AMPATH Nepal Partners Collaborate to Improve Critical Care
The global pandemic highlighted the importance of hospitals having mechanical ventilators and doctors and nurses with the expertise to use them effectively. Critically important to patient survival and recovery is also the expertise to know the best time and process to remove a patient from a ventilator.
Doctors from Dhulikhel Hospital and Mount Sinai are collaborating on care, research and training initiatives.
Through the AMPATH Nepal partnership, doctors from Icahn School of Medicine at Mount Sinai in New York are working with their colleagues at Dhulikhel Hospital and Kathmandu University School of Medical Sciences to train and implement evidence-based protocols for ventilator management to improve care and outcomes for people they serve in rural Nepal. The Arnhold Institute for Global Health at Mount Sinai leads the AMPATH Consortium’s involvement in the partnership.
"Dhulikhel Hospital has a very strong and dedicated team of intensive care unit (ICU) physicians and nurses," said Cappi Lay, MD, director of the Institute for Critical Care Medicine (ICCM) Global Critical Care Program and lead of the project for Mount Sinai. "Through collaborating, we aim to build on their existing strengths: through a variety of educational initiatives we can improve the skill set of physicians and nurses on the front lines; we are introducing protocol changes in the ICU that will directly improve patient care; and performing critical care research in the Nepalese context, we can define the specific practices and patterns of care that will best serve the population there."
Dr. Cappi Lay, Dr. Sangina Ranjit and Dr. Mirna Mohanraj
The team will utilize an adaptation of paired spontaneous awakening and breathing trials, a standard approach to reducing sedation and deciding when a patient no longer needs to be connected to a ventilator. The evidence-based intervention decreases the potential sedation related complications such as deconditioning and weakness, as well as adverse cognitive, emotional and psychological effects from having too much sedation. Discontinuing mechanical ventilation is based on many factors, but determining the optimal time reduces infections and a range of complications from being on the ventilator for longer than necessary.
“As an anesthesiology-trained physician, I always strive for quality care for our critically ill patients,” said Dr. Sangina Ranjit, associate professor and head of the Department of Anesthesiology and Critical Care at Dhulikhel Hospital and Kathmandu University School of Medical Sciences. “Our mission is ‘quality health accessible to the poor.’ Improving the quality of critical care was our priority because our poor patients could not afford the fancy ICU in the capital city. To meet this target, we were seeking an international partnership that would complement our wishes through capacity building, resources and quality improvement projects.” Dr. Ranjit is co-investigator for the project and leads the data collection, implementation, and training doctors, nurses and physiotherapists on the protocol.
The AMPATH Nepal critical care partnership launched with a visit to Mount Sinai last fall by Dr. Ranjit and Bhawana Regmi, assistant professor in the Department of Medical-Surgical Nursing at Kathmandu University School of Medical Sciences and nurse manager at the intensive care unit of Dhulikhel Hospital.
During the intensive one-month visit, the Nepal team met with the ICCM team at Mount Sinai including nursing, pharmacy and spiritual care and spent time in four different intensive care units—medical, surgical, cardiothoracic and neurosurgical. They visited Mount Sinai hospitals in various locations throughout New York City so they could see how critical care practices are modified based on personnel and strategic allocation of available resources.
They also spent a day at the Center for Advanced Medical Simulation at Mount Sinai West and observed methods for bedside teaching during daily rounds. Of course, they also had the opportunity to experience New York City historical and culinary highlights.
As part of the reciprocal foundation of the AMPATH partnership, Dr. Lay traveled to Nepal this past spring with his colleague Mirna Mohanraj, MD, associate professor of medicine and medical education at the Icahn School of Medicine at Mount Sinai.
A training with healthcare workers in Nepal
During the visit, the Mount Sinai team spent time in appreciative inquiry to better understand local challenges and resources and how to best contribute to meeting the needs and ideas of their Nepalese colleagues. They met with hospital leadership; faculty from the emergency room, anesthesia and infection control; and nurses who lead respiratory care at the rural hospital.
“At Dhulikhel Hospital, they are an extraordinary team,” reflected Dr. Mohanraj. “It really was just such a beautiful, eye-opening experience for me to see the level of devotion, the hours and commitment that they display in their work, and the intention to really improve health and lives there. It's incredibly inspiring considering the limited resources and staffing for the amount of work that they do.”
While in Nepal, Dr. Lay and Dr. Mohanraj also led lectures and provided bedside education for trainees. They transported a simulation mannequin from New York and provided training for nurses on conducting a code. Dr. Lay was also able to perform a tracheostomy insertion education course on a cadaver for a core group of physicians.
Dr. Mohanraj co-leads the critical care fellowship at Mount Sinai and is passionate about teaching. “The learners there are just so thirsty for every drop of information that you can give them. It felt fulfilling in a very different way. I felt very connected to everyone there. The hospital welcomed us with so much graciousness and so much openness to learn. So, it was just a really wonderful place to be.”
Virtual education sessions have continued monthly with the sessions rotating between presentations by faculty in Nepal and New York. The 9 hour and 45-minute time difference necessitates trainings that begin in the evening in the U.S. and early morning in Nepal, but there has been no shortage of faculty eager to participate. Other hospitals in Nepal are also invited to attend the virtual sessions.
Dr. Lay and Dr. Mohanraj plan to return to Nepal in November to continue the simulation education and provide support to the Nepal leaders in dealing with any challenges they are facing in implementing the new protocol.
The team will collect and analyze several variables before and after the intervention including patient demographics, severity of illness, ventilator-associated conditions and complications, and critical care outcomes. While the intervention itself is low-cost, development and maintenance of the education and research infrastructure, including a patient database, requires a significant investment of personnel, time and materials.
“Our partnership represents one of only a few international collaborations that specifically focuses on developing intensive care,” said Dr. Lay. “We believe that concentrating on this historically overlooked area of global health has the potential to deliver meaningful improvements to the health of Nepal over time.”
"Quality healthcare need not always be expensive,” added Dr. Ranjit. “Cost-effective improvement projects can bring significant positive outcomes. Good ICU patient management will hasten patient recovery. The shorter duration of ICU stay and lower costs for the patient will have a huge impact on people of Nepal.”
While the AMPATH partners are focused on making sure their first collaboration on the adapted protocol is a success, they have many ideas for growing the collaboration. In addition to extending training on the ICU protocol to other facilities in the region and the country, the team in Nepal is also interested in developing a rapid response team which is common for hospitals in the U.S.
“The AMPATH partnership is distinguished by its comprehensive approach, sustainable impact, and commitment to innovation,” added Regmi, co-investigator for the project who draws on her expertise in critical care and nursing education to contribute to the design, implementation and evaluation of the project.
“By integrating global expertise with local insights, AMPATH effectively addresses healthcare challenges in countries like Nepal,” she continued. “Its emphasis on health equity ensures that underserved populations receive quality care, while its focus on research and education fosters the development of advanced, evidence-based medical practices. This model not only enhances healthcare delivery but also builds local capacity, making it particularly advantageous for improving health outcomes and strengthening healthcare systems in Nepal.”
“The most personally rewarding aspect of the exchange so far has been the development of personal friendships with Dr. Ranjit and other members of her team,” summarized Dr. Lay. “Investing the time to get to know each other as human beings has increased our motivation to make sure this partnership is a success.”