Roshana Shrestha | Kathmandu University School of Medical Sciences (original) (raw)
Papers by Roshana Shrestha
DOAJ (DOAJ: Directory of Open Access Journals), Jan 9, 2016
Health professionals involved in a disaster are not immune to the stressors. However, little atte... more Health professionals involved in a disaster are not immune to the stressors. However, little attention is given on the psychological consequences among these professionals. This study has explored the frequency of posttraumatic stress disorder (PTSD) among them after the Nepal earthquake 2015. A descriptive cross sectional study was carried out amongst the medical professionals at Manmohan Memorial Teaching Hospital, Kathmandu to assess the PTSD among them after the Nepal earthquake 2015. Two months after the post disaster the standard PTSD Checklist for DSM-5 (PCL 5) was administered to medical personnel of a hospital(n=64) along with demographic features, disaster related experience and working hours. PTSD was defined by two ways: 1.using DSM V diagnostic criteria (the presence of at least one intrusion, one avoidance, two negative alterations in cognitions/mood and two alterations in arousal and reactivity symptoms); and 2. a cutoff score of 30. The overall prevalence of PTSD was 21.9% and 17.1% using cutoff score and diagnostic criteria respectively. Females scored significantly higher than males. No significant difference was observed according to age, marital status, profession, previous disaster experience, tragic events with relatives. Those who were present in the hospital during the initial influx of victims, witnessed patients suffering, worked extra time were at significantly high risk for development of PTSD. This study suggest that PTSD is highly prevalent among healthcare professionals after disaster management and therefore it highlights the need for targeted interventions to specific staff who respond to large disasters to reduce the psychological burden.
Journal of General Practice and Emergency Medicine of Nepal
Introduction: There are numbers of epidemiological studies that shows clear correlation between o... more Introduction: There are numbers of epidemiological studies that shows clear correlation between obesity and cardiovascular risk factors like systemic hypertension, diabetes, dyslipidemia. The primary aim of this study was to assess the absolute cardiovascular risk (ACR) and cardiovascular risk factors in obese patient. Methods: A descriptive cross sectional study was conducted at this hospital in a population who came for preventive health checkup package. The study was done over a period of 2 years from April 2011 to march 2013. Hypertension was defined as per JNC-7 guidelines. Lipid profile was assess following the criteria of Third report of National Cholesterol Education. Cardiovascular risk assessment was done by Farmingham risk assessment calculator 2008. Result: Total 197 people: male 95(55.5%), female 75(44.5%) participated in this study. Out of which 101 (59.4%) had high BMI with equal prevalence among gender. There was significant relation of BMI with high cholesterol and ...
South-East Asian Journal of Medical Education, 2021
Background: Despite the fact that feedback improves learner performance, the feedback culture rem... more Background: Despite the fact that feedback improves learner performance, the feedback culture remains primitive. This paper explores the feedback behavior from a medical educator perspective. Furthermore, we explored the specific areas of improvement and attempts to suggest solutions to develop an effective feedback culture. Methods: The personal experience and opinion of 33 medical educators from 20 medical institutions of India and one each from Nepal and Sudan on feedback were analyzed with mixed quantitative and qualitative methods. The response to an online self-assessment form and the individual narratives during online discussion were analyzed. Finally, their suggestions on way forward to implementation of an effective feedback culture was summarized. Results: On average 78% of the participants reported having followed the action mentioned in the checklist. Vague terms for giving feedback were used by 18 (54.5 %), and only 15 (45.5%) planned for a specific time frame for stud...
Journal of General Practice and Emergency Medicine of Nepal
The emergency departments (ED) present as the gateway to healthcare services for an increasing nu... more The emergency departments (ED) present as the gateway to healthcare services for an increasing number of older adults. Acute care of this vulnerable population in a busy ED presents its own unique challenge. They have higher mortality in the hospital and following discharge, a higher revisit rate to the ED, and are at a higher risk of functional decline following an ED visit. Extra caution and mindfulness are needed when caring for them as they differ from younger patients in several ways. This article tries to put forward feasible strategies with an integral and holistic view to meet their complex need in the ED.
Journal of Nepal Health Research Council, 2015
BACKGROUND Health professionals involved in a disaster are not immune to the stressors. However, ... more BACKGROUND Health professionals involved in a disaster are not immune to the stressors. However, little attention is given on the psychological consequences among these professionals. This study has explored the frequency of posttraumatic stress disorder (PTSD) among them after the Nepal earthquake 2015. METHODS A descriptive cross sectional study was carried out amongst the medical professionals at Manmohan Memorial Teaching Hospital, Kathmandu to assess the PTSD among them after the Nepal earthquake 2015. Two months after the post disaster the standard PTSD Checklist for DSM-5 (PCL 5) was administered to medical personnel of a hospital(n=64) along with demographic features, disaster related experience and working hours. PTSD was defined by two ways: 1.using DSM V diagnostic criteria (the presence of at least one intrusion, one avoidance, two negative alterations in cognitions/mood and two alterations in arousal and reactivity symptoms); and 2. a cutoff score of 30. RESULTS The ove...
Additional file 1. The English and Nepali version of GDS-15.
PLOS ONE, 2021
Introduction Head injury, a common presentation to the emergency department (ED), is a substantia... more Introduction Head injury, a common presentation to the emergency department (ED), is a substantial problem in developing countries like Nepal. The current national institute for health and clinical excellence (NICE) guideline revised in January 2014 focuses on effective clinical assessment and early management of head injuries according to their severity in all age groups. This study assessed the impact of implementing this guideline on the proportions of computed tomography (CT) head scans, guideline adherence, and confidence level of the attending physicians. Methods We consecutively recruited 139 traumatic head injury (THI) patients in this prospective pre-post interventional study conducted in the ED of a tertiary care center. We implemented the NICE guideline into routine practice using multimodal intervention through physicians’ education sessions, information sheets and guideline-dissemination. The pre and post-implementation CT head scan rates were compared. The post-impleme...
International Journal of Chronic Obstructive Pulmonary Disease, 2021
Purpose: Acute care of patients with exacerbation of chronic obstructive pulmonary disease (AECOP... more Purpose: Acute care of patients with exacerbation of chronic obstructive pulmonary disease (AECOPD) in the emergency department (ED) is crucial, however not studied extensively in Nepal. The purpose of this study is to identify the opportunities for succinct measures to optimize the AECOPD care in ED with a multifaceted bundle care approach in a resource-limited setting. Methods: We conducted a prospective cross-sectional observational study as an initial baseline stage of the quality improvement project. Demographic data, clinical characteristics, the current diagnosis and treatment performances of AECOPD were recorded. The primary outcome measures were 30-day ED revisit and near-fatal events which were compared with other variables and performances with binary and logistic regression. The multidisciplinary team performed the root cause and Pareto analysis to identify the potential gaps in the AECOPD care. Results: The AECOPD performance measures were suboptimal. Written AECOPD emergency management clinical guidelines and advice regarding pulmonary rehabilitation were absent. Among the 249 AECOPD encounters, bilevel positive-airway pressure ventilation was started in 6.4%. At discharge, 11.8% and 39.7% were given oral steroids and antibiotics respectively; 2.2% were advised vaccination. Near-fatal events and 30-day revisit occurred in 19% and 38.2% of the encounters respectively. Those who required domiciliary oxygen had significantly higher 30-day revisits (OR=2.5; 95% CI=1.43-4.4; P value =0.001) as did those who were previously admitted (OR=1.98; 95% CI 1.11-3.59; P value =0.022). Those who had a 30-day revisit had increased near-fatal events (OR=2.86; 95% CI=1.362-6.18; P value =0.006). The opportunities for improving the ED care were identified and feasible interventions and their indicators are summarized for future implementation. Conclusion: The current COPD performance measures were suboptimal with high 30-day revisit and near-fatal outcomes. We suggest the urgent implementation of the enlisted feasible bundles-care involving multifaceted team and protocol-based management plans for AECOPD in a busy resource-limited ED.
![Research paper thumbnail of In-Situ Simulation: Effective and Efficient? [Response to Letter]](https://attachments.academia-assets.com/79150022/thumbnails/1.jpg)
](Advances in Medical Education and Practice, 2020
Roshana Shrestha 1 Dinesh Badyal Anmol Purna Shrestha 1 Abha Shrestha 3 1Department of General Pr... more Roshana Shrestha 1 Dinesh Badyal Anmol Purna Shrestha 1 Abha Shrestha 3 1Department of General Practice and Emergency Medicine, Kathmandu University School of Medical Sciences, Dhulikhel, Kavrepalanchok, Nepal; 2Department of Pharmacology/Medical Education, CMCL-FAIMER Regional Institute, Ludhiana, India; 3Department of Community Medicine, Kathmandu University School of Medical Sciences, Dhulikhel, Kavrepalanchok, Nepal Dear editor Thank you for the opportunity to respond to the issues raised in the letter byAbbass et al. We appreciate Dr Rami Abbass and his colleagues for their keen interest in our paper and for taking their time to express some concerns. The disparity among the cohort of interns who had various previous experiences in resuscitation may be a confounding factor to analyze the impact of the simulation alone; however, it is not feasible to form a homogenous cohort of interns posted to the ED. Five to six interns are posted in the ED at different phases of their intern...
Ashis Shrestha1*, Sumana Bajracharya1, Samita Acharya1, Roshana Shrestha2, Rashmi Thapa3, and Kab... more Ashis Shrestha1*, Sumana Bajracharya1, Samita Acharya1, Roshana Shrestha2, Rashmi Thapa3, and Kabita H. Batajoo4 1Department of General Practice and Emergency Medicine, Patan Academy of Health Sciences, Kathmandu, Nepal 2Department of Emergency Medicine, Manmohan Memorial Hospital, Nepal 3Department of General Practice and Emergency Medicine, Kathmandu Medical College Teaching Hospital, Nepal 4Department of General Practice and Emergency Medicine, KIST Medical College, Nepal
Trauma Surgery & Acute Care Open
BackgroundThoracoabdominal trauma presents a diagnostic challenge for the emergency physician. Th... more BackgroundThoracoabdominal trauma presents a diagnostic challenge for the emergency physician. The introduction of bedside ultrasonography (USG) provides a screening tool to detect hemoperitoneum, hemothorax, pneumothorax and pericardial effusion in torso injuries.AimTo evaluate the accuracy of extended focused assessment with sonography for trauma (EFAST) for chest and abdominal injuries performed by first responders in a tertiary care hospital of Nepal.MethodsThis was a prospective study including all trauma patients who obtained either an Injury Severity Score ≥15 or direct trauma to the trunk in 1 year period in the emergency department (ED) of Dhulikhel Hospital-Kathmandu University Hospital. The results of the EFAST were then compared with contrast-enhanced CT (CECT), radiology ultrasound (USG)/chest X-ray, or intraoperative findings when the EFAST was positive. The negative EFAST cases were observed for a minimum of 4 hours in the ED. Descriptive statistics and sensitivity, s...
Open Access Emergency Medicine
Purpose: During the outbreak of Coronavirus disease of 2019 (COVID-19), the preparedness of emerg... more Purpose: During the outbreak of Coronavirus disease of 2019 (COVID-19), the preparedness of emergency departments (EDs) for triaging of the patients and safety of staff is of utmost importance. The aim of our study was to develop and implement COVID-19 ED triage and protected intubation protocols for COVID-19 patients with in-situ simulation (ISS) training. The latent safety threats (LST) detection also served as a platform to test new system amendments and refine the protocols and workflows with infection control issues. We also explored the effectiveness of this approach based on Kirkpatrick's model of evaluating training outcomes. Participants and Methods: The protocols and simulation scenarios were developed and validated. A total of 22 triage and 13 intubation simulation sessions were conducted in the ED with multidisciplinary staff (physicians=18, nurses=20) during a period of four months. Each simulation was followed by a debriefing session to discuss the team performance. Preand post-simulation performances were compared. LSTs were identified and remediated. An online voluntary feedback was collected from the participants to explore the opinion about the ISS sessions and confidence level using a 5-point Likert scale. Results: There was a significant improvement in triage knowledge score after ISS [5.5/10 (IQR 4-6) versus 8.5/10 (IQR 8-9), p<0.001]. There was a desirable proportion of correct responses (>75%) following the ISS for triage case scenarios. A pre-designed checklist was used during protective intubation simulations. Some important LSTs were missing medications, lack of mechanism to deliver patient samples to lab and faulty airway maneuvers. The participants' feedback on ISS showed increased skills and confidence level on triaging and protected intubation (p<0.001). They found the protocols easy to follow and they recommended for more such modules in future. Conclusion: ISS is a quick and efficient tool to implement the ED protocols for preparation of outbreaks like COVID-19. It helps the ED staff to triage and manage the airway safely. We recommend such an approach to train the multidisciplinary staff and continue to improve ourselves through ISS addressing the changing nature of the pandemic.
Background Depression is prevalent but poorly recognized in the Emergency Department (ED). We aim... more Background Depression is prevalent but poorly recognized in the Emergency Department (ED). We aimed to determine the prevalence of geriatric depression and its possible determinants in the ED using the 15-item geriatric depression scale (GDS). We also aimed to explore the performance of the shorter, five-item GDS as compared to the 15-item GDS. Methods This was a cross-sectional study with convenience sampling of the ED patients ≥ 60 years. The previously validated Nepali version of GDS-15 screened the sample into “no”, “mild-moderate” and “severe" depression using cutoff values of 4/5, and 8/9 respectively. Demographic and socioeconomic factors, comorbidities and health seeking behaviour were studied and the relation was assessed with binary (Chi-square and Kruskal-Wallis test) and multinomial regression analysis. The performance of GDS-5 was compared with the GDS-15 as standard. Cronbach’s alpha was calculated to investigate reliability. Validity was assessed by calculating s...
Background: Internationally emergency medicine is a relatively young specialty that is increasing... more Background: Internationally emergency medicine is a relatively young specialty that is increasingly recognized for its potential for growth. In low middle-income countries (LMICs) like Nepal resources are quite limited and the development of new specialties such as emergency medicine can be slow to evolve. Specific areas of emergency care, including pediatric critical care have significant challenges due to clinical and educational limitations in countries like Nepal. Countries with robust healthcare systems like the United States can play a significant role in bridging this education and clinical divide in LMICs. In 2018 and 2019 the University of Toledo Medical Center in collaboration with Dhulikhel Hospital-Kathmandu University Hospital School of Medicine developed adult and pediatric critical emergency care workshops and educational sessions in an effort to improve the development of emergency medicine in Nepal. These sessions included hands-on workshops, educational lectures, a...
Open Access Emergency Medicine
Point-of-care ultrasound (POCUS) is a quick bedside tool that has the potential to improve emerge... more Point-of-care ultrasound (POCUS) is a quick bedside tool that has the potential to improve emergency care in resource-limited settings due to its relatively low cost and accessibility. Effort to disseminate the knowledge and skills about POCUS is inadequate in low and middle income countries like Nepal. We conducted a two-day interdisciplinary advanced emergency ultrasound workshop that targeted physicians working in emergency department and primary care, especially in rural Nepal. We explored the effectiveness of this training based on validated Kirkpatrick's 4 steps of evaluating training outcomes. Materials and Methods: We conducted a prospective quasi-experimental study with mixed research design. Multidisciplinary physicians working in emergency departments participated in the two-day workshop. We assessed and compared the pre-and post-workshop knowledge. We collected on-site and a follow-up feedback to explore pre-and post-workshop confidence level, perceived usefulness and clinical use of ultrasound using a 5-point Likert scale. The barriers to use POCUS were explored. Results: A total of 50 physicians from different parts of Nepal participated in the workshop. The academic level of the participants, duration of their clinical experience and the previous use of POCUS did not have a significant difference in their pre-and posttest knowledge scores. The difference between the median (IQR) pre-and posttest scores [14 (12.75-17.75) and 24.5 (22.25-25.5), respectively] was statistically significant (p<0.001). Perceived confidence level and usefulness of the POCUS increased significantly in all of its domains (p<0.001). Self-reported increase in its clinical use was significant (p<0.001) for all fields. Conclusion: The participation in this emergency ultrasound workshop increased the knowledge of participants in POCUS. Their confidence, perceived usefulness and clinical use of POCUS improved significantly. Objective longitudinal follow-up of participants' skill and demonstration of increased clinical use of POCUS in emergency department influencing the clinical outcome would be the focus of future research.
PLOS ONE
The COVID-19 pandemic is a global challenge that is not just limited to the physical consequences... more The COVID-19 pandemic is a global challenge that is not just limited to the physical consequences but also a significant degree of a mental health crisis. Self-harm and suicide are its extreme effects. We aim to explore the impact of this pandemic on suicide and self-harm in our Emergency Department. A cross-sectional study was conducted including all fatal and nonfatal self-harm patients presenting to the emergency department during the lockdown period (March 24-June 23, 2020; Period1), matching periods in the previous year (March 24-June 23,2019; Period 2) and 3 months period prior (December 24 2019-March 23, 2020; Period 3) were included through the electronic medical record system. The prevalence and the clinical profile were compared between these three periods. A total of 125 (periods 1 = 55, 2 = 38, and 3 = 32) suicide and self-harm cases were analyzed. Suicide and self-harm had increased by 44% and 71.9% during the lockdown in comparison to periods 2 and 3. Organophosphate p...
Background: Depression is prevalent but poorly recognized in the Emergency Department (ED). We ai... more Background: Depression is prevalent but poorly recognized in the Emergency Department (ED). We aimed to identify the frequency of unrecognized geriatric depression and its possible determinants in the ED using the 15-item geriatric depression scale (GDS). We also aimed to explore the performance of the shorter, five-item GDS as compared to the 15-item GDS.Methods: This was a cross-sectional study of the ED patients ≥ 60 years. The previously validated Nepali version of GDS-15 screened the sample into “no”, “mild-moderate” and “severe" depression using cutoff values of 4/5, and 8/9 respectively. Demographic and socioeconomic factors, comorbidities and health seeking behaviors were studied and the relation was assessed with binary (Chi-square and Kruskal-Wallis test) and multinomial regression analysis. The performance of GDS-5 was compared with the GDS-15 as standard. Cronbach’s alpha was calculated to investigate reliability. Validity was assessed by calculating sensitivity, sp...
Advances in Medical Education and Practice
Purpose: Competency to perform cardiopulmonary resuscitation is essential to improve the outcome ... more Purpose: Competency to perform cardiopulmonary resuscitation is essential to improve the outcome during an event of cardiac arrest. Medical internship is a "transition phase" beyond which physicians are exposed to the unpreparedness and anxiety while dealing with lifethreatening conditions which need rapid actions. Experiential learning, deliberate practice and immediate feedback are the primary advantages of simulation-based medical education. In-situ simulation occurs in a real patient care environment utilizing the available resources. Our aim was to introduce in-situ simulation-based resuscitation skills training for medical interns. Methodology: This was a prospective quasi-experimental study with mixed research design conducted in the emergency department. The knowledge score questionnaire, skill-score sheet, post-simulation feedback from the interns and staff were designed, validated through experts, peer-reviewed and pilot tested. All the interns posted in the emergency department participated in the training. Appropriate statistical analyses were applied for quantitative data. Thematic analysis of the data from the open-ended questions was used to identify the themes. Results: Six groups of interns (n=35) participated in at least one of the 40 in-situ simulation sessions. The means of the pre-and post-simulation knowledge scores were 5.89± 2.8 SD and 11.74± 1.8 SD, respectively, and the difference was statistically significant [t (35) = 16.705, p<0.001]. The skill score had a positive correlation (Pearson correlation coefficient r=0.985, p=0.01) with the number of simulations performed in each group. The thematic analysis uncovered the themes related to the simulation methodology, reflective learning, enhancement of the non-technical skills and effective feedback. The self-reported enhancement in teamwork skills and the confidence level was significant. The feedback of the staff in the Emergency Department showed a positive attitude towards in-situ simulation. Conclusion: This study demonstrated an increase in the knowledge and skills of the interns after participation in the in-situ simulation sessions. Based on the results, the study recommends that in-situ simulation-based teaching should be incorporated in the existing medical education system.
Journal of Nepal Medical Association
Introduction: Basic life support is foundation to save lives. In contrast to the developed countr... more Introduction: Basic life support is foundation to save lives. In contrast to the developed countries, there is still no national standard BLS training module in Nepal. Basic life support training is being provided by various institutions but lack in consistency and coordination. The Nepal basic life support Course is the video based training in Nepali language with reference to recent advances which was intended for all health care personnel of Nepal in urban as well as rural setting. We aimed to describe the features of this video based training module in local language, to analyse the differences of knowledge and find out the participants perception and satisfaction with this course. Methods: This is a descriptive cross-sectional study based on data of trainings conducted over the study period. Ethical approval was taken. The post-test score was recorded and compared with the occupational using ANOVA. On the spot and delayed feedbacks from the participants were collected voluntari...
Journal of Nepal Medical Association
Emergency medicine (EM) is a young but prestigious medical discipline worldwide.1 However, in Nep... more Emergency medicine (EM) is a young but prestigious medical discipline worldwide.1 However, in Nepal, it is in preliminary phase.2 EM is not only restricted to urban emergency departments but also a multifaceted discipline.3 Several EM training modules are currently practiced fragmented with different curriculum and duration.4,5 Pre-hospital emergency medical services (EMS), hospitals, trauma centres, and public health are working in silos and most of them devoid of proper emergency facility.2 This brought us to the realization of an urgent need of bringing all the stakeholders together in a symposium like this. The symposium was arranged into four different sessions as listed below: To familiarize with the history and current state of EM from Global Emergency Medicine perspective. To highlight the different clinical experiences and advancements in EM in Nepal. To emphasize the importance and possibilities in EM education and research in Nepal. To discuss the roadmap to develop and e...
DOAJ (DOAJ: Directory of Open Access Journals), Jan 9, 2016
Health professionals involved in a disaster are not immune to the stressors. However, little atte... more Health professionals involved in a disaster are not immune to the stressors. However, little attention is given on the psychological consequences among these professionals. This study has explored the frequency of posttraumatic stress disorder (PTSD) among them after the Nepal earthquake 2015. A descriptive cross sectional study was carried out amongst the medical professionals at Manmohan Memorial Teaching Hospital, Kathmandu to assess the PTSD among them after the Nepal earthquake 2015. Two months after the post disaster the standard PTSD Checklist for DSM-5 (PCL 5) was administered to medical personnel of a hospital(n=64) along with demographic features, disaster related experience and working hours. PTSD was defined by two ways: 1.using DSM V diagnostic criteria (the presence of at least one intrusion, one avoidance, two negative alterations in cognitions/mood and two alterations in arousal and reactivity symptoms); and 2. a cutoff score of 30. The overall prevalence of PTSD was 21.9% and 17.1% using cutoff score and diagnostic criteria respectively. Females scored significantly higher than males. No significant difference was observed according to age, marital status, profession, previous disaster experience, tragic events with relatives. Those who were present in the hospital during the initial influx of victims, witnessed patients suffering, worked extra time were at significantly high risk for development of PTSD. This study suggest that PTSD is highly prevalent among healthcare professionals after disaster management and therefore it highlights the need for targeted interventions to specific staff who respond to large disasters to reduce the psychological burden.
Journal of General Practice and Emergency Medicine of Nepal
Introduction: There are numbers of epidemiological studies that shows clear correlation between o... more Introduction: There are numbers of epidemiological studies that shows clear correlation between obesity and cardiovascular risk factors like systemic hypertension, diabetes, dyslipidemia. The primary aim of this study was to assess the absolute cardiovascular risk (ACR) and cardiovascular risk factors in obese patient. Methods: A descriptive cross sectional study was conducted at this hospital in a population who came for preventive health checkup package. The study was done over a period of 2 years from April 2011 to march 2013. Hypertension was defined as per JNC-7 guidelines. Lipid profile was assess following the criteria of Third report of National Cholesterol Education. Cardiovascular risk assessment was done by Farmingham risk assessment calculator 2008. Result: Total 197 people: male 95(55.5%), female 75(44.5%) participated in this study. Out of which 101 (59.4%) had high BMI with equal prevalence among gender. There was significant relation of BMI with high cholesterol and ...
South-East Asian Journal of Medical Education, 2021
Background: Despite the fact that feedback improves learner performance, the feedback culture rem... more Background: Despite the fact that feedback improves learner performance, the feedback culture remains primitive. This paper explores the feedback behavior from a medical educator perspective. Furthermore, we explored the specific areas of improvement and attempts to suggest solutions to develop an effective feedback culture. Methods: The personal experience and opinion of 33 medical educators from 20 medical institutions of India and one each from Nepal and Sudan on feedback were analyzed with mixed quantitative and qualitative methods. The response to an online self-assessment form and the individual narratives during online discussion were analyzed. Finally, their suggestions on way forward to implementation of an effective feedback culture was summarized. Results: On average 78% of the participants reported having followed the action mentioned in the checklist. Vague terms for giving feedback were used by 18 (54.5 %), and only 15 (45.5%) planned for a specific time frame for stud...
Journal of General Practice and Emergency Medicine of Nepal
The emergency departments (ED) present as the gateway to healthcare services for an increasing nu... more The emergency departments (ED) present as the gateway to healthcare services for an increasing number of older adults. Acute care of this vulnerable population in a busy ED presents its own unique challenge. They have higher mortality in the hospital and following discharge, a higher revisit rate to the ED, and are at a higher risk of functional decline following an ED visit. Extra caution and mindfulness are needed when caring for them as they differ from younger patients in several ways. This article tries to put forward feasible strategies with an integral and holistic view to meet their complex need in the ED.
Journal of Nepal Health Research Council, 2015
BACKGROUND Health professionals involved in a disaster are not immune to the stressors. However, ... more BACKGROUND Health professionals involved in a disaster are not immune to the stressors. However, little attention is given on the psychological consequences among these professionals. This study has explored the frequency of posttraumatic stress disorder (PTSD) among them after the Nepal earthquake 2015. METHODS A descriptive cross sectional study was carried out amongst the medical professionals at Manmohan Memorial Teaching Hospital, Kathmandu to assess the PTSD among them after the Nepal earthquake 2015. Two months after the post disaster the standard PTSD Checklist for DSM-5 (PCL 5) was administered to medical personnel of a hospital(n=64) along with demographic features, disaster related experience and working hours. PTSD was defined by two ways: 1.using DSM V diagnostic criteria (the presence of at least one intrusion, one avoidance, two negative alterations in cognitions/mood and two alterations in arousal and reactivity symptoms); and 2. a cutoff score of 30. RESULTS The ove...
Additional file 1. The English and Nepali version of GDS-15.
PLOS ONE, 2021
Introduction Head injury, a common presentation to the emergency department (ED), is a substantia... more Introduction Head injury, a common presentation to the emergency department (ED), is a substantial problem in developing countries like Nepal. The current national institute for health and clinical excellence (NICE) guideline revised in January 2014 focuses on effective clinical assessment and early management of head injuries according to their severity in all age groups. This study assessed the impact of implementing this guideline on the proportions of computed tomography (CT) head scans, guideline adherence, and confidence level of the attending physicians. Methods We consecutively recruited 139 traumatic head injury (THI) patients in this prospective pre-post interventional study conducted in the ED of a tertiary care center. We implemented the NICE guideline into routine practice using multimodal intervention through physicians’ education sessions, information sheets and guideline-dissemination. The pre and post-implementation CT head scan rates were compared. The post-impleme...
International Journal of Chronic Obstructive Pulmonary Disease, 2021
Purpose: Acute care of patients with exacerbation of chronic obstructive pulmonary disease (AECOP... more Purpose: Acute care of patients with exacerbation of chronic obstructive pulmonary disease (AECOPD) in the emergency department (ED) is crucial, however not studied extensively in Nepal. The purpose of this study is to identify the opportunities for succinct measures to optimize the AECOPD care in ED with a multifaceted bundle care approach in a resource-limited setting. Methods: We conducted a prospective cross-sectional observational study as an initial baseline stage of the quality improvement project. Demographic data, clinical characteristics, the current diagnosis and treatment performances of AECOPD were recorded. The primary outcome measures were 30-day ED revisit and near-fatal events which were compared with other variables and performances with binary and logistic regression. The multidisciplinary team performed the root cause and Pareto analysis to identify the potential gaps in the AECOPD care. Results: The AECOPD performance measures were suboptimal. Written AECOPD emergency management clinical guidelines and advice regarding pulmonary rehabilitation were absent. Among the 249 AECOPD encounters, bilevel positive-airway pressure ventilation was started in 6.4%. At discharge, 11.8% and 39.7% were given oral steroids and antibiotics respectively; 2.2% were advised vaccination. Near-fatal events and 30-day revisit occurred in 19% and 38.2% of the encounters respectively. Those who required domiciliary oxygen had significantly higher 30-day revisits (OR=2.5; 95% CI=1.43-4.4; P value =0.001) as did those who were previously admitted (OR=1.98; 95% CI 1.11-3.59; P value =0.022). Those who had a 30-day revisit had increased near-fatal events (OR=2.86; 95% CI=1.362-6.18; P value =0.006). The opportunities for improving the ED care were identified and feasible interventions and their indicators are summarized for future implementation. Conclusion: The current COPD performance measures were suboptimal with high 30-day revisit and near-fatal outcomes. We suggest the urgent implementation of the enlisted feasible bundles-care involving multifaceted team and protocol-based management plans for AECOPD in a busy resource-limited ED.
Advances in Medical Education and Practice, 2020
Roshana Shrestha 1 Dinesh Badyal Anmol Purna Shrestha 1 Abha Shrestha 3 1Department of General Pr... more Roshana Shrestha 1 Dinesh Badyal Anmol Purna Shrestha 1 Abha Shrestha 3 1Department of General Practice and Emergency Medicine, Kathmandu University School of Medical Sciences, Dhulikhel, Kavrepalanchok, Nepal; 2Department of Pharmacology/Medical Education, CMCL-FAIMER Regional Institute, Ludhiana, India; 3Department of Community Medicine, Kathmandu University School of Medical Sciences, Dhulikhel, Kavrepalanchok, Nepal Dear editor Thank you for the opportunity to respond to the issues raised in the letter byAbbass et al. We appreciate Dr Rami Abbass and his colleagues for their keen interest in our paper and for taking their time to express some concerns. The disparity among the cohort of interns who had various previous experiences in resuscitation may be a confounding factor to analyze the impact of the simulation alone; however, it is not feasible to form a homogenous cohort of interns posted to the ED. Five to six interns are posted in the ED at different phases of their intern...
Ashis Shrestha1*, Sumana Bajracharya1, Samita Acharya1, Roshana Shrestha2, Rashmi Thapa3, and Kab... more Ashis Shrestha1*, Sumana Bajracharya1, Samita Acharya1, Roshana Shrestha2, Rashmi Thapa3, and Kabita H. Batajoo4 1Department of General Practice and Emergency Medicine, Patan Academy of Health Sciences, Kathmandu, Nepal 2Department of Emergency Medicine, Manmohan Memorial Hospital, Nepal 3Department of General Practice and Emergency Medicine, Kathmandu Medical College Teaching Hospital, Nepal 4Department of General Practice and Emergency Medicine, KIST Medical College, Nepal
Trauma Surgery & Acute Care Open
BackgroundThoracoabdominal trauma presents a diagnostic challenge for the emergency physician. Th... more BackgroundThoracoabdominal trauma presents a diagnostic challenge for the emergency physician. The introduction of bedside ultrasonography (USG) provides a screening tool to detect hemoperitoneum, hemothorax, pneumothorax and pericardial effusion in torso injuries.AimTo evaluate the accuracy of extended focused assessment with sonography for trauma (EFAST) for chest and abdominal injuries performed by first responders in a tertiary care hospital of Nepal.MethodsThis was a prospective study including all trauma patients who obtained either an Injury Severity Score ≥15 or direct trauma to the trunk in 1 year period in the emergency department (ED) of Dhulikhel Hospital-Kathmandu University Hospital. The results of the EFAST were then compared with contrast-enhanced CT (CECT), radiology ultrasound (USG)/chest X-ray, or intraoperative findings when the EFAST was positive. The negative EFAST cases were observed for a minimum of 4 hours in the ED. Descriptive statistics and sensitivity, s...
Open Access Emergency Medicine
Purpose: During the outbreak of Coronavirus disease of 2019 (COVID-19), the preparedness of emerg... more Purpose: During the outbreak of Coronavirus disease of 2019 (COVID-19), the preparedness of emergency departments (EDs) for triaging of the patients and safety of staff is of utmost importance. The aim of our study was to develop and implement COVID-19 ED triage and protected intubation protocols for COVID-19 patients with in-situ simulation (ISS) training. The latent safety threats (LST) detection also served as a platform to test new system amendments and refine the protocols and workflows with infection control issues. We also explored the effectiveness of this approach based on Kirkpatrick's model of evaluating training outcomes. Participants and Methods: The protocols and simulation scenarios were developed and validated. A total of 22 triage and 13 intubation simulation sessions were conducted in the ED with multidisciplinary staff (physicians=18, nurses=20) during a period of four months. Each simulation was followed by a debriefing session to discuss the team performance. Preand post-simulation performances were compared. LSTs were identified and remediated. An online voluntary feedback was collected from the participants to explore the opinion about the ISS sessions and confidence level using a 5-point Likert scale. Results: There was a significant improvement in triage knowledge score after ISS [5.5/10 (IQR 4-6) versus 8.5/10 (IQR 8-9), p<0.001]. There was a desirable proportion of correct responses (>75%) following the ISS for triage case scenarios. A pre-designed checklist was used during protective intubation simulations. Some important LSTs were missing medications, lack of mechanism to deliver patient samples to lab and faulty airway maneuvers. The participants' feedback on ISS showed increased skills and confidence level on triaging and protected intubation (p<0.001). They found the protocols easy to follow and they recommended for more such modules in future. Conclusion: ISS is a quick and efficient tool to implement the ED protocols for preparation of outbreaks like COVID-19. It helps the ED staff to triage and manage the airway safely. We recommend such an approach to train the multidisciplinary staff and continue to improve ourselves through ISS addressing the changing nature of the pandemic.
Background Depression is prevalent but poorly recognized in the Emergency Department (ED). We aim... more Background Depression is prevalent but poorly recognized in the Emergency Department (ED). We aimed to determine the prevalence of geriatric depression and its possible determinants in the ED using the 15-item geriatric depression scale (GDS). We also aimed to explore the performance of the shorter, five-item GDS as compared to the 15-item GDS. Methods This was a cross-sectional study with convenience sampling of the ED patients ≥ 60 years. The previously validated Nepali version of GDS-15 screened the sample into “no”, “mild-moderate” and “severe" depression using cutoff values of 4/5, and 8/9 respectively. Demographic and socioeconomic factors, comorbidities and health seeking behaviour were studied and the relation was assessed with binary (Chi-square and Kruskal-Wallis test) and multinomial regression analysis. The performance of GDS-5 was compared with the GDS-15 as standard. Cronbach’s alpha was calculated to investigate reliability. Validity was assessed by calculating s...
Background: Internationally emergency medicine is a relatively young specialty that is increasing... more Background: Internationally emergency medicine is a relatively young specialty that is increasingly recognized for its potential for growth. In low middle-income countries (LMICs) like Nepal resources are quite limited and the development of new specialties such as emergency medicine can be slow to evolve. Specific areas of emergency care, including pediatric critical care have significant challenges due to clinical and educational limitations in countries like Nepal. Countries with robust healthcare systems like the United States can play a significant role in bridging this education and clinical divide in LMICs. In 2018 and 2019 the University of Toledo Medical Center in collaboration with Dhulikhel Hospital-Kathmandu University Hospital School of Medicine developed adult and pediatric critical emergency care workshops and educational sessions in an effort to improve the development of emergency medicine in Nepal. These sessions included hands-on workshops, educational lectures, a...
Open Access Emergency Medicine
Point-of-care ultrasound (POCUS) is a quick bedside tool that has the potential to improve emerge... more Point-of-care ultrasound (POCUS) is a quick bedside tool that has the potential to improve emergency care in resource-limited settings due to its relatively low cost and accessibility. Effort to disseminate the knowledge and skills about POCUS is inadequate in low and middle income countries like Nepal. We conducted a two-day interdisciplinary advanced emergency ultrasound workshop that targeted physicians working in emergency department and primary care, especially in rural Nepal. We explored the effectiveness of this training based on validated Kirkpatrick's 4 steps of evaluating training outcomes. Materials and Methods: We conducted a prospective quasi-experimental study with mixed research design. Multidisciplinary physicians working in emergency departments participated in the two-day workshop. We assessed and compared the pre-and post-workshop knowledge. We collected on-site and a follow-up feedback to explore pre-and post-workshop confidence level, perceived usefulness and clinical use of ultrasound using a 5-point Likert scale. The barriers to use POCUS were explored. Results: A total of 50 physicians from different parts of Nepal participated in the workshop. The academic level of the participants, duration of their clinical experience and the previous use of POCUS did not have a significant difference in their pre-and posttest knowledge scores. The difference between the median (IQR) pre-and posttest scores [14 (12.75-17.75) and 24.5 (22.25-25.5), respectively] was statistically significant (p<0.001). Perceived confidence level and usefulness of the POCUS increased significantly in all of its domains (p<0.001). Self-reported increase in its clinical use was significant (p<0.001) for all fields. Conclusion: The participation in this emergency ultrasound workshop increased the knowledge of participants in POCUS. Their confidence, perceived usefulness and clinical use of POCUS improved significantly. Objective longitudinal follow-up of participants' skill and demonstration of increased clinical use of POCUS in emergency department influencing the clinical outcome would be the focus of future research.
PLOS ONE
The COVID-19 pandemic is a global challenge that is not just limited to the physical consequences... more The COVID-19 pandemic is a global challenge that is not just limited to the physical consequences but also a significant degree of a mental health crisis. Self-harm and suicide are its extreme effects. We aim to explore the impact of this pandemic on suicide and self-harm in our Emergency Department. A cross-sectional study was conducted including all fatal and nonfatal self-harm patients presenting to the emergency department during the lockdown period (March 24-June 23, 2020; Period1), matching periods in the previous year (March 24-June 23,2019; Period 2) and 3 months period prior (December 24 2019-March 23, 2020; Period 3) were included through the electronic medical record system. The prevalence and the clinical profile were compared between these three periods. A total of 125 (periods 1 = 55, 2 = 38, and 3 = 32) suicide and self-harm cases were analyzed. Suicide and self-harm had increased by 44% and 71.9% during the lockdown in comparison to periods 2 and 3. Organophosphate p...
Background: Depression is prevalent but poorly recognized in the Emergency Department (ED). We ai... more Background: Depression is prevalent but poorly recognized in the Emergency Department (ED). We aimed to identify the frequency of unrecognized geriatric depression and its possible determinants in the ED using the 15-item geriatric depression scale (GDS). We also aimed to explore the performance of the shorter, five-item GDS as compared to the 15-item GDS.Methods: This was a cross-sectional study of the ED patients ≥ 60 years. The previously validated Nepali version of GDS-15 screened the sample into “no”, “mild-moderate” and “severe" depression using cutoff values of 4/5, and 8/9 respectively. Demographic and socioeconomic factors, comorbidities and health seeking behaviors were studied and the relation was assessed with binary (Chi-square and Kruskal-Wallis test) and multinomial regression analysis. The performance of GDS-5 was compared with the GDS-15 as standard. Cronbach’s alpha was calculated to investigate reliability. Validity was assessed by calculating sensitivity, sp...
Advances in Medical Education and Practice
Purpose: Competency to perform cardiopulmonary resuscitation is essential to improve the outcome ... more Purpose: Competency to perform cardiopulmonary resuscitation is essential to improve the outcome during an event of cardiac arrest. Medical internship is a "transition phase" beyond which physicians are exposed to the unpreparedness and anxiety while dealing with lifethreatening conditions which need rapid actions. Experiential learning, deliberate practice and immediate feedback are the primary advantages of simulation-based medical education. In-situ simulation occurs in a real patient care environment utilizing the available resources. Our aim was to introduce in-situ simulation-based resuscitation skills training for medical interns. Methodology: This was a prospective quasi-experimental study with mixed research design conducted in the emergency department. The knowledge score questionnaire, skill-score sheet, post-simulation feedback from the interns and staff were designed, validated through experts, peer-reviewed and pilot tested. All the interns posted in the emergency department participated in the training. Appropriate statistical analyses were applied for quantitative data. Thematic analysis of the data from the open-ended questions was used to identify the themes. Results: Six groups of interns (n=35) participated in at least one of the 40 in-situ simulation sessions. The means of the pre-and post-simulation knowledge scores were 5.89± 2.8 SD and 11.74± 1.8 SD, respectively, and the difference was statistically significant [t (35) = 16.705, p<0.001]. The skill score had a positive correlation (Pearson correlation coefficient r=0.985, p=0.01) with the number of simulations performed in each group. The thematic analysis uncovered the themes related to the simulation methodology, reflective learning, enhancement of the non-technical skills and effective feedback. The self-reported enhancement in teamwork skills and the confidence level was significant. The feedback of the staff in the Emergency Department showed a positive attitude towards in-situ simulation. Conclusion: This study demonstrated an increase in the knowledge and skills of the interns after participation in the in-situ simulation sessions. Based on the results, the study recommends that in-situ simulation-based teaching should be incorporated in the existing medical education system.
Journal of Nepal Medical Association
Introduction: Basic life support is foundation to save lives. In contrast to the developed countr... more Introduction: Basic life support is foundation to save lives. In contrast to the developed countries, there is still no national standard BLS training module in Nepal. Basic life support training is being provided by various institutions but lack in consistency and coordination. The Nepal basic life support Course is the video based training in Nepali language with reference to recent advances which was intended for all health care personnel of Nepal in urban as well as rural setting. We aimed to describe the features of this video based training module in local language, to analyse the differences of knowledge and find out the participants perception and satisfaction with this course. Methods: This is a descriptive cross-sectional study based on data of trainings conducted over the study period. Ethical approval was taken. The post-test score was recorded and compared with the occupational using ANOVA. On the spot and delayed feedbacks from the participants were collected voluntari...
Journal of Nepal Medical Association
Emergency medicine (EM) is a young but prestigious medical discipline worldwide.1 However, in Nep... more Emergency medicine (EM) is a young but prestigious medical discipline worldwide.1 However, in Nepal, it is in preliminary phase.2 EM is not only restricted to urban emergency departments but also a multifaceted discipline.3 Several EM training modules are currently practiced fragmented with different curriculum and duration.4,5 Pre-hospital emergency medical services (EMS), hospitals, trauma centres, and public health are working in silos and most of them devoid of proper emergency facility.2 This brought us to the realization of an urgent need of bringing all the stakeholders together in a symposium like this. The symposium was arranged into four different sessions as listed below: To familiarize with the history and current state of EM from Global Emergency Medicine perspective. To highlight the different clinical experiences and advancements in EM in Nepal. To emphasize the importance and possibilities in EM education and research in Nepal. To discuss the roadmap to develop and e...