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.

Pathways to effective surgical coverage in a lower-middle-income country: A multiple methods study of the family physician-led generalist surgical team in rural Nepal.

The Lancet Commission on Global Surgery (LCoGS) recommends using specialist surgical workforce density as one of 6 core indicators for monitoring universal access to safe, affordable surgical and anaesthesia care. Using Nepal as a case study, we explored the capacity of a generalist workforce (led by a family physician or MD general practitioner and non-physician anaesthetist) to enable effective surgical delivery through task-shifting. Using a multiple-methods approach, we retrospectively mapped essential surgical care and the enabling environment for surgery in 39 hospitals in 25 remote districts in Nepal and compared it with LCoGS indicators. All 25 districts performed surgery, 21 performed Caesarean section (CS), and 5 met at least 50% of district CS needs. Generalist surgical teams performed CS, the essential major operation at the district level, and very few laparotomies, but no operative orthopaedics. The density of specialist Surgeon/Anaesthesiologist/Obstetrician (SAO) was 0·4/100,000; that of Generalist teams (gSAO) led by a family physician (MD General Practitioners-MDGP) supported by non-physician anaesthetists was eight times higher at 3·1/100,000. gSAO presence was positively associated with a two-fold increase in CS availability. All surgical rates were well below LCoGS targets. 46% of hospitals had adequate enabling environments for surgery, 28% had functioning anaesthesia machines, and 75% had blood transfusion services. Despite very low SAO density, and often inadequate enabling environment, surgery can be done in remote districts. gSAO teams led by family physicians are providing essential surgery, with CS the commonest major operation. gSAO density is eight times higher than specialists and they can undertake more complex operations than just CS alone. These family physician-led functional teams are providing a pathway to effective surgical coverage in remote Nepal.

Distance-Learning Initiatives Targeting Non-physician Anesthesia Providers in Low-Resource Environments.

PURPOSE OF REVIEW: "Distance-learning" encompasses a variety of didactics, from self-directed online learning to focused courses and programs. Despite increasing internet availability, focused distance-learning courses are rarely practiced in low- or middle-income countries, particularly among non-physician anesthetists. This review aims to discuss the availability, significance, and challenges of distance-learning programs for non-physician anesthesia providers in low-resource settings. RECENT FINDINGS: Task shifting and sharing in anesthesia remains essential in low-resource settings to meet the demand of surgical need. Distance-learning may be the ideal option in these settings, as it can be used to train the individual at their workplace even in remote areas. Different models and techniques are described. Success depends on the course design, communication strategies, handling of technical issues, and support mechanisms. SUMMARY: Distance-learning should be an essential part of training and in-service support for non-physician anesthetists. Global advocates of safe, effective anesthesia services need to support the development and delivery of distance-learning courses.

Endobronchial Ultrasound Guided Transbronchial Needle Aspiration.

Evaluation of mediastinal lymphadenopathy is often challenging. Endobronchial Ultrasound (EBUS) is a novel technique which provides real time sonographic guidance during Transbronchial Needle Aspiration (TBNA) from mediastinal and hilar lesions. A 60-year-old smoker presented with two months history of cough and chest pain on the right side. CT thorax revealed a right upper lobe spiculated mass with paratracheal (Station 4R) and subcarinal (Station 7) lymph nodes. Bronchoscopy did not reveal any endobronchial mass. Since EBUS-TBNA is superior to conventional TBNA for malignant mediastinal node, an EBUS- TBNA was performed from both lymph node stations. . Cytopathology and histopathology revealed non-small cell lung cancer. We hereby report the first use of EBUS-TBNA in Nepal, in a patient with lung cancer and mediastinal lymphadenopathy. Keywords: Endobronchial ultrasound; lung cancer; mediastinal lymph node; transbronchial needle aspiration.

School-aged functioning of children diagnosed with autism spectrum disorder before age three: parent-reported diagnostic, adaptive, medication, and school placement outcomes.

Eighty children with early autism spectrum disorder (ASD) diagnoses (under 36 months) were identified using a chart abstraction protocol applied to early intervention charts. Parents filled out questionnaires by mail when the children were school-aged (ages 6-16 years). Similar to previous studies, approximately 20% no longer had ASD diagnoses; the other participants were assigned to Moderate/Severe versus Mild ASD outcome groups. These three groups were compared across several variables, including diagnostic features and functional features including adaptive behavior, social experiences, medication use, and school placement. The findings expand our knowledge about outcomes in longitudinal studies of children with ASD, as well as provide support for using relatively indirect methods (chart review, parent questionnaire) to gather this type of information.

Study of prevalence of hypertension in Chronic Obstructive Pulmonary Disease patients admitted at Nepal Medical College and Teaching Hospital.

A retrospective study of 237 cases of Chronic Obstructive Pulmonary Disease (COPD) patients admitted in medical ward of Nepal Medical College Teaching Hospital (NMCTH) was performed to find out the prevalence of hypertension in such COPD subjects. The prevalence of COPD amongst the total number of patients admitted at NMCTH medical ward was 17.3%. Prevalence of COPD was more after the onset of middle age, the peak was found to be at the age of 60-69 years. Out of these COPD subjects, 98 patients (37 patients were known case of hypertension) had hypertension. Thus prevalence of hypertension was 41.3% in COPD subjects studied. Prevalence increased with age after the age of 50 years and the highest prevalence was at the age of 60-69 years which directly correlates with the prevalence of COPD. The prevalence of hypertension in COPD patients was significantly higher than the normal population that may reflect COPD itself as a risk factor for developing hypertension. A larger and detailed study is needed to confirm such finding.