Monday, April 5, 2010

Emergency triage assessment and treatment course: Kenya, Dec 2009

Report on ETAT+ held at KMTC Nairobi 9-13 and 16-20 November 2009

Purpose: The Ministry of Medical Services has requested that the Ministry’s Paediatric Protocols be taught as part of the appropriate programmes at KMTC. The letter of request stating this goal led to discussion between KMTC and KEMRI personnel. These courses became joint efforts between the two organisations in conjunction with MoMS. KMTC’s Project Implementation Unit (PIU) and KEMRI representatives worked closely to set up the course. KMTC provided venue and lunches as well as transportation and appropriate lodging fees for faculty from their campuses across the country. The 23 campuses with schools of nursing and 16 with schools of clinical medicine all sent lecturers to participate in the courses. A particular request from KMTC was to hold larger than normal classes to allow greater numbers of lecturers to participate and KEMRI met this request but with commitment to maintain participant:faculty ratios less than 8:1. KEMRI supplied textual and printed materials, training equipment and insructors as well as teas with snacks.

Venue: KMTC Nursing School Assembly Hall and HMS Auditorium for plenary sessions and Skills Laboratory for practical sessions

Dates: Two courses were held; 9-13 November and 16-20 November

Course Directors: 9-13 Nov. Dr. Teresa Alwar
16-20 Nov. Rebecca Mwengi and Jalemba Aluvaala

Course Coordinators: KEMRI: Dr. Bill Bevins assisted by Judy Ng’ang’a and Jason Kiruja
KMTC: Florence Maina with assistance from Lucy Kuria, Joseph Bwogo and Rosemary Andendo and others.

Logistics: Organisation went relatively smoothly. A series of pre-course meetings were held with KMTC Deputy Director of Academic Affairs and heads of departments. Pre-course reading materials were assembled by KEMRI and distributed by PIU across Kenya. Materials were delivered at least the requisite 4 weeks in advance. Due to shuffling among participants a few received materials later than two weeks before the course.  The course opened both sessions with Dr. Grace Irimu giving a history of the Ministries’ Paediatric Protocols and ETAT+ with encouragement to use the material to update teaching and practice of paediatrics rather than view the course from an implementation strategy; the material presented is based on sound paediatrics with an evidence base designed and proven in Kenya. The hospital patient file and mortality audit and inspection was performed at Mbagathi District Hospital. This facility is more like the hospitals with which the various MTCs are associated. These visits were orchestrated with the assistance of the paediatrician at Mbagathi, Dr. Loice Mutai.  A separate report will detail the site visit and summarise inspection findings. The feedback sessions were organised to discuss how to conduct inspection and reflection on the audit process using the protocols and a group discussion led by Dr. Ngwiri the first week and Dr. Aluvaala the second week on how these courses should impact the lecturers. This is discussed further in a separate section.

Venue: The venues worked well. The Assembly Hall worked well and has good acoustics. 7/10 days were held there with the last 3/10 days held in HMS auditorium due to scheduling conflicts. Because of the size of the classes five breakout groups were organised for the practical sessions. These were scattered reasonably closely to the plenary session rooms. Access was opened between the Nursing school and Skills Laboratory to reduce walking times. The participants had many questions and there was a tendency for especially practical sessions to go overtime but largely the schedule was adhered to. 

Transportation: The reasons for close adherence to time to allow the course material to be well covered was explained initially. Through the week adherence to schedule improved in regards to participant timeliness. Transportation from lodging in the morning was often cited as challenging. Transportation to and from Mbagathi DH was provided by KMTC buses.

Meals: Meals were served at the KMTC kitchen in KNH and were well received. The walking distance made keeping to time more challenging. Water was provided by KMTC during the days. Teas and snacks were provided by KEMRI using the services of Comcare Café who were very good about keeping to requested times.

Sponsors: KMTC and KEMRI shared costs of the course as described in the opening. KEMRI’s contributions will be detailed in a separate document. MoMS greatly assisted in the impetus for the trainings and with release and letters of release for the clinicians who serve as ETAT+ faculty. Faculty were released from other duties from government hospitals, KNH education and paediatric staff, KMTC lecturers and UoN post-graduate registrars in Paediatrics.

Facilitation of courses: 9-13 November, Full Instructors:
    Dr. Teresa Alwar (post-graduate UoN)
    Dr. John Wachira (post-graduate UoN)
    Dr. Thomas Ngwiri (MoMS, Paediatrician Embu Provincial Hospital)
    Dr. Bernard Awuonda (MoMS, Paediatrician, Voi District Hospital)
    Dr. James Gitau (MoMS, Paediatrician, Garissa District Hospital)
Instructor candidates:
    Dr. John Ngugi (MoMS, Paediatrician, Karatina District Hospital)
    Mr. Jason Kiruja (KRN, KNH)
    Ms. Carol Ouma (KRN, KNH)
    Ms. Caroline Malingu (KRN, KNH)
    Ms. Linda Chemtai (RCO, KNH)
    Dr. Prisca Amolo (post-graduate UoN)
In the evaluation of the ICs at the end of the first course Kiruja and Amolo were advanced to full instructor status.
16-20 November, Full Instructors:
    Mrs. Rebeccah Mwengi (KRN, KMTC Kitui)
    Dr. Jalemba Aluvaala (MoMS, Nyahururu District Hospital)
    Mr. Jason Kiruja (KRN, KNH)
    Dr. Brian Mauga (post-graduate, UoN)
    Dr. Bill Kigathi (post-graduate, UoN)
    Dr. Grace Nalwa (post-graduate, UoN)
Instructor candidates:
    Ms. Carol Ouma (KRN, KNH)
    Ms. Caroline Malingu (KRN, KNH)
    Ms. Linda Chemtai (RCO, KNH)
    Mr. Eliud Okello (KRN, KNH)
    Dr. Abdisalam Maalim (post-graduate, UoN)
In the evaluation of the ICs at the end of the second course Chemtai and Maalim were advanced to full instructor status.

Discussion Session re: Way Forward with Basic Paediatric Protocols/ETAT+:
Discussion was held with all participants and faculty on the 4th day of each course after the visit to Mbagathi District Hospital. Common themes emerged in both weeks and considerations are herein discussed together from both courses.
It was acknowledged that many stakeholder consider ETAT+ important and as a contributor to meeting MDG. MoMS, KPA, WHO (KCO), UoN, Moi University and MTRH all agree that implementing the material should be given priority. KMTC is collaborating as well with these two courses for lecturers. KMTC is vital to ensure that health care workers in Kenya acquire these skills in pre-service training. KMTC lecturers are teachers and so are familiar with concepts of adult education that are built into the ETAT+ delivery. Modern teaching methods are being embraced including e-learning and skills laboratories. There is also the extensive and nationwide presence which can allow for potential rapid scaling up of dissemination of the Basic Paediatric Protocols. It was agreed these are more updating of information and skills than implementation of new material allowing for speedier scaling up than a re-write of curriculum. It was recognised that how the material is presented in ETAT+ is unique and contributes to retention of knowledge, skills and attitudes.
ETAT+ challenges some old practices and trainers must be willing to adapt to new evidence and current best practice guidelines with the continuous challenge of life long learning as new data emerges. ETAT+ is hands on and requires trainers to spend bedside time teaching but also practicing. We must all be spending time in the hospital training for the market.
It was pointed out that the lecturers do not always feel welcome in the hospitals where their facilities are located due to regulations in those hospitals and the existing institutional policies between the Ministries and other government institutions.
It was also pointed out that the regulatory bodies may have policies in place differing from KMTC policies making changes in teaching difficult. It was recommended that the Chief Nursing and Chief Clinical Officer and the representative governing boards be involved in discussions with KMTC for this need.

Conclusions:
The overall performance of both groups of lecturers was very good with a very high pass rate. Five people in each class, or a total of ten overall, were identified as Instructor Potential, which makes them eligible for consideration for invitation to the Generic Instructor Course. The GIC is the UK standard needed to become a recognised Instructor Candidate. The IC is then eligible to become a full instructor for ETAT+ after observation in two full ETAT+ courses.
Four IC were advanced to full instructor status during these two courses.

16 December 2009
Dr. Bill Bevins


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