Agents of Change: the word from Halima Adam - emergency medicine nurse, Uganda

Dr. Emilie J. Calvello Hynes

The Global Emergency Care Initiative contributed to sponsoring Halima Adam and Violet Mirembe to attend the 2018 African Conference on Emergency Medicine. As described in the November 13, 2018 post by Dr. Jen Bellows, Halima and Violet showed the world during their presentations how implementation of proven low cost solutions with local champions can create great change in emergency care outcomes.

 Violet Mirembe presenting her data on before and after the  WHO Basic Emergency Care Course  was implemented in her hospital in 2016.

Violet Mirembe presenting her data on before and after the WHO Basic Emergency Care Course was implemented in her hospital in 2016.

We asked Halima, what were your top 3 contributors to success and ongoing challenges with changing emergency care in Uganda? She answered:
Contributors to success:

  1. Applying knowledge, skills and experience while on duty.

2. Positive attitude towards work.

3. Communicating expectations e.g,helping the team to stay focused and on track.

Challenges:

1. Negative attitude of some staffs towards work and change.

2. Inadequate resources in terms of human, equipments, drugs and sundries

3. Lack of enough skilled health personnel

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Halima Adam at AfCEM 2018

Agents of Change for Emergency Medicine in Africa: Nurses!

Dr. Jennifer Whitfield Bellows

This week found the GECI faculty in Kigali, Rwanda at the African Federation of Emergency Medicine Conference. Despite having been to several international EM conferences in the past, I never fail to be humbled and honored to meet the EM physicians that are on the leading edge of our specialty in Africa, who advocate for their patients to receive high quality acute care even as our specialty still struggles to receive recognition and resources.  

 This time, however, it was a different kind of champion that impressed and humbled me. Nurses. 

Developing and implementing emergency medicine systems - the package of advanced triage processes, provision of essential resources, and training of the staff working in emergency departments – does not happen overnight. A remarkable investment is needed for success: to not only implement the processes but to continue to teach and assess them, and to make sure that they remain in place even as staffing, patient volumes, and resources change. Success relies on months or even years of constant monitoring and re-training. Thus a unique kind of local champion is necessary: a person embedded in the community served by this emergency department, who works there every day and intimately understands the cultural and social nuances that effect patient care. 

You know who does that best?  Yep. Nurses. 

Health care human resource shortages are endemic to many low-resource hospitals; and oft-quoted statistic is the alarmingly low ratio of physicians to 100,000 people. Nurses are also in short supply but thankfully not in the same critically low levels as doctors. By necessity, they often step in to provide duties normally ascribed to doctors, a phenomenon known as “task – shifting”.  

As we saw this week, EM systems development is no exception. Nurses have been the leaders creating and maintaining functional, high quality emergency departments, with results that are nothing short of extraordinary. 

Halima Adam and Violet Mirembe are nurses in the Emergency Department at Mubende Regional Hospital in Kampala, Uganda. From 2016 to 2018, they implemented a comprehensive overhaul of the emergency ward including the following:

1.     Got providers trained in the WHO 5 day Basic Emergency Course.

2.     Defined clear roles for providers.

3.     Instituted a triage system.

4.     Ensured basic essential equipment and medications were available and staff was trained on their use. 

5.     Used pathways and checklists to standardize patient care and ensure safe handoffs. 

As a result, massive improvements were seen. From 2015 to 2018: 

1. Vitals were taken on emergency patients 80% of the time, from 30% in 2015.

2. Essential equipment and medicine stocked 70% of the time, up from 40% in 2015.

3. Mortality dropped in their surgical unit (where the ED is located) by an incredible 50%!

Success of this magnitude is extraordinary, and it is a testament to the dedication, resilience and leadership of these nurses to providing excellent care to their patients. I am in awe. 

Every medical resident has a story about how, at least once (or in my case, like once a week) a nurse saved their patient - by catching an error or recognizing when one is decompensating. If Violet and Halima are any indication, nurses that step in and lead their hospitals through emergency care system reform will save countless more.  

 

Implementation of Emergency Clinical Pathways to Improve Patient Outcomes in Zambia

In March 2018, a team of three emergency medicine residents (Kimberly Hill, Chelsea McCullough, and Jennifer Zhan) and one attending physician (Dr. Jennifer Bellows) traveled to Zambia to begin their journey in implementing clinical care pathways to advance emergency care. The team visited five hospitals and engaged in discussions with local staff as well as officials within the Zambian Ministry of Health with regards to feasibility and applicability of the emergency clinical care pathways that GECI has developed over the past few years.

The story began two years before, when the University of Colorado Global Emergency Care Initiative (GECI) launched a study to develop and implement clinical pathways that would provide a systematic approach to early resuscitation and stabilization of acutely ill patients. The GECI team constructed a list of empirically derived chief complaints from multiple African countries. From those lists, the most life-threatening complaints were extracted, and clinical pathways that were consistent with best practice emergency care guidelines - described in the African Federation for Emergency Medicine’s Handbook on Acute and Emergency Care - were developed. The pathways were organized with consideration of resource levels at multiple different types of hospitals common to low and middle-income countries. They were also made available to providers via a free application available on smartphones, allowing for rapid electronic access using the proven AgileMDä platform.

This trip to Zambia represented the initial fact-finding mission and a foundation for the pilot study to be performed in early 2019. The team visited five facilities and met with local health care providers at each site. These facilities represented a spectrum of facility tiers ranging from primary to tertiary levels of care and all completed the World Health Organization’s Basic Emergency Care Course, which provided an essential foundation of emergency care. The team presented overall project aims and five pertinent adult and paediatric clinical care pathways for review: asthma, sepsis, seizure, cough with fever, and blunt and penetrating trauma. A pre-

determined list of questions regarding the facility, the structure of the local emergency unit (EU), and available staff was then answered by the highest ranking provider available with the goal of informing future implementation strategies and site selection for the upcoming pilot study. Clinicians were also asked to provide feedback on the pathways with regards to applicability, feasibility and appropriateness of the selected pathways.

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The team was met with tremendous enthusiasm. Zambian providers overwhelmingly agreed that the pathways would be useful in the emergency care setting and feasible to implement with current levels of training amongst emergency staff. The GECI team now prepares for a return trip in January 2019 to begin the pilot study, where they will select two hospital sites to pilot pathway implementation and data collection on process and clinical patient outcomes as well as pathway utilization by providers.

Additionally, the team facilitated the World Health Organization’s Basic Emergency Care (BEC) course at Chongwe District Hospital. The BEC course is clinical training aimed at frontline providers (doctors, nurses, clinical officers) who by necessity provide emergency care at their facilities, but have received little or no formal training in the field. Chongwe District Hospital is the only hospital in the town of Chongwe, serving a catchment area of 200,000 residents. This is the fifth facility in Zambia where the BEC Course has been taught. The course now spans three provinces and includes a total of 146 participants.

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This project was initiated and driven by GECI and the emergency medicine residents at Denver Health who are passionate about advancing emergency care on a global level. The clinical pathways are the culmination of two years of teamwork and collaboration between GECI, the African Federation for Emergency Medicine, AgileMDä, and GECI’s generous donors. As Dr. Jennifer Zhan describes, “This is the beginning of something great. Not only does this project have a tremendous personal impact, it has the capability to influence emergency care in Zambia and potentially the world. That keeps me ticking.”

2018 American Medical Association Global Health Challenge - Team CU SOM

The Khayelitsha township in South Africa lies just 31.6 kilometers from the cosmopolitan Cape Town, yet is profoundly distant in health outcomes, exampled by Khayelitsha’s 2006 under five infant mortality rate that was 342% higher than that of the country’s Southern Peninsula as a whole. Our experience working in the emergency department of Khayelitsha District Hospital powerfully underscored the importance of understanding the constellation of social determinants that define individual health and inform healthcare decision-making. The disproportionate poverty, violence, and disease burden of the townships are underpinned by historical prejudice that has endured as social inequality. This marginalization is not a tragic relic of a bygone era, but rather an artifact being actively preserved and restored in a new light.

Located on the fringe of Cape Town, these townships are an illustration of apartheid’s lasting mark on South Africa. By design, they are amongst the most densely populated places on Earth, resulting in overcrowding that amplifies disenfranchisement through inescapable economic hardship and disease burden. A majority of the trauma that presented to the emergency department was derived from gangs composed of boys with no direction, no other option within an opportunity-barren landscape beget by a lack of community bond, itself a product of the destruction of vibrant communities by apartheid policies. Unquestionably there has been tremendous progress in South Africa; however, 20 years later, there are still sizable inequities that are too blatant to be ignored.

Sitting on the rocks of Clifton beach #3 was a moment that captured the inescapable contradictions at work in South Africa- the setting sun projecting its color wheel over the ocean, splashing on the jettisons of Table Mountain, seemingly in sync with the rhythmic snap of the electric fence placed atop a layer of barbed wire, protecting the perimeter of the beachside mansion behind us. Structural inequality of this nature cannot be tucked away, out of sight in the Cape Flats, Brazilian Favelas, or Southside Chicago.

In Xhosa, the word Khayelitsha means ‘our new home.’ Indeed, outside of the stabbings, assaults, overdoses, and preventable deaths Khayelitsha is home to a community of over one million people, a majority of which just want better lives and greater opportunity for themselves and their loved ones. Healthcare, particularly global health, puts one at the receiving end of a large sieve that has filtered out the communities, relationships, and everything else that composes an individual and presented you- the physician, the nurse, the student, the technician- with someone at their most vulnerable. A transformation toward a more equitable society does not happen overnight; yet, as members of the global medical field, we can help galvanize it by mustering within ourselves the same self-preservation and fortitude exhibited by those who are marginalized.

Content source: https://amaghc.com/2018-finalists/cusom/

GECI in Panama: Introduction to Emergency Medicine course

In June 2017, Panamanian medical students participated in the “Introduction to Emergency Medicine: Tools for the Medical Frontline” course taught by Dr. Martin Musi, Dr. Julia Dixon and Joel Vaughan, EMT, all staff at the University of Colorado. The course was developed in collaboration with and sponsored by the Universidad de Panamá, Facultad de Medicina (School of Medicine). Medical training in Panama consists of 6 years of undergraduate medical school, followed by a required two years of clinical work. The first year is typically at one of the large hospitals on different rotations followed by one year in more rural communities. After this, they may pursue specialty training.  Currently, medical students have limited training in emergency medicine, yet most will spend one of their post grad years in a setting that requires they be adept at recognizing and treating emergency conditions.

 Medical student participants in Introduction to Emergency Medicine course

Medical student participants in Introduction to Emergency Medicine course

The weeklong course emphasized a multidisciplinary team approach to management of emergencies. Students participated in lectures, workshops, procedures labs, and simulation-case scenarios that covered topics in trauma, medical, pediatric and obstetric emergencies.

 Medical students practice essential trauma skills

Medical students practice essential trauma skills

 Joel Vaughan, EMT instructs on IV placement on a low-fidelity model

Joel Vaughan, EMT instructs on IV placement on a low-fidelity model

The Facultad de Medicina has several high fidelity simulators where small groups of students practiced assessing and treating patients with a variety of conditions. Once acclimated, Dr. Dixon notes, the students thrived in this learning environment. The final simulation scenarios took place in the Emergency Department of the teaching hospital, and included residents from the EM Panamanian Residency to round out the realistic team-based approach.