All the facilities surveyed had general availability of 24/7 emergency services, and showed availability of most services inquired in the survey. Most emergency laboratory testing and diagnostic imaging were available at all facilities. Emergent therapeutics like ventilators, glucose administration, aspirin, antibiotics, vasopressors, and wound care were reported as available at all facilities surveyed. However there were some gaps found at each facility and differences in infrastructure, diagnostic, consultant, human resource availability and signal functions were noted. Below presents the highlights of findings from each facility with focus on the gaps and differences in facilities. Figure 4 provides the overall summary of findings. Detailed description of results from each facility can be supplied by the corresponding author upon request. The COVID-19 related assessment will be presented in future publications. F
Facility Characteristics
Figure 1 presents summary of facility characteristics.
Bir Hospital, a public governmental hospital, is one of the busiest medical centers in Nepal, with 24/7 emergency services available, including MRI availability. On the infrastructure and essential equipment assessment, Bir Hospital received a score of 2.00 out of 3.00, and it scored 2.24 out of 3 on diagnostic services. Notably, the emergency room (ER) did not have a designated triage area or waiting area, nor a designated resuscitation room. Electronic charting was not available. The National Trauma Center (NTC) is a public governmental hospital and the only trauma center in Nepal, with 32 beds for general emergency care and 6 beds for acute resuscitations, with 24/7 availability of the ER. Emergency overnight MRIs were done at adjacent Bir Hospital. On the infrastructure and essential equipment assessment and diagnostic services assessment, NTC received a 2.57 and 2.56 out of 3.00, respectively. Limited availability of adequate isolation rooms and hand washing facilities was reported. Point-of-care ultrasound was readily available in the ER.
Patan Hospital is an academic hospital with nearly 36,000 emergency visits per year and has 24/7 availability of emergency services (except for MRI). A separate ER for COVID-19 patients was established during the time of the study. Patan Hospital scored 2.89 on the infrastructure and essential equipment assessment and 2.64 on diagnostic services. Inadequate availability of toilet facility and isolation rooms were reported. Electronic charting was under development during this assessment. Dhulikhel Hospital is a teaching hospital with nearly 20,000 emergency visits per year. The ER has 30 general emergency beds and three acute resuscitation beds. Emergency services availability is 24/7 (except for MRI). On the infrastructure and essential equipment assessment, Dhulikhel Hospital received a score of 2.76 and on diagnostic services it scored 2.48.. Limited isolation rooms, waiting area space, toilet facilities, and inadequate crash trolley were reported. The ER charting is done in an electronic medical recording system that was recently developed. Tribhuvan University (TU) Teaching Hospital, a semi-governmental hospital (under the Ministry of Education), reported 45,000 emergency unit visits per year, with 24/7 availability of emergency facilities. On infrastructure and essential equipment assessment, Tribhuvan University received a score of 2.29, and on diagnostic services it scored 2.56. TU reported limited availability of electronic ER charting, adequate isolation rooms for infectious diseases, a designated waiting area, and did not have access to toilet facilities in each patient care area.
Grande Hospital is a private non-teaching hospital with nearly 5,856 emergency unit visits per year and a 24/7 availability of ER services. The ER reported having 15 general emergency care beds and two beds for acute resuscitation. On the infrastructure and essential equipment assessment, Grande received a score of 2.97, and 2.68 for diagnostic services. A lack of adequate isolation beds was reported. HAMS is also a private non-teaching hospital with 4800 emergency unit visits per year, with 17 rooms for general emergency care and 2 for acute resuscitation. The emergency unit services were reported available 24/7. On the infrastructure and essential equipment assessment, HAMS received a score of 2.90, and 2.60 for diagnostic services. There is no electronic ER charting.
Human Resources
Figure 2 provides summary of human resources findings.
Bir Hospital scored 1.75 for consulting services and 2.33 for ancillary services. ER was staffed with General Practice (GP) specialists and medical officers primarily. Burn specialists were available at time, and no Ob/Gyn, orthopedics, pediatric, or psychiatry consulting services were available in the emergency department. Limited availability of patient transport services and security personnel was also reported. NTC received 2.22 for consulting services and 3.00 for ancillary services. NTC ER was run primarily by staffed medical officers and mid-level providers, with orthopedic specialists at certain times. Notable unavailability included Ob/Gyn providers, pediatricians, psychiatrists, and plastic/reconstructive surgeons. Ancillary services, including social workers, received a high score of 3.00.
Patan Hospital ER received 2.70 for consulting services and 2.67 for ancillary services. The ER staffing included medical officers, General Practitioners, and fellowship-trained emergency medicine (EM) providers. Patan hospital started the first fellowship in EM. Limited availability of burn specialists, plastic/reconstructive surgeons, and patient transport services was reported. Dhulikhel Hospital scored 2.50 for consulting services and 2.67 for ancillary services. The ER staffing included medical officers and at least one general practitioner or fellowship-trained EM provider during a shift. Limited availability of burn and plastic/reconstructive specialists, and patient transport service was reported. TU received 3.00 for consulting services and 2.33 for ancillary services. Limited availability of social work services and security personnel assigned to the emergency service area was reported.
Grande Hospital received 2.65 for consulting services and 2.33 for ancillary services. Grande is staffed with general practitioners, EM fellowship/DM trained physicians, and medical officers. Limited availability of burn and plastic/reconstructive surgeons, ENT, neurology, ophthalmology, and social work services were reported. HAMS received a score of 2.75 for consulting service and 2.33 for ancillary service. The ER was staffed with a medical officer and GP specialist or fellowship/DM in EM trained physician. Limited availability of burn and plastic/reconstructive surgeons, and social work services was reported.
Clinical Services
At Bir Hospital, vital signs are measured on registration, but there was no formal triage system reported. Specific clinical management or condition-specific protocols, transfer protocols, and discharge protocols were reported missing. Safety protocols, including infection prevention and post-exposure prophylaxis, were reported available. Quality improvement (QI) is conducted in the ER. Missing aspects of QI include a systematic process for collecting patient data that links conditions and regular meetings for quality improvement. At NTC, 20% of patients arrive by ambulances with formally trained prehospital providers. A time target for each triage category was reported missing. Most safety protocols were reported available. Absent protocols included transfer, neonatal resuscitation, volume resuscitation of children and adults, adjusting interventions for malnourished patients, and management of labor and delivery in low risk women. All six condition-specific management protocols asked about were reported missing, including asthma exacerbation, pneumonia, maternal hemorrhage, sepsis, diabetic ketoacidosis, and burn care management. For QI, regular meetings with review of clinical data was reported.
Patan Hospital reported that 20% of patients arrive with formally trained prehospital care providers. Time targets for each triage category and triage protocols for both children < 5 years of age and pregnant women were missing. Four of six safety protocols were reported available.. Three of five discharge protocols and transfer/referral protocols for burn care were reported missing. In QI, most of the asked questions were reported as available. At Dhulikhel hospital, nearly 35% of emergency patients arrived by ambulance with formally trained prehospital providers. Time targets for each triage category were reported missing. Furthermore, missing protocols for volume and medical resuscitation, burn care, and discharge/transfer were reported. Management of hazardous exposure was also reported missing. Most QI interventions were reported to be conducted except for holding regular meetings using clinical data and tracking to ensure QI actions are implemented after review meetings. At TU, a formal triage system was available, but protocols for triage were reported missing. Time targets for each triage category, triage protocols for children < 5 years of age, and triage protocols for pregnant women were reported missing. All condition-specific management protocols in the data were available. Unavailable clinical management protocols included medical resuscitation checklists, neonatal resuscitation, burn care, and adjusting interventions for malnourished patients. Discharge protocols were also reported missing. Most safety protocols, including infection prevention and post-exposure prophylaxis, were available. QI metrics were reported available.
At Grande, 15–20% of the patients come to the ER facility by ambulance with formally trained prehospital providers. Protocols for time targets in triage, triage for children < 5 years of age, trauma care, volume resuscitation, burn care, and all six condition-specific management were reported missing. Most discharge protocols and condition-specific transfer protocols were missing. All QI metrics surveyed were reported as available, except for documentation of supervisor visits with feedback or comments. At HAMS, 15–20% of patients were reported to arrive with formally trained prehospital care providers. Protocols missing were time targets for triage, triage for patients < 5 years old or pregnant women, neonatal resuscitation, trauma care, and burn care. Three of six condition-specific protocols were available. Most discharge and transfer protocols were reported available. Safety protocols are missing, including for managing hazardous exposures and protection of staff and patients from violence.
Signal Functions
Figure 3 summarizes signal function findings.
Bir Hospital received scores of 2.29 for vital signs/airway/breathing interventions, 2.24 for circulation interventions, 2.33 for neurologic interventions, 2.75 for sepsis interventions, 1.90 for trauma interventions, 1.00 for obstetric interventions, and 1.86 for burn interventions. Notable unavailable interventions included invasive mechanical ventilation in the ED, external defibrillator, training for intraosseous (IO) access, venous cutdown, thrombolytics administration for MI, and training for pelvic binding, point of care ultrasound, pericardiocentesis and external pacing. Unavailable neurological interventions included training for temperature management and mental status exam (MSE), IV magnesium, and equipment for safe physical restraints. trauma, burn, and obstetric cases were transferred quickly to adjacent hospitals, most of the items on the survey were unavailable. NTC received 2.71 for vital signs/airway/breathing interventions, 2.47 for circulation interventions, 2.00 for neurologic interventions, 2.50 for sepsis interventions, 2.50 for trauma interventions, 1.00 for obstetric interventions, and 3.00 for burn interventions. Bir Hospital has limited availability of interventions for breathing and circulation including and are unable to offer the creation of surgical airway, non-invasive ventilation, invasive mechanical ventilation, central venous line placement, pericardiocentesis, thrombolytic administration, IO access and external defibrillation/cardioversion. Unavailable neurological interventions included lumbar puncture (LP), IV magnesium administration for eclampsia, MSE, safe physical restraints, and relevant antidote administration for toxic exposure. Diagnostic paracentesis was reported unavailable for sepsis intervention. Unavailable trauma interventions included three-way dressing for sucking chest wounds due to lack of training and rabies vaccination or IVIG. Obstetric interventions were mostly unavailable. Burn interventions were reported as a score of 3.00, although burn protocols and training were unavailable as reported in an earlier section.
Patan Hospital received a 3.00 for vital signs/airway/breathing interventions, a 2.62 for circulation interventions, a 2.67 for neurologic interventions, a 3.00 for sepsis interventions, a 2.80 for trauma interventions, a 3.00 for obstetric interventions, and a 3.00 for burn interventions. Cardiac pacing and thrombolytic administration for MI were generally unavailable, and IO access, central venous line placement and pericardiocentesis were somewhat available. For neurologic interventions, extreme temperature management, safe physical restraint, and relevant antidote administration for toxic exposure had limited availability. In trauma care, limited interventions were fasciotomy and rabies vaccinations. Dhulikhel Hospital received a score of 2.88 for vital signs/airway/breathing interventions, 2.76 for circulation interventions, 2.83 for neurologic interventions, 3.00 for sepsis interventions, 2.70 for trauma interventions, 3.00 for obstetric interventions (with a separate birthing center available), and a 3.00 for burn interventions. Limited breathing and circulation interventions included low availability of invasive mechanical ventilation, external cardiac pacing, and thrombolytic administration for MI. For neurological interventions, safe physical restraints had limited availability. There was limited availability of fasciotomy or escharotomy, tetanus, and rabies vaccines or IVIG for trauma interventions. TU received a score of 2.82 for vital signs/airway/breathing interventions, 2.50 for circulation interventions,2.75 for neurologic interventions, 3.00 for sepsis interventions, 2.70 for trauma interventions, 2.00 for obstetric interventions, and 3.00 for burn interventions. Somewhat unavailable interventions in breathing and circulation included lack of equipment for placement of oral- or nasal-pharyngeal airway device, invasive mechanical ventilation, and lack of training and surgical personnel for creation of surgical airway. Circulation interventions were limited by lack of equipment for pelvic binding, limited equipment for point of care ultrasound, no trained personnel for intraosseous access, pericardiocentesis, or external cardiac pacing, and limited stock and personnel for thrombolytic administration for MI. Of note, a separate cardiac emergency unit is located 100 meters away from the TU ER. Neurological interventions were reported to be limited due to the absence of equipment for protection from secondary injury and safe physical restraint. Trauma interventions were limited by lack of training and personnel for three-way dressing for sucking chest wound, fasciotomy/escharotomy for compartment syndrome, and limited stock for rabies vaccination and IVIG as appropriate. Obstetric cases were transferred to the labor room 100 meters away. All burn interventions were reported available, however, burn patients are not kept for 24 hours with resuscitation prior to transfer.
Grande Hospital received 2.82 for vital signs/airway/breathing interventions, 2.48 for circulation interventions, 2.75 for neurologic interventions, 3.00 for sepsis interventions, 2.50 for trauma interventions, 1.33 for obstetric interventions, and 2.57 for burn interventions. Breathing and circulation interventions that were limited included creation of surgical airway due to lack of training, IO access and tourniquet placement due to absent equipment, pericardiocentesis, cardiac pacing, and point of care ultrasound due to lack of training and equipment. Neurological interventions missing included safe physical restraints and lack of antivenom and certain antidotes. No diagnostic paracentesis was available for sepsis workup in the emergency room. For trauma, three-way dressing for sucking chest wounds, fasciotomy, and reduction of fractures/dislocations were reported to be limited due to lack of training. Obstetric interventions had a low score due to lack of uterotonic drugs, lack of training in neonatal resuscitation, and limited availability of emergency vaginal delivery due to inadequate training. For burn care, IV fluid resuscitation with hourly adjustments and experience with burn care management was missing. HAMS received 2.94 for vital signs/airway/breathing interventions, 2.57 for circulation interventions, 2.75 for neurologic interventions, 3.00 for sepsis interventions, 2.60 for trauma interventions, 2.67 for obstetric interventions, and 2.89 for burn interventions. For breathing and circulation, there was limited availability of surgical airways due to lack of training, external cardiac pacing, pericardiocentesis, and thrombolytic administration for MI. For neurological interventions, limited interventions were lack of extreme temperature management, safe physical restraints, and relevant antidotes for toxic exposures. For trauma, there was a lack of fasciotomy, three-way dressings, and supplies for rabies vaccines or IVIG. For obstetrics, there was limited availability of vaginal deliveries due to a lack of training and equipment. For burn interventions, fluid resuscitation with hourly adjustments was not done.