepts and to present relative change in score of each competency domains of the training. METHODS: The training was created by interdisciplinary faculty from Brown University and delivered virtually. Training included eight COVID-19 specific modules on infection prevention and control, screening and triage, diagnosis and management, stabilization and resuscitation, surge capacity, surveillance, and risk communication and community education. The assessment of knowledge attainment in each of the course competency domain was conducted using 10 question pre-and post-test evaluations. Paired t-test were used to compare interval knowledge scores in the overall cohort and stratified by WHO regions. TOT dissemination data was collected from in-country partners by Project Hope. RESULTS: Over the period of 7 months, 4,291 personnel completed the TOT training in 55 countries, including all WHO regions. Pre-test and post-test were completed by 1,198 and 706 primary training participants, respectively. The mean scores on the pre-test and post-test were 68.45% and 81.4%, respectively. The mean change in score was 11.72%, with P value <0.0005. All WHO regions had a statistically significant improvement in their score in post-test. The training was disseminated to 97,809 health workers through local secondary training. CONCLUSION: Innovative educational tools resulted in improvement in knowledge related to the COVID-19 pandemic, significantly increasing the average score on knowledge assessment testing. Academic - humanitarian partnerships can serve to implement and disseminate effective education rapidly across the globe.

Access to care solutions in healthcare for obstetric care in Africa: A systematic review.

BACKGROUND: Emergency Medical Services (EMS) systems exist to reduce death and disability from life-threatening medical emergencies. Less than 9% of the African population is serviced by an emergency medical services transportation system, and nearly two-thirds of African countries do not have any known EMS system in place. One of the leading reasons for EMS utilization in Africa is for obstetric emergencies. The purpose of this systematic review is to provide a qualitative description and summation of previously described interventions to improve access to care for patients with maternal obstetric emergencies in Africa with the intent of identifying interventions that can innovatively be translated to a broader emergency context. METHODS: The protocol was registered in the PROSPERO database (International Prospective Register of Systematic Reviews) under the number CRD42018105371. We searched the following electronic databases for all abstracts up to 10/19/2020 in accordance to PRISMA guidelines: PubMed/MEDLINE, Embase, CINAHL, Scopus and African Index Medicus. Articles were included if they were focused on a specific mode of transportation or an access-to-care solution for hospital or outpatient clinic care in Africa for maternal or traumatic emergency conditions. Exclusion criteria included in-hospital solutions intended to address a lack of access. Reference and citation analyses were performed, and a data quality assessment was conducted. Data analysis was performed using a qualitative metasynthesis approach. FINDINGS: A total of 6,457 references were imported for screening and 1,757 duplicates were removed. Of the 4,700 studies that were screened against title and abstract, 4,485 studies were excluded. Finally, 215 studies were assessed for full-text eligibility and 152 studies were excluded. A final count of 63 studies were included in the systematic review. In the 63 studies that were included, there was representation from 20 countries in Africa. The three most common interventions included specific transportation solutions (n = 39), community engagement (n = 28) and education or training initiatives (n = 27). Over half of the studies included more than one category of intervention. INTERPRETATION: Emergency care systems across Africa are understudied and interventions to improve access to care for obstetric emergencies provides important insight into existing solutions for other types of emergency conditions. Physical access to means of transportation, efforts to increase layperson knowledge and recognition of emergent conditions, and community engagement hold the most promise for future efforts at improving emergency access to care.

Lessons Learned from Rwanda: Innovative Strategies for Prevention and Containment of COVID-19.

Introduction: Rwanda has made significant advancements in medical and economic development over the last 20 years and has emerged as a leader in healthcare in the East African region. The COVID-19 pandemic, which reached Rwanda in March 2020, presented new and unique challenges for infectious disease control. The objective of this paper is to characterize Rwanda's domestic response to the first year of the COVID-19 pandemic and highlight effective strategies so that other countries, including high and middle-income countries, can learn from its innovative initiatives. Methods: Government publications describing Rwanda's healthcare capacity were first consulted to obtain the country's baseline context. Next, official government and healthcare system communications, including case counts, prevention and screening protocols, treatment facility practices, and behavioral guidelines for the public, were read thoroughly to understand the course of the pandemic in Rwanda and the specific measures in the response. Results: As of 31 December 2020, Rwanda has recorded 8,383 cumulative COVID-19 cases, 6,542 recoveries, and 92 deaths since the first case on 14 March 2020. The Ministry of Health, Rwanda Biomedical Centre, and the Epidemic and Surveillance Response division have collaborated on preparative measures since the pandemic began in January 2020. The formation of a Joint Task Force in early March led to the Coronavirus National Preparedness and Response Plan, an extensive six-month plan that established a national incident management system and detailed four phases of a comprehensive national response. Notable strategies have included disseminating public information through drones, robots for screening and inpatient care, and official communications through social media platforms to combat misinformation and mobilize a cohesive response from the population. Conclusion: Rwanda's government and healthcare system has responded to the COVID-19 pandemic with innovative interventions to prevent and contain the virus. Importantly, the response has utilized adaptive and innovative technology and robust risk communication and community engagement to deliver an effective response to the COVID-19 pandemic.

COVID-19 Pandemic Prompts a Paradigm Shift in Global Emergency Medicine: Multidirectional Education and Remote Collaboration.

To date, the practice of global emergency medicine (GEM) has involved being "on the ground" supporting in-country training of local learners, conducting research, and providing clinical care. This face-to-face interaction has been understood as critically important for developing partnerships and building trust. The COVID-19 pandemic has brought significant uncertainty worldwide, including international travel restrictions of indeterminate permanence. Following the 2020 Society for Academic Emergency Medicine meeting, the Global Emergency Medicine Academy (GEMA) sought to enhance collective understanding of best practices in GEM training with a focus on multidirectional education and remote collaboration in the setting of COVID-19. GEMA members led an initiative to outline thematic areas deemed most pertinent to the continued implementation of impactful GEM programming within the physical and technologic confines of a pandemic. Eighteen GEM practitioners were divided into four workgroups to focus on the following themes: advances in technology, valuation, climate impacts, skill translation, research/scholastic projects, and future challenges. Several opportunities were identified: broadened availability of technology such as video conferencing, Internet, and smartphones; online learning; reduced costs of cloud storage and printing; reduced carbon footprint; and strengthened local leadership. Skills and knowledge bases of GEM practitioners, including practicing in resource-poor settings and allocation of scarce resources, are translatable domestically. The COVID-19 pandemic has accelerated a paradigm shift in the practice of GEM, identifying a previously underrecognized potential to both strengthen partnerships and increase accessibility. This time of change has provided an opportunity to enhance multidirectional education and remote collaboration to improve global health equity.