PERSPECTIVES Bolstering Medical Education to Enhance Critical Care Capacity in Cambodia Tyler J. Albert1,2, Thomas Fassier3,4, Meng Chhuoy4,5, Youttiroung Bounchan4, Sokhak Tan4,5, No Ku4,6, Nareth Chhor4,5, James P. LoGerfo7,8, and T. Eoin West1,2,8 1
Division of Pulmonary and Critical Care Medicine, Department of Medicine, 2International Respiratory and Severe Illness Center, 7Division of General Internal Medicine, Department of Medicine, and 8Department of Global Health, University of Washington, Seattle, Washington; 3French Cooperation, Phnom Penh, Cambodia; 4University of Health Sciences, Phnom Penh, Cambodia; 5Calmette Hospital, Phnom Penh, Cambodia; and 6Khmer Soviet Friendship Hospital, Phnom Penh, Cambodia
Abstract The capacity to care for the critically ill has long been viewed as a fundamental element of established and comprehensive health care systems. Extending this capacity to health care systems in low- and middle-income countries is important given the burden of disease in these regions and the significance of critical care in overall health system strengthening. However, many practicalities of improving access and delivery of critical care in resource-limited settings have yet to be elucidated. We have initiated a program to build capacity for the care of critically ill patients in one low-income Southeast Asian country, Cambodia. We are leveraging existing international academic partnerships to enhance postgraduate critical care education in Cambodia. After conducting a needs assessment and literature review, we developed a three-step initiative targeting training in mechanical ventilation. First, we assessed and revised the
current resident curriculum pertaining to mechanical ventilation. We addressed gaps in training, incorporated specific goals and learning objectives, and decreased the hours of lectures in favor of additional bedside training. Second, we are incorporating e-learning, e-teaching, and e-assessment into the curriculum, with both live, interactive and independent, self-paced online instruction. Third, we are developing a train-the-trainer program defined by bidirectional international faculty exchanges to provide hands-on, case-based, and bedside training to achieve competency-based outcomes. In targeting specific educational needs and a key population—the next generation of Cambodian intensivists—this carefully designed approach should address some existing gaps in the health care system and hopefully yield a lasting impact. Keywords: Cambodia; critical care; critical illness; delivery of health care; health resources
(Received in original form December 5, 2014; accepted in final form February 28, 2015 ) Supported by an INTERSECT-Ellison Fellowship and an Alpha Omega Alpha Postgraduate Award (both to T.J.A.). Author Contributions: All listed authors contributed to the preparation of this manuscript. Correspondence and requests for reprints should be addressed to Tyler J. Albert, M.D., 1959 NE Pacific Street, Box 356522, Seattle, WA 98195-6522. E-mail: [email protected] Ann Am Thorac Soc Vol 12, No 4, pp 491–497, Apr 2015 Copyright © 2015 by the American Thoracic Society DOI: 10.1513/AnnalsATS.201412-557AR Internet address: www.atsjournals.org
The capacity to care for the critically ill has long been viewed as a fundamental element of established and comprehensive health care systems. Extending this capacity to health care systems in low- and middle-income countries is now increasingly recognized as an important endeavor (1–3); however, many practicalities of improving access and delivery of critical care in resource-limited settings have yet to be elucidated. As partners with local clinicians and hospital leaders, we have launched an
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initiative to build capacity for the care of critically ill adults in one such resourcelimited nation, Cambodia. The World Bank categorizes Cambodia as a low-income country (gross national income per capita, $709 in 2013) of 14.9 million inhabitants (4). Cambodia’s health care system is in flux with rapid progress by some measures; however, critical care capacity remains limited (5). We discuss the rationale and approach to our educational initiative focusing on postgraduate training that is
designed to augment the provision of critical care in Cambodia.
Rationale: Why Enhance Critical Care Capacity in Resource-Limited Settings? Investment of time, energy, and money toward enhancing critical care capacity in resource-limited settings can encounter considerable resistance. Yet there are
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PERSPECTIVES numerous reasons why this resistance must be overcome. First, care of the critically ill individual does not necessarily require complex therapies. In fact, many life-saving treatments need not be particularly expensive or labor-intensive, nor need they occur in an intensive care unit (ICU). For example, antibiotic and fluid administration for septic shock (6), oxygen administration for hypoxemia (7), and prereferral rectal antimalarial therapy (8) have all been shown to be effective while using minimal resources. Second, current internationally embraced efforts that address health necessitate the consideration of critical care. The United Nations’ Millennium Development Goals include reduction in child mortality, improvement in maternal health, and combating HIV/AIDS, malaria, and other diseases (9). Although severe sepsis, respiratory failure, and hemorrhagic shock may be complications of these target conditions, unfortunately there is limited to no inclusion of critical care within many health system–strengthening initiatives. Third, the capacity to treat the critically ill is a central element to any health care system. An often-heard argument is that limited resources should be allocated preferentially to prevention efforts. However, the reality is that despite beneficial prevention measures, people still become sick and require treatment, with a subset becoming severely ill. Moreover, these components of health care—prevention and treatment—need not be isolated or managed separately, as they are in fact complementary. Provision of timely and appropriate care to the severely ill may build community confidence in the local health care system, leading to increased use of primary care. In effect, this can prevent the progression of chronic disease, and, coming full circle, subsequently lower the prevalence of critical illness (1). Fourth, although a disproportionate burden of critical illness occurs in resourcelimited settings (10, 11), epidemiologic data are scarce (12). As ICUs do not exist in many hospitals, this may be in part due to the heightened difficulty in capturing the critically ill in the absence of geographic advantages afforded by ICUs. An additional contributor may be a lack of widespread use of syndromic diagnostic terminologies that identify severe illness, such as respiratory failure, acute respiratory distress syndrome, acute kidney injury, and severe 492
sepsis. Enhancing critical care capacity will enable the capture of epidemiologic data on critically ill patients and aid in the development of preventive and therapeutic interventions. Together, these factors support the importance of developing critical care capacity in resource-limited countries, a concept that is increasingly being recognized (10–13). Core principles to consider in this endeavor include the integration of disease-specific interventions within a broader training in critical care medicine, regionalization of critical care, investment in human resource training, and careful assessment and tailoring of interventions for specific environments.
The Cambodian Context Although there have been substantial economic improvements in recent years in Cambodia, such as a decrease in the poverty rate from 53% in 2004 to 21% in 2011, many people remain extremely vulnerable (14). The majority (80%) of the Cambodian population lives in rural settings (15) and tends to have poor housing conditions and levels of education compared with urban residents (16). The country receives annual international aid of close to $1 billion, accounting for almost 70% of public expenditure dispersed through multilateral agencies, bilateral government cooperation projects, and more than 100 national and international nongovernmental organizations (15, 17). Cambodia’s health care system is in transition. There have been marked improvements in maternal health, infant mortality, and HIV/AIDS care (14, 18). The number of hospitals increased from 44 to 68 and the number of regional health centers jumped from 101 to 516 over the last 6 years (18). As of 2012, life expectancy has increased to 71 years. Despite these encouraging statistics, a major challenge facing the country is the lack of adequate resource capabilities. There are meager ratios of 2.3 physicians and 7.9 nurses for every 10,000 people, compared with regional averages of 15.2 and 19.5, respectively (15, 17), and the overall majority of specialized physicians in Cambodia reside within urban boundaries (19). Furthermore, the health care professional training system is severely limited, with annual graduation of only 290
doctors and 410 nurses, one major public university, and only one specialist postgraduate training program in pulmonary and anesthesiology for the entire country (20). In this context, critical care capacity in Cambodia is important. Of major regions defined by the World Bank, Southeast Asia has the highest number of deaths and highest potential burden of sepsis, acute lung injury, and patients requiring mechanical ventilation (12). At present, acute respiratory infections are the leading cause of both morbidity and mortality in Cambodia (15), probably due to sepsis and respiratory failure. Robust data on Cambodian critical care capacity are scarce (perhaps due to the lack of data on ICUs) but more than 50 public referral hospitals in the country are reported to have some ICU capacity (5). Despite this, one study estimated that Cambodia would have the highest rates of avoidable deaths in the region during an influenza pandemic, mainly due to severe shortages of mechanical ventilators and a lack of adequately trained health care personnel, specifically physicians and nurses (21). Thus, it is not only imperative to expand Cambodian critical care capacity, but training health care workers is a central element of any proposed strategy.
An Approach to Enhance Critical Care Capacity International Educational Collaboration
A number of foreign institutions and individuals have partnered with Cambodian colleagues to promote enhanced provision of care to the critically ill, sometimes as part of emergency medicine or anesthesiology training programs. These initiatives include education in triage and resuscitation, pediatric critical care, advanced trauma life support, airway management, and treatment of severe acute respiratory infection and use of mechanical ventilation. In addition, the Cambodian Society of Anesthesia, Critical Care, and Emergency Medicine (SCARMU, www.scarmu.org) hosts an annual scientific congress that includes intensivists from around the world. Many of these valuable efforts target practicing clinicians rather than trainees. Concurrently extending international collaborations to existing institutional training systems and focusing
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PERSPECTIVES on trainee intensivists carries the potential to further enhance sustainability of critical care educational initiatives in Cambodia. The University of Health Sciences in Cambodia (UHSC) is the only public institution in Cambodia to offer postgraduate training in critical care medicine—as part of an educational program encompassing anesthesia, emergency medicine, and critical care medicine. The clinical component of this training is conducted at two national hospitals in Phnom Penh: Calmette Hospital and the Khmer Soviet Friendship Hospital. UHSC and these partnering hospitals have been the focal point for international collaborations in Cambodia. There has been a longstanding French–Cambodian partnership involving UHSC to strengthen training of undergraduate and postgraduate students in medicine. The University of Washington (UW) has also joined UHSC to help achieve the dual goals of improving patient care and expanding medical education. Focusing educational efforts on trainees in academic institutions complements initiatives augmenting the skills of accomplished practicing clinicians by better preparing the next generation of health care providers. We proposed, therefore, to leverage these established international collaborations to further enhance postgraduate critical care training at UHSC. Participants in this strategy included the leadership of the UHSC anesthesia, emergency medicine, and critical care medicine residency, the directors of the training hospital ICUs, the UHSC-based French Ministry of Foreign Affairs technical assistant, and academic intensivists from UW. In initial discussions over several months, we identified provision of mechanical ventilation as a therapy that was used commonly but around which there was tremendous variation in practice and uncertain competency of trainees. As a first step, we elected to focus our efforts on this topic and endeavored to adopt an approach to developing an educational collaboration that would be informed, targeted, practical, sustainable, and applicable to other topics. Needs Assessment
Three of our authors (T.J.A., T.F., T.E.W.) subsequently performed a needs assessment in a systematic manner over the course of a 2-week visit to Phnom Penh. Three 4-hour on-site visits to ICUs and emergency Perspectives
departments were held to observe the use and practices of mechanical ventilation at the two hospitals affiliated with UHSC. Four open-ended, group interviews were held with the health care leadership (hospital, ICU and emergency room directors, chiefs of nursing) and 8 clinicians from Khmer Soviet Friendship Hospital and Calmette Hospital, as well as educators (vice dean of medicine, chiefs of pulmonary and anesthesia, emergency medicine, and critical care) and 18 current and past trainees from UHSC that focused on perceptions of needs, opportunities, and barriers. We then reviewed former, existing, and planned interventions through other international collaborations that aimed to support critical care education and we evaluated existing critical care curricula at UHSC. Last, we assessed current critical care resident knowledge, using a previously validated knowledge assessment tool (22) that was considered pertinent given the resources at UHSC training sites. After confirming adequate language proficiency, this questionnaire was administered to 19 of 21 current critical care trainees in English during one 4-hour session and identified a wide range of understanding of pulmonary physiology and mechanical ventilation (23). For example, residents were skilled at diagnosing auto-PEEP (positive end-expiratory pressure) and selecting patients ready for liberation from mechanical ventilation but were less capable of correctly using PEEP for hypoxemia or identifying tension pneumothorax. The overall needs assessment identified a broad range of clinical practice around mechanical ventilation, specific trainee knowledge gaps, limited clinical time and responsibility assigned to trainees, and a lack of competency-based curricula or standardized assessment tools (24) (Table 1). There was also restricted academic support for clinical faculty and a need for institutionalization of partnerships. Literature Review
We undertook a thorough review of the literature to learn from previously successful models of education. Despite a recent surge, there have been a limited number of publications discussing adult critical illness in resource-limited settings (1–3, 10, 12, 25–29), with most focusing on the management of severe sepsis in subSaharan Africa and only a few focusing on
education (30–34). Education in mechanical ventilation is enhanced by targeted multifaceted approaches, and simulation offers new tools (35). Published reports reveal improvements in knowledge, teaching behavior, and learning climate with the use of train-the-trainer curricula (33, 34, 36, 37), and have demonstrated significant improvements with both education and clinical practice in lowresource settings (33, 38–40). However, there have been only two reports of train-the-trainer curricula focusing on mechanical ventilation (33, 34), and we could identify no reports of train-thetrainer curricula occurring in Cambodia. Evidence suggests that train-the-trainer programs can effectively disseminate and implement guidelines and curricula to health care professionals from diverse cultures working in a variety of clinical areas by incorporating interactive, multifaceted teaching methods (case studies and scenarios, didactic presentations, interactive role plays, group discussions) and accompanying learning materials for selfdirected learning (40). Effective programs use competency-based outcomes, clarify expectations for both the trainers and the newly trained leaders, and take into account cultural differences when modifying teaching and feedback methods (41). Evaluation of Barriers
We also characterized potential barriers to success during site visits. We found a lack of equipment and supplies (oxygen, endotracheal tubes, suction catheters, etc.), time restraints, systemic and structural limitations, and funding limitations that will need to be overcome. In addition, we found significant language and cultural barriers, a lack of empowerment and ownership, limited faculty and academic support, and long-term sustainability issues that will need to be addressed. Development of an Educational Initiative
These efforts informed the design of an initiative centered on improving postgraduate training in mechanical ventilation. We based the initiative within the existing UW–UHSC collaborative framework, endorsed by interinstitutional memoranda of understandings. After evaluating the training needs of all health care professionals involved with mechanical ventilation, we chose to target postgraduate residents because of their availability and 493
PERSPECTIVES Table 1. Needs assessment for postgraduate education in mechanical ventilation Area Assessed MV use and practices Perception of need MV education and training
Assessment Tools
Findings
ICU/ED site visits at Calmette and Khmer Soviet Friendship Hospitals Structured interviews and focus groups with health care leadership, educators, clinicians, and trainees Evaluation of existing critical care curricula at UHSC; structured interviews and focus groups; ICU/ED site visits
International cooperation
Review and mapping of existing educational initiatives, interviews with health care leadership
Understanding of pulmonary physiology and MV
Current critical care resident knowledge assessment
Heterogeneous equipment; lack of standardization or multidisciplinary care Widespread enthusiasm and institutional support for improvement in medical education and clinical training Lack of competency-based curricula, standardized assessment tools, or simulation-based education; limited clinical time and responsibility for trainees; restricted availability and academic support for clinical faculty Need for institutionalization of partnerships (memorandum of understandings, working agendas, funding), coordination with other partners Specific target areas for future training, e.g., use of PEEP and identifying tension pneumothorax
Definition of abbreviations: ED = emergency department; ICU = intensive care unit; MV = mechanical ventilation; PEEP = positive end-expiratory pressure; UHSC = University of Health Sciences, Cambodia.
accessibility to pre- and in-service training, minimal language barriers, and appropriate group sizes for small-group training and longitudinal follow-up. We defined three components to the initiative. First, we proposed to assess and revise the design of the existing critical care resident curriculum with respect to respiratory failure and mechanical ventilation education. Second, we sought to incorporate new educational tools into this curriculum, using e-learning, e-teaching, and e-assessment. Third, we planned to develop and integrate a trainthe-trainer program within the curriculum. Progress to Date
To date, we have completed the first component of the initiative. We evaluated the current curriculum used by UHSC and
compared it with residency curricula in use in the United States, France, and elsewhere in Southeast Asia. The UHSC curriculum is divided into 12 modules that are taught in lecture format over 3 years. Clinical ICU time totals 8 weeks at the two referral hospitals, with roles ranging from observation to admission of patients overnight. We then revised and reframed much of the curriculum pertaining to mechanical ventilation. We first addressed gaps in mechanical ventilation training and the related topics of pulmonary physiology and respiratory failure. We next assessed the balance of didactic versus bedside teaching in the curriculum, decreasing the amount of annual didactic training by one-third and creating additional time for bedside training. Finally, we incorporated specific goals and
learning objectives into the curriculum, based on core competencies. The second component is nearly finalized and will be pilot-tested in the coming months. It has been developed using evidence-based medical education principles of e-learning, e-teaching, and e-assessment (42–44). It takes advantage of widely available Internet access for trainees, existing web-based resources, and sophisticated video-conferencing capacity at UHSC and UW. This component will incorporate several live, interactive distance e-teaching/e-learning sessions between UW and UHSC interspersed with online e-learning tutorials (45, 46). Formative and summative e-assessment modules will be used to identify knowledge gaps and monitor achievement of milestones. Special
Table 2. Proposed e-learning, e-teaching, and e-assessment scheme Time Frame Week 1: Initial e-teaching session Weeks 1–2: e-learning, formative e-assessment
Week 3: Subsequent e-teaching sessions Week 4: Summative e-assessment
Goals To establish objectives and introduce the basic concepts of MV To allow students to learn at their own pace and identify knowledge gaps
To review concepts, fill gaps, and provide feedback based on formative assessment To evaluate student learning
Tools Video conferences, syllabus, learning objectives Online tutorials, relevant chapters of textbooks and reference articles, pocket cards covering (1) respiratory physiology, (2) respiratory critical illness, and (3) basic principles in MV; clinical case–based MCQs Targeted, interactive clinical case examples; unstructured question-and-answer time MCQs (single best answer format, “type A”)
Definition of abbreviations: MCQs = multiple choice questions; MV = mechanical ventilation.
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PERSPECTIVES consideration will be given to issues related to language, participant confidentiality, and validity of assessments (43). A 4-week scheme is proposed in Table 2. The design, delivery, and assessment of the component will be orchestrated by two key coordinators from each site. Concurrently, we are designing the third component of the initiative: a practical train-the-trainer program with a major objective being improvement in the process of training. In addition to improving trainee knowledge of mechanical ventilation, this will lead to greater self-sufficiency of UHSC educators, enhancing sustainability of the initiative. The model we propose involves a UHSC– UW faculty partnership with bidirectional exchanges. UHSC faculty will visit UW to directly observe models of resident and fellow training in critical care. UW faculty will subsequently travel to Phnom Penh several times annually to partner with UHSC faculty in performing didactic and bedside teaching on MV at critical care training sites. A key focus will be hands-on, casebased, and bedside training to achieve competency-based outcomes and other elements of effective train-the-trainer programs as outlined in Table 3. In addition
to exposing UHSC faculty to pedagogical techniques and assessment of core competencies used in the United States, this interactive exchange will provide abundant opportunities for evaluation and discussion of ICU design and processes of care, usefulness of mechanical ventilation care bundles, and interdisciplinary care. In subsequent years, as the partnership matures and UHSC faculty gain familiarity with and adopt these contemporary training methodologies, the direct involvement of UW faculty in teaching will be reduced and/or redirected. Although the fundamental principles of the initiative are durable, we fully anticipate that our approach to implementation will require constant and creative revision. The educational impact of the initiative can be tracked by assessments of resident knowledge and satisfaction. To further ensure that the initiative remains feasible, relevant, and appropriately targeted, and that it is fostering self-sufficiency, participating faculty from both UW and UHSC will be regularly debriefed. These data will be reviewed by all stakeholders and used to guide and modify the initiative as necessary. Notably, the first and second components of our initiative have been/can
Table 3. Elements of an effective train-the-trainer program Educational Climate Preparation (“know before you go”)
Medical environment Cultural norms and differences Identify future partners Identify learners’ needs Identify content
Critical elements to success
Establish common goals Be flexible Be knowledgeable Use your own teaching strategies Maximize your partners’ strengths Teach by example
Interactive training methods
Case studies and scenarios Problem-based learning Group discussions Practical demonstrations and exercises Role-plays Bedside teaching
Posttraining follow-up
Real-time feedback Prepare trainers for future workshops Peer education Graduated responsibility Maintain a long-term presence Continual curriculum revision
Data derived from References 40 and 41.
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be accomplished at relatively low cost, relying heavily on adaption of existing curricula and established assessment tools, and communicating and interacting virtually, using inexpensive Internet-based technologies. The train-the-trainer component is the most expensive as this requires considerable international travel and time abroad. Thus far, we have received pilot funding to implement the initiative from the UW International Respiratory and Severe Illness Center (INTERSECT [47]), as well as from the Alpha Omega Alpha Honor Medical Society, but additional funds will be necessary. Ensuring adequate and durable involvement of international faculty is also essential to the success of this initiative. Globally, intensivists are displaying an increasing interest in critical care in low-resource settings, however, and there is a large cohort of critical care fellows and faculty at UW and elsewhere that is committed to participating in initiatives such as this.
Future Directions and Related Activities We hope that this initiative will not only improve resident education but also enhance the quality of care delivered. Ideally, this initiative will prove to be a model that can be extended to other topics and specialties in Cambodia and potentially to other resource-limited countries. The initiative also offers additional opportunities to tackle many of the intrinsic barriers in Cambodian health care and contribute to system-wide changes. Fully overcoming the hurdles we identified in our needs assessment is likely to take many years, but the established and vibrant partnership between the two academic institutions, with the associated support of administrative leadership, renders this more feasible. Training future practitioners who will care for generations of Cambodians in the foreseeable future ensures sustainability. Moreover, continuous interaction between foreign and Khmer faculty will help open doors for future training, education, and clinical research, expanding the role of academic medicine and widening Cambodia’s international exposure. Thus, through specialized training in the management of acute respiratory failure, long-term collaborations will be fostered 495
PERSPECTIVES with a common goal of improving communication and funds of knowledge within the Cambodian medical education system and the health care system as a whole. Although our current activities target physicians, nurses in the ICUs handle much of the management of mechanical ventilation. The position of respiratory therapist, common in other countries such as the United States, does not exist in Cambodia. In light of this, we are concurrently partnering with nurses,
respiratory therapists, and respiratory therapy educators to develop nurse-specific training for mechanical ventilation. We note that our initiative is only one of many related efforts underway in Cambodia and is not the first to address critical care education. We are optimistic that our approach will not only prove longitudinally effective but will complement existing training efforts and thereby facilitate synergistic interactions to further improve care of the critically ill in
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program: a systematic review. J Contin Educ Health Prof 2012; 32:215–226. Weiner SG, Totten VY, Jacquet GA, Douglass K, Birnbaumer DM, Promes SB, Martin IB; Society for Academic Emergency Medicine’s Global Emergency Medicine Academy. Effective teaching and feedback skills for international emergency medicine “train the trainers” programs. J Emerg Med 2013;45:718–725. Ellaway R, Masters K. AMEE Guide 32: e-Learning in medical education. Part 1: Learning, teaching and assessment. Med Teach 2008;30:455–473. Masters K, Ellaway R. e-Learning in medical education Guide 32. Part 2: Technology, management and design. Med Teach 2008;30: 474–489. Ruiz JG, Mintzer MJ, Leipzig RM. The impact of e-learning in medical education. Acad Med 2006;81:207–212. Department of Anaesthesia and Intensive Care, Chinese University of Hong Kong. ICU web [accessed 2015 Feb 25]. Available from: http:// www.aic.cuhk.edu.hk/web8/index.htm Neligan P; University of Pennsylvania. Critical care medicine tutorials [accessed 2015 Feb 25]. Available from: http://www.ccmtutorials. com International Respiratory and Severe Illness Center (INTERSECT). Home page [accessed 2015 Feb 25]. Available from: http:// www.intersectuw.org
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Division of Pulmonary and Critical Care Medicine, Department of Medicine, 2International Respiratory and Severe Illness Center, 7Division of General Internal Medicine, Department of Medicine, and 8Department of Global Health, University of Washington, Seattle, Washington; 3French Cooperation, Phnom Penh, Cambodia; 4University of Health Sciences, Phnom Penh, Cambodia; 5Calmette Hospital, Phnom Penh, Cambodia; and 6Khmer Soviet Friendship Hospital, Phnom Penh, Cambodia
Abstract The capacity to care for the critically ill has long been viewed as a fundamental element of established and comprehensive health care systems. Extending this capacity to health care systems in low- and middle-income countries is important given the burden of disease in these regions and the significance of critical care in overall health system strengthening. However, many practicalities of improving access and delivery of critical care in resource-limited settings have yet to be elucidated. We have initiated a program to build capacity for the care of critically ill patients in one low-income Southeast Asian country, Cambodia. We are leveraging existing international academic partnerships to enhance postgraduate critical care education in Cambodia. After conducting a needs assessment and literature review, we developed a three-step initiative targeting training in mechanical ventilation. First, we assessed and revised the
current resident curriculum pertaining to mechanical ventilation. We addressed gaps in training, incorporated specific goals and learning objectives, and decreased the hours of lectures in favor of additional bedside training. Second, we are incorporating e-learning, e-teaching, and e-assessment into the curriculum, with both live, interactive and independent, self-paced online instruction. Third, we are developing a train-the-trainer program defined by bidirectional international faculty exchanges to provide hands-on, case-based, and bedside training to achieve competency-based outcomes. In targeting specific educational needs and a key population—the next generation of Cambodian intensivists—this carefully designed approach should address some existing gaps in the health care system and hopefully yield a lasting impact. Keywords: Cambodia; critical care; critical illness; delivery of health care; health resources
(Received in original form December 5, 2014; accepted in final form February 28, 2015 ) Supported by an INTERSECT-Ellison Fellowship and an Alpha Omega Alpha Postgraduate Award (both to T.J.A.). Author Contributions: All listed authors contributed to the preparation of this manuscript. Correspondence and requests for reprints should be addressed to Tyler J. Albert, M.D., 1959 NE Pacific Street, Box 356522, Seattle, WA 98195-6522. E-mail: [email protected] Ann Am Thorac Soc Vol 12, No 4, pp 491–497, Apr 2015 Copyright © 2015 by the American Thoracic Society DOI: 10.1513/AnnalsATS.201412-557AR Internet address: www.atsjournals.org
The capacity to care for the critically ill has long been viewed as a fundamental element of established and comprehensive health care systems. Extending this capacity to health care systems in low- and middle-income countries is now increasingly recognized as an important endeavor (1–3); however, many practicalities of improving access and delivery of critical care in resource-limited settings have yet to be elucidated. As partners with local clinicians and hospital leaders, we have launched an
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initiative to build capacity for the care of critically ill adults in one such resourcelimited nation, Cambodia. The World Bank categorizes Cambodia as a low-income country (gross national income per capita, $709 in 2013) of 14.9 million inhabitants (4). Cambodia’s health care system is in flux with rapid progress by some measures; however, critical care capacity remains limited (5). We discuss the rationale and approach to our educational initiative focusing on postgraduate training that is
designed to augment the provision of critical care in Cambodia.
Rationale: Why Enhance Critical Care Capacity in Resource-Limited Settings? Investment of time, energy, and money toward enhancing critical care capacity in resource-limited settings can encounter considerable resistance. Yet there are
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PERSPECTIVES numerous reasons why this resistance must be overcome. First, care of the critically ill individual does not necessarily require complex therapies. In fact, many life-saving treatments need not be particularly expensive or labor-intensive, nor need they occur in an intensive care unit (ICU). For example, antibiotic and fluid administration for septic shock (6), oxygen administration for hypoxemia (7), and prereferral rectal antimalarial therapy (8) have all been shown to be effective while using minimal resources. Second, current internationally embraced efforts that address health necessitate the consideration of critical care. The United Nations’ Millennium Development Goals include reduction in child mortality, improvement in maternal health, and combating HIV/AIDS, malaria, and other diseases (9). Although severe sepsis, respiratory failure, and hemorrhagic shock may be complications of these target conditions, unfortunately there is limited to no inclusion of critical care within many health system–strengthening initiatives. Third, the capacity to treat the critically ill is a central element to any health care system. An often-heard argument is that limited resources should be allocated preferentially to prevention efforts. However, the reality is that despite beneficial prevention measures, people still become sick and require treatment, with a subset becoming severely ill. Moreover, these components of health care—prevention and treatment—need not be isolated or managed separately, as they are in fact complementary. Provision of timely and appropriate care to the severely ill may build community confidence in the local health care system, leading to increased use of primary care. In effect, this can prevent the progression of chronic disease, and, coming full circle, subsequently lower the prevalence of critical illness (1). Fourth, although a disproportionate burden of critical illness occurs in resourcelimited settings (10, 11), epidemiologic data are scarce (12). As ICUs do not exist in many hospitals, this may be in part due to the heightened difficulty in capturing the critically ill in the absence of geographic advantages afforded by ICUs. An additional contributor may be a lack of widespread use of syndromic diagnostic terminologies that identify severe illness, such as respiratory failure, acute respiratory distress syndrome, acute kidney injury, and severe 492
sepsis. Enhancing critical care capacity will enable the capture of epidemiologic data on critically ill patients and aid in the development of preventive and therapeutic interventions. Together, these factors support the importance of developing critical care capacity in resource-limited countries, a concept that is increasingly being recognized (10–13). Core principles to consider in this endeavor include the integration of disease-specific interventions within a broader training in critical care medicine, regionalization of critical care, investment in human resource training, and careful assessment and tailoring of interventions for specific environments.
The Cambodian Context Although there have been substantial economic improvements in recent years in Cambodia, such as a decrease in the poverty rate from 53% in 2004 to 21% in 2011, many people remain extremely vulnerable (14). The majority (80%) of the Cambodian population lives in rural settings (15) and tends to have poor housing conditions and levels of education compared with urban residents (16). The country receives annual international aid of close to $1 billion, accounting for almost 70% of public expenditure dispersed through multilateral agencies, bilateral government cooperation projects, and more than 100 national and international nongovernmental organizations (15, 17). Cambodia’s health care system is in transition. There have been marked improvements in maternal health, infant mortality, and HIV/AIDS care (14, 18). The number of hospitals increased from 44 to 68 and the number of regional health centers jumped from 101 to 516 over the last 6 years (18). As of 2012, life expectancy has increased to 71 years. Despite these encouraging statistics, a major challenge facing the country is the lack of adequate resource capabilities. There are meager ratios of 2.3 physicians and 7.9 nurses for every 10,000 people, compared with regional averages of 15.2 and 19.5, respectively (15, 17), and the overall majority of specialized physicians in Cambodia reside within urban boundaries (19). Furthermore, the health care professional training system is severely limited, with annual graduation of only 290
doctors and 410 nurses, one major public university, and only one specialist postgraduate training program in pulmonary and anesthesiology for the entire country (20). In this context, critical care capacity in Cambodia is important. Of major regions defined by the World Bank, Southeast Asia has the highest number of deaths and highest potential burden of sepsis, acute lung injury, and patients requiring mechanical ventilation (12). At present, acute respiratory infections are the leading cause of both morbidity and mortality in Cambodia (15), probably due to sepsis and respiratory failure. Robust data on Cambodian critical care capacity are scarce (perhaps due to the lack of data on ICUs) but more than 50 public referral hospitals in the country are reported to have some ICU capacity (5). Despite this, one study estimated that Cambodia would have the highest rates of avoidable deaths in the region during an influenza pandemic, mainly due to severe shortages of mechanical ventilators and a lack of adequately trained health care personnel, specifically physicians and nurses (21). Thus, it is not only imperative to expand Cambodian critical care capacity, but training health care workers is a central element of any proposed strategy.
An Approach to Enhance Critical Care Capacity International Educational Collaboration
A number of foreign institutions and individuals have partnered with Cambodian colleagues to promote enhanced provision of care to the critically ill, sometimes as part of emergency medicine or anesthesiology training programs. These initiatives include education in triage and resuscitation, pediatric critical care, advanced trauma life support, airway management, and treatment of severe acute respiratory infection and use of mechanical ventilation. In addition, the Cambodian Society of Anesthesia, Critical Care, and Emergency Medicine (SCARMU, www.scarmu.org) hosts an annual scientific congress that includes intensivists from around the world. Many of these valuable efforts target practicing clinicians rather than trainees. Concurrently extending international collaborations to existing institutional training systems and focusing
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PERSPECTIVES on trainee intensivists carries the potential to further enhance sustainability of critical care educational initiatives in Cambodia. The University of Health Sciences in Cambodia (UHSC) is the only public institution in Cambodia to offer postgraduate training in critical care medicine—as part of an educational program encompassing anesthesia, emergency medicine, and critical care medicine. The clinical component of this training is conducted at two national hospitals in Phnom Penh: Calmette Hospital and the Khmer Soviet Friendship Hospital. UHSC and these partnering hospitals have been the focal point for international collaborations in Cambodia. There has been a longstanding French–Cambodian partnership involving UHSC to strengthen training of undergraduate and postgraduate students in medicine. The University of Washington (UW) has also joined UHSC to help achieve the dual goals of improving patient care and expanding medical education. Focusing educational efforts on trainees in academic institutions complements initiatives augmenting the skills of accomplished practicing clinicians by better preparing the next generation of health care providers. We proposed, therefore, to leverage these established international collaborations to further enhance postgraduate critical care training at UHSC. Participants in this strategy included the leadership of the UHSC anesthesia, emergency medicine, and critical care medicine residency, the directors of the training hospital ICUs, the UHSC-based French Ministry of Foreign Affairs technical assistant, and academic intensivists from UW. In initial discussions over several months, we identified provision of mechanical ventilation as a therapy that was used commonly but around which there was tremendous variation in practice and uncertain competency of trainees. As a first step, we elected to focus our efforts on this topic and endeavored to adopt an approach to developing an educational collaboration that would be informed, targeted, practical, sustainable, and applicable to other topics. Needs Assessment
Three of our authors (T.J.A., T.F., T.E.W.) subsequently performed a needs assessment in a systematic manner over the course of a 2-week visit to Phnom Penh. Three 4-hour on-site visits to ICUs and emergency Perspectives
departments were held to observe the use and practices of mechanical ventilation at the two hospitals affiliated with UHSC. Four open-ended, group interviews were held with the health care leadership (hospital, ICU and emergency room directors, chiefs of nursing) and 8 clinicians from Khmer Soviet Friendship Hospital and Calmette Hospital, as well as educators (vice dean of medicine, chiefs of pulmonary and anesthesia, emergency medicine, and critical care) and 18 current and past trainees from UHSC that focused on perceptions of needs, opportunities, and barriers. We then reviewed former, existing, and planned interventions through other international collaborations that aimed to support critical care education and we evaluated existing critical care curricula at UHSC. Last, we assessed current critical care resident knowledge, using a previously validated knowledge assessment tool (22) that was considered pertinent given the resources at UHSC training sites. After confirming adequate language proficiency, this questionnaire was administered to 19 of 21 current critical care trainees in English during one 4-hour session and identified a wide range of understanding of pulmonary physiology and mechanical ventilation (23). For example, residents were skilled at diagnosing auto-PEEP (positive end-expiratory pressure) and selecting patients ready for liberation from mechanical ventilation but were less capable of correctly using PEEP for hypoxemia or identifying tension pneumothorax. The overall needs assessment identified a broad range of clinical practice around mechanical ventilation, specific trainee knowledge gaps, limited clinical time and responsibility assigned to trainees, and a lack of competency-based curricula or standardized assessment tools (24) (Table 1). There was also restricted academic support for clinical faculty and a need for institutionalization of partnerships. Literature Review
We undertook a thorough review of the literature to learn from previously successful models of education. Despite a recent surge, there have been a limited number of publications discussing adult critical illness in resource-limited settings (1–3, 10, 12, 25–29), with most focusing on the management of severe sepsis in subSaharan Africa and only a few focusing on
education (30–34). Education in mechanical ventilation is enhanced by targeted multifaceted approaches, and simulation offers new tools (35). Published reports reveal improvements in knowledge, teaching behavior, and learning climate with the use of train-the-trainer curricula (33, 34, 36, 37), and have demonstrated significant improvements with both education and clinical practice in lowresource settings (33, 38–40). However, there have been only two reports of train-the-trainer curricula focusing on mechanical ventilation (33, 34), and we could identify no reports of train-thetrainer curricula occurring in Cambodia. Evidence suggests that train-the-trainer programs can effectively disseminate and implement guidelines and curricula to health care professionals from diverse cultures working in a variety of clinical areas by incorporating interactive, multifaceted teaching methods (case studies and scenarios, didactic presentations, interactive role plays, group discussions) and accompanying learning materials for selfdirected learning (40). Effective programs use competency-based outcomes, clarify expectations for both the trainers and the newly trained leaders, and take into account cultural differences when modifying teaching and feedback methods (41). Evaluation of Barriers
We also characterized potential barriers to success during site visits. We found a lack of equipment and supplies (oxygen, endotracheal tubes, suction catheters, etc.), time restraints, systemic and structural limitations, and funding limitations that will need to be overcome. In addition, we found significant language and cultural barriers, a lack of empowerment and ownership, limited faculty and academic support, and long-term sustainability issues that will need to be addressed. Development of an Educational Initiative
These efforts informed the design of an initiative centered on improving postgraduate training in mechanical ventilation. We based the initiative within the existing UW–UHSC collaborative framework, endorsed by interinstitutional memoranda of understandings. After evaluating the training needs of all health care professionals involved with mechanical ventilation, we chose to target postgraduate residents because of their availability and 493
PERSPECTIVES Table 1. Needs assessment for postgraduate education in mechanical ventilation Area Assessed MV use and practices Perception of need MV education and training
Assessment Tools
Findings
ICU/ED site visits at Calmette and Khmer Soviet Friendship Hospitals Structured interviews and focus groups with health care leadership, educators, clinicians, and trainees Evaluation of existing critical care curricula at UHSC; structured interviews and focus groups; ICU/ED site visits
International cooperation
Review and mapping of existing educational initiatives, interviews with health care leadership
Understanding of pulmonary physiology and MV
Current critical care resident knowledge assessment
Heterogeneous equipment; lack of standardization or multidisciplinary care Widespread enthusiasm and institutional support for improvement in medical education and clinical training Lack of competency-based curricula, standardized assessment tools, or simulation-based education; limited clinical time and responsibility for trainees; restricted availability and academic support for clinical faculty Need for institutionalization of partnerships (memorandum of understandings, working agendas, funding), coordination with other partners Specific target areas for future training, e.g., use of PEEP and identifying tension pneumothorax
Definition of abbreviations: ED = emergency department; ICU = intensive care unit; MV = mechanical ventilation; PEEP = positive end-expiratory pressure; UHSC = University of Health Sciences, Cambodia.
accessibility to pre- and in-service training, minimal language barriers, and appropriate group sizes for small-group training and longitudinal follow-up. We defined three components to the initiative. First, we proposed to assess and revise the design of the existing critical care resident curriculum with respect to respiratory failure and mechanical ventilation education. Second, we sought to incorporate new educational tools into this curriculum, using e-learning, e-teaching, and e-assessment. Third, we planned to develop and integrate a trainthe-trainer program within the curriculum. Progress to Date
To date, we have completed the first component of the initiative. We evaluated the current curriculum used by UHSC and
compared it with residency curricula in use in the United States, France, and elsewhere in Southeast Asia. The UHSC curriculum is divided into 12 modules that are taught in lecture format over 3 years. Clinical ICU time totals 8 weeks at the two referral hospitals, with roles ranging from observation to admission of patients overnight. We then revised and reframed much of the curriculum pertaining to mechanical ventilation. We first addressed gaps in mechanical ventilation training and the related topics of pulmonary physiology and respiratory failure. We next assessed the balance of didactic versus bedside teaching in the curriculum, decreasing the amount of annual didactic training by one-third and creating additional time for bedside training. Finally, we incorporated specific goals and
learning objectives into the curriculum, based on core competencies. The second component is nearly finalized and will be pilot-tested in the coming months. It has been developed using evidence-based medical education principles of e-learning, e-teaching, and e-assessment (42–44). It takes advantage of widely available Internet access for trainees, existing web-based resources, and sophisticated video-conferencing capacity at UHSC and UW. This component will incorporate several live, interactive distance e-teaching/e-learning sessions between UW and UHSC interspersed with online e-learning tutorials (45, 46). Formative and summative e-assessment modules will be used to identify knowledge gaps and monitor achievement of milestones. Special
Table 2. Proposed e-learning, e-teaching, and e-assessment scheme Time Frame Week 1: Initial e-teaching session Weeks 1–2: e-learning, formative e-assessment
Week 3: Subsequent e-teaching sessions Week 4: Summative e-assessment
Goals To establish objectives and introduce the basic concepts of MV To allow students to learn at their own pace and identify knowledge gaps
To review concepts, fill gaps, and provide feedback based on formative assessment To evaluate student learning
Tools Video conferences, syllabus, learning objectives Online tutorials, relevant chapters of textbooks and reference articles, pocket cards covering (1) respiratory physiology, (2) respiratory critical illness, and (3) basic principles in MV; clinical case–based MCQs Targeted, interactive clinical case examples; unstructured question-and-answer time MCQs (single best answer format, “type A”)
Definition of abbreviations: MCQs = multiple choice questions; MV = mechanical ventilation.
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PERSPECTIVES consideration will be given to issues related to language, participant confidentiality, and validity of assessments (43). A 4-week scheme is proposed in Table 2. The design, delivery, and assessment of the component will be orchestrated by two key coordinators from each site. Concurrently, we are designing the third component of the initiative: a practical train-the-trainer program with a major objective being improvement in the process of training. In addition to improving trainee knowledge of mechanical ventilation, this will lead to greater self-sufficiency of UHSC educators, enhancing sustainability of the initiative. The model we propose involves a UHSC– UW faculty partnership with bidirectional exchanges. UHSC faculty will visit UW to directly observe models of resident and fellow training in critical care. UW faculty will subsequently travel to Phnom Penh several times annually to partner with UHSC faculty in performing didactic and bedside teaching on MV at critical care training sites. A key focus will be hands-on, casebased, and bedside training to achieve competency-based outcomes and other elements of effective train-the-trainer programs as outlined in Table 3. In addition
to exposing UHSC faculty to pedagogical techniques and assessment of core competencies used in the United States, this interactive exchange will provide abundant opportunities for evaluation and discussion of ICU design and processes of care, usefulness of mechanical ventilation care bundles, and interdisciplinary care. In subsequent years, as the partnership matures and UHSC faculty gain familiarity with and adopt these contemporary training methodologies, the direct involvement of UW faculty in teaching will be reduced and/or redirected. Although the fundamental principles of the initiative are durable, we fully anticipate that our approach to implementation will require constant and creative revision. The educational impact of the initiative can be tracked by assessments of resident knowledge and satisfaction. To further ensure that the initiative remains feasible, relevant, and appropriately targeted, and that it is fostering self-sufficiency, participating faculty from both UW and UHSC will be regularly debriefed. These data will be reviewed by all stakeholders and used to guide and modify the initiative as necessary. Notably, the first and second components of our initiative have been/can
Table 3. Elements of an effective train-the-trainer program Educational Climate Preparation (“know before you go”)
Medical environment Cultural norms and differences Identify future partners Identify learners’ needs Identify content
Critical elements to success
Establish common goals Be flexible Be knowledgeable Use your own teaching strategies Maximize your partners’ strengths Teach by example
Interactive training methods
Case studies and scenarios Problem-based learning Group discussions Practical demonstrations and exercises Role-plays Bedside teaching
Posttraining follow-up
Real-time feedback Prepare trainers for future workshops Peer education Graduated responsibility Maintain a long-term presence Continual curriculum revision
Data derived from References 40 and 41.
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be accomplished at relatively low cost, relying heavily on adaption of existing curricula and established assessment tools, and communicating and interacting virtually, using inexpensive Internet-based technologies. The train-the-trainer component is the most expensive as this requires considerable international travel and time abroad. Thus far, we have received pilot funding to implement the initiative from the UW International Respiratory and Severe Illness Center (INTERSECT [47]), as well as from the Alpha Omega Alpha Honor Medical Society, but additional funds will be necessary. Ensuring adequate and durable involvement of international faculty is also essential to the success of this initiative. Globally, intensivists are displaying an increasing interest in critical care in low-resource settings, however, and there is a large cohort of critical care fellows and faculty at UW and elsewhere that is committed to participating in initiatives such as this.
Future Directions and Related Activities We hope that this initiative will not only improve resident education but also enhance the quality of care delivered. Ideally, this initiative will prove to be a model that can be extended to other topics and specialties in Cambodia and potentially to other resource-limited countries. The initiative also offers additional opportunities to tackle many of the intrinsic barriers in Cambodian health care and contribute to system-wide changes. Fully overcoming the hurdles we identified in our needs assessment is likely to take many years, but the established and vibrant partnership between the two academic institutions, with the associated support of administrative leadership, renders this more feasible. Training future practitioners who will care for generations of Cambodians in the foreseeable future ensures sustainability. Moreover, continuous interaction between foreign and Khmer faculty will help open doors for future training, education, and clinical research, expanding the role of academic medicine and widening Cambodia’s international exposure. Thus, through specialized training in the management of acute respiratory failure, long-term collaborations will be fostered 495
PERSPECTIVES with a common goal of improving communication and funds of knowledge within the Cambodian medical education system and the health care system as a whole. Although our current activities target physicians, nurses in the ICUs handle much of the management of mechanical ventilation. The position of respiratory therapist, common in other countries such as the United States, does not exist in Cambodia. In light of this, we are concurrently partnering with nurses,
respiratory therapists, and respiratory therapy educators to develop nurse-specific training for mechanical ventilation. We note that our initiative is only one of many related efforts underway in Cambodia and is not the first to address critical care education. We are optimistic that our approach will not only prove longitudinally effective but will complement existing training efforts and thereby facilitate synergistic interactions to further improve care of the critically ill in
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