Transcript Pediatric Emergency Medicine in Georgia AIHA Initiatives 4

Emory Pediatric Emergency
Medicine in Georgia
at M. Iashvili Children's
Hospital
Ken Walker, MD
Steve Lanski, MD
David Goo, MD
Irakli Sasania, MD
Nino Kikotze, MD
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?

Overview

Initiatives in the project
– Establish an identity
– Train basic skill sets
– Monitor progress
Impediments to progress
 Strategies to accomplish goals

Georgia
Map of Georgia
M. Iashvili Emergency
Department
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.
Goals and Objectives

Goals included:
– Opening the first western style emergency
room in Georgia
– Nursing triage
– Teaching clinical skills to physicians
Goals and Objectives

Goals included:
– Establishing the identity of an pediatric
emergency medicine physician
– Establishing a pediatric teaching center in
Tbilisi
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
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.
Nursing triage

In fact, the nurses were no longer triaging
at all. The junior doctors were now doing
this function. Indicator = 0%
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
Percentages of Sutures by Emergency Medicine Physician
General surgeon
Month
Neurosurgeon
ER Doctor
Total
June
47
23 (49%)
21 (45%)
3
(6%)
July
33
22 (67%)
11 (23%)
0
August
22
9 (41%)
5 (23%)
8
September
25
6 (24%)
8 (32%)
11 (44%)
October
28
6 (21%)
9 (32%)
13 (46%)
November
34
9 (27%)
10 (29%)
15 (44%)
December
22
3 (14%)
6 (27%)
13 (59%)
January
25
1 (4%)
2 (8%)
22 (88%)
February
28
4 (14%)
5 (18%)
19 (68%)
March
27
4 (15%)
2 (7%)
21 (78%)
April
27
2 (7%)
5 (19%)
20 (74%)
(36%)
Assessment
Procedural knowledge

To test the actual knowledge base of the
physicians a pretest on suturing was give
Pretest
Pre-test suturing results
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.
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Average score was 57.8%
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

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
Post workshop results
Clinical skills were passed by all participants
observed.
 Those 5 who 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
Demonstrating Clinical Skills
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.

Mentoring and Proctoring
Training 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.
Suturing competency
Post test results
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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;

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Average was 90%
Pretest average was 57.8%
Month
General surgeon
Neurosurgeon
ER Doctor
Total
June
47
23 (49%)
21 (45%)
3
July
33
22 (67%)
11 (23%)
0
August
22
9 (41%)
5 (23%)
8
September
25
6 (24%)
8 (32%)
11 (44%)
October
28
6 (21%)
9 (32%)
13 (46%)
November
34
9 (27%)
10 (29%)
15 (44%)
December
22
3 (14%)
6 (27%)
13 (59%)
January
25
1 (4%)
2 (8%)
22 (88%)
February
28
4 (14%)
5 (18%)
19 (68%)
March
27
4 (15%)
2 (7%)
21 (78%)
April
27
2 (7%)
5 (19%)
20 (74%)
May
61
0
0
(6%)
(36%)
61 (100%)
Wound care data
03.01.05 - 09.01.05
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Wound and laceration management
Total patients – 99
Managed in the ER – 90
Discharged – 90
Hospitalized – 9
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
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.

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

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

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
New Narcotic Lockbox in ER
Subspecialty Utilization in ER
April 2005
Month
August 2004
Sept 2004
Oct 2004
Nov 2004
Dec 2004
Jan 2005
Feb 2005
March 2005
Subspecialty utilization/ Total ER visits
141/622
193/458
170/ 528
161/555
189/647
145/622
150/637
115/681
Percentage
=
=
=
=
=
=
=
=
36%
42%
32%
29%
29%
23%
23.5%
16.8%
Emergency Room Visits
800
700
600
500
2003
400
2004
300
200
100
3
2
1
12
11
10
9
8
7
m
on
th
0
ER visits/Admission Rates/ Subspecialty
Utilization
3/1/05 – 9/1/05
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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
Continuous Quality Improvement
Education
 Morbidity and Mortality
 Quality Indicators
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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.
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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
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Educational conference
Case of Atropine
poisoning
 Toxidromes
 Literature review
 Therapy
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Educational Conference
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Case Presentation
Pulmonary Empyema
versus Diaphragmatic
Hernia
Clinical correlation
Analysis of history,
physical findings,
radiographs
Final Outcome
Morbidity and Mortality
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ER fatality review
Mushroom poisoning
Toxic effects
Management
Review of Literature
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.

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.
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

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
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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
Suture Materials - $8000
Respiratory Supplies
Egleston ER and Atlanta, GA,
PALS Course
Course Fees and Materials $700.00 US
Physician Expertise
Considerable time and resources of the
Division of Pediatric Emergency Medicine
at Emory University have gone toward this
initiative.
 Previous visits included 5 weeks of
pediatric emergency medicine physician
time.

Physician Expertise

July visit brought 6 pediatric emergency
medicine physicians and all the necessary
equipment to put on a 5 day course on
pediatric emergency medicine. Emory
donated $16,000 toward this trip for
airfares.
PALS July 2005
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First PALS course completed July 14, 2005
certified 23 Georgian physicians from M.
Iashvili Children’s Hospital and Gudashauri
National Medical Center
PALS COURSE
In kind donations of Equipment for
PALS course
$1,000 in supplies left in Tbilisi
PALS COURSE
PALS COURSE
Official Certification from the
American Heart Association
Special participants:
Dr. Ken Walker and Dr. Zviad Kirtava
Train the trainers
PALS Manual Translated into Georgian
Instructors
14 providers were trained in a day long
course to be instructors. They
successfully completed the instructors
course.
 They then gave the course to another 24
participants while being monitored and
proctored.
 All participants were certified as PALS
instructors
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Future Goals and Objectives
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Nursing in triage and continuing nursing education
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Tri-annual Emory visits to monitor progress and teach
clinically. Partnership with Emory’s Office of
International Affairs to support this endeavor
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Establish M. Iashvili as an official PALS training center
in Tbilisi
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Utilize physicians from M. Iashvili to train other
emergency physicians in Georgia. This will require
monetary support to allow physician time off for these
objectives
Future Goals and Objectives
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Prehospital care
Adult emergency medicine
Annual Regional Emergency Medicine conference
Set up observational international pediatric
emergency fellowship
Serve as consultant for pediatric emergency and
pediatric medicine for any international site
USAID - Outstanding Citizen
Citation
From the USAID website:
USAID Honors Atlanta,
Tbilisi Partners with
Outstanding Citizen
Citation
 On April 19, 2006, USAID
honored H. Kenneth
Walker, M.D. of Emory
University with its
Outstanding Citizen
Achievement Citation with
Dr. Irakli Sasania, MD
Map of Georgia
Kutaisi Children’s Hospital
Facility and Exam Rooms
CHOA Emergency Department
Summary
Continued work on establishing
emergency services in Georgia
 Reaffirming relationship with Emory and
Office of International Affairs
 Funding for self sustaining teaching
initiatives from the government of the
Republic of Georgia, American
International Health Alliance and whatever
other sources may be available

What did we accomplish?
Opened first western style emergency
department in ex- Soviet union
 Established an identity of an emergency
room physician
 Taught clinical skills and measured their
success
 Established nursing triage and expertise
 Change admissions policies and utilization

What did we accomplish?
Established a PALS training center
 Began CQI and Morbidity and Mortality
 Began educational conferences
 Continued affiliation with Iashvili with
hope of a sustainable relationship

What skills do I have?
Clinical
 Adminstrative
 Teaching
 Research
 Advocacy

Reality Check
Although all this was calculated as salaried
time, ALL of the time was either vacation,
CME, or time off.
 Division allocated hours to hour teaching
endeavors
 Otherwise, the effort was donated
 Volunteerism is the backbone of most
international work

Summary
PEM fellows and attendings have the skills
to international experts
 The field of international pediatric
emergency medicine is just emerging
 You can be an integral part of initiatives
such as these
 Pick your passion and follow it!

Thank You!