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29существенно через 2, 4 и 6 часов после приёма ме-топресса (р<0,02, <0,04). Однако в 06 .00, в 08.00 изменения МСЛЖ были несущественными. Ve недостоверно повышалось в 24.00 и в 02.00. В остальные периоды суток динамика Ve была недостоверной. Также недостоверными оказались изменения А, Крац, ДП под влиянием метопресса, принимаемого в 20.00. Таким образом, при приёме мето-пресса-ретарда в 20.00 отмечалось его отрицательное хронотропное и гипотензивное действие. Снижение САД и АДср (на 6.6%) происходило за счёт урежения ЧСС (на 14%). Следует отметить различие гемодинамического обеспечения гипотензивного эффекта метопресса утром и вечером. При приёме метопресса в 08.00 отмечалось более выраженное отрицательное хронотропное действие метопресса (урежение ЧСС на 25%), тогда как при приёме препарата в 20.00 урежение ЧСС составило лишь 14%. Снижение САД при приёме метопресса составило 13%, тогда как при приёме препарата в 20.00 САД снизилось лишь на 6.6%.
Заключение.
Результаты проведенных исследований свидетельствуют о хронофармакологических особенностях метопресса-ретарда, проявляющихся в виде время-зависимых эффектов этого селективного бета-адреноблокатора пролонгированного действия у больных ГБ 2ст. Отмеченные особенности
устанавливались при наличии феномена более выраженного и длительного отрицательного хроно-тропного и гипотензивного эффектов и уменьшении энергетических затрат миокарда при применении метопресса-ретарда утром - в 08.00. Описанные эффекты были значительно менее выражены при применении данного препарата вечером - в 20.00. Эти данные позволяют рекомендовать назначение метопресса-ретарда, используя режим хронотерапии с учётом фактора времени при лечении больных ГБ 2 стадии
Список литературы
1. Белоусов Ю.Б., Грацианская А.Н. - Клиническая фармакология метопролола (корвитола) // Москва. - «Университет Паблишинг». - 1997.-с.32-40
2. Ольбинская Л.И. - Современные позиции применения бета-адреноблокаторов в лечении гипертонической болезни // Клин. фарм, и терапия. -1997.- №3.- с. 10-1
3. Заславская Р.М. с соавт. - Хроночувстви-тельность к гипертензивным препаратам и их время-зависимые эффекты при артериальной гипертонии // М.: ИД. «Медпрактика-М». - 2017.-168с
4. Заславская Р.М. с соавт. - Время-зависимые эффекты бета-адреноблокаторов и антагонистов кальция в терапии ишемической болезни сердца //-М.:ИД. «Медпрактика-М». - 2017.-136с.
EFFECTIVENESS OF THE NEW MODEL OF CONTINUING MEDICAL EDUCATION IN EMERGENCY MEDICINE IN THE KYRGYZ REPUBLIC
Omukeeva G.,
Head of the Emergency Medicine Course at the Kyrgyz State Medical Institute of Post-graduate training
and continuous education named after S.B. Daniyarov
Kyrgyz Republic, Bishkek https://orcid.org/0000-0002-8486-3529 Kurmanov R.,
MD, DSc, Professor, Rector at the Kyrgyz State Medical Institute of Post-graduate training and continuous
education named after S.B. Daniyarov Kyrgyz Republic, Bishkek http://orcid. org/0000-0002-6104-0538 Chubakov T.,
MD, DSc, Professor, Head of the Department of Phthisiopulmonology at the Kyrgyz State Medical Institute
of Post-graduate training and continuous education named after S.B. Daniyarov
Kyrgyz Republic, Bishkek https://orcid.org/0000-0002-7876-5332 Dushimbekova K.
Ph.D., assistant and head teacher of the Department of Phthisiopulmonology at the Kyrgyz State Medical Institute of Post-graduate training and continuous education named after S.B. Daniyarov
Kyrgyz Republic, Bishkek http://orcid. org/0000-0003-1367-59 74
Abstract
Introduction: The emergency care system (ECS) is a critical component of national health care systems and remains an underdeveloped aspect of health care in many low- and middle-income countries of the world.
Goal of the study: to analyze the effectiveness of the new continuing emergency care education model intraduction in the Kyrgyz Republic.
Materials and methods: A comprehensive retrospective analysis of preclinical and clinical training results was carried out based on the newly introduced training model. To assess the initial and final level of the course participants' knowledge, form-based tests were used. Practical skills were evaluated using patient simulators and
simulation-based clinical scenarios, and the effectiveness and quality of the training courses were evaluated. The final evaluation of the theoretical and practical training parts is presented based on the monitoring of the work of medical workers with repeated clinical training in the workplace.
The study findings: A conceptual model of emergency medical care training and new curricula and materials were developed by adapting the international recommendations and standards to the country's context, practical training was provided based on innovative manikins with different clinical scenarios close to real-life situations. All health care workers have a high knowledge growth rate and practical skills improvement after the training. The indicator of the knowledge growth rate (KGR) for doctors was 62,7%, for nurses and paramedics it was 84,8% and 78,1% respectively. During the monitoring and evaluation of the EMS workers after the training, it was found that they had acquired the necessary knowledge and practical skills at a high level.
Conclusion: A conceptual emergency medical care training model for emergency medical service specialists has been developed, which significantly increases the effectiveness of training and subsequently has become a long-term and sustainable system.
Keywords: prehospital, emergency service doctors, paramedics, nurses, curricula, modeling, monitoring and evaluation.
Introduction. The urgent or emergency medical service (EMS) system is a critical component of national health care systems which remains an underdeveloped aspect of health care in many low- and middle-income countries of the world. EMS is an effective method of preventing the development of disease complications resulting in lower mortality, especially in resource-limited settings where most of the global disease and injury burden is. In emergency settings, it becomes necessary to provide timely, high-quality and effective medical care. [1,2,3,4,5,6].
The composition of mobile EMS team depends on the adopted model of medical care provision: the Anglo-American model based on paramedics and the Franco-German model based on doctors [8,9,10]. Since 1970s, the prehospital EMS regime has evolved around these two main models of emergency care with different characteristics. Today, most EMS systems around the world have a different composition for each model. According to the Franco-German or Anglo-American EMS philosophy model at the prehospital level, they can be divided into basic life support (BLS) and advanced (in-depth) life support (ALS) according to the level of EMS provision. [11,9].
The Anglo-American model is based on a scoop-and-run philosophy with the goal of getting a patient to the hospital quickly and with fewer prehospital interventions. [11,9,12] It is usually associated with public security services such as police or firefighters, rather than with public health services and hospitals [14]. Trained paramedics and emergency medical technicians (EMT) operate the system under the clinical supervision of a physician trained in emergency medicine. In the countries using this model emergency medicine is well developed and recognized as a separate medical specialty. Almost all patients of the Anglo-American model are delivered by ambulance paramedics to developed emergency departments and not to hospital wards, believing that the sooner a patient is delivered to the department the greater are his/her chances for stabilization. The countries that use this EMS delivery model are the USA, Canada, Australia, New Zealand, Sultanate of Oman, Kingdom of Bahrain, etc. [11, 13,14,15,16]
The Franco-German model of EMS delivery is based on the "stay and play" principle, which in terms
of the EMS delivery level refers to advanced life support. This model of care promotes care provision at the place of accident, at home, on the way to medical organizations, and not all patients will be delivered reducing the frequency of hospitalizations. [11,12] Patients delivered to medical organizations can be admitted to the emergency departments (EDs). Teams providing EMS based on the Franco-German model are composed of several members: doctors, paramedics and medical technicians. Usually, these teams are led by physicians with extensive practice who use cutting-edge technology. Such teams are equipped with medical equipment, drugs, medical devices (MDs), ambulance vehicles, and in addition to land vehicles, aviation (helicopters) can also used [9]. The Franco-German model of EMS provision is widely used in Europe, where emergency medicine is a relatively young field [17]. Such countries as Germany, France, Greece, Malta, Austria, Belgium, Italy, Spain, Brazil and Chile have well-developed Franco-German EMS systems. [18,19,20,21,22]
Providing high-quality emergency care requires medical personnel trained in emergency care. The list of WHO recommended actions in 2019 included the following: ensure that all emergency medical workers are trained, for example, by developing specialized training programs, providing training on basic emergency skills for primary health care workers, and integrating a specialized emergency course in training programs for nurses and doctors in higher educational institutions. [23]
The purpose of our study is to analyze the effectiveness of introducing a new model of continuing medical education in emergency medicine in the Kyrgyz Republic.
Materials and methods. There are 7 provinces in the Kyrgyz Republic: Chui, Naryn, Talas, Issyk-Kul, Osh, Jalal-Abad, Batken provinces. All training courses for the period from 2010 to 2019 were conducted by instructors of the Kyrgyz State Medical Institute for Retraining and Advanced Training (KSMIRAT) in Bishkek and SBKSMIRAT (SB-Southern Branch) in Osh. Most of the training courses were conducted at the Training Center in Bishkek. In order to increase the percentage of coverage and ensure access, reduce training costs and ensure capacity building of healthcare workers, courses in Batken, Jalal-Abad, Osh, Issyk-Kul
provinces were conducted and simulated in a real work environment in hospitals, clinics and training centers.
A comprehensive retrospective analysis of pre-clinical and clinical training was carried out to see the progress of participants depending on: the level of EMS provision (primary and secondary level of health care), conducted courses, specialties, age, gender, work experience, and the results of theoretical knowledge were evaluated in the form of pre-/post-tests (blank forms) as well as practical skills at the preclinical level. In order to determine the effectiveness of training and feedback about all training courses included in the training
model, the participants evaluated the course (blank forms) according to the developed evaluation scheme based on the Likert scale. To determine long-term results based on the example of Batken province, the final evaluation of theoretical and practical training parts based on the conducted monitoring and evaluation with clinical training in the workplace is presented.
All training courses for the specified period were financed by the state budget, projects of the German Bank for Reconstruction and Development kfW, UNICEF, RBF (results-based funding), the Swiss Embassy VEK.
Table 1
The total number of EMS specialists trained at all courses available for the prehospital level by age category ___and by specialty.___
Age in years EMS doctors n=352 (20.4%) EMS paramedics n=910 (52.8%) EMS paramedics n=233 (13.5%) EMS drivers n=227 (13.3%) Total:
Absolute number Proportion in % Absolute number Proportion in % Absolute number Proportion in % Absolute number Proportion in % Absolute number Proportion in %
20-29 100 28,4 271 29,8 39 16,7 9 4,0 419 24,3
30-39 70 19,9 216 23,7 51 21,9 29 12,8 366 21,3
40-49 80 22,7 241 26,5 87 37,3 54 23,8 462 26,8
50-59 73 20,7 144 15,8 45 19,3 106 46,7 368 21,4
60 and over 29 8,2 38 4,2 11 4,7 29 12,8 107 6,2
Total: 352 100,0 910 100,0 233 100,0 227 100,0 1722 100
As it can be seen in Table 1, 352 (100%) EMS doctors were trained at the prehospital level. The young age of 20-29 years old among doctors is probably associated with the employment of recent graduates of educational institutions with the Emergency Medicine Centers (EMCs) to practice practical skills and abilities, lack of opportunities to get a job in hospitals, since surgeons and urologists predominated among the trained participants. The participants aged 60 and over made up a low percentage - 8.2%. This fact is associated with the retirement of medical workers or their transition to another job. Due to the instability of socio-economic situation in the country, there is a high turnover of personnel, which leads to a shortage of staff in the EMS.
Among EMS medical workers, EMS paramedics are predominant, in all courses provided for the pre-hospital level, their number was 910 trained participants. When analyzing this category, the dominant age is 20-49 years. The number of working paramedics at the age of 50-59 noticeably decreased and was equal to 15.8%. The proportion of paramedics aged 60 and over was very low (4.2%).
At the FMCs of Bishkek, Osh and other regions of the Kyrgyz Republic, 233 (100%) nurses worked as part of mobile teams of emergency departments/ emergency stations (EDs/ESs) and emergency call service 103. Perhaps the predominance of age in the category of 40-49 years old is associated with the transition of stationary, polyclinic nurses to the EMS; some of them were looking for a calmer job with emergency call service as nurses to receive emergency calls.
One of the mobile team members is an EMS driver. A total of 227 drivers were trained. In the age category of drivers, the prevailing age is 50-59 years
old - 46.7%, 40-49 years old - 23.8%. This is probably due to their pre-retirement age or opportunity of additional earnings, since shift work gives them the chance to work in other places.
To assess the initial and final level of knowledge, all course participants completed form-based tests and statistical processing of pre- and post-tests for each module was performed. Procedural skill evaluation was performed on simulated patients using simulation-based clinical scenarios. It should be noted that the passing score at the KSMIRAT level is 70 points and after passing the post-tests on the theoretical and practical parts of the training, the participants received state certificates with indicated credit hours.
In order to assess the training courses effectiveness, a Likert scale was used based on the evaluation method from 1 to 5 points. The course evaluation was carried out by the participants through the evaluation of theoretical and practical parts quality demonstrated by the instructors and self-evaluation of participants' practice was performed. This evaluation made it possible to assess the training effectiveness and change the format of simulation-based training. The use of feedback contributed to a change in the topic of procedural skills, improvement of training methods, and identification of training deficiencies.
Monitoring and evaluation (M&E) with clinical training was carried out. The results of M&E with clinical training are presented based on the example of EMS paramedics (n = 62) of Batken province. Score-cards were used as a tool to evaluate the emergency care provision to patients. In order to evaluate the theoretical level of knowledge tests were used which contained questions on the studied training materials.
Statistical processing of the obtained results was carried out with the help of Excel 2019 and Statistica for Windows (10) software with the calculation of the arithmetic mean (M), the mean error of the corresponding indicators (m) and reliability determination.
Discussion of results. With the collapse of the Soviet Union and Kyrgyzstan's independence, medical education required urgent reforms. Regulatory and legal documents regulating medical education were developed and published. Many medical disciplines remained within the Soviet science framework, old educational technologies and methods of treatment were used, and there was no sufficient material and technical base, human and scientific potential and wide access to world achievements in education and medicine [7].
During this period, Kyrgyzstan, the same as other CIS countries, was on a long and challenging path of transformations towards market relations which changed the nature and methods of medical and educational institutions' work. The health care system needed not only funding, but also training of EMS personnel. Only after acquiring the sovereignty, open international cooperation with financial and medical organizations, adaptation to new socio-economic conditions contributed to the revision of the state policy rearing the personnel training system and, in general, the much-needed reform of the health care system and medical education. In order to identify problems in training, it was necessary to analyze the existing training programs and determine the need for training and training courses for emergency medicine specialists. International experts from other developed countries were invited to Kyrgyzstan to make the analysis, develop EMS training programs and courses. In 2005, the EMST-North team was formed in response to an invitation from the Ministry of Health of the Kyrgyz Republic. A team of international experts was commissioned to conduct a situation analysis for the purpose of reforming the paramedics' curriculum throughout the country. The analysis carried out by the EMST-North team of experts revealed: a very low level of knowledge, lack of information and resources, a weak material and technical base, and a low supply of medicines to the EMS. Evaluation of the EMS training process at the initial stage showed that there were no training standards, necessary training equipment and training programs,
teaching aids. Since 2010, within the project of "Strengthening the Emergency Medical Care System in the Kyrgyz Republic" funded by the German Bank for Reconstruction and Development, training programs, training courses, training materials were developed to ensure CME for emergency medicine specialists. In order to implement the project, international experts had been working in the Kyrgyz Republic for two to five years on average. During this time, instructors were prepared and trained using mentoring and coaching methods since the future growth and success of the training program implementation depended on the development of instructors.
The problems of personnel imbalance (the best specialists were concentrated in cities) and the training of qualified specialists reflected the crisis situation in education and medicine of the post-Soviet period. Outdated medical education curricula were predominantly focused on inpatient care and were unavailable for primary health care professionals, so the quality and level of health care services were going down [7].
Training model
For the first time in the Kyrgyz Republic in 20092010, within the framework of the National Healthcare System Reform Program of the Kyrgyz Republic and the "Strengthening the Emergency Medical Care System in the Kyrgyz Republic" program implementation funded by the German Bank for Reconstruction and Development, a conceptual model of emergency medical care training was developed, which later became a long-term and sustainable training system for EMS specialists (Fig. 1). The developed model which determines the continuity and step-by-step training of specialists has the purpose of maintaining and developing knowledge, skills and attitudes aimed to ensure the provision of contemporary, evidence-based, safe and patient-centered EMS.
The training curricula and materials were developed based on the international recommendations adapted to the context of our country (various models were used for their development such as the six-step approach of Thomas, Miller's pyramid, Bloom's taxonomy (the training was aimed at developing cognitive, affective, psychomotor areas).
Figure 1. The developed EMS training model in the Kyrgyz Republic
When developing the EMS training model, a step-by-step approach and continuity of training was determined.
Step 1 of the training: "Advanced life support" (ALS-1) course, a short-term cycle (STC) for 10 days, was intended for hospital and prehospital level personnel. In order to develop continuity between prehospital and hospital health care levels, hospital-level doctors were trained on EMS. Hospital-level doctors were trained separately and hospital nurses were trained together with EMS workers. The ALS-1 course consisted of 3 modules: "Emergency cardiology" (4 days), "Emergency traumatology" (3 days), "Emergency pediatrics" (3 days). This course is a fundamental training for many EMS workers and is a platform for gathering doctors of different specialties; it is a bridge between the prehospital and hospital levels of healthcare. EMS drivers, as members of the team, were trained on the EMS basics; only one step of the training was intended for them.
Step 2 of the training: At this stage, all participants are assigned to the courses designed for the prehospital and hospital levels. Doctors, paramedics, nurses of the emergency medical service were trained at ALS-2 courses (STC of 10 days), intended for the pre-hospital level of health care.
Hospital-level doctors were assigned for specialized training "Course for ED doctors" (STC of 10 days), and hospital nurses were trained at the "Course for ED nurses" (STC of 10 days). At this stage of the training, the "Course for ED doctors" and ALS-2 consisted of 3 modules: "Emergency obstetrics and gynecology" (2.5 days), "Symptomatic approaches" (2.5
days), "Recent achievements in medicine" (5 days of ALS-2/7 days for ED doctors). The "Course for ED doctors" covered the hospital management of patients, and the course "ALS-2" covered the prehospital care.
Step 3 of the training "Course for Dispatch Operators" was designed for paramedics and nurses on receiving calls. The training program was aimed at the methods of active listening to callers, sorting urgent calls, sending the appropriate team to the place of accident, advising the caller on first aid and assistance of the arriving team.
Step 4 of the training: Monitoring and evaluation with clinical training in the workplace aims to provide training in real-life situations. After completing steps 12, EMS doctors, paramedics, nurses and hospital doctors and nurses were trained in the workplace with the evaluation of their clinical skills and abilities.
In order to increase the training effectiveness, interactive training methods and multimedia equipment were used. According to the curriculum, the practical skills session of the training was conducted with the use of innovative manikins and simulation of different clinical scenarios close to real-life situations. All training programs were designed for short-term cycles. The duration of the cycles ranged from 3 to 12 days of training, and it was an eight-hour a day training program. As required, lectures and practical skills sessions were conducted in Russian and Kyrgyz languages. The practical session of the training was conducted in two or three groups with one instructor for 3-6 participants. This article will describe the results of the ALS-1 course for prehospital workers.
For better understanding of the EMS provision process, in particular teamwork methods, EMS doctors, paramedics and nurses were trained together, the groups were multidisciplinary (doctors, paramedics, nurses), which made it possible to understand the integration of the prehospital level into the hospital level since the goal of the prehospital level is to safely transfer patients to the inpatient level of EMS delivery. Joint training enabled to conduct the same assessment of the condition and presented a uniform approach to patients in emergencies.
The training process consisted of theoretical and practical parts where the theoretical part was based on slides using multimedia equipment in Russian, and in regions where Russian is rarely used, the training was conducted in two languages - Russian and Kyrgyz, and the practical session of the training was conducted on manikins with high and low accuracy using clinical scenarios, medical equipment, real medical devices and medication. Clinical scenarios were developed for each topic, taking into account their reliability, validity, educational impact, feasibility, applicability and assessment. They were aimed to discuss a specific clinical situation, form clinical thinking, stimulate participants and assess their practical skills. The simulators were used to increase the training effectiveness, provide feedback, practice and repeat practical skills, and integrate the curricula into practical environment.
The training program also included workshops (as part of theoretical training), i.e. in addition to the information contained in the presentations, additional information was provided on a board. This improved the quality of training and the perception of information by the participants, which significantly impacted the final level of knowledge of the participants, and video materials were also used. During these classes, the emphasis was made on assessing the condition in order to identify and eliminate life-threatening conditions in a patient by performing emergency interventions. The tool for evaluating procedural skills (psychomotor area) during simulations was based on Miller's pyramid: knows, knows how, shows how, and does.
For 10 days (for example, the ALS-1 course) of training, the participants took three exams in the form of theoretical post-tests and a practical test based on clinical situations with the help of manikins. At the end of the training, each participant participated in the course evaluation which included the questions determining the quality of trainings by instructors (theoretical and practical parts of training). This made it possible to determine further tactics for changing the format and structure of the training. In particular, changes were made to the practical part of the training, the trainings duration and the development of the course in the Kyr-gyz language.
Within the framework of EMS training, training materials for all the courses were developed in collaboration with international consultants and experienced local specialists in accordance with the thematic training curriculum. The training manual for the ALS-1 course consists of three sections: "Advanced measures to maintain cardiac activity", "Emergency care in trauma", "Emergency care in pediatrics" which are translated from Russian into Kyrgyz. Each training guide has a unified pathogenetic approach to the assessment, diagnosis and treatment of emergency conditions in cardiology, traumatology and pediatrics based on a step-by-step algorithm. The work is presented in tables, diagrams, in the description of clinical cases to improve mastering of the material. Training results
The training results are distributed by modules with points as units of measurement. The course participants received handouts and were previously informed that the evaluation of the initial level (pre-test) and final level of theoretical knowledge (post-test) as well as the evaluation of practical skills would be a mandatory requirement of the training process. In order to achieve training outcomes, class attendance was monitored based on the participants' list form signed by the participants daily. For the registration and reporting purposes about the work done by the instructors, an electronic journal was developed in the Microsoft Office Excel software and a database of participants of all training courses was created.
Table 2.
Training results of EMS doctors, paramedics and nurses trained at ALS-1
Module names Test results (points) Knowledge growth Reliability, Practical exam results, points
M±m M±m rate % p M±m
Pre-test Post-test
Doctors n=209
Emergency cardiol- °gy 53,6±0,1 87,2±0,3 62,7 p<0,001 84,7±,03
Emergency care in trauma 59,2±1,2 90,6±0,4 53,0 p<0,001 86,3±0,4
Emergency care in pediatrics 57,3±1,0 89,1±0,4 55,5 p<0,001 87,0±0,1
Total: 56,7±1,1 89,0±0,4 57,1 p<0,001 86,0±0,6
Paramedics n=486
Emergency cardiol- °gy 47,5±0,66 84,6±0,23 78,1 p<0,001 81,0±0,23
Emergency care in trauma 51,2±0,66 87,8±0,25 71,5 p<0,001 83,3±0,23
Emergency care in pediatrics 52,5±0,64 86,9±0,23 68,7 p<0,001 83,4±0,27
Total: 50,4±0,65 86,4±0,24 72,8 p<0,001 82,6±0,24
Nurses n=107
Emergency cardiol- °gy 46,0±1,6 85,0±0,5 84,8 p<0,001 79,6±0,5
Emergency care in trauma 54,3±1,4 88,5±0,6 62,4 p<0,001 81,5±0,5
Emergency care in pediatrics 55,8±1,3 88,0±0,5 57,7 p<0,001 83,1±0,5
Total: 52,1±1,4 87,2±0,5 68,3 p<0,001 81,4±0,5
M ± m is intensive indicator and non-sampling error for mean values; p-efficiency of error-free prediction (with p = 95.0%, 99.9%).
Table 2 reflects the results of the initial level evaluation (pre-test) and the final level of theoretical knowledge (post-test) as well as practical skills of EMS workers (pre-hospital level) for ALS-1 course. When evaluating the theoretical part of the training in the first module "Emergency Cardiology", the results of preliminary testing of doctors were within (n = 209) 53,6±0,1 points; for paramedics (n = 486) 47,5±0,66 and for nurses (n = 107) 46,0±1,6 points. According to the posttest results, the results in the group of doctors were higher and were equal to 87,2 ± 0,3 (p <0,001). When comparing the knowledge growth rate (KGR), for doctors it was 62,7, and for nurses - 84,8, and for paramedics - 78,1. A significant part of the training was devoted to the evaluation of practical skills based on clinical scenarios and simulators of different levels, equipment, medical devices, and drugs.
The Emergency Cardiology module was the most difficult and complicated module, where the participants and instructors experienced difficulties and took greater efforts to acquire knowledge. As a result, the knowledge gained significantly enhanced the practical skills of the participants, both in a group of doctors and medium level of health care workers (paramedics and nurses).
The results of the theoretical part of the second module "Emergency trauma care" showed that the initial level of knowledge was above 50 points in all groups of trainees. Values in the post-test training indicators were high in the group of doctors 90,6±0,4 (p <0,001), while for paramedics it was 87,8 ± 0,25 (p <0,001) and for nurses - 88,5±0,6 (p <0,001). After the training (post-test), the knowledge of trauma increased, that the knowledge growth rate was 53,0% for doctors, 71,5% for paramedics, and 62,4% for nurses. The practical part of the training was evaluated based on manikins the advanced life support in trauma course, medical devices, medical equipment designed to manage injured patients based on clinical scenarios. Evaluation of the practical skills of the entire group in the module "Emergency care in trauma" showed the results above 80 points for all the participants.
The evaluation of the third module results "Emergency care in pediatrics" was similar to the previous training modules. The results of the theoretical part of the third module "Emergency care in pediatrics" showed that the initial level of knowledge was above 50 points in all groups of trainees. After the training, the level of knowledge increased and the knowledge
growth rate was 55,5% for doctors, 68,7% for paramedics, and 57,7% for nurses. Evaluation of procedural skills of the entire group for the "Emergency care in pediatrics" module provided the following results: 87,0±0,1 for doctors, 83,4±0,27 for paramedics, and 83,1±0,5 for nurses.
It should be noted that the practical skills of the participants were evaluated after completion of each module. To increase the capacity of health care workers, the team of instructors included a "rehabilitation exam" for the participants who could not pass the exams at the first attempt. In all groups of participants, the level of theoretical knowledge was higher than their practical skills. For this reason, one of the key elements of the modern training process concept in the framework of simulation learning was optimization of theory and practice. The results of the practical exam indicate that the level of mastering practical skills and abilities with the use of simulated training among EMS workers was increasing. The training outcomes were multifac-torial. According to our research, the factors that impacted the final training results are the following: initial level of participants' knowledge, quality of provided training (level of instructors' preparedness, financial costs for simulators and equipment, simulation training methods, clinical scenarios with a clear goal, premises, handouts, exam complexity, participants' abilities and interests, work experience, professional competencies specified in the curriculum (must know and be able to), training environment (in a training center and field cycles), attendance by participants with a break from work, financing of travel and transport costs. The training results subsequently impacted the design of problem focused training programs.
Course evaluation
After the training, in addition to the evaluation of theoretical knowledge and practical skills, it was necessary to establish feedback with the training process participants to determine their satisfaction with the training program which used simulation training extensively. In order to measure the increase of knowledge and practical skills, the participants evaluated the theoretical and practical part of the training based on a score sheet in an open form. The advantage of real-time training program effectiveness evaluation was communication which allowed the instructors to change their approaches as needed to meet the needs of the participants and to address the training gaps of the instructors. The assessment sheet consists of three sections and was
evaluated on a point system from 1 to 5 (1-very poor, 30 points), the third section was practical part - partic-2-poor, 3-satisfactory, 4-good, 5-excellent), the first ipants' practice (6 questions - 30 points), which gave a section was evaluation of theoretical part and lectures maximum of 100 points. (8 questions - 40 points), the second section was practical part - demonstration by instructors (6 questions -
Table 3.
Evaluation of theoretical and practical parts of the training by instructors and self-evaluation of the practice by ALS-1 course participants: EMS doctors, paramedics, and nurses.
Evaluation of instructors' Reliability, P Self-evaluation
Specialty Number of participants training by participants (points) of participants (points)
Absolute number Proportion in % M±m Theoretical part M±m Practical part M±m Practical part
Doctors 209/207 26,1/26,7 39,2±0,12 29,4±0,08 p<0,001 29,4±0,09
Paramedics 486/464 60,6/59,8 39,3±0,06 29,5±0,07 p<0,001 29,5±0,06
Nurses 107/105 13,3/13,5 39,5±0,12 29,5±0,12 p<0,001 29,3±0,14
Total: 802/776 100/100 39,3±0,10 29,5±0,08 p<0,001 29,3±0,10
Table 3 shows the ALS-1 training program evaluation results. The value of points for the theoretical training part was 39,3±0,10, and the practical part evaluation was 29,5±0,08 (p <0,001), the self-evaluation of participants was equal to 29,3±0,10 points. Consequently, the participants (doctors, paramedics, nurses) of ALS-1 course provided high evaluation for the training with positive feedback in all three sections.
Monitoring and Evaluation (M&E) with clinical training in the workplace
In order to determine the practical application of the acquired knowledge and skills based on the training results (professional competencies), evaluation of the use of the acquired knowledge and skills in a real clinical environment was conducted. During the training process, all participants who took part in the courses were informed (simulation was announced) of the upcoming M&E with clinical training. The instructors acted as training staff, so the final step of the training was the most difficult and challenging, since they had to perform two functions: training and evaluation. We modeled clinical training in such a way as to be able to evaluate theoretical knowledge based on the studied materials and to travel with the team to the place of accident or call. No external evaluators were involved for M&E since there was a specific goal to train the participants in real conditions and to evaluate the power of simulation in practice.
During the training, a matrix of tests was prepared, consisting of 3 modules with questions for application based on the test questions on tests from the training process. To evaluate practical skills, a checklist was developed to evaluate a participant's work by instructors, and for the registration of patients who called for help and were managed by paramedics the blank forms were given indicating complaints, medical history, objective examination, diagnostics and emergency interventions. We were engaged not only in training of paramedics in the real settings, but also in the study of organizational issues. The level of acquired knowledge, ensuring access to quality medical care also depended on organizational issues since the work with limited resources affected many aspects of care. In some situations, paramedics could not use the gained knowledge in practice, since the supply of drugs, medical equipment, medical devices and premises was low and unequal. The provision of EDs with drugs ranged from 10 to 85%, medical equipment and medical devices - from 19 to 93%, premises - from 27 to 71%. The M&E process was carried out 6, 11 and 12 months after of the training. To conduct EMS training for employees of Batken province, KSMIRAT instructors with the support from UNICEF were sent to Batken for one year to conduct field cycles.
Table 4.
The results of monitoring and evaluation (M&E) with clinical training of the theoretical part of the ALS-1 training for paramedics of EMS of Batken province
Name of course/modules
Number of participants, absolute number
Test results (points)
M±m Course pretest for all modules
M±m Final posttest, M&E
Knowledge
growth rate
%
Reliability, P
ALS-1: Emergency cardiology; Emergency care in trauma; Emergency care in pediatrics
62
40,5±1,2
84,2±1,2
107,9
p<0,001
As it can be seen in Table 4, when analyzing the training's theoretical part evaluation for all three modules, the initial level (pre-test) during the trainings of paramedics who participated in M&E was low (40,5±1,2) compared to the evaluation of paramedics in
the general structure which included 62 monitored participants indicated in Table 5. (50,4±0,65). The level of theoretical knowledge during M&E compared with the initial level was 84,2 ± 1,2 (p <0,001), the knowledge growth rate was 107,9, and despite the long training interval, the participants knowledge was retained.
Table 5.
The results of monitoring and evaluation (M&E) with clinical training of the theoretical part of the ALS-1 training for paramedics of EMS of Batken province.
Course name
Number of
participants, absolute number
Results of practical exam (points)
M±m Final evaluation for all modules
M±m Final M&E exam
Knowledge growth rate %
Reliability, p
ALS-1: Emergency cardiology; Emergency care in trauma; Emergency care in pediatrics
62
81,0±0,65
87,7±0,7
8,3
p<0,001
Table 5 shows the M&E results of ALS-1 course practical skills of Batken EMS paramedics. As it can be seen from the table, the practical part evaluation results during the initial training were 81,0±0,65 points, and during evaluation in real settings, the level of this indicator turned out to be higher and was equal to 87,7±0,7 (p <0,001), the knowledge growth rate was 8,3.
Thus, after the training, the performance results at the primary health care level have significantly improved. Many paramedics at the place of accidents and on the way started carrying out medical interventions before hospitalizing a patient. Employees as well as managers of the primary and secondary health care level have noted the changes that were happening with EMS. Many employees achieved good results in practical skills and abilities, which was proved by the results of providing medical assistance in response to the calls when working with patients. Improving the quality of medical care, first of all, is associated with the introduction and use of the obtained theoretical
Conclusion. In the Kyrgyz Republic, a conceptual model of emergency medical care training for emergency medical service specialists was developed, which subsequently became a long-term and sustainable system. The training methods were multicomponent and interactive, which ultimately required a lot of efforts from the instructors and participants. The training used effective approaches to the training process, such as full coverage by the training and practical skills development of all team members who provide assistance to patients in emergency settings (doctors, paramedics, nurses, and paramedics and nurses on call). As part of the training, a comprehensive evaluation of theoretical knowledge and practical skills of prehospital level EMS workers of the healthcare facilities of the Kyrgyz Republic was carried out, followed by monitoring and evaluation with clinical training at the workplace, and long-term results of theoretical knowledge were obtained with their clinical competence evaluation.
BLS Basic life support
MDs Medical devices
KR Kyrgyz Republic
KSMIRAT Kyrgyz State Medical Institute for Retraining and Advanced Training
MoH Ministry of Health
EMC Emergency medical care
HCO Healthcare organization
ED Emergency department
ES Emergency station
ECS Emergency call service
KGR Knowledge growth rate
ALS Advanced life support
EC Emergency center
EM Emergency medicine
EMC Emergency medical care
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