A Distance Blended Learning Program to Upgrade the Clinical Competence of District Non-doctor Anesthesia Providers in Nepal.

BACKGROUND: Across Nepal, anesthesia at a district level is provided mostly by non-doctor anesthesia providers (anesthesia assistants-AAs). Nepal's Government recognized the need to sustain competence with continuous professional development and to upgrade 6-month trained working AAs to professional equivalence with the new national standard of 12-month training. As they are essential district health workers and AA clinical training sites are full, an innovative distance blended learning, competency-based, upgrade 1-year course was developed and conducted in 2014-2017 for two batches. METHODS: The course content was developed over 18 months by a team of Nepali and overseas AA training experts. The 1-year course started with a refresher course, continued with tablet-based 12-month self-learning modules and clinical case logs, regular educational mentor communication, midcourse 2-week contact time in an AA training site, regular text messaging and ended with clinical examination and multiple-choice questions. Tablet content included 168 new case studies, pre- and posttests, video lectures, matching exercises and a resource library. All module work and logged clinical cases were uploaded centrally, where clinical mentors were able to review work. Clinical skills were upgraded, as needed, through direct clinical contact midway through the course. Quantitative and qualitative course assessments were included. RESULTS: Fourteen working AAs in first batch and eight working AAs in second batch from district, zonal and mission hospitals across Nepal were enrolled. All remained working at their hospitals throughout the course, and there were no significant tablet problems inhibiting course completion. Twenty-one AAs completed all modules successfully with time required for module completion averaging 19.2 h (range 11.2-32). One AA left the course after 3 months with a personal problem. Subjectively, AAs felt that the obstetric and pediatric modules were more difficult; lowest marks were objectively seen in the airway module. Clinical mentors averaged 8.2 h mentoring review work per module with direct student communication of 2.9 h per module per month. Participants logged a total of 5473 clinical cases, ranging between 50 and 788 cases each. Complications were recorded; outcomes were good. Challenges were the national IT infrastructure making data synchronization difficult and the lack of clinical exposure at some AA's hospitals. Nineteen AAs attended the final examination, and all passed. Two AAs withdrew before the final examination period due to personal and logistic reasons. CONCLUSION: This is the first use of distance blended learning to upgrade district health workers in Nepal and perhaps for non-doctor anesthesia providers globally. Key success factors were motivated students, cultural and contextualized clinical content, good educational mentoring relationships with regular communication, central IT and motivational support, and face-to-face midcourse clinical contact time.

Tablet e-Logbooks: Four Thousand Clinical Cases and Complications e-Logged by 14 Nondoctor Anesthesia Providers in Nepal.

BACKGROUND: To meet the need for essential surgery across rural Nepal, anesthesia at district level is delivered by nondoctor anesthetists. They require support to maintain confidence and competence, and upgraded professional registration to secure their status. To meet these needs, a distance-blended learning course was pioneered and delivered. A core course requirement was to log all clinical cases; these were logged on a new e-logbook. METHODS: Fourteen nondoctor anesthesia providers working in 12 different districts across Nepal were enrolled in the 1-year course. The course is based on self-completion on a tablet loaded with new learning modules, a resource library, and a case logbook. Continuous educational mentoring was provided by anesthesiologists by phone and email. The logbook included preanesthesia assessment and interventions, American Society of Anesthesiologists (ASA) grading, types of cases and anesthesia given, monitors used, complications, outcomes and free text remarks. Cases were uploaded monthly to a database, and mentors reviewed all logbook entries. RESULTS: The 14 nondoctor anesthesia providers were widely distributed across the country in district, zonal, community, and mission hospitals, and had different levels of clinical experience and caseloads. Logbooks and uploads were regularly completed without difficulty; 1% cases were entered incompletely with no case details provided. A total of 4143 cases were recorded. Annual caseload per nondoctor anesthesia provider ranged from 50 to 788, the majority of which were under spinal anesthesia; 34% of the total cases were cesarean deliveries, of which 99% received spinal anesthesia. Fifty gastrointestinal laparotomies (1% total) were recorded. Ninety-one percent of cases were ASA I, 0.8% ASA III/IV. Pulse oximetry was used in 98% of cases. Complications were recorded in 6% of cases; the most common were circulation problems (69%) including hypotension and occasional bradycardia after spinal anesthesia. Airway complications were usually under ketamine anesthesia requiring basic airway maneuvers; 4 difficult intubations were recorded under general anesthesia. Anesthesia outcomes were good with overall mortality of 0.1% (total 4 cases). Causes of death included severe preeclampsia, sepsis postlaparotomy, and patients with multiorgan failure for minor procedure. CONCLUSIONS: The tablet-based electronic anesthesia logbook was successfully used to record cases, complications, and outcomes across rural Nepal. The nondoctor anesthesia providers had trust and confidence in recording outcomes. It remains to be tested whether an e-logbook would be routinely completed outside of a specific training course. Such a logbook could be incorporated into all continuous professional development programs for rural nondoctor anesthetists.

Electronic diagnostic algorithms to assist mid-level health care workers in Nepal: a mixed-method exploratory study.

INTRODUCTION: The use of mobile health applications for data collection and disease management by rural health care workers in developing countries has been shown to be accepted by patients and health care workers. However, the acceptances of diagnostic decision applications have not been studied. Moreover, verbal acceptance of these tools has not been shown to equate with actual usage by the health care workers when use is not compulsory. OBJECTIVE: To measure the acceptance, usage and reasons for use or non-use of electronic diagnostic applications by health care workers to aid in clinical diagnosis. METHODS: Eleven health care workers (HCW) from rural facilities were asked to use the e-algo application on an electronic tablet with patients over the age of five presenting with acute complaints. Use was compulsory for the first 30 working days and after that optional. Patients were asked by questionnaire about their preference and confidence between the traditional approach and that of the e-algo. HCW acceptance was measured by focus group discussions after the compulsory period. The HCW was then told to use the application as they desired. After two months of non-compulsory usage, reasons were explored for use or non-use through a focus group discussion and interviews. RESULTS: A total of 1410 out-patient encounters occurred in the first phase. Of this, the e-algo was used with 1177 encounters (83%). 496 patients were asked about their preference and confidence in the use of the e-algo. 325 preferred the e-algo over the traditional visit 65.8-25.1%. Patient confidence was higher in the e-algo 72.2-17.4%. In the second phase, three of the nine HCWs did not use the e-algo at all, the remaining six HCWs reported e-algo use dropped to approximately 15% of total OPD visits. E-algos were reported to be used primarily with more complicated or confusing cases. Reasons for non-use was primarily time related. CONCLUSIONS: We concluded that patients had confidence in and preferred the HCW using the e-algo in their patient care. The HCW users were also positive about the e-algo application, seeing its primary benefit as assisting them in more difficult cases through the use of a differential diagnosis and focused questions. HCWs also reported that the e-algo functioned as a learning tool as well as a diagnostic tool. However, actual usage of the application dropped off significantly when its use was not mandatory. The primary reason was that they did not feel the time required to use the application was warranted in the vast majority of their cases which they perceived as being simple and easily diagnose without the assistance of the application. Unless the HCW perceives the decision-support application to be valid, time-saving and easy to use, they will not use them.