Leveraging tele-mentoring and remote learning to strengthen the emergency care capacity of health workers in Uganda

Background

A robust emergency care system is a cost-effective method of reducing preventable death and disability, especially in low-and middle-income countries. To scale emergency care expertise across the country, the Uganda Ministry of Health and Seed Global Health established the Emergency Medical Services (EMS) ECHO program. We describe the process of establishing the program in a resource-limited setting, best practices, and lessons learned in Uganda.

Methods

Investigators conducted a mixed-methods evaluation to assess the initial 4 months' implementation of the EMS ECHO. We conducted pre/post-program assessments of healthcare worker knowledge, self-efficacy, and professional's satisfaction with the program. The analysis compared the differences between pre/post-test scores descriptively.

Results

The EMS ECHO was initiated in November 2021. A phased curriculum was developed with the initial phase focusing on the ABCDE (Airway, Breathing, Circulation, Disability, and Exposure) approach to the emergency patient. This phase reached 2,030 health workers cumulatively across 200 health facilities. The majority of the participants were medical doctors (n = 751, 37%), and nurses (n = 568, 28%). Majority of participants (95%) rated the sessions as informative. On whether the ECHO sessions diminished professional isolation, 66% agreed or strongly agreed.

Conclusions

Similar to other ECHO program evaluation results, Uganda's EMS ECHO program improved knowledge, skills, and the development of a virtual community of practice thereby diminishing professional isolation. It also demonstrates that through a planned stepwise process, virtual learning and telementorship can be used efficiently to improve healthcare worker knowledge,skills and multiply the limited number of emergency care experts available in the country.

A Sierra Leone 2021 Midwifery Clinical Training Needs Assessment: A Call to Action to Augment Clinical Precepting

Objective

Sierra Leone has one of the highest maternal mortality and infant mortality rates globally. We share findings from a Midwifery Clinical Training Needs Assessment, conducted in 2021 as a collaboration between the Government of Sierra Leone and Seed Global Health. The assessment identified existing needs and gaps in midwifery clinical training at health facilities in Sierra Leone from various stakeholders' perspectives.

Methods

The descriptive needs assessment utilized mixed methods, including surveys, focus group discussions (FGDs), interviews, and reviews of maternal medical records.

Results

The following showed needs and gaps in labor and delivery management; record keeping; triage processes; clinical education for students, recent graduates, and preceptors; and lack of infrastructure and resources.

Conclusion

The knowledge gained from this needs assessment can further the development of midwifery clinical training programs in Sierra Leone and other low-income countries facing similar challenges. We discuss the implication of our findings.

Building Nursing and Midwifery Capacity Through Rwanda's Human Resources for Health Program

Global disparities in the quantity, distribution, and skills of health workers worldwide pose a threat to attainment of the Sustainable Development Goals by 2030 and deepens already existing global health inequities. Rwanda and other low-resource countries face a critical shortage of health professionals, particularly nurses and midwives. This article describes the Human Resources for Health (HRH) Program in Rwanda, a collaboration between the Ministry of Health of Rwanda and a U.S. consortium of academic institutions. The ultimate goal of the HRH Program is to strengthen health service delivery and to achieve health equity for the poor. The aim of this article is to highlight the HRH nursing and midwifery contributions to capacity building in academic and clinical educational programs throughout Rwanda. International academic partnerships need to align with the priorities of the host country, integrate the strengths of available resources, and encourage a collaborative environment of cultural humility and self-awareness for all participants.

SNAP participation in preschool-aged children and prevalence of overweight and obesity

BACKGROUND

An increased prevalence of overweight and obesity for adults on government-funded nutrition assistance, such as the Supplemental Nutrition Assistance Program (SNAP), has been observed; however, this association among preschool-aged children is not well understood. Longitudinal research designs tracking changes in body mass index-for-age (BMI) in children of low-income households may provide a clearer picture of the association between SNAP participation and overweight and obesity among this age group. To determine if there is a relationship between SNAP participation and overweight and obesity prevalence in low-income, preschool children, we conducted a cross-sectional analysis of children in a Head Start program, and a longitudinal analysis of those children who were enrolled for 2 years.

METHODS

Height and weight data and SNAP participation of 386 students (207 male, 179 female, 4.2 ± 0.5 years) enrolled in a Head Start program were analyzed; data for 2 years were available for 167 of the students. Height and weight measures were used to determine BMI percentile per Centers for Disease Control and Prevention guidelines. SNAP participation was obtained through a nutritional questionnaire given to parents at time of Head Start Program enrollment.

RESULTS

No significant differences were found between SNAP and non-SNAP participants for BMI percentile in either the cross-sectional or longitudinal analysis. BMI percentile increased for both groups over time, but failed to reach significance (p = .13).

CONCLUSION

Future studies are warranted with an inclusion of a larger and more geographically diverse sample to further determine the association between SNAP participation and overweight and obesity in preschool-aged children.

A spirituality teaching program for depression: a randomized controlled trial

OBJECTIVE

This randomized controlled trial assessed the efficacy of a Spirituality Teaching Program to treat unipolar major depression.

METHOD

A randomized controlled, assessor blinded trial design was used. A total of 84 individuals aged 18 years or older with unipolar major depression of mild to moderate severity were recruited in Calgary, Canada and randomized to two study arms: 1) Spirituality Teaching Program Group (8 week, home-based Spirituality Teaching Program); and 2) Waitlist Control Group (no intervention followed by Spirituality Teaching Program starting at week 9). Outcome measures (depression severity, response rate, remission rate) were assessed at baseline, 8, 16, and 24 weeks using the Hamilton Depression Rating Scale (HAM-D).

RESULTS

The two trial groups were similar in their demographic and disease characteristics at baseline. At the 8-week point, the change in depression severity was significantly different between the two groups (change in HAM-D score: 8.5 for the Spirituality Group and 2.3 for the Waitlist Control Group, p < 0.001). The Spirituality Teaching Program Group had significantly higher response (36% vs. 4.4%, p < 0.001) and remission rates (31% vs. 4.4%, p < 0.001) than the Waitlist Control Group. The benefits remained throughout the observation period for the Spirituality Teaching Program Group participants with response rates of 56.4% at 16 weeks and 58.9% at 24 weeks.

CONCLUSION

The Spirituality Program significantly reduced depression severity and increased response and remission rates. This non-drug treatment program should be investigated further as a treatment option for depression.

Relative distribution of West Nile virus RNA in blood compartments: implications for blood donor nucleic acid amplification technology screening

BACKGROUND

Despite implementation of targeted individual-donor nucleic acid test (NAT) screening of blood donors for West Nile virus (WNV), three "breakthrough" WNV transfusion transmission cases were reported (2004-2008), suggesting that current plasma-based assays are unable to detect all WNV-infectious donations. A 2007 report found that 19 of 20 red blood cell components from WNV-infected donors contained 1 log higher viral load than plasma components. This study's aim was to further establish the value of screening whole blood relative to plasma for WNV RNA by generating differential viral loads on paired samples derived from blood screening tubes.

STUDY DESIGN AND METHODS

WNV RNA-positive donors identified by routine NAT screening were enrolled and quantitative viral data were generated using cross-sectional (index-donation) and longitudinal (follow-up) specimens. A real-time reverse transcription-polymerase chain reaction viral load assay was used on both study sample sets and replicate qualitative NAT screening assays were also used on the longitudinal study samples.

RESULTS

For the cross-sectional study, seronegative index donations (n = 29) had WNV RNA concentrations fourfold higher in plasma than in whole blood, whereas for seropositive donations (n = 13), the WNV RNA concentrations were 10-fold higher in whole blood than in plasma. All 10 longitudinal study participants were seropositive throughout the follow-up study; whole blood viral load was consistently greater than plasma viral load (mean difference, 343 copies; p < 0.001) up to 200 days after index.

CONCLUSION

The improved sensitivity of WNV NAT using whole blood instead of plasma was confirmed, but appears to be limited to better detection in seropositive stages. However, the implication of these findings for blood screening requires further study to establish the infectivity of persistent whole blood viremia.

Indigos in Hawai'i: a phenomenological study of the experience of growing up with spiritual intelligence

There is a special group of children around the world who have high intelligence and intuition, healing abilities, and a strong spiritual connection with God, yet these children are often mislabeled as having behavior disorders. Little is known from scientific research about the Indigo phenomenon in America, although many countries, especially among indigenous populations, are familiar with Indigo-like children. The purpose of studying these children when they are adults is to better understand these children when they are older and advance behavior health sciences by increasing awareness of the Indigo phenomenon and learning about their lived experiences. This phenomenological study explored the lived experiences of 10 adult Indigos (> or = 18+ years old) on the island of Oahu, Hawai'i (7 females, 3 males; mean age = 52.4 + SD). Through in-depth semi-structured personal interviews, the experiences of these adults were analyzed and interpreted to identify the common experiences faced during childhood, what worked for their assimilation into society, and recommendations for parents, educators, and health professionals on how to work with Indigos. Bioenergy field (aura) photographs of each participant were also taken. Statements related to the phenomenon were placed into themes, coded, and categorized as the investigators reached a consensus of common themes. Seven primary themes and nine secondary themes emerged from the findings. The primary themes were: grandmother/mother had a similar gift; guided by a higher power to heal self and others; felt "different" or misunderstood; did not openly share their unique abilities; having challenges with partner relationships; history of abuse/violence or frequently disciplined; and use of intuition at work and/or school. Secondary themes included: Using Hawaiian and cultural healing methods; everyone has a degree of intuition and the use of intuition to know when to see a doctor or not; various unique abilities from body and multiple careers; mental health institutions, and financial struggle. Self reports on participants' life purpose, their unique abilities, and being misunderstood were also collected. It was concluded that Indigos felt mislabeled or misunderstood throughout their lives in spite of their belief that their life purpose was to help humankind.

A Mental Health Assessment and Support Team for Community Elders in Fife (EAST)

Background

The aging population combined with the increased recognition of the need to assess elderly patients with mental health difficulties in their own environment encouraged service redesign in Fife with the focus on community assessment of older people with mental health needs.

Aims

To establish and assess the functioning of a joint Health and Social Services enhanced assessment and support team (EAST) for community-dwelling elders with significant mental health needs living in a Scottish health region, and to determine the impact of this team on the requirement for acute psychogeriatric hospital services.

Methods

Prospective three-year data collection of service activity involving EAST and the local psychogeriatric acute inpatient and day hospital facilities.

Results

EAST assessed 111 patients during the study, 83% with a diagnosis of dementia. The mean duration of assessment was six weeks with 9% of patients receiving an overnight home assessment and 6% requiring hospital admission. Overall there was a substantial reduction in utilization of both acute psychogeriatric admission beds and day hospital placements.

Conclusions

Multi-agency community assessment of elders with mental health problems can be addressed effectively without recourse to hospital admission, which may allow resource release for further service developments.

Induction down under

An Australian hospital revamped its induction arrangements for new interns (the equivalent of pre-registration house officers in the UK) in response to negative comments about the traditional programme. The programme was rebuilt to meet their challenge--the result being both more practical and more enjoyable. The three major components of the new programme were skills stations, intern shadowing and a treasure hunt.

Fractured neck of the femur (DRG 210/211): prospective outcome study

BACKGROUND

An ageing population will increase the need for resources to treat patients with a fractured neck of femur (DRG 210/211). Provision of these resources will be helped by a better understanding of current practices.

METHODS

A prospective study of outcome at discharge for 100 consecutive patients with DRG 210/211 was conducted at five Victorian metropolitan teaching hospitals to assess length of stay and the reasons for any variations.

RESULTS

The major influences on timing of discharge were: delayed availability of rehabilitation beds; the timing of referral and assessment by the Geriatric Assessment Team; delay in surgery more than 24 h after admission; and development of postoperative complications.

CONCLUSION

The efficient management of patients with DRG 210/211 requires a strong protocol of treatment and referral strategies with adequate resources.

Predictors of groin complications after balloon and new-device coronary intervention

We reviewed the clinical course of 5,042 patients who underwent percutaneous transluminal coronary angioplasty (PTCA) using balloons or new devices: (stent, laser, directional and rotational atherectomy). A vascular complication was defined as the formation of a groin hematoma, bleeding, pseudoaneurysm, fistula, or the need for surgical repair. Vascular complications occurred in 309 (6.1%) patients, and 117 (2.3%) required vascular repair; among these patients, surgery was performed for correction of an an arteriovenous fistula in 12%, repair of pseudoaneurysm in 72%, repair for expanding hematoma and femoral artery lacerations in 10%, and retroperitoneal bleeding in 6%. The correlates of vascular complications were older age (66.8 vs 62.1 years; p < 0.0001), female gender (43% vs 26%; p < 0.0001), increased weight (82.1 +/- 16.46 vs 78.0 +/- 16.6 kg; p < 0.001), higher systolic blood pressure (140 +/- 25 vs 134 +/- 20 mm Hg; p < 0.001), increased heparin dose during the procedure (14,352 +/- 3,879 vs 13,599 +/- 3,508 IU; p = 0.001), administration of heparin after the procedure (232 vs 2,985 patients; p < 0.0001) and intracoronary stenting (14.9% vs 3.5%; p < 0.0001). Fifteen patients of 214 (7.0%) who underwent stent implantation had surgical repair. Vascular complications were not related to the size of the arterial sheath (8.11 +/- 0.8 vs 8.8 +/- 0.7Fr; p = 0.11) and the use of devices other than stents (laser, atherectomy) did not increase the rate of vascular complications.

Bile duct injury during laparoscopic cholecystectomy: a report of the Standards Sub-committee of the Victorian State Committee of the Royal Australasian College of Surgeons

A survey of Victorian surgeons performing laparoscopic cholecystectomy was carried out. This report discusses the bile duct injuries identified in the survey. Twelve injuries were recorded, a rate of 0.2%. Three of the 12 required formal repair, the other 9 being treated by T-tube alone. Possible mechanisms of these injuries, the experience of the surgeon, the role of operative cholangiography and delays in recognition of the injury are discussed.

Klatskin tumours: a 20 year experience

The management of 27 patients who presented with cholangiocarcinoma of the hepatic confluence over the past 20 years is reviewed, and the dramatic changes, both in accuracy of diagnosis and modes of treatment, are documented. All 27 presented with jaundice, three underwent laparotomy only, four had a T-tube inserted, one had a straight transhepatic tube inserted, seven U-tubes were placed and four patients underwent surgical resection. More recently, seven patients were drained percutaneously and a further patient was treated by an endoscopic stent. There were six postoperative deaths. Of the 24 who received active treatment, the mean survival was 8 months with a range of 0-40 months. The advantages and disadvantages of the various methods of diagnosis and treatment are discussed. The possible role of radiotherapy and chemotherapy are reviewed briefly.

Percutaneous drainage of subphrenic biliary collections using a Ring-McLean sump catheter

This communication reports three consecutive cases of subphrenic biliary collections, resulting from biliary procedures. All were successfully treated percutaneously using a 16 French Ring-McLean sump drainage catheter without the need for secondary surgical intervention. Although percutaneous drainage of fluid collections is now commonplace, this is the first reported use of this drainage catheter for subphrenic biliary collections.