Emory Pediatric Emergency Emory Pediatric Emergency Medicine in GeorgiaMedicine in Georgia

at M. Iashvili Children's at M. Iashvili Children's HospitalHospital

Ken Walker, MDKen Walker, MDSteve Lanski, MDSteve Lanski, MDDavid Goo, MD David Goo, MD

Irakli Sasania, MDIrakli Sasania, MDNino Kikotze, MDNino Kikotze, MD

What skills do I have?What skills do I have?

How can I use my expertise in other How can I use my expertise in other parts of the world?parts of the world?

What limitations are there in terms of What limitations are there in terms of time, energy, and finances?time, energy, and finances?

What are my goal and objectives?What are my goal and objectives? How does this help our field of How does this help our field of

medicine?medicine? What scholarly endeavors can this What scholarly endeavors can this

produce?produce?

OverviewOverview

Initiatives in the projectInitiatives in the project– Establish an identityEstablish an identity– Train basic skill setsTrain basic skill sets– Monitor progressMonitor progress

Impediments to progressImpediments to progress Strategies to accomplish goalsStrategies to accomplish goals

GeorgiaGeorgia

Map of GeorgiaMap of Georgia

M. Iashvili Emergency M. Iashvili Emergency DepartmentDepartment

BackgroundBackground

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

Goals and ObjectivesGoals and Objectives

Goals included:Goals included:– Opening the first western style Opening the first western style

emergency room in Georgiaemergency room in Georgia– Nursing triageNursing triage– Teaching clinical skills to physiciansTeaching clinical skills to physicians

Goals and ObjectivesGoals and Objectives

Goals included:Goals included:– Establishing the identity of an pediatric Establishing the identity of an pediatric

emergency medicine physicianemergency medicine physician– Establishing a pediatric teaching center Establishing a pediatric teaching center

in Tbilisiin Tbilisi

AssessmentAssessment

Assessment of:Assessment of: Nursing triage systemNursing triage system Clinical skills: procedural usage of Clinical skills: procedural usage of

suturing, pain management, and suturing, pain management, and sedation practicesedation practice

Quality indicators; data collected Quality indicators; data collected from the last timefrom the last time

Nursing TriageNursing Triage

Background:Background:

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

Nursing triageNursing triage

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

AssessmentAssessment

Procedural skillsProcedural skills Suturing skills – After two suture Suturing skills – After two suture

workshops the number of doctors workshops the number of doctors who were suturing totaled 5. The who were suturing totaled 5. The rest of the 13 physicians were relying rest of the 13 physicians were relying on these 5 to perform the sutures.on these 5 to perform the sutures.

Suturing by the ER doctors Suturing by the ER doctors increased after the October visit, but increased after the October visit, but still was below expectedstill was below expected

Month

Total

General surgeon Neurosurgeon ER Doctor

June 47 23 (49%) 21 (45%) 3 (6%)

July 33 22 (67%) 11 (23%) 0

August 22 9 (41%) 5 (23%) 8 (36%)

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%)

Percentages of Sutures by Emergency Medicine Physician

AssessmentAssessment

Procedural knowledgeProcedural knowledge

To test the actual knowledge base of the To test the actual knowledge base of the physicians a pretest on suturing was physicians a pretest on suturing was givegive

PretestPretest

Pre-test suturing resultsPre-test suturing results

Pretest resultsPretest resultsTiniko Aptciauri – 60 %Tiniko Aptciauri – 60 %Maka Intskirveli – 77,5 Maka Intskirveli – 77,5 Lali Kashaishvilin – 60 % Lali Kashaishvilin – 60 % Nika Kvachdze – 72,5 % Nika Kvachdze – 72,5 % Jaba Qipiani - 82,5 % Jaba Qipiani - 82,5 % Nato Tavxelidze – 82,5 % Nato Tavxelidze – 82,5 % Nana Rurua – 25 % Nana Rurua – 25 % Giga Beria – 65,5 % Giga Beria – 65,5 % Merab Joxaridze – 85 %Merab Joxaridze – 85 %Maia Tsotniashvili – 52,5 Maia Tsotniashvili – 52,5

% % Beso kavlashvili – failed.Beso kavlashvili – failed.

Average score was Average score was 57.8%57.8%

Wound care workshopWound care workshop

A comprehensive lecture and skills A comprehensive lecture and skills clinic were given to teach the clinic were given to teach the physiciansphysicians

Clinical skills stations were set up to Clinical skills stations were set up to teach suturing skillsteach suturing skills

Observation of suturing technique Observation of suturing technique was required to pass the procedural was required to pass the procedural component of the coursecomponent of the course

PEDIATRIC EMERGENCY MEDICINE PEDIATRIC EMERGENCY MEDICINE PLASTICS SUTURE WORKSHOPPLASTICS SUTURE WORKSHOP

AgendaAgenda0800: Introduction0800: Introduction0810: Pretest0810: Pretest0830: Wound care lecture0830: Wound care lecture

Basics of wound assessmentBasics of wound assessmentAnesthesiaAnesthesiaWound care preparation – irrigation, debridementWound care preparation – irrigation, debridementSuture characteristics and usageSuture characteristics and usageNeedle characteristics and usageNeedle characteristics and usageBasic suture techniquesBasic suture techniquesAdvanced suture techniquesAdvanced suture techniques

0945: Break0945: Break0955:0955: Wound care lecture (continued)Wound care lecture (continued) Background about tissue adhesives and other wound closure techniquesBackground about tissue adhesives and other wound closure techniques

Tissue adhesive application, and proper usageTissue adhesive application, and proper usage1015: Suture workshop1015: Suture workshop

Basic techniquesBasic techniquesAdvanced techniquesAdvanced techniquesTissue adhesivesTissue adhesives

1140: Post test Written and clinical1140: Post test Written and clinical1230: Adjourn1230: Adjourn

Post workshop resultsPost workshop results

Clinical skills were passed by Clinical skills were passed by all all participants observed.participants observed.

Those Those 55 who had already been suturing who had already been suturing in the ER, were given plastics surgery in the ER, were given plastics surgery certification.certification.

All others were to be proctored by the All others were to be proctored by the newly certified physicians. newly certified physicians. – After successfully suturing 5 patients, they After successfully suturing 5 patients, they

would then earn their certificationwould then earn their certification

Demonstrating Clinical Demonstrating Clinical SkillsSkills

Suturing competencySuturing competency

Goal was to have 100% of all the Goal was to have 100% of all the emergency medicine doctors emergency medicine doctors suturingsuturing

Goal would be for greater than 90% Goal would be for greater than 90% of all lacerations to be completed by of all lacerations to be completed by ER physician, and 100% of simple ER physician, and 100% of simple lacerations done by the ER MD.lacerations done by the ER MD.

Mentoring and ProctoringMentoring and ProctoringTraining teachersTraining teachers

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

Suturing competency Suturing competency Post test resultsPost test results

Tiniko Aptciauri – 95 % Tiniko Aptciauri – 95 % passed;passed;

Maka Intskirveli – 90 % Maka Intskirveli – 90 % passed;passed;

Lali Kashaishvilin – 90 % Lali Kashaishvilin – 90 % passed;passed;

Nika Kvachdze – 80 % Nika Kvachdze – 80 % passed;passed;

Jaba Qipiani - 90 % Jaba Qipiani - 90 % passed;passed;

Nato Tavxelidze – 90 % Nato Tavxelidze – 90 % passed;passed;

Nana Rurua – 90 % Nana Rurua – 90 % passed;passed;

Giga Beria – 90% passed;Giga Beria – 90% passed; Merab Joxaridze – 95 % Merab Joxaridze – 95 %

passed;passed;

Average was 90%Average was 90% Pretest average was 57.8%Pretest average was 57.8%

Month

Total

General surgeon Neurosurgeon ER Doctor

June 47 23 (49%) 21 (45%) 3 (6%)

July 33 22 (67%) 11 (23%) 0

August 22 9 (41%) 5 (23%) 8 (36%)

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 61 (100%)

Wound care dataWound care data03.01.05 - 09.01.0503.01.05 - 09.01.05

Wound and laceration management Wound and laceration management

Total patients – 99Total patients – 99 Managed in the ER – 90Managed in the ER – 90 Discharged – 90 Discharged – 90 Hospitalized – 9 Hospitalized – 9

April 2005 Clinical April 2005 Clinical IndicatorsIndicators

Discussions with ER adminstrators to Discussions with ER adminstrators to follow clinical indicatorsfollow clinical indicators– Pain controlPain control– Admission ratesAdmission rates– Subspecialist consultationSubspecialist consultation

Continuous quality improvement, Continuous quality improvement, and continuing medical educationand continuing medical education

Pain Control – AssessmentPain Control – Assessment

Utilization of pain control measures is Utilization of pain control measures is very lowvery low

There was no way to store or give There was no way to store or give narcotics previously, and only Tylenol narcotics previously, and only Tylenol and ibuprofen were given for painand ibuprofen were given for pain

Local anesthesia was given for Local anesthesia was given for suturing, but no topical anesthetics suturing, but no topical anesthetics were employed.were employed.

Pain ControlPain Control

Lectures were given on assessment Lectures were given on assessment and treatment of pain in the pediatric and treatment of pain in the pediatric patientpatient

Work on getting a lockbox with Work on getting a lockbox with appropriate pharmacy control was appropriate pharmacy control was initiatedinitiated

Pain controlPain control

Lock box is in place and now IV Lock box is in place and now IV medications for pain and anxiety are medications for pain and anxiety are being used routinelybeing used routinely

Clinical indicators can now be Clinical indicators can now be collected on pain managementcollected on pain management

Pain medication usagePain medication usage

Midazolam –– 24 ampoulesMidazolam –– 24 ampoules– 06/24/05 through 09/16/0506/24/05 through 09/16/05

Toradol –– 12 ampules Toradol –– 12 ampules – 07/11/05 through 09/16/0507/11/05 through 09/16/05

LET LET (Lidocaine/Epinephrine/Tertracaine)(Lidocaine/Epinephrine/Tertracaine)– 300ml 300ml

New Narcotic Lockbox in ERNew Narcotic Lockbox in ER

Subspecialty Utilization in Subspecialty Utilization in ERER

April 2005April 2005

Month Month Subspecialty utilization/ Total ER visitsSubspecialty utilization/ Total ER visitsPercentagePercentage

August 2004 August 2004 141/622141/622 = 36%= 36%Sept 2004Sept 2004 193/458193/458 = 42%= 42%Oct 2004Oct 2004 170/ 528170/ 528 = 32%= 32%Nov 2004Nov 2004 161/555161/555 = 29%= 29%Dec 2004Dec 2004 189/647189/647 = 29%= 29%Jan 2005Jan 2005 145/622145/622 = = 23%23%Feb 2005Feb 2005 150/637150/637 = = 23.5%23.5%March 2005March 2005 115/681115/681 = = 16.8%16.8%

0

100

200

300

400

500

600

700

800

2003

2004

Emergency Room Emergency Room VisitsVisits

ER visits/Admission Rates/ Subspecialty ER visits/Admission Rates/ Subspecialty UtilizationUtilization

3/1/05 – 9/1/053/1/05 – 9/1/05 Total patients admitted – 7546Total patients admitted – 7546 Hospitalized – 3511Hospitalized – 3511 Not Hospitalized – 4035Not Hospitalized – 4035 Delayed in the ER – 4027Delayed in the ER – 4027 Hospitalized after delay – 1165Hospitalized after delay – 1165 Discharged after delay – 2864Discharged after delay – 2864 Examined and discharged without delay – Examined and discharged without delay –

11691169 Consulted by other specialists – 500 Consulted by other specialists – 500 Mortality – 2 Mortality – 2

Continuous Quality Continuous Quality ImprovementImprovement

EducationEducation Morbidity and MortalityMorbidity and Mortality Quality IndicatorsQuality Indicators

Educational ConferencesEducational Conferences

For continuing medical education, planned For continuing medical education, planned conferences reviewing pediatric conferences reviewing pediatric emergency medicine are mandatoryemergency medicine are mandatory

Previously, no routine learning was on Previously, no routine learning was on going in the department. going in the department.

No review of mortality or poor outcomes No review of mortality or poor outcomes was in placewas in place

Our objective was to have the group Our objective was to have the group understand the need for conferences and understand the need for conferences and to show them how to do it.to show them how to do it.

Educational ConferencesEducational Conferences

Grand Rounds were given daily, 2 Grand Rounds were given daily, 2 cases per day which were interactive cases per day which were interactive learning sessions focused on critical learning sessions focused on critical thinking skills, and clinical thinking skills, and clinical managementmanagement

3 cases were from actual cases in the 3 cases were from actual cases in the emergency center at M.Iashviliemergency center at M.Iashvili

2 were clinical cases2 were clinical cases 1 was Morbidity and Mortality1 was Morbidity and Mortality

Educational conferenceEducational conference

Case of Atropine Case of Atropine poisoningpoisoning

ToxidromesToxidromes Literature reviewLiterature review TherapyTherapy

Educational ConferenceEducational Conference

Case PresentationCase Presentation Pulmonary Pulmonary

Empyema versus Empyema versus Diaphragmatic Diaphragmatic HerniaHernia

Clinical correlationClinical correlation Analysis of history, Analysis of history,

physical findings, physical findings, radiographsradiographs

Final OutcomeFinal Outcome

Morbidity and MortalityMorbidity and Mortality

ER fatality reviewER fatality review Mushroom Mushroom

poisoningpoisoning Toxic effectsToxic effects ManagementManagement Review of Review of

LiteratureLiterature

International Education International Education Web ResourceWeb Resource

Efforts are in place to provide for real time Efforts are in place to provide for real time education internationally.education internationally.

Provide a web cast of lectures on specific Provide a web cast of lectures on specific continuing education topics allowing for an continuing education topics allowing for an interactive exchange of information.interactive exchange of information.

Emory physicians and nurses to develop a Emory physicians and nurses to develop a specific educational curriculum for the specific educational curriculum for the Georgian doctors, focusing on the initiation Georgian doctors, focusing on the initiation of a Pediatric Emergency Department.of a Pediatric Emergency Department.

International Education International Education Web ResourceWeb Resource

Provide an online case-based creation Provide an online case-based creation and presentation tool.and presentation tool.

Formal objectives and testing for the Formal objectives and testing for the purposes of continuing medical purposes of continuing medical education.education.

Mechanisms for Tbilisi PED Physicians to Mechanisms for Tbilisi PED Physicians to provide education on the spectrum of provide education on the spectrum of sick and injured children in Republic of sick and injured children in Republic of Georgia.Georgia.

Emory University Emory University CollaborationCollaboration

Emory University’s President, James Emory University’s President, James Wagner has committed educational Wagner has committed educational resources to the Republic of Georgia, resources to the Republic of Georgia, and hopes to continue this and hopes to continue this collaboration in the futurecollaboration in the future

Global Health InitiativeGlobal Health Initiative

TextbooksTextbooks Pediatric Emergency Medicine, Fleisher Pediatric Emergency Medicine, Fleisher

and Ludwigand Ludwig Pediatric Emergency Medicine Pediatric Emergency Medicine

ProceduresProcedures Pediatric Wound Care, Singer et al.Pediatric Wound Care, Singer et al. PALS manuals/ PALS instructor manualsPALS manuals/ PALS instructor manuals Pediatric Emergency RadiologyPediatric Emergency Radiology Nelson’s Textbook of PediatricsNelson’s Textbook of Pediatrics Harriet Lane HandbookHarriet Lane Handbook Nursing Triage ProtocolsNursing Triage Protocols

Suture materialsSuture materials

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

Suture Materials - $8000Suture Materials - $8000

Respiratory SuppliesRespiratory Supplies

Egleston ER and Atlanta, Egleston ER and Atlanta, GA, PALS CourseGA, PALS Course

Course Fees and Materials $700.00 US

Physician ExpertisePhysician Expertise

Considerable time and resources of Considerable time and resources of the Division of Pediatric Emergency the Division of Pediatric Emergency Medicine at Emory University have Medicine at Emory University have gone toward this initiative.gone toward this initiative.

Previous visits included 5 weeks of Previous visits included 5 weeks of pediatric emergency medicine pediatric emergency medicine physician time. physician time.

Physician ExpertisePhysician Expertise

July visit brought 6 pediatric July visit brought 6 pediatric emergency medicine physicians and emergency medicine physicians and all the necessary equipment to put all the necessary equipment to put on a 5 day course on pediatric on a 5 day course on pediatric emergency medicine. Emory donated emergency medicine. Emory donated $16,000 toward this trip for airfares.$16,000 toward this trip for airfares.

PALS July 2005PALS July 2005

First PALS course completed July 14, First PALS course completed July 14, 2005 certified 23 Georgian 2005 certified 23 Georgian physicians from M. Iashvili Children’s physicians from M. Iashvili Children’s Hospital and Gudashauri National Hospital and Gudashauri National Medical CenterMedical Center

PALS COURSEPALS COURSE

In kind donations of Equipment In kind donations of Equipment for PALS course for PALS course

$1,000 in supplies left in Tbilisi

PALS COURSEPALS COURSE

PALS COURSEPALS COURSE

Official Certification from the Official Certification from the American Heart AssociationAmerican Heart Association

Special participants:Special participants:Dr. Ken Walker and Dr. Zviad Dr. Ken Walker and Dr. Zviad

KirtavaKirtava

Train the trainersTrain the trainers

PALS Manual Translated into PALS Manual Translated into GeorgianGeorgian

InstructorsInstructors

14 providers were trained in a day 14 providers were trained in a day long course to be instructors. They long course to be instructors. They successfully completed the successfully completed the instructors course.instructors course.

They then gave the course to They then gave the course to another 24 participants while being another 24 participants while being monitored and proctored.monitored and proctored.

All participants were certified as All participants were certified as PALS instructorsPALS instructors

Future Goals and Future Goals and ObjectivesObjectives

Nursing in triage and continuing nursing educationNursing in triage and continuing nursing education

Tri-annual Emory visits to monitor progress and Tri-annual Emory visits to monitor progress and teach clinically. Partnership with Emory’s Office of teach clinically. Partnership with Emory’s Office of International Affairs to support this endeavorInternational Affairs to support this endeavor

Establish M. Iashvili as an official PALS training Establish M. Iashvili as an official PALS training center in Tbilisicenter in Tbilisi

Utilize physicians from M. Iashvili to train other Utilize physicians from M. Iashvili to train other emergency physicians in Georgia. This will require emergency physicians in Georgia. This will require monetary support to allow physician time off for monetary support to allow physician time off for these objectivesthese objectives

Future Goals and Future Goals and ObjectivesObjectives

Prehospital carePrehospital care Adult emergency medicineAdult emergency medicine Annual Regional Emergency Medicine Annual Regional Emergency Medicine

conferenceconference Set up observational international pediatric Set up observational international pediatric

emergency fellowshipemergency fellowship Serve as consultant for pediatric emergency Serve as consultant for pediatric emergency

and pediatric medicine for any international and pediatric medicine for any international site site

USAID - Outstanding Citizen USAID - Outstanding Citizen CitationCitation

From the USAID website:From the USAID website:

USAID Honors Atlanta, Tbilisi USAID Honors Atlanta, Tbilisi Partners with Outstanding Citizen Partners with Outstanding Citizen CitationCitation

On April 19, 2006, USAID honored On April 19, 2006, USAID honored H. H. Kenneth Walker, M.D.Kenneth Walker, M.D. of Emory of Emory University with its Outstanding Citizen University with its Outstanding Citizen Achievement Citation with Achievement Citation with Dr. Irakli Dr. Irakli Sasania, MDSasania, MD

Map of GeorgiaMap of Georgia

Kutaisi Children’s HospitalKutaisi Children’s Hospital

Facility and Exam RoomsFacility and Exam Rooms

CHOA Emergency CHOA Emergency DepartmentDepartment

SummarySummary

Continued work on establishing Continued work on establishing emergency services in Georgiaemergency services in Georgia

Reaffirming relationship with Emory Reaffirming relationship with Emory and Office of International Affairsand Office of International Affairs

Funding for self sustaining teaching Funding for self sustaining teaching initiatives from the government of the initiatives from the government of the Republic of Georgia, American Republic of Georgia, American International Health Alliance and International Health Alliance and whatever other sources may be whatever other sources may be availableavailable

What did we accomplish?What did we accomplish?

Opened first western style emergency Opened first western style emergency department in ex- Soviet uniondepartment in ex- Soviet union

Established an identity of an emergency Established an identity of an emergency room physicianroom physician

Taught clinical skills and measured their Taught clinical skills and measured their successsuccess

Established nursing triage and expertiseEstablished nursing triage and expertise Change admissions policies and utilizationChange admissions policies and utilization

What did we accomplish?What did we accomplish?

Established a PALS training centerEstablished a PALS training center Began CQI and Morbidity and Began CQI and Morbidity and

MortalityMortality Began educational conferencesBegan educational conferences Continued affiliation with Iashvili with Continued affiliation with Iashvili with

hope of a sustainable relationshiphope of a sustainable relationship

What skills do I have?What skills do I have?

ClinicalClinical AdminstrativeAdminstrative TeachingTeaching ResearchResearch AdvocacyAdvocacy

Reality CheckReality Check

Although all this was calculated as Although all this was calculated as salaried time, salaried time, ALLALL of the time was of the time was either vacation, CME, or time off.either vacation, CME, or time off.

Division allocated hours to hour Division allocated hours to hour teaching endeavorsteaching endeavors

Otherwise, the effort was donatedOtherwise, the effort was donated Volunteerism is the backbone of Volunteerism is the backbone of

most international workmost international work

SummarySummary

PEM fellows and attendings have the PEM fellows and attendings have the skills to international expertsskills to international experts

The field of international pediatric The field of international pediatric emergency medicine is just emergingemergency medicine is just emerging

You can be an integral part of You can be an integral part of initiatives such as theseinitiatives such as these

Pick your passion and follow it!Pick your passion and follow it!

Thank You!Thank You!