March 2013

The role of the physician anaesthetist/anesthesiologist extends beyond the direct
delivery of intraoperative anesthesia to involvement in the entire perioperative
process. Anesthesiologists should provide leadership to improve the various stages
of the surgical process. Mbarara will therefore be a center of excellence that has a
wide impact by graduating highly educated leaders.

Based on this rationale, we have a number of existing and planned projects.

Sadiq Kagwa (Anesthesia Chief Resident) with students in the Anesthesia library

Two years ago, we identified improvement of education as a primary initiative. At
that time the three residents/registrars did not have a formal didactic program,
the three consultants in the department had little time to prepare lectures due to
clinical commitments, and there were few educational resources.

We therefore piloted a lecture series via Skype in 2011, and then formalized the
format in 2012. So far over 48 weeks we have attempted 26 lectures, 20 of which
have been completed successfully with adequate connection. Other weeks have
been filled with local lectures by visiting staff, other educational efforts or holidays).
We initiated an educational research project. This study will examine whether
knowledge transfer, a marker for education, is feasible via videoconferencing
despite low bandwidth and minimal physical resources. While differences in student
groups preclude direct comparison, initial evidence suggests that the MUST trainees
score similarly to the Harvard program students.

Joseph Kiwanuka completed his MMed thesis on this topic and is now a department
consultant with a University appointment funded via an MGH CGH donor. This has
increased the number of anesthesia consultants to four, up from three two years
ago.

In partnership with publishers Elsevier, Charlie Cote organized the donation of an
anesthesia library. David Bangsberg delivered the first tranche recently; the second
batch on this trip completed the library. Mbarara now has a full library of brand
new copies of the latest editions of anesthesia textbooks in various subspecialties.
(Actually it is more up to date than the MGH library).  Additionally a contributing
author of a recent well-known pediatric anesthesia textbook was astonished to see
copies of the latest edition of the book reach Uganda before he received his author’s
copy from the publisher!)

Students in the new anesthesia library

The Department has established a local lecture rota, with the trainees and
consultants producing lectures and presentations. The new library and associated
electronic access will provide a resource for preparation of these intradepartmental
lectures.

The AAGBI funds visiting consultants for 6-month periods; an obstetric anaesthetist
arrived this month for a 6-month period. The Global Health Service Corps (“Medical
Peace Corps”) will be sending out an ICU consultant for a one-year period.

A computer projector supplied by MGH is in regular use for lectures and
presentations.

Combined with visiting academics (MGH, AAGBI, Corps and others), the weekly
Skype lectures, a well stocked library, computer projector, and local lecture
schedule, there is now a full academic program. Additional resources may include
on-line material via AAGBI, the Society for Pediatric Anesthesia, Elsevier and others.
In 2013, Joseph Kiwanuka will co-ordinate Skype lectures with contributions from
visiting lecturers in the Thursday afternoon lecture slot.

Richard Bugembe is completing his data gathering for his MMed thesis and should
graduate in 2013. Two new residents, George Kateregga and Richard Kwikiriza,
are junior to Sadiq Kaqwa. Richard is running a checklist project headed by Stephen
Ttendo and Isabeau Walker of the AAGBI. George will be a point man for regional
anesthesia. There is now sufficient educational capacity to expand the numbers of
residents at some point in in the future.

George Kateregga, new anesthesia resident

We will aim to publish a review on the anesthesia educational approach at Mbarara
in Anesthesiology; the relevant editor expressed an interest.

(ii) Ultrasound Guided Regional Anesthesia

In 2011 we identified ultrasound guided regional anesthesia (UGRA) as a skill that
was lacking in Mbarara and Uganda. Introducing this skill is consistent with the goal
of producing highly qualified graduates, as well as the concept of involvement in the
perioperative process beyond the operating theater. We ran a UGRA teaching camp
in 2011. Rollout was slowed in 2012 due to the move to the new hospital. However
the move is partly complete, so we will introduce this skill in 2013.

Vicki Modest will lead this effort through a number of 1-week visits; Margaret
Gargarian and Katherine Fleischman will also contribute by a week visit. Two
MGH residents, Joseph Sharma and Mark Hoeft, will visit for a month and provide
sustained instruction. We will focus on developing two local experts, a consultant
and a registrar, who can drive further implementation.

We aim to complete 100 blocks in a year, with quality assurance and outcome
documentation. Once we have demonstrated proof of concept, we will establish a
UGRA 6 month fellowship, and attract philanthropic educational funding. This will
increase the number of clinicians at MRRH while simultaneously advancing MUST
as a center of excellence and advanced study. In addition it will promote Faculty
Development at MUST – i.e. instead of focusing solely on resident education we will
aim to continue faculty education and enrichment.

Research/Quality Improvement

The focus of initial inquiry is operational research – how to deliver improvements
in care.

(i) Computerized Surgical Services Quality Assurance Database (“C-SQUAD”)

This will be one of the signature programs of the collaboration. In 2011 we began
to explore how to capture and utilize clinical data for quality improvement. In
2012 we obtained funding from the Harvard Milton Fund and from General Electric
Foundation to establish a computerized quality assurance database for the surgical
services. The project has passed MUST/Partners IRB review and UNCST, and is
awaiting Presidential Council registration.

Information empowers

On this trip administrative tasks were completed, to prepare for hiring of four data
entry clerks and a database manager. Hopefully data entry will start in June. The
operating system will be Open MRS. Initial discussion were held for the system to
be built locally by Nicolas Musinguzi, which will promote local expertise and allow
sustainable IT support. Mo Hussian, of MIT Sloan School, did an initial feasibility
analysis. Thoughtworks, an IT company, is willing to provide further technological
support.

The SQUAD will be overseen by five team members at Mbarara (Anes – Stephen
Ttendo, Ob/Gynx2 – Joseph Ngonzi and Godfrey Mugyenyi, surgery – Deus
Twesigwe, and medical records – TBD) and by six members at MGH (2 x Anes/
ICU P Firth and Vanessa Bradford-Kerry, 2 x surgery Peter Fagenholz and Mark
Preston, 2 x Ob/Gyn Blair Wylie and Jeff Ecker). The SQUAD team will review
monthly data, determine how to improve the database, make suggestions for clinical
improvement, review requests for detailed data access and generally oversee the
project.

The SQUAD is being rolled out under a Plan-Do-See-Act technique. We expect to
modify and improve the SQUAD with experience born of time. Once established, this
will provide the broad platform for future research and quality improvement across
the surgical specialties.

The Hospital Director asked us to immediately expand this program to the entire
hospital (pediatrics, medicine, psychiatry). Bearing in mind our other immediate
commitments, this is something we will look into. Long term we may aim to expand
this to other hospitals, in line with our academic approach of modeling reproducible
initiatives. In addition we will aim ultimately to integrate this with other systems that can talk to each other (e.g. stocking inventories, cell phone outreach), incollaboration with IT specialists with overview of the IT ecosystem. The current
focus, however, is on establishing a solid functional platform in the immediate future.

We will submit an IRB to analyze and publish a retrospective analysis of surgical
and ICU data. Ideally we should publish at least a brace of clinical articles in the
foreseeable future.

Other – research/education

Involvement in peri-operative process improvement is one important goal of the
Anesthesia Department. Sadiq Kagwa is planning on examining post-operative
analgesia for his MMed thesis. Mark Hoeft, an MGH pain fellow, may collaborate with
him during his one-month trip in June.

Margaret Gargarian and Katherine Fleischman will deliver lectures during their trip
in May, and look into opportunities to improve peri-operative pain control.

We may also get involved in nursing education via running a Pain Treatment
workshop. (Mark Hoeft +/- Sadiq Kagwa)

Richard Bugembe is examining the use of single shot spinals for labor analgesia. This
may be an exciting area of clinical research to support in future.

The use of UGRA has been outlined earlier. This technique may be useful for specific
surgical procedures.

Interdepartmental Collaborations

ENT residents
The Mass Eye and Ear is looking to establish collaboration with the Otolaryngology
Dept.at Mbarara. We will explore ways to facilitate this. Jo Shapiro (BWH) has
along relationship with MRRH. Mack Cheney donated some textbooks that were
transported with the Anesthesia Library books.

Massy Mutumba (L) with Nursing College Faculty

The MGH and the Global Heath Service Corps will support the College of Nursing
later in the year. The Nursing College expressed interest in working on producing
lecture material, the relevant topics to anesthesia being resuscitation/critical care
and pain control. We will look into obtaining off-the-shelf workshop material in
critical care and pain control via international anesthesia connections. Mary Kelly,
anesthesia resident scheduled for a short visit in May, might also give some critical
care lectures. These possibilities will be explored with relevant people at MGH and
MRRH before constructing a plan.

Pat Daoust and Massy Mutumba, Global Health Service Corps

Vanessa Bradford-Kerry is CEO of the Global HealthService Corps, is part of the
“Enhancing Critical Care Outcomes” group at MGH (a group interested in ICU in low
income settings) and is a MGH SQUAD team member. This is the ideal intersection
to coordinate various collaborative efforts.

Exchanges and trips 2013

Lisa Bebell (ID/ICU fellow) March/April 1 month – improve/review ICU chart
documentation and data capture; consider ID project, lecture on ID

Sharma Joseph (Anes resident going into ICU) April 1 month – continue Lisa’s work,
teach UGRA, lecture(?)

Vicki Modest (Anes attending) – 1 week April, 2-3 follow up visits – UGRA
Margaret Gargarian/Katherine Fleischmann (Anes attendings)– 1-week visit May –
teach UGRA; pain lectures
Katie Kelly (Anes resident) -1 week May with MG/KF – lecture on critical care? – site
visit in prep for 2014 1-month visit during pain fellowship

Mark Hoeft June or July – Pain Fellow – 1-month visit – ? link up with Sadiq Kaqwa
on pain project, aim to present at ASA in 2014; ? deliver teach-the-teachers
workshop to Nursing Faculty

Paul Firth – visits TBD – SQUAD rollout and support

To US:
? Stephen Ttendo – MGH and ASA October

? Joseph KIwanuka – MGH and ASA October

Academic Output/ Publications 2012

We put out two abstracts at the World Congress of Anesthesia, Buenos Aires and the
ASA Annual Meeting, DC. In addition Richard Bugembe presented an abstract at the
Soc. Pedi Anesthesia meeting in DC, while Joseph Kiwanuka presented at the ASA.

JK at MLK Memorial in DC

Joseph Kiwanuka and Richard Bugembe attended the Harvard Educational Review
in October, presenting on Internet education. Joseph also lectured on anesthesia
education in Uganda at the MGH:“On Being One in a Million”

JK, PF & RB @ HMS in October

It would be remiss not to mention the academic result of Stephen Ttendo’s many
years of work in the Mbarara ICU, reflected in the collaboration’s first peer-
reviewed publication:
Intensive care in low-income countries– acritical need. N Engl J Med. 2012 Nov
22;367(21):1974-6.

It’s Stephen’s exceptional leadership, energy and initiative that are driving this
collaboration. Recognition should also go to David Bangsberg’s extensive support
and vision that underpins these initiatives.

Education – variety of initiatives at different levels going well or building
Quality Assurance/ research – IT program – building at present; will provide
platform for broad range of research and capacity building initiatives
Academic output – one publication out, two or three more targeted.

This is a brief summary of some of the current
efforts – due to brevity not all is covered, and certainly not everyone involved is
mentioned or thanked.

The study involved the collaboration of 486 scientists from 302 institutions in 50 countries worldwide.

GPAS partners had the privilege to contribute to components of the study.

Thanks again to everyone involved with the conference and follow-up call.

Please contact us if you would like to join future calls.

Below is an outline of some of the many topics discussed at the recent conference, wonderfully organized by InternationalOutreach.ca and sponsored by St. Joseph’s Health System, McMaster University, Boston Scientific and many others.

This year the conference was 100% small focus group discussions. Summaries of the topics from these discussions are below as well as the key areas of focus for the coming year.

If you are interested in participating in our follow-up conference calls/meetings to push forward progress in the focus areas, then please email us partners AT globalsurgery.org .

Suggested areas of focus emanating from conference discussion:

1. Organizing internal trainee rotations

2. Matching advanced training needs with the appropriate group to deliver the courses

3. Harmonizing appropriate international group expertise with regional hospital requests

4. Collating research ideas

Contents
-Background Information
-MoH Priorities
-Background on Training Sites
-Topics for Discussion -In-depth Discussion
-Curriculum Development
-Management Skills
-Human Resource Capacity
-Safety
-Mechanisms for Skills Sharing
-Top priorities for each site

Following the Vancouver conference 2011 there were a series of conference calls to determine seven collaborative priorities to support surgical delivery and education in Uganda (see Outcomes after Vancouver Conference).  Most of those objectives have been achieved and now following the Hamilton conference we are in the process of re-employing this process to develop a new set of priorities and associated deliverables.

Follow-up meetings are underway. If you would like to participate, please contact us through the website.

Background Information

Uganda Ministry of Health priorities related to surgery and anesthesia
-make Mulago more specialized
-make referral system work more effectively
-does not currently have a strategic plan for surgery and anesthesia
-Key Issues from government perspective
-essential surgical care
-obstetric issues
-Cardiac surgery??
-anesthesia training

Politics
Population is now demanding health services
giving more compensation to level 4 centres should expand all health worker pay

Need for Advocacy
Surgery needs to enter the broader global health discussion
Are C-sections (ob. skills course) the entry point?

Relationship between Ugandan medical schools
Medical students apply jointly to all three (have 1st or 2nd choice)
-Common competency-based curriculum (Makerere, Gulu, Mbarara)

Mulago/Makerere

Current Number Trainees
Surgery (General) – ~45
Orthopaedics – ~35
Anesthesia – 23
ENT – 5?
Urology
Neurosurgery – 2
Plastics – not yet
Makerere has a faculty ceiling
Trainees want to go to Mulago for specialty exposure

Training Priorities
Advanced training (closed surgery)
Need adequate infrastructure

Soroti (one of 13 regional hospitals)
Requires a resource centre (books, journal access, Skype capacity.)
Potential to reduce referrals to Mulago
No residents, currently
Intern doctors (about 14)
4 surgeons

Gulu University
university and hospital must work together
limited human capacity (uni. and hosp.)
number of faculty and skills are limited
Essential Surgical Skills training has begun
Surgery dept is staffed well
No accredited surgery training program available, should start in next academic year

Lancor (Gulu, Uganda) – NGO Hospital
trying to recruit future staff while they are finishing medical school
have short-term Orthopaedics visits
international visitors should attract trainees
can’t recruit an anesthesiologist

Mbarara
Surgery – 9 trainees

Topics for Discussion
1. Perioperative Process
-Nursing
-Patient Care/Safety
2. ICU
3. Curriculum Development
a. -COSECSA
b. -Standards – Colleges
c. -Internal exchanges
4. Patient Access to Hospital
a. -Community perception of surgical services
5. Research Translation into Policy
6. Infrastructure
7. Procurement
8. Refresher Training
9. Timeline for Government Ownership
10. Retention and Sustainability
11. Moving resources to regional centres
12. Training/Trainee exchange
13. Supplies and Supply Chain – targeted
14. Training and Trainee Exchange

In-Depth Discussion
Curriculum and Accreditation
-integration between undergraduate and postgraduate
-most had theoretical skills but lacked practical skills
-modified undergraduate to have essential surgical skills course
-postgraduate challenge to meet needs of the region
-minimally invasive training noticeably absent
-people ask for this service
-attracts students to training program (marketing)
-now have rotation into critical care (4 weeks in 2nd year)
-does that amount make them competent?
-they are evaluated within the surgery dept.
-limited capacity to support trainees at Mulago, so they now send students also to IHK, Nakesaro, one other centre

Skills training has two aspects
-basic (targeting medical officers)
-super-specialized

Current programs: (aimed at a variety of health workers, medical officers)
-essential surgical skills (supported by CNIS)
-5 day course
-low cost models
-requires training local faculty
-primary trauma care (use foundation manual, initially supported by THET)

Build centres of excellence:
-Mbarara – ENT
-Makerere – Laproscopy

Needs:
-trainers (faculty with appropriate skills)
-adequate equipment and technical support
-advanced trauma care

Management Skills – Administration
Ukosi University – health management program currently available

Capacity – Human Resources
Fundamental question: How do we harness external faculty to support training?

recruitment (attraction)
education – CME
targeted education session/skills/donation
retention
create a better work environment
-nursing
-clinical officers
-biomedical support
Needs:
-obstetric anesthesia training

Perioperative Process Capacity

Utilization of expatriate training

Utilization of internal training

Moving training resources out at centres

Safety – Patient Care
basic equipment, competently working
program to have oximeters (Lifebox) in all areas
new anesthetic machines arriving in Uganda
national curriculum
evaluation
examiners
accreditation (can you combine colleges with universities)
COSECSA
Mmed
National College for Higher Education
EACA
audit

Needs
research
training
coordination
evaluation and standardization of training and equipment
lack of coordinated college oversight
need for harmonization
ensure adequate skills for anesthetic officers, medical officers, clinical officers

Mechanisms to Improve Skill Sharing in Region
Issues:
Lack of coordination of existing skills
-coordinate and skill share within region
-share human resources
-trainee exchanges
-share curriculum (Gen Surg curriculum update. on USB)
-create needs map
-resident rotations – 2nd year Mmed to Gulu & Mbarara
-mandatory
-accommodation/logistic barriers
-accreditation concerns

Lack of specific skills
-implement new specialist training program

Top Priorities for Each Training Site
Gulu
-build capacity in specialities, diagnostics and laboratories
-has been focused on undergraduate
-ensure that all graduates go through essential surgical skills, and basic trauma care
-research support – for Masters, PhD programs
-ensure basic patient safety
-balance specialization between Lancor and Gulu
-Lancor
-orthopaedics
-urology

Mbarara
-neurosurgery needs support
-pediatric surgery (30% of surgical caseload)
-minimally access surgery
-ENT
-

Soroti
-need basic diagnostic
-urology
-trauma is the biggest challenge (counting on Naomi to come back)
-pediatric surgery
-resource centre for computer lab, library

Mulago/Makerere
-need to develop trauma unit
-breast and endocrinology
-plastic surgery
-microsurgery

All programs
Assess basic surgical equipment, tools
research capacity

Founded by RoadPeace in 1993 and endorsed by the UN in 2005, the third Sunday in November has been designated as World Day of Remembrance for Road Traffic Victims.

Read about events worldwide – WDOR.org

Directory of NGOs for Road Traffic Safety

More on Global Health Hub.org

“There is a compelling body of evidence from high-, middle- and low-income countries that a rural background increases the chance of graduates returning to practise in rural communities. Some studies have shown they continue to practise in those areas for at least 10 years.”

Our collaboration has adopted some of these strategies for increase surgical care workforce in Uganda. Time will tell how Uganda does with retention, but preliminary findings are promising.

For the original article:

Healthcare news | doctor stories | AHP news | health system news.

Introduction

MGH visitors: Paul Firth (MGH Anesthesia); Lars Hagander (Harvard Global Health Fellow, Pediatric Surgeon); Peter Fagenholz (MGH Trauma Surgeon, ICU attending); Mark Preston (MGH Urologist)

The purpose of the visit was to begin implementation of electronic data capture, follow-up on prior projects and explore the expansion of surgical and ICU collaborations and capacity building.

The group arrived on Monday 7th, and met with Dr Stephen Ttendo (Anesthesia), Dr Gerald Tumusiime (Surgery), and Drs Joseph Ngozi and Godfrey Mugyeni (Obs-Gynae). During the next four days we had various discussions about a variety of topics. We also met with various other doctors and key hospital employees. We met with Anna Baylor and Annet Kawuma (MGH/MUST/Harvard Collaboration Staff).

Current initiative:

Electronic Data Entry Project

The existing paper data collection and data flow were examined. Extensive demographic data are entered into the surgical admission log books and operating theatre log books. On the emergency ward admissions are logged as they occur; on the surgical ward admissions are often not recorded on arrival but may be recorded when the charts are sent to medical records. Operating room logs are well kept.

An effort will have to be made to ensure admissions are documented as they arrive, in order to ensure all patient records are captured. The quality of the data entered into the log books seemed to be adequate.

Manfred Amanya the anesthetic department assistant proved to extremely capable at data entry, well organized and displayed considerable initiative. He was able to organize and enter surgical data with great competence.

There are a number of registers in the OBs-Gynae department – birth register, delivery register, admission register, OR log book. These seem to be kept in reasonable order with accurate data entry. Two Harvard undergraduate students are scheduled to arrive in the summer for two months and the preliminary assessment is that they will be in a position to initiate the electronic entry of this data.

The new ICU is functional. The ICU has a small tablet computer donated by a Canadian anesthesiologist. Accurate and extensive records have been kept previously in a log book. We designed a user friendly interface that can be used to enter data on the tablet.

The medical records department is small and crowded. Paper charts are kept in stacks with a filing system but it is difficult and slow to extract old patients’ records. This makes retrospective chart review quite difficult, although it would appear to be feasible. There is almost now way of identifying prior records for individual patients on their return at a later date.

The IRB application for a quality assurance project has been submitted and initial preliminary review was favorable subject to some minor adjustments. However it is essential this is passed as an IRB exempt Quality assurance project rather than a research project, as a research project would mean the project has to be approved by the Ugandan National Science Council, which would delay initiation by months.

Another issue is the suitable salary of the data entry clerks. Dr Tumusiime and Dr Ttendo felt strongly that the salaries should be relevant to the hospital employee salaries, the problem being that these salaries are widely acknowledged as being low. Dr Ttendo felt the position of data entry clerks should be a temporary one, designed to assist young people get on to more independent jobs, rather than a full time one. This would be something similar to the “volunteer stipend’ for temporary work outlined by the MGH research office. Anna Baylor and Annet Kawuma provided a lot of helpful insight in this respect.

Prior initiatives:

Internet Skype lectures

This is a project to examine the efficacy of a lecture format delivered by Skype, often with poor internet connection. A few lectures have been run following a defined format, and initial experience is that these have worked well. The Mbarara residents have organized the physical set-up on their end.

A MUST IRB application has been submitted and initial review is favorable subject to minor changes.

This project is going well and has potential for expansion.

____________________________

Head Trauma Initiative

This is an initiative supporting management of head trauma and other neurosurgical interventions. A new neurosurgeon, Dr David Kitya, has been appointed, and he has been able to use the donated Stryker drill to good effect. A number of craniotomies have been performed. The ICU care is available and head trauma patients can receive suitable close monitoring and dedicate care.

Dr Kitya is keen to collaborate further with MGH and would like to expand from head trauma to pediatric cases (shunt insertion). He is also interested in starting spinal surgery. Long term meningocoele and spina bifida could be treated. He will need a variety of equipment. There is a neurosurgeon at Childrens’ Hospital, Ben Warf, who has worked in Uganda and who could probably provide some advice. With the electronic data collection project we will be able to track outcomes in detail.

One of the surgical residents has started a thesis on head trauma under the guidance of Dr Tumusiime. This will promote academic depth within the department on the subject.

Dr Fagenholz demonstrated a technique he pioneered on using ultrasound to assess intracranial pressure via optic nerve diameter. One of the anesthesia residents was interested and this could be another thesis project.

Dr Patrick Cobb MGH neurosurgery resident is due out for a couple of weeks in the future. Dr Kitya suggested this visit could coincide with a neurosurgery camp to initiate new techniques in Mbarara – e.g. shunt insertion for hydrocephalus. Sending out a neurosurgery scrub assistant to teach the local scrub staff would be helpful.

Equipment needed include Mayfield head pins, Philadelphia stiff collar, halo, brain retractors, pediatric shunts, EVD, etc. A neurosurgical program exists in ?Mbali (Dr Warf will have more details)

This project is going well and has potential for expansion.

____________________________

Ultrasound guided regional anesthesia

Last year there was a collaboration to demonstrate ultrasound guided regional anesthesia as a way on managing post operative pain. The course was well-delivered and well-received. However, subsequently very few blocks have been performed. These bocks are difficult to do and there is a steep learning curve before they can be performed with speed and ease. Consequent an organization infrastructure around the perioperative period is needed to ensure adequate uptake of the skill. This was anticipated prior to the project being initiated. Although there have been a fair number of orthopedic procedures that would be suitable for nerve blocks, the anesthesia staff have been very busy teaching medical students at the University and also loaded with a high volume of clinical cases .

At the MGH some ultrasound technicians are interested in coming out for a prolonged period. One possibility is that this is a project they could pursue while out there. In addition it seems two British anesthetic registrars are due out for 2 x 3 month periods, so they could help relieve the load on local clinicians to focus on developing a block service.

Further support is needed to develop this initiative.

____________________________

Future Initiatives

ICU collaboration

The ICU currently has 4 beds with ventilator support down the weight of about a 5 kg patients. Cardiovascular support can be provided by ionotrope infusions. Renal support is not available but dialysis should become available at some point in the future.

This was identified by Dr Ttendo as a key need. The main input he would like is academic knowhow on a nursing and physician level.

Nursing is a key weakness. He would be keen to have one or two MGH ICU nurses come out for extended periods (say 3 months) to develop local standards of care in ICU nursing. Long term placements would be best.

He would also like to see an expansion of ICU knowledge in the anesthesia physicians trainees. A British anesthetic registrar is coming out for 6 months and the plan is for her to focus in on the ICU. She could provide a local link to MGH collaborations or initiatives.

The prospective ICU data collection and electronic data entry is running and will provide good quality data to guide further work. It will be useful to expand the electronic data collection hospital wide to asses the utility of the ICU in saving lives or improving outcome – i.e. what are the relevant needs of the various specialties/wards for IUC support/back-up. Once the electronic data capture is running on the surgical wards and the IUC it would be useful to expand it to the medical /pediatric wards and assess the role of the ICU in a hospital context.

____________________________

Automated cell phone follow-up

Dr Hagander discussed the development of a research project  follow up with cell phones with Dr Tumusiime. The paperwork for IRB submission was started. Once this is through an application can be made to the Ugandan Science council. This project still awaits funding.

This would be key in establishing long term follow-up of outcomes and community outreach

____________________________

MGH Fellowships at Mbarara

Dr Fagenholz raised the possibility of a year long MGH fellowship in Mbarara. Dr Tumussime was enthusiastic about this. It may be possible and desirable to pair this with an anesthesia fellowship, although given the time constraints this was not discussed with Dr Ttendo.

____________________________

Prostate Cancer Treatment

Dr Preston met with a local urologist to discuss the initiation of a prostate cancer management program. There is very limited local capacity to manage this disease and the development of prostate management would be helpful

____________________________

Other topics

New hospital

The new hospital has been built but there was an issue with the correct specifications of the electrical transformers. Once this are correctly instilled the new building will have electricity and transfer of departments will occur.

____________________________

Emergency room/ A &E

Dr Ttendo says the plan is for the new hospital to have a functioning emergency admissions area, run by a collaboration of medicine, surgery and anesthesia. Given that approximately 50% of surgical patients are emergent/urgent admissions this will be a productive area for clinical improvement and research. This should happen in the new building.

____________________________

Ugandan Community Hospital Collaboration

This is a long term goal, to establish Mbarara as a proactive leader of quality assessment and improvement in surrounding hospitals. Given the current constraints on time it makes more sense to focus ion MRRH for the present.

____________________________

Obs- Gynae

This was not discussed on this visit beyond data capture but MGH gynaecologists have visited recently.

____________________________

MGH/MUST Strategic Plan

Current collaborations are on individual levels with Ugandan colleagues at Mbarara. However as these expand and deepen, a broader strategic overview may be useful to guide collaborations. Topics to clarify and discuss might include how best to support local staff without disrupting existing hospital staffing and bureaucracy, appropriate salary levels and means of funding individuals, overall hospital/university direction, and long term sustainability. Overview might occur on individual, hospital/university, and ultimately Ministry of Health, levels.

Conclusions

This was a very busy and productive trip. There is considerable potential for collaboration. Co-ordination of efforts will optimize efficiency.

We all know trauma is the biggest burden, and that training in this area has a great capacity to save lives. Still this course raised a number of questions about the best training curriculum for the limited resource context. “trauma in the austere environment” is limited to an appendix in ATLS…and discusses mostly trauma in the setting of war or disaster, not the every day heavy trauma burden faced by limited resource public hospitals in the region that must devise their own algorithms based on available human and physical resources. The Primary Trauma Course (PTC) is a great resource for the district hospital setting and has been rolled out in a number of countries in a “training the trainers” fashion, but it is more suited for the small rural hospital than the tertiary of regional center where there may be specialists. It seems whats needed though likely is a locally endorsed course suitable for the local context run by local experts, as they are here. They are the best to advise trainees about context relevant cases and actual scenarios rather than surgeons who predominantly practice in a high-income country setting. Likely COSECSA is the best group to organize such an endeavor in this region. In addition, the challenge with such training courses and workshops always is the follow up and robust impact, ideally at the level of clinical outcomes, which is something that all groups struggle with as they run “capacity building” activities in global surgery and anesthesia. Innovative tools to do so need to be shared among groups!

Some of the topics addressed on the trip include teaching in orthopedics, nursing, anesthesia, and physiotherapy.