International Emergency Medicine
URC CAMBODIA QUALITY HEALTH SERVICES
Cambodia has seen remarkable progress in a number of health and wellbeing outcomes over the past decades, particularly in the areas of maternal, infant, and child health. Life expectancy at birth for males and females has increased by over a decade while the maternal mortality ratio and under-five mortality rate have fallen drastically. However despite this progress, Cambodia continues to lag behind its regional neighbors in all of these measures and many others.
Both with significant experience Cambodia, Stanford Emergency Medicine International (SEMI) and University Research Co. (URC) have continued their partnership; collaborating to implement the 5-year USAID Quality Health Services (QHS) project. The overarching goal of this project is to further decrease maternal, infant and child deaths in Cambodia.
In order to do so the project works to sustainably improve:
• Quality of basic newborn care
• Detection, referral, and management of neonatal complications
• Timeliness and quality of care provided to women with obstetric complications
• Availability, quality, and utilization of family planning counseling, screening, and referral of malnourished and severely malnourished children
SEMI is leading one component of the project, focused on developing and strengthening each link in the chain of emergency care, particularly for maternal and neonatal patients. The main interventions being implemented are as follows:
Improve identification of patients with emergency conditions:
Health facilities in Cambodia struggle to sort through and prioritize large numbers of presenting patients. As a result, truly ill patients often face long waits while more mobile or vocal patients are seen promptly. Stanford has designed a simplified triage system to help assess, identify and prioritize sick patients as they arrive. This system, the 1-2 Triage System, is now being used in referral hospitals throughout the project’s target provinces.
Supply providers with evidence based emergency care guidelines:
The majority of Cambodian health care providers treating emergency patients have little or no emergency medical training. In hopes of increasing the capacity of these providers, SEMI has worked with local experts to develop over 70 emergency care and referral guidelines. These guidelines will help enable minimally trained providers to administer consistent, high quality emergency care.
Strengthen referral linkages:
In the current system, providers have very little support when making the complex decision to refer a sick patient. It is often unclear where the patient should be referred, who to contact to facilitate the transfer, how to physically transport the patient, and how to transmit essential patient treatment information. SEMI is working to implement an assortment of tools to assist in the referral process, including province wide clinical and referral hotlines, a standardized referral slip, updated referral guidelines.
Help establish a pre-hospital care system:
Cambodia possesses much of the infrastructure needed to create a functioning inter-facility transport system, however coordination is lacking. SEMI is working closely with the Ministry of Health and Provincial Health leaders to stitch these resources together. Efforts are focusing on improving communication systems and coordinating ambulance activity with a centralized call and dispatch center.
One key component in a successful pre-hospital care system is trained ambulance providers. Up until recently none existed in Cambodia. SEMI has worked with local partners to identify ambulance providers within each referral hospital, and is in the process of providing them with ambulance skills training using a newly created, Cambodian specific, modular curriculum.
With interventions aimed at each link in the chain of emergency care, SEMI will collaborate with their project partners to bring about comprehensive and permanent improvements in the quality of health delivered in Cambodia, helping to fulfill the overall project goal of further decreasing maternal, infant and child deaths.
URC/CHS CAMBODIA EMERGENCY TRIAGE AND RESUSCITATION ROOM
Stanford Emergency Medicine International (SEMI) and URC-CHS have partnered with USAID to address throughput and delivery of emergency care in hospitals in Cambodia. To further this goal, SEMI developed a novel triage system, One-Two-Triage (OTT), which was initially deployed in select government hospitals in Cambodia in December, 2011.
Low and middle-income countries, like Cambodia, are often unable to apply the triage systems used in high-income countries because of a lack of both resources and experienced health care providers. Patients with emergent conditions often wait in dangerously long lines for registration or intake, placing them at increased risk for preventable morbidity and mortality.
Rapid identification of these patients and immediate interventions can prevent clinical deterioration and improve resource utilization (by assigning appropriate wait times to those with less urgent reasons for their visit).
The One-Two-Triage system is an objective, comprehensive triage scale for adults and pediatric patients that can be applied with minimal healthcare training or resources. OTT standardizes the identification of patients needing emergency care in austere environments. While OTT addresses common emergency illnesses that are global, portions of the system are specifically targeted to the cultural context and emergency illnesses of Cambodia.
One-Two-Triage is a two-stage triage process whereby critical and emergent patients are immediately identified based on their ability to respond to a query regarding their chief complaint, objective measures such as pulse oximetry and heart rate, and their chief complaint itself. Patients undergo the second stage of triaging if they do not meet criteria for critical or emergent. Urgent and non-urgent patients are delineated using a set of up to six chief-complaint based, binary questions and vital signs. The triage system uses a job aid to remind providers of relevant questions and help them rapidly and effectively prioritize patients into one of four levels: Red (Resuscitation), Orange (Emergent), Yellow (Urgent) and Green (Non-urgent).
Training in OTT was originally conducted in English by Stanford faculty with Khmer translators in five hospitals in Cambodia. As the system proved successful and demand grew, the training was standardized in Khmer and turned over to on-the-ground Khmer staff.
URC/CHS CAMBODIA SEECC COURSE (2012-2015)
Stanford Emergency Medicine International is partnering with URC (with support from USAID) to strengthen the delivery of emergency care in Cambodia. One of the objectives of this two-year project is to develop an educational course focusing on essential emergency medical care. This course, SEECC (Seminars on Essential Emergency Care), took place in Battambang, Cambodia, from May 21st-24th, 2012.
At present, Cambodia does not have a formal medical curriculum or standardized training in emergency medicine. Many treatable emergency conditions are neither recognized nor addressed at Cambodian hospitals as a result of these educational deficiencies. The SEECC course was designed to address clinical topics essential to the practice of emergency medicine in Cambodia, and emphasize a methodical approach to emergency patient evaluation and management. The SEECC curriculum emphasizes the use of available medical equipment and medications to address common emergency medical conditions and reduce morbidity and mortality.
The SEECC course features high quality PowerPoint presentations, hands-on skills workshops, interactive case-based discussions, and a detailed syllabus with practical illustrations. The PowerPoint presentations and the syllabus were translated from English into Khmai. During the SEECC course, all of the lectures were given in English with a real-time translation into Khmai. These lectures were videotaped using specialized screen-capture software, which allows simultaneous viewing of both the PowerPoint presentation and the lecturers.
The hands-on skills workshops focused on basic life support and advanced airway management. These skills stations allowed the course participants to practice hands-on cardiopulmonary resuscitation and airway management using mannequins. The participants familiarized themselves with skills requisite for the practice of emergency medicine (such as chest compressions, bag-mask ventilation and endotracheal intubation).
During the case-based discussions, facilitators led small groups of participants in interactive discussions of common emergency medical scenarios. Emphasis was placed on a methodical approach to patient evaluation and the importance of time-sensitive emergency interventions. Common medical myths and pitfalls were also discussed.
Videotaped Lecture Examples
Hands-on Skills Workshops
Closing remarks were provided by H.E. Tep Lun, General Director, Ministry of Health.
The inaugural SEECC course was successfully conducted in Battambang, Cambodia, from May 21st-24th, 2012. At the conclusion of the course, all of the course participants were given a detailed printed syllabus (in Khmai) covering the entire course curriculum. The course participants also received continuing medical education certificates endorsed by the Cambodian Ministry of Health, URC and Stanford Emergency Medicine International.
As with all traditional seminar series, the lectures and case-based discussions were conducted live (with active participation of the Stanford faculty and the local instructors). What made this seminar series unique was the real-time translation of all of the lectures into Khmai (to try to improve participant comprehension) and the specialized video capture of each lecture (allowing all the lectures to be re-viewed or utilized for future training).
Our future goals are to conduct a second SEECC course (part 2) that will address relevant emergency medical topics (such as trauma, allergic emergencies, altered mental status, poisoning, snakebites, burns and wound management) and to further develop and train local Cambodian facilitators (utilizing a train the trainer model) for the sustained dissemination of the SEECC courses across Cambodia. It is our hope that this newly created emergency medicine educational curriculum will strengthen the clinical evaluation and treatment skills of local doctors and nurses, and lead to better outcomes for Cambodian emergency patients.
URC/CHS CAMBODIA EMERGENCY MEDICINE CASE-BASED EDUCATIONAL CURRICULUM (2011-2014)
- a. On site observation at local hospitals to identify the most common emergency complaints/conditions (e.g., fever, altered mental status, stroke, sepsis)
- b. Development of evidence-based emergency care algorithms and checklists for these common patient complaints
- i. Will focus on key early interventions that decrease morbidity and mortality
- ii. Will allow for standardization of emergency care
- iii. Will account for the variability of hospital resources (Level 1 vs. 3 hospitals)
- c. Education and training of the management of common emergency complaints/conditions will be conducted in designated hospitals across Cambodia.
- i. Training will be accomplished through a combination of video and in-person lectures, hands-on workshops and small group case discussions.
- ii. A case-based format will be employed when appropriate to ensure that the clinical knowledge is translated into real-world scenarios encountered in Cambodia.
- iii. When appropriate, educational materials will be translated into the local language.
URC/CHS EMERGENCY EPIDEMIOLOGY RESEARCH (2012)
Prospective evaluation of pediatric patients presenting to a provincial hospital emergency department in Cambodia
Many developing countries lack sufficient medical resources, and do not have an established emergency medicine services system. Patients often expend tremendous resources and travel great distances seeking care, and face long waiting times and lack of coordination. Due to the shortage of data about emergency medical care, many health providers in hospitals and clinics in developing nations are unaware of the acute conditions presenting with the highest frequency. Furthermore, hospitals in developing countries tend to be ill equipped to treat medical emergencies and frequently do not follow international treatment protocols specifically designed for patients in resource-limited settings.
The goal of the proposed study is to assess and describe the epidemiology of patients presenting to emergency departments (EDs) at two provincial hospitals in Cambodia. We will collect data on patients chief complaint(s), demographic information, treatment, and disposition, and assess the health outcomes of these patients.. We are hopeful that this information will help guide the development of emergency care practice guidelines and high-impact training modules (for Cambodian healthcare professionals), aimed at improving quality of care for all patients presenting to EDs in Cambodia. Should these training modules deliver measurable improvements to outcomes of patients in Cambodian EDs, this approach might provide a model for improving pediatric emergency medical services in resource-limited settings globally.