Video-based feedback as a method for training rural healthcare workers to manage medical emergencies: a pilot study.

BACKGROUND: Video-based feedback has been shown to aid knowledge retention, skills learning and improve team functionality. We explored the use of video-based feedback and low fidelity simulation for training rural healthcare workers along the Thailand-Myanmar border and Papua New Guinea (PNG) to manage medical emergencies effectively. METHODS: Twenty-four study participants were recruited from three Shoklo Malaria Research Unit clinics along the Thailand-Myanmar border and eight participants from Kudjip Nazarene Hospital, PNG. The teams were recorded on video managing a simulated medical emergency scenario and the video was used to aid feedback and assess performance using Observed Structured Clinical Examination (OSCE) scoring and Team Emergency Assessment Measure (TEAM) questionnaire. The process was repeated post-feedback at both sites and at 6 weeks at the Thailand-Myanmar border site. Thailand-Myanmar border participants' individual confidence levels and baseline knowledge (using OSCE scoring) were assessed before team assessment and feedback at week 1 and repeated post-feedback and at 6 weeks. Focus group discussions (FGD) were held at each Thailand-Myanmar border clinic at week 1 (8 participants at each clinic). RESULTS: Individual paired tests of OSCE scores showed significant improvement post-feedback at week 1 (p < 0.001) and week 6 (p < 0.001) compared to baseline OSCE scores. There was a trend for increased team OSCE scores compared to baseline at week 1 (p = 0.068) and week 6 (p = 0.109) although not significant. Thailand-Myanmar border TEAM scores demonstrated improvement post-feedback mainly in leadership, teamwork and task management which was sustained up to week 6. PNG showed an improvement mainly in teamwork and task management. The global rating of the teams' non-technical performance at both sites improved post feedback and at week 6 on the Thailand-Myanmar border site. Self-rated confidence scores by Thailand-Myanmar border participants increased significantly from baseline following training at week 1 (p = 0.020), and while higher at 6 weeks follow up than at baseline, this was not significant (p = 0.471). The FGD revealed majority of participants felt that watching the video recording of their performance and the video-based feedback contributed most to their learning. CONCLUSION: Video-assisted feedback resulted in an improvement in clinical knowledge, confidence and quality of teamwork for managing medical emergencies in two low resource medical facilities in South East Asia and the South Pacific.

The role of point-of-care tests in antibiotic stewardship for urinary tract infections in a resource-limited setting on the Thailand-Myanmar border.

OBJECTIVE: Published literature from resource-limited settings is infrequent, although urinary tract infections (UTI) are a common cause of outpatient presentation and antibiotic use. Point-of-care test (POCT) interpretation relates to antibiotic use and antibiotic resistance. We aimed to assess the diagnostic accuracy of POCT and their role in UTI antibiotic stewardship. METHODS: One-year retrospective analysis in three clinics on the Thailand-Myanmar border of non-pregnant adults presenting with urinary symptoms. POCT (urine dipstick and microscopy) were compared to culture with significant growth classified as pure growth of a single organism >10(5)  CFU/ml. RESULTS: In 247 patients, 82.6% female, the most common symptoms were dysuria (81.2%), suprapubic pain (67.8%) and urinary frequency (53.7%). After excluding contaminated samples, UTI was diagnosed in 52.4% (97/185); 71.1% (69/97) had a significant growth on culture, and >80% of these were Escherichia coli (20.9% produced extended-spectrum ß-lactamase (ESBL)). Positive urine dipstick (leucocyte esterase ≥1 and/or nitrate positive) compared against positive microscopy (white blood cell >10/HPF, bacteria ≥1/HPF, epithelial cells <5/HPF) had a higher sensitivity (99% vs. 57%) but a lower specificity (47% vs. 89%), respectively. Combined POCT resulted in the best sensitivity (98%) and specificity (81%). Nearly one in ten patients received an antimicrobial to which the organism was not fully sensitive. CONCLUSION: One rapid, cost-effective POCT was too inaccurate to be used alone by healthcare workers, impeding antibiotic stewardship in a high ESBL setting. Appropriate prescribing is improved with concurrent use and concordant results of urine dipstick and microscopy.