CME update (Nov. 8, 2009), Bayalpata Hospital, Nyaya Health

Ruma Rajbhandari

This is an update of what I have been able to do with continuing medical education of staff at Bayalpata Hospital so far over the period Sept. 29^th-Nov. 8^th 2009.

Teaching materials used:

1.       NSI’s Mid-Level Practicum includes lectures dubbed in Nepali on the top 20 chief complaints encountered in the outpatient/emergency setting by mid-level health care workers at rural district hospitals, primary health care centers and health posts.   There are also cases/questions to go along with the powerpoint lectures.  In addition, there are videos of proper physical exam technique by system and also the 10 most common procedures that an HA would be required to do--e.g. incision and drainage, suturing, etc.  There is approximately 13GB of files saved on Shefali Oza’s computer entitled “NSI”.   These will be uploaded to the Nyaya server once we get to the US.  The materials have also been burned on to 3 DVDs which are located in the “CME Box” in the office.  Our contact at NSI for obtaining these materials is Steve Knoble (stevek(AT)nsi(DOT)edu(DOT)np)

2.       Skilled Birth Attendant (SBA) training CD developed by JHPIEGO—also in “CME Box” in the office.   Associated with this CD are two books on Managing Complications in Childbirth and Newborn Care.

3.       Obstetric First Aid lectures [part of NSI’s mid-level practicum for mid-level health workers—particularly health assistants and AHWs(auxillary health workers)/CMAs(community medical assistants].  These lectures are also on the various folders and DVDs described in (1).

4.       Community based PMTCT manual (part of the training course that Urmila sister attended in Mangalsen)—currently is in the ANC room with all of the PMTCT materials. 

Organization/Time of Teaching

We tried a number of different times and formats.  Initially, I tried to do one lecture separately with the health assistants and one with the ANMs in the afternoon but found this too cumbersome and time consuming for both myself and the staff.  Later we tried one lecture a day with the health assistants and ANMs alternating every day.  But, we only had one health assistant for much of the time I was here.  And I also found that the health assistants were attending the ANMs lectures and vice versa.  So, we decided to combine everything together in such a way that there is a lecture from 3-4pm every single working day.   I’ve asked Dr. KC to help with teaching and he has come on 4 or 5 occasions.  Sometimes the topics covered in the health assistant lectures are too foreign for the ANMs to understand—for example, the “Skin Rashes and Lesions” lecture was too detailed for them and they had never covered such material in their ANM curriculum. 

ANM training

1.       All 5 ANMs did the pre-course questionnaire that is available on the SBA CD developed by JHPIEGO and we went through all of the answers for the 100 questions, focusing on the ones most got incorrect.  Their scores were 59, 66, 67, 68 and 76 out of a total of 100.

2.       Finished the first lecture on the “Role of the SBA”.  Unfortunately, my computer was not able to display the Nepali fonts so the English lecture slides had to be used.  These were a bit cumbersome to translate but with Dr. Man  Bahadur KC’s help, I was able to get through most of the translations.

3.       Started the NSI Obstetric First Aid lectures as these were dubbed in Nepali.  Completed the following lectures:

a.       Anatomy and Physiology

b.      ANC History

c.       ANC Exam

d.      Discomforts during Pregnancy

e.      Bleeding during Pregnancy

f.        PPH (Post-partum hemorrhage)

g.       HTN during pregnancy

4.       Carried out a quick overview of PMTCT

5.       The ANMs overall were very interested in the teaching.  They would ask me if lecture was going to happen that day.  They saw the SBA coursework as a means to learn the theoretical portion of the course.

6.       There is a section of lectures/videos on Infection Control that it would be worthwhile to go through with the ANMs and the health aides in the particular.

Health Assistant training

I have mainly used NSI’s mid-level practicum with the health assistants.  They have had very good things to say about the course.  I don’t think that they have ever had an audio-visual teaching tool like this targeted towards them that was in Nepali and thus, easy to understand and learn from.  Lal was leaving for the Tihar holidays and asked me to copy the training lectures on his computer.  He has been going through them on his own and says that he really enjoys them.  Also on many occasions, the ANMs, lab assistant and pharmacist have joined in on the HA lectures.

Because there are only 2 health assistants and one or the other was on vacation while I have been here, we have not been able to do many lectures with them.  I have been able to complete the following lectures with the health assistants:

1.       Vaginal bleeding

2.       Skin manifestations

3.       Depression (Susan Warren was able to do this lecture with the health assistants)

4.       PMTCT overview

In addition to the digital NSI materials, there are also a number of hard copy NSI training manuals including a Case book, a book of Algorithms for the top 20 problems.  These should be used in conjunction with the lectures.

Doctor training

I unfortunately have not been very successful with CME for the doctors.  We were going to institute a weekly journal club but due to various reasons (being away from Bayalpata for  trips to Kathmandu/Mangalsen, doctor being busy studying for USMLE), this was not done.

Feedback on NSI curriculum

1.        Particularly for “Obstetric First Aid”, the dubbed Nepali translations of the English slides are not very good.  There are some inaccuracies in what is written and what is translated.

2.       Although I have used “Obstetric First Aid” with the ANMs, it is a little too basic for them.  It is meant more as a mid-wifery refresher for health assistants.  I think going through the SBA CD with them would be very good once they are done with “Obstetric First Aid”.  Dr. KC would be the best person to do this because he is able to easily translate the English slides into Nepali and he is also a good teacher.

3.       There is a section of lectures/videos on Infection Control that it would be worthwhile to go through with the ANMs and the health aides in particular.

4.       Very specific Feedback on NSI lectures:

a.       Skin Rashes and Lesions lecture: A)A lot of the disease pictures in the power point only stay on for a few seconds so the students hardly have a chance to look at it.  If you could somehow make the pictures stay on for longer or for the whole time the topic is presented, that would be very helpful.  B) More example pics would be even better, especially pics depicting darker skinned individuals (nepalis) if they are available. 

b.      The health assistants seemed to learn a lot from the Vaginal Bleeding lecture.

Tentative Schedule for Further CME for mid-levels

Perhaps alternating the Health assistant and ANM lectures every day is the best format.  For example, Sunday/Tuesday/Thursday could be health assistant day and Mon/Wed/Fri  could be ANM day.  Teaching time would be best between 3-4pm.  If every day teaching is too time consuming for staff and teachers, one could also do teaching three times a week.

In the table below is a tentative plan for teaching topics and dates for the next month: