Emory Pediatric Emergency Medicine in Georgia at M. Iashvili Children's Hospital

1. Emory Pediatric Emergency Medicine in Georgiaat M. Iashvili Children's Hospital Ken Walker, MD Steve Lanski, MD David Goo, MD Irakli Sasania, MD Nino Kikotze, MD

2. What skills do I have? • How can I use my expertise in other parts of the world? • What limitations are there in terms of time, energy, and finances? • What are my goal and objectives? • How does this help our field of medicine? • What scholarly endeavors can this produce?

3. Overview • Initiatives in the project • Establish an identity • Train basic skill sets • Monitor progress • Impediments to progress • Strategies to accomplish goals

5. Georgia

6. Map of Georgia

7. M. Iashvili Emergency Department

8. Background Working with the American International Health Alliance, we established an ongoing relationship between pediatric emergency medicine physicians from Emory University, and administrators, doctors and nurses at the M. Iashvili Central Children’s Hospital.

9. Goals and Objectives • Goals included: • Opening the first western style emergency room in Georgia • Nursing triage • Teaching clinical skills to physicians

10. Goals and Objectives • Goals included: • Establishing the identity of an pediatric emergency medicine physician • Establishing a pediatric teaching center in Tbilisi

11. Assessment Assessment of: • Nursing triage system • Clinical skills: procedural usage of suturing, pain management, and sedation practice • Quality indicators; data collected from the last time

12. Nursing Triage Background: Surveillance of the nursing triage system revealed that changes in clinical practice were not as broad as hoped for, and that reassessment and reinforcement of previous objectives was necessary.

13. Nursing triage • In fact, the nurses were no longer triaging at all. The junior doctors were now doing this function. Indicator = 0%

14. Assessment Procedural skills • Suturing skills – After two suture workshops the number of doctors who were suturing totaled 5. The rest of the 13 physicians were relying on these 5 to perform the sutures. • Suturing by the ER doctors increased after the October visit, but still was below expected

15. Percentages of Sutures by Emergency Medicine Physician

16. Assessment Procedural knowledge • To test the actual knowledge base of the physicians a pretest on suturing was give

17. Pretest

18. Pretest results Tiniko Aptciauri – 60 % Maka Intskirveli – 77,5 Lali Kashaishvilin – 60 % Nika Kvachdze – 72,5 % Jaba Qipiani - 82,5 % Nato Tavxelidze – 82,5 % Nana Rurua – 25 % Giga Beria – 65,5 % Merab Joxaridze – 85 % Maia Tsotniashvili – 52,5 % Beso kavlashvili – failed. Average score was 57.8% Pre-test suturing results

19. Wound care workshop • A comprehensive lecture and skills clinic were given to teach the physicians • Clinical skills stations were set up to teach suturing skills • Observation of suturing technique was required to pass the procedural component of the course

20. PEDIATRIC EMERGENCY MEDICINE PLASTICS SUTURE WORKSHOP Agenda 0800: Introduction 0810: Pretest 0830: Wound care lecture Basics of wound assessment Anesthesia Wound care preparation – irrigation, debridement Suture characteristics and usage Needle characteristics and usage Basic suture techniques Advanced suture techniques 0945: Break 0955: Wound care lecture (continued) Background about tissue adhesives and other wound closure techniques Tissue adhesive application, and proper usage 1015: Suture workshop Basic techniques Advanced techniques Tissue adhesives 1140: Post test Written and clinical 1230: Adjourn

21. Post workshop results • Clinical skills were passed by all participants observed. • Those 5who had already been suturing in the ER, were given plastics surgery certification. • All others were to be proctored by the newly certified physicians. • After successfully suturing 5 patients, they would then earn their certification

22. Demonstrating Clinical Skills

23. Suturing competency • Goal was to have 100% of all the emergency medicine doctors suturing • Goal would be for greater than 90% of all lacerations to be completed by ER physician, and 100% of simple lacerations done by the ER MD.

24. Mentoring and ProctoringTraining teachers • Provided and opportunity to utilize the physicians certified in plastic surgery techniques to serve as teachers, and proctors for the residents, and other physicians in the ER that will need further instruction.

25. Tiniko Aptciauri – 95 % passed; Maka Intskirveli – 90 % passed; Lali Kashaishvilin – 90 % passed; Nika Kvachdze – 80 % passed; Jaba Qipiani - 90 % passed; Nato Tavxelidze – 90 % passed; Nana Rurua – 90 % passed; Giga Beria – 90% passed; Merab Joxaridze – 95 % passed; Average was 90% Pretest average was 57.8% Suturing competency Post test results

27. Wound care data03.01.05 - 09.01.05 • Wound and laceration management • Total patients – 99 • Managed in the ER – 90 • Discharged – 90 • Hospitalized – 9

28. April 2005 Clinical Indicators • Discussions with ER adminstrators to follow clinical indicators • Pain control • Admission rates • Subspecialist consultation • Continuous quality improvement, and continuing medical education

29. Pain Control – Assessment • Utilization of pain control measures is very low • There was no way to store or give narcotics previously, and only Tylenol and ibuprofen were given for pain • Local anesthesia was given for suturing, but no topical anesthetics were employed.

30. Pain Control • Lectures were given on assessment and treatment of pain in the pediatric patient • Work on getting a lockbox with appropriate pharmacy control was initiated

31. Pain control • Lock box is in place and now IV medications for pain and anxiety are being used routinely • Clinical indicators can now be collected on pain management

32. Pain medication usage • Midazolam –– 24 ampoules • 06/24/05 through 09/16/05 • Toradol –– 12 ampules • 07/11/05 through 09/16/05 • LET (Lidocaine/Epinephrine/Tertracaine) • 300ml

33. New Narcotic Lockbox in ER

34. Subspecialty Utilization in ERApril 2005 Month Subspecialty utilization/ Total ER visits Percentage August 2004 141/622 = 36% Sept 2004 193/458 = 42% Oct 2004 170/ 528 = 32% Nov 2004 161/555 = 29% Dec 2004 189/647 = 29% Jan 2005 145/622 = 23% Feb 2005 150/637 = 23.5% March 2005 115/681 = 16.8%

35. Emergency Room Visits

36. ER visits/Admission Rates/ Subspecialty Utilization3/1/05 – 9/1/05 • Total patients admitted – 7546 • Hospitalized – 3511 • Not Hospitalized – 4035 • Delayed in the ER – 4027 • Hospitalized after delay – 1165 • Discharged after delay – 2864 • Examined and discharged without delay – 1169 • Consulted by other specialists – 500 • Mortality – 2

37. Continuous Quality Improvement • Education • Morbidity and Mortality • Quality Indicators

38. Educational Conferences • For continuing medical education, planned conferences reviewing pediatric emergency medicine are mandatory • Previously, no routine learning was on going in the department. • No review of mortality or poor outcomes was in place • Our objective was to have the group understand the need for conferences and to show them how to do it.

39. Educational Conferences • Grand Rounds were given daily, 2 cases per day which were interactive learning sessions focused on critical thinking skills, and clinical management • 3 cases were from actual cases in the emergency center at M.Iashvili • 2 were clinical cases • 1 was Morbidity and Mortality

40. Educational conference • Case of Atropine poisoning • Toxidromes • Literature review • Therapy

41. Educational Conference • Case Presentation • Pulmonary Empyema versus Diaphragmatic Hernia • Clinical correlation • Analysis of history, physical findings, radiographs • Final Outcome

42. Morbidity and Mortality • ER fatality review • Mushroom poisoning • Toxic effects • Management • Review of Literature

43. International Education Web Resource • Efforts are in place to provide for real time education internationally. • Provide a web cast of lectures on specific continuing education topics allowing for an interactive exchange of information. • Emory physicians and nurses to develop a specific educational curriculum for the Georgian doctors, focusing on the initiation of a Pediatric Emergency Department.

44. International Education Web Resource • Provide an online case-based creation and presentation tool. • Formal objectives and testing for the purposes of continuing medical education. • Mechanisms for Tbilisi PED Physicians to provide education on the spectrum of sick and injured children in Republic of Georgia.

45. Emory University Collaboration • Emory University’s President, James Wagner has committed educational resources to the Republic of Georgia, and hopes to continue this collaboration in the future • Global Health Initiative

46. Textbooks • Pediatric Emergency Medicine, Fleisher and Ludwig • Pediatric Emergency Medicine Procedures • Pediatric Wound Care, Singer et al. • PALS manuals/ PALS instructor manuals • Pediatric Emergency Radiology • Nelson’s Textbook of Pediatrics • Harriet Lane Handbook • Nursing Triage Protocols

47. Suture materials • Educational grant applied for and successfully obtained from Ethicon for suture materials for ongoing clinical education, and provision of up to date materials for the pediatric emergency department at M. Iashvilli

48. Suture Materials - $8000

49. Respiratory Supplies

50. Egleston ER and Atlanta, GA, PALS Course Course Fees and Materials $700.00 US