Evaluation of Essential Surgical Skills-Emergency Maternal and Child Health Training
Condition: Sepsis; Asthma; Heart Failure; Seizure; Coma
MeSH terms: Seizures; Emergencies
Study type: Interventional

Summary: 
      The aim of the proposed study is to determine if specific training in management of general,
      obstetric, neonatal and pediatric emergencies results in a change in practice of doctors
      working in emergency departments of public sector hospitals in three districts of Pakistan.
      The overall goal of the proposed study is to test the ability of a standard course (5-days
      training) to promote the provision of effective and evidence based practices in public sector
      hospital settings.
    

Detailed description: 
      Pakistan is the 6th most populous country of the world 1 and has the largest population in
      the Eastern Mediterranean Region, accounting for about 30 percent of the regional population.
      The level of socio-economic development is still low - GDP per capita is US$ 7302; HDI is
      142nd in the world 1; and, one fourth of the entire population lives below the poverty line
      2. The health profile of Pakistan is characterized by high population growth rate, high
      infant and child mortality rate, high maternal mortality ratio, and high burden of
      communicable diseases.

      In conjunction with neonatal, infant and child mortality, maternal mortality ratio is also
      extremely high as 350 per 100,000 population in Pakistan 3. In addition, only 23 percent of
      the deliveries are being conducted by skilled birth attendants and major causes of mortality
      include hemorrhage, hypertensive diseases, sepsis and other obstetrical complications 4.
      Although the health facilities are available ubiquitously, but these facilities lack proper
      equipments and trained health workers. Health worker also lacks necessary skills and training
      to manage the children, newborns and mothers in emergency situations. Management in the first
      few hours - the Golden hours 5 of the presentation of obstetric, neonatal and pediatric
      emergencies, including major trauma (if not given immediate attention are likely to result in
      death or severe brain damage in 6 hours) is a major determinant of the eventual outcome. If
      the vast majority of these potentially avoidable deaths and long-term or permanent morbidity
      are to be avoided, a continuity of care with particular emphasis on golden hours management
      and safe transfer has to be established starting from the communities to health facilities 6.

      There is evidence that if structured life support trainings are introduced in a systematic
      method it helps in reducing mortality and morbidity during the emergency phase in a very cost
      effective manner 4. Local public sector hospitals need to be configured to serve a community
      and not just to provide episodic care for the few patients who transiently pass through their
      doors during an acute episode. It is mandatory to upgrade the knowledge of first line health
      worker in managing emergency situations. It is also necessary to elevate their capacity to
      recognize the common emergencies and manage accordingly. By instituting accredited structured
      training for these skills we can dramatically decrease mortality and morbidity rates in
      Pakistan 6. The training activities of Essential Surgical Skills with emphasis on Emergency
      Maternal and Child Health (ESS-EMCH) are based on two tried and tested structured training
      methodologies of Advanced Pediatric Life Support (APLS) and Management of Obstetric
      Emergencies and Trauma (MOET). The ESS-EMCH training programme is being conducted by Child
      Health Advocacy International (CAI) in Pakistan and Gambia 6. The Advanced Life Support
      Group-UK (ALSG-UK) and World Health Organization (WHO) provide technical support for the
      training and the programme has been endorsed as a first ALSG-UK certified training course
      targeted specifically for developing countries 7. These courses have been used for some years
      in various developed countries as essential requirements for all health workers involved in
      emergency care in these specialties. In Pakistan these training activities have been modified
      according to local needs and conditions 6.

      The aim of the proposed study is to determine, if and what degree, specific training in
      management of general, obstetric, neonatal and pediatric emergencies results in a change in
      practice of doctors working in emergency departments of public sector hospitals in three
      districts of Pakistan. The overall goal of the proposed study is to test the ability of a
      standard course (5-days training) to promote the provision of effective and evidence based
      practices in public sector hospital settings.

      Justification:

      Improving mortality and morbidity during the emergency phase presents a major challenge in
      many developing countries including Pakistan. It is important that health workers working at
      public health facilities at district level have necessary skills and equipment to provide
      effective management during an emergency phase. Research has shown that structured life
      support trainings can help in reducing mortality and morbidity during the emergency phase in
      a very cost effective manner 4. However, the evaluation of course participants poses a major
      problem, because it is rarely possible to develop a perfect testing method, and awareness of
      the inherent limitations of evaluation methods used in life support courses is important 8.
      Jabbour and colleagues reviewed the effectiveness of life support courses and found that the
      majority of studies on evaluation of the ability of life support courses have focused on less
      direct outcomes like health workers' knowledge and silks 9. Such surrogate outcomes may not
      necessarily reflect practice changes, which is a more useful and direct way of measuring the
      effectiveness of life support training courses 9.

      We are not aware of any previous randomized controlled trials determining the effect of
      ESS-EMCH training on health workers practices in a true clinical setting. Therefore, our
      intention is to test the ability of ESS-EMCH training on practices by randomly assigning
      pediatric ward, labor room and emergency department staff at district level to either
      providing ESS-EMCH training or no training, considering the health worker as a unit of
      cluster. Although, our primary outcome will only able to capture the initial steps in
      effective practice, but we believe it will indicate an important behavior change effect.
    

Intervention name(s): ESS-EMCH training
Intervention type(s): Behavioral
Intervention description(s): The trainings of the ESS-EMCH programme are based on two well-tried and tested structured training methodologies of "Advanced Pediatric Life Support (APLS)" and "Management of Obstetric Emergencies and Trauma (MOET)".
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Double (Participant, Outcomes Assessor)
Primary purpose: Other
Keywords: Cluster Randomized Trial; ESS-EMCH; Neonatal; Maternal; Life threatening emergency event