CCNEPal will return to the Himalayas, with a bigger and more audacious plan!
Proposal Summary (Executive Summary)
This is a request for funding of a project to train bedside nurses, critical care nurses, fourth-year MBBS students, interns and medical officers in a course that imparts the skills of “Advanced Cardiac Life Support” (ACLS). The term “ACLS” is often associated with the American Heart Association of USA; please note that this proposal is independent of AHA and does not constitute an “official” AHA course in any way. I am requesting up to 20,000 USD for this effort. The proposed time frame would be during the 2017 calendar year.
CCNEPal has used a short-term course to teach critical care skills in Nepal since 2011 and we seek to ramp up the availability to include all Medical Colleges in Terai as well as Colleges of Nursing. This course has been recognized to ease the transition from MBBS study to first-year internship and we seek to demonstrate the need to place this content at this juncture of medical education. This project will organize a sustainable national network of nurses and doctors to promote widespread skill in resuscitation throughout Nepal. This project will build on an extensive group of contacts from nine previous trips to Nepal, including more than half of the medical colleges.
II Organizational Description and History
History – CCNEPal was started in 2011 by Joe Niemczura, RN, MS.
above: a closer view of ecg simulation setup. ecg is not universally taught in Nepal. Most people get ojt.
Niemczura originally spent summer of 2007, 2008 and 2009 teaching PCL nursing at Tansen Nursing School in Palpa District. At the time, he was a nursing faculty member of the University of Hawaii (no longer employed there). Mr. Niemczura holds a Nepal RN license. He has taught critical care in USA since 1981. From the beginning he noticed that USA-style ACLS was not generally implemented in Nepal hospitals. In 2011 he rented classroom space at Lalitpur Nursing Campus, taught some courses there and made two trips out of KTM Valley to teach. He returned to Nepal in 2013, 2014-2015, and 2016.
Each subsequent trip built on the previous trips and a continual process of improvement in course content was employed to produce a course that focused on specific teaching needs of nurses and doctors.
Word of mouth spread rapidly among bedside nurses and doctors. The course sessions are always filled. CCNEPal adopted a system of working with host hospitals for most sessions of the course. Potential hosts contact him and he constructs the schedule after arrival in Kathmandu each year.
In 2016, the eleven week trip consisted of 21 sessions taught outside KTM Valley and 3 inside, with a focus on Terai including Bharatpur, Janakpur and Biratnagar.
In 2013, Niemczura met with officials of Purbanchal University who requested to train nursing faculty at all fifty nursing schools under P.U. (both PCL, BN, and B Sc). CCNEPal was unable to fulfill this, but this grant will help us to conduct training on a scale we previously were unable to do.
Structure This is a one-person privately-funded operation. CCNEPal will teach the course for any Nepali organization that agrees to host them. There is no office, no headquarters, no infrastructure other than a box of supplies.
Office locations – no physical location. We run “virtual”. Lean.
Major accomplishments – CCNEPal has already conducted 90 sessions in locations all around Nepal, and awarded 2,885 certificates. We trained 800 nurses and doctors in Kathmandu Valley who used their skills in the aftermath of the 2015 earthquakes. We have trained nurses from eight cath labs in Nepal including SGNHC, MMCVTTC, Norvic, Bayoda, Dulikhel, CMC, CMS, and Nobel Medical College. We consulted with Center for Medical Simulation to set up their AHA International Training Center for ACLS. CCNEPal has 7,200 “likes” on their FaceBook page, which is used to publicize educational efforts. https://www.facebook.com/2013KtmCriticalCareNursingCourse/
Relevant experience and accomplishments – Joe Niemczura has fifteen years of adult ICU experience in USA, and ten years of nursing management of an ICU/CCU as well as nursing faculty experience.
How the information makes CCNEPal an appropriate grantee – CCNEPal is not bound to any specific geographical location, and has traveled to many locations in the country. A network of previously-trained doctors and nurses is in place to support future efforts. This is truly a collaborative approach that respects the knowledge and experience of Nepali participants.
III Statement of Need
At present, the MBBS curriculum is classroom-focused until graduation. The internship year begins with interns who never managed an emergency, gave a written order, took a cpr class, or assessed critical patient. In the past, ACLS has only been taught at the Medical Officer level. It is CCNEPal’s assessment that the window for this training should be adjusted so that it is delivered during the fourth year of MBBS or at the beginning of internship year.
In USA, by comparison, ACLS is taken during second year of medical school prior to beginning 3rd year clinical clerkships. ACLS is generally required for postgraduate internship in USA.
In Nepal at present, there is a boom in hospital construction and most are starting ICUs, with the attending purchase of ecg monitors, defibrillators and mechanical ventilators, etc. Nursing education at the PCL level in Nepal does not include formal training in ICU skills, and the process to update PCL curriculum via CTEVT is cumbersome. At the B Sc level, a semester is devoted to critical care, but there are not enough faculty who themselves possess the knowledge of resuscitation skills sufficient to teach this material. I have been told that since 2007 the B Sc curriculum included sixteen hours for “Advanced Cardiac Life Support” but the widespread lack of understanding of this was interpreted to mean that the teacher should lecture about heart diseases. In other words, the scenario-based teaching was added to the curriculum but nobody in the country implemented it.
To develop an ICU nurses requires more than just assigning them to ICU, yet this is often the practice.
Most often a school will only own one CPR manikin. The ICU training in Nepal is mostly on-the-job or none. There are several three-month courses of training available, at TU and Norvic. As above, these do not teach ecg or ACLS in the sense that an American would recognize. The number of nurses who complete these programs is insufficient to meet more than small fraction of the need for health manpower in this area.
It is noted that Nepal Critical Care Development Foundation (NCCDF) has begun teaching the “BASIC” course, using a curriculum developed in Hong Kong. CCNEPal applauds this effort, which has now been offered three times. http://www.nccdfnepal.org/basic-for-nurses-training-dhulikhel-hospital/ The course curriculum can be found at: https://www.aic.cuhk.edu.hk/web8/BASIC_for_Nurses.htm It does not specifically focus on resuscitation.
Formal training in the “official” USA ACLS course (up to the USA standard, leading to a card), is not practicable in Nepal. The AHA publishes a specific list of minimum mandatory equipment needed to mount a course, and the total cost is about $25,000, beyond the reach of most schools in Nepal. To see the list, go to: http://www.resuscitationcouncil.co.za/acls-provider-course-equipment-list
In addition, the USA ACLS course teaches certain standards that do not apply to Nepal, and drug doses that are not used in Nepal. Most importantly, the USA “official” courses requires the use of the DVD for lecture sessions, in English. All lectures and discussions in a USA course are required to be in English-language-only. Many nurses and doctors in Nepal have excellent English, but in the rural area where the skills are needed the most, the language requirement puts the course out of reach of many otherwise qualified nurses. One of CCNEPal’s slogans is “You can be expert at this even if you speak no English.” And “the ecg is the same whether you interpret it in English or Nepali or Newari or Hindi.”
Please note that Mr. Niemczura is a former ACLS-Instructor and ACLS Regional Faculty with the AHA, though these are presently lapsed. This course is NOT represented as being the “official” AHA course. Participants in CCNEPal do NOT receive an AHA ACLS card. The point being, AHA ACLS is not the best fit given the conditions of Nepal.
There have been discussions as to how to implement more widespread training like this in Nepal, and it is hoped this can serve as a prototype. With the current attention on placement of young doctors to serve in rural areas for a year after internship, this course is needed as continuing education.
It takes a while to grow the personnel who can teach this confidently. They need “street credibility” of a certain level. More than “train the trainer” is needed. We can create a broad-based movement that extends beyond Kathmandu Valley and mitigates excess deaths due to lack of access to lifesaving emergency skills.
Simulation education is very new to Nepal, and this is a scenario-based course. It relies on techniques that teach teamwork, initiative and problem solving within the framework of an ACLS protocol.
IV Project Description (Program Narrative)
We plan to continue conducting sessions at nursing schools, teaching hospitals and medical colleges. Host locations will be chosen to represent agencies most likely to followthrough with their own programs. The initial list will start with the previous hosts for the training and add locations based on a focus of schools outside KTM Valley.
One of the key skills for critical care is ecg reading, and CCNEP owns two AT-35 rhythm generators (Pinnacle Technology). We plan to purchase enough so each medical college in Terai can own one and use it for teaching. We will gather a group of them for use in our own scenario-based stations.
The course as presently offered, as well as the pedagogical approach, is amply described on the Nursing in Nepal wordpress blog. www.joeniemczura.wordpress.com
In 2016 I travelled to Pokhara, Bharatpur, Janakpur, and Biratnagar, ending with three sessions in Kathmandu. I’ve previously taught at UCMS in Bhairawaha, and would return there. In 2017 I would plan to add Birgunj, Nepalgunj, Dharan, and Jumla to the list.
CCNEPal was approached in 2013 by Siddharta Koirala, MD Vice-Chancellor of P.U. who asked if we would organize a program that would include nursing faculty from all nursing campuses under P.U., so they could incorporate this into P.U. curriculum. This willing ness was reconfirmed in 2016. There are about thirty schools under the P.U. umbrella. The list of affiliated nursing colleges of P.U. can be found at: http://wapnepalonline.com/purbanchal-university-health-science-affiliated-colleges-admission/
With this ANMF funding we can work with P.U., a major stakeholder, to make it happen. We can also use the regional conference approach to promote this training for other schools.
What Makes CCNEPal different?
Our approach to classroom management. We organize each session into small groups and we appoint the top participants into the role of “assistant” for the class. Short lectures are delivered in English, then the groups act out each scenario under the guidance of the “assistant.” Using this approach, groups practice each scenario in Nepali (or in some cases Hindi or Maithili) and discuss the scenarios in a language they are most comfortable with. Students receive feedback in Nepali. Many video examples of small group work for the typical CCNEPal session can be found at: www.youtube.com/joeniemczura