Grant # AID-114-A-09-00009

October 1, 2009—Present

Emory University

Partners for International Development

This remarkably successful ongoing program is changing the face of nursing in Georgia and can serve as a template for doing the same in similar countries. Nurses are crucial caregivers and leaders in every facet of the health care sector: rural areas; outpatient clinics; hospitals; primary care; and public health. The nursing profession can be the vital backbone of the health care sector in developing countries that are in transition. Transitional countries make little use of the enormous potential that nurses have to make an impact upon every part of the health care sector. The nursing profession in these countries, almost without exception, is at a very low professional level. This is especially true of Georgia. This program is designed to upgrade the capacity of nursing immensely, in an achievable economical fashion.

The program has currently upgraded the skills of 750 practicing nurses out of an anticipated total of 2500; it has these goals:

• Upgrading of skills and instilling the practice of lifelong learning in currently practicing nurses in the country of Georgia
• A sea change transformation in the role and professional level of nurses in the health care system of Georgia
• Establishing the first four year baccalaureate degree nursing school in Georgia

Summary of Teaching During First Five Quarters of Grant

Total Number Taught	768 (Goal: 1000/yr)
General nursing	582 (71 from regions outside Tbilisi)
Emergency nursing	24
Operating room nursing	16
Intensive care nursing	26
Labor and delivery nursing	23
Pediatric general nursing	97
Distribution of Students by Source
Multiprofile general hospitals	65%
Pediatric hospitals	23%
Maternity hospitals	11%
Emergency Medical Service (911)	1%
Years Working as Nurse
1-5	31%
5-10	10%
10-15	13%
16-20	18%
21-30	21%
31-40	7%

 

There are 21,000 physicians and 19,000 nurses and midwives in Georgia for a ratio of 0.9 nurses: physicians. This figure is near the bottom in the world: Greece and China 0.7; Bangladesh 1.0; United States 4.

The competencies and what nurses are allowed to do in hospitals in Georgia reflect their low professional level. There is no nursing licensure or written standards of nursing care:

• They only obtain vital signs and distribute medications
• They can only write "+" or "-" next to medications, indicating whether or not they were given; they are not permitted to write anything else in the patient's chart
• They do not do patient assessments, including any interview or examination of the patient
• There are no nursing care plans
• They have no knowledge of common or critical laboratory values and what they indicate about patient health
• A 75-question pretest of 679 practicing nurse applicants of basic factual nursing knowledge produced an average score of 37% out of 100%
• Knowledge of disease pathways or nursing care associated with disease is virtually nonexistent
• No health education for patients is performed by nurses
• Minimal knowledge about infection control or self-protection
• Minimal to no knowledge of evidence based practice or lifelong professional learning
• No knowledge of preventive health

The grant began with interviewing and testing fifty applicants for faculty positions, using personal interviews and testing of English ability and factual knowledge. Seventeen were chosen. They underwent an intensive three-month faculty development course taught by visiting faculty from Emory and an on-site Emory nurse with a BSN and MSN/MPH.

The faculty then began giving three to five week courses to practicing nurses in the following areas:

1. General Nursing: required prerequisite for the other courses
2. Pediatric Nursing
3. Emergency Nursing
4. Surgical Nursing
5. Critical Care nursing
6. Maternal and Neonatal Nursing

The students spend half of every day in the course, and the other half continuing to work their usual hospital job. Sixty percent of the material is didactic and forty percent clinical, including simulation and structured observed evaluations. All teaching is in Georgian, with slides and other material translated or prepared by the Georgian faculty. The clinical experience occurs in nursing units in three hospitals. In each of these hospitals one unit has been reorganized to more closely approximate modern US nursing units.

The curricula for the courses were updated from a previous USAID grant to Emory: four Georgian nurses spent four months in a faculty development course at Emory in Atlanta. They returned to Georgia with 40 modules they had prepared at Emory that were designed to be used for teaching nursing in Georgia. Each module contained slides, handouts, videos and reference material. These modules were revised in Tbilisi at the start of the current grant, and undergo periodic revision by the Georgian faculty. Each course contains two broad sections:

• Material on ethics, health promotion, clinical pharmacology, preventive health, health education, leadership, patient assessment by history and physical exams, critical thinking and the nursing process
• Clinical material that is organized into three subsets
• Basic science and pathophysiology
• Clinical manifestations of disease
• Nursing implications for the specific disease

The skill set is taught in lecture, simulation laboratory and clinical experience. The set includes:

• Patient history and physical examination
• Writing in the chart
• Patient assessment
• Medication administration
• Procedural charting
• Intake and output monitoring
• Procedures
• Venipuncture and medication injections
• Bladder catheterization
• Nasogastric tube insertion
• Daily care of inserted lines
• Suctioning
• Bed making and transferring a patient
• Maintaining basic sterile technique
• Basic Wound care
• Patient communication skills and teaching techniques
• Infection control
• Disease prevention and health promotion
• Critical thinking skills
• Basic disease processes and common diseases

A number of techniques are used in order to accomplish the two broad goals: improving the skills and knowledge of practicing nurses, and changing the professional role of nurses in Georgia:

• A "contract" is written with each hospital that specifies what the hospital can expect from its newly trained nurses, and the expectations from the partnership of how the nurses' role will be changed in the hospital when the course is finished. Their new role will include writing in the chart (patient assessments, progress notes), a great increase in their duties (starting iv's, catheterizing urinary bladders, wound care, infection control, etc.), and hospital support for continuous education.
• The hospital will give the partnership a report in three months on the functioning of the course graduates, and the partnership will survey the nurses to determine if in fact their roles have changed according to the agreement with the hospital.
• Social networking (Facebook) will be used for continuing education after the nurse finishes a course. Relevant articles, links and other educational information will be put on Facebook for the nurse to continue the education process.
• Each student prepares a personal plan for continuing education at the end of the course
• A follow-up one-half day of continuing education will be given every four months for all course graduates to attend
• A one-week refresher course will be offered each year to graduates of the courses.

The course has now been given to 768 nurses. Two courses for 71 nurses were given in two regions distant from Tbilisi, where the partnership established temporary learning centers. These outreach activities will increase greatly during the coming 18 months. Two minivans have been purchased that will be equipped as mobile learning centers. Ultimately there will be permanent learning centers established in three regions of the country.

A four-year baccalaureate degree nursing school has been planned. A significant obstacle that had to be overcome by working with Georgian authorities was legal recognition of nursing as a "high profession" on a level with other professions, such as medicine. This recognition allows nurses to attend university level courses and to receive a B.S. and higher degrees. This has just been finished, and the planning is well under way for the nursing school. The curriculum has been prepared and negotiations are underway for establishing required basic science courses such as microbiology, anatomy, physiology, etc. The current start date is September 2012.

 

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II. Georgia Nursing Education Program

Donor organization: USAID

Implementing Period: 2009-2011

Implementing partner/s: Emory University School of Medicine, Emory University School of Nursing

 

Objectives:

1. Development of a Learning Center that will institutionalize the capacity for teaching practicing nurses and nursing students clinical skills. The center will include a simulation center, a clinical simulation laboratory, classrooms, distance learning, telemedicine and a library providing access to the medical literature of the world.
2. Establishment of a model floor of nursing at Kipshidze Hospital in Tbilisi. This floor will serve as the clinical laboratory for the nurses. They will be able to see and participate in a modern nursing unit, understanding how it is designed and managed to provide excellent patient care. They will participate in patient care and be introduced to methods of quality control.
3. Institute a vocational education program for practicing nurses from throughout the country that will be housed in the Learning Center. The majority of nurses are expected to come from big hospitals, but the availability of courses will be widely publicized. A particular effort will be made to get nurses from the August conflict zone and other disadvantaged areas. Nursing leadership teams will be created at each of the participating hospitals. These teams will be trained in management, continuous nursing education and quality control techniques.
4. Establish a nursing school that is tightly affiliated with Chavchavadze State University. A three year program will produce nurses with a bachelor's degree. In the future postgraduate degrees will be offered also. Degrees will be granted jointly by the School of Nursing and Ilia's State State University.
5. Develop nursing vocational and higher education models that can be used by the Government, using its own financing, to improve nursing education and practice throughout the country.
6. Work with the MOHLSA and the MOE to develop an appropriate regulatory environment that includes credentialing and accreditation

Cooperative Agreement No. 114-A-00-07-00064-00

CONTRACT NUMBER: GHS-I-00-03-00039-00

September 2007 - September 2010

In 2004, under a USAID grant (given to the American International Health Alliance, with a subgrant to Emory University), Emory University was instrumental in establishing the first pediatric Emergency Department (ED) in the Caucasus at Iashvili Children's Central Hospital in Tbilisi, Georgia. The ED at Iashvili Children's Central Hospital replaced the Soviet concept of an admitting room, which had these shortcomings: i) absence of triage resulting in increased morbidity and mortality due to prolonged time between patient presentation and treatment initiation; ii) ineffective and inefficient diagnosis and care resulting in lengthened hospital stays; iii) unnecessary hospitalization of patients who could be treated and discharged; and iv) patient and provider dissatisfaction with care. The modern ED established at Iashvili yielded significant improvements in patient care and utilization of hospital services. From 2003, before the change in the ED, to 2004 after the ED change:

• Patient visits increased from 7,623 to 16,274;
• Hospitalization of ED patients decreased from 73% to 47% of arrivals as a result of training related to organization of diagnosis and outpatient treatment methods;
• Length of stay of hospitalized patients decreased by 50%, due to more rapid diagnosis and initiation of treatment of patients who were then hospitalized;
• Utilization rates of sub-specialists for ED patients decreased from 42% to 17%, resulting in more rapid initiation of treatment and better patient care provided by trained ED physicians; and
• Hospital costs were reduced by 800,000 GEL ($430,000).

Based upon this experience USAID gave a grant to Emory to establish an emergency medicine miniresidency at the Kipshidze Central University Hospital (KCUH) and to plan a full-scale three-year emergency medicine residency in Georgia.

The first goal of the program was to establish a state-of-the-art modern emergency department at KCUH. The first step was the development of a strategic plan for the ED. The ED was reorganized and triage was instituted. An intensive training program of nurses and physicians was implemented. Protocols were designed and instituted. A quality control program was put in place. This was accomplished through visits from Emory faculty, working closely with personnel of KCUH.

The second goal was to implement an eight-month miniresidency. A Learning Center was developed and equipped with simulation manikins and computers with online access to web-based training materials for emergency medicine. Meetings with the Postgraduate Institute led to the formal recognition of emergency medicine as a specialty. Thirty applicants were screened and ten selected as the first students. These students were practicing physicians largely from the specialties of anaesthesiology and critical care. An eight-month course was given by fifteen Emory faculty. Fifty percent of the course was didactic and the rest was clinical mentoring in the ED. A second miniresidency is now being given by Georgian faculty who were graduates of the first miniresidency. Ten students are in the group.

The miniresidency will be given for eight months every year by the Georgian faculty. Funding will come from hospitals and owners of hospitals (principally insurance companies) who as a result of the hospital reform in Georgia need specialists in emergency medicine.

The three-year residency in emergency medicine is now nearing completion of the planning stage, and will begin in 2012. This will mark the first time emergency medicine specialists have been trained in the former Soviet Union. The advantages they will bring to a country's overall patient care are partially outlined in the experience given at Iashvili Hospital in the first paragraph.

 

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Georgia Emergency Medicine Development Program (extension)

 

Donor organization: USAID

Implementing Period: 2010

Implementing partner/s: Emory University School of Medicine, Emory Midtown Hospital Emergency Department

Program Site/s: Kipshidze Central University Hospital (Tbilisi)

 

Objectives:

1. Create a state-of-the art emergency services delivery system at Kipshidze Central University Hospital (KCUH).
2. Institutionalize effective and sustainable teaching capacity in emergency services at KCUH in order to improve current care and to train future generations of medical professionals.
3. Develop models that the Government can apply to improve emergency care throughout Georgia.
4. Maximize the number of people served by the program, through improving interventions such as referral and outreach services.
5. Design and carry out the program in a way that will encourage and leverage increased investment of the Georgian Government in health care.

Within the extension phase of the program a second course of emergency medicine certificate (mini-residency) program is planned to train 10 new specialists of emergency medicine in Georgia. Priority will be given to candidates from regions to establish a basis for future emergency departments in regions of Georgia.

The Main Implementing Organization:"Partners for International Development/Georgia"

Sub-contractors:LLC "Blood Transfusion Station" (Tbilisi)

 

Program goals:

• Provide international expertise for implementing QA system;
• Improvement and implementation of the action plan made by local experts’ pool, in order to implement quality control system in the Safe Blood Service.
• Blood Services’ staff trainings focusing on the quality control and management issues;
• Blood Services monitoring and evaluation;
• Donor database implementation;

 

Introduction:

Purpose of the blood and blood products' quality control is to provide the monitoring on the process of product creation.

 

Quality control system minimizes the probability of mistakes and provides that:

• Diagnostic tests performed on blood and blood samples are suitable;
• Test results are accurate;
• Suitable and safe blood was transferred to the properly selected patient;

 

Generally, quality control of blood transfusion services includes:

• Organizational capacity building;
• Quality Control policy and action plan elaboration;
• Existence of responsible persons for QA;
• Existence of international and national standards;
• Detailed job descriptions;
• Staff training and development;
• Evaluation, internal/external control, audit, etc.
  
  

1. Internal Quality Control

Periodic validity check of each activity, process, procedure, reagent and equipment.

A standard operating procedure is the set of written instructions for different procedures, developed by ISO 9000. Each blood transfusion station should be committed to operating in full compliance with internal standards that will be a solid guarantee of quality.

With our support, 9 blood transfusion agencies created SOPs. This process will continue through 2011 and cover all the main blood transfusion centers.

 

2. External Quality Control

External Quality Control program goals:

• Participation in external quality assurance scheme/system;
• External audit carried out by recognized experts/reference laboratories;

In 2010 we have planned and implemented the pilot study of external quality control, which results allow us to implement the routine, mandatory practice. Global Fund project will support country to increase the blood safety level according to the UN standards.

Our research showed us that, external control of the blood diagnostic laboratories should be an integral part of the quality control system, in order to identify problems and compare with other laboratories.

The scope of the external quality control is to detect problems, by testing the same blood samples in different laboratories and than comparing the reference rages. This scheme is the best way, to identify difficulties and adequately implement appropriate measures to eliminate problems. The system of independent external quality control is a tool that supports the normal functioning of the internal quality control system.

Various preparatory works and the pilot study conducted in 2010 will foster the implementation of compulsory quality assurance system in laboratories in 2011.

Diagnostic laboratories of project participant blood stations will be involved in external quality control program organized by Infection Diseases, Aids and Clinical Immunology Research Center (AIDS Center) reference laboratory. During the first year, HIV, Hepatitis B and C serological tests control studies were conducted within the program.

In 2011 ABO blood typing and Rh factor tests will be added to the above mentioned list. AcroMetrix has offered an independent external quality control for the serology reference laboratory of AIDS center. After the program completion laboratory will receive an international certificate.

In 2009-2010 AcroMetrix provided the quality control in the virology laboratory of AIDS Center and hence the laboratory received international certificates. Besides AIDS Center has obtained the ISO quality certification.

External Quality Control schemes allow the participant laboratories to monitor their accuracy and implement appropriate measures for the further enhancement that includes the acquisition of the high-quality test-systems and the trainings of staff about problematic issues.

 

3. Introduction of the International Quality Management Expertise

During the project's second year, Partners for International Development is planning to continue implementing the best practices of Emory University and other partners, in order to improve QA system in Georgia.

QA specialist from Emory University, Alexander Duncan, will join us, visit Georgia periodically and conduct trainings.

 

4. Improvement and Implementation of the Action Plan, Developed by Local Experts' Pool

Quality control action plan (2011-2015), was elaborated in 2010.

Local experts together with their colleagues from Emory University will continue to work for the improvement of the project plan and ensure its approval by the competent authority of the Ministry of Health, Labor and Social Affairs.

Project plan components:

• Examination of the National Blood Transfusion Service of Georgia;
• Quality management illustration and its importance for the Blood Transfusion Services;
• Necessary pre-conditions for the implementation of QA;
• Quality management organizational structure in blood transfusion service.
• Different types of quality monitoring (internal and external) and their components;
• Measures for the improvement and implementation of external quality control system;
• Measures for the improvement and implementation of internal quality control system;
• Estimated budget. (budget will be determined during the first six month of 2011).
  
  

 

5. Blood Services Staff Trainings about Quality Control and Management Issues

In 2010 local experts' pool together with their colleagues from Emory University, elaborated curriculum for the QA training program. Within the program, blood services' staff was trained and prepared for the implementation of QA system.

It is planned to conduct 10 trainings annually and prepare at least 10 specialists within each course, totally 200 specialists will be trained by the end of 2011.

 

6. Monitoring and Evaluation

Monitoring of blood services is an integral part of QA. Experts (2 persons) hired by main contractor (Partners for International Development) will be in charge of the monitoring plan elaboration and implementation. Key components of the plan are the schedule of visits in program participating laboratories and QA monitoring plan. We are planning to organize ten monitoring visits during the first year of the project.

 

7. Blood Donor Database Implementation

In accordance with the above mentioned statement, Partners for International Development together with sub-contractor organizations is planning to strengthen the donor database by renovating the material-technical base and adding different parameters. Within the project, internet service will be available.

 

8. Additional Measures

We are planning to organize events aimed at encouraging voluntary donations that will foster the improvement of blood and blood products quality. We have established club "Donation" on Facebook unifying donors and informing Facebook users about the importance of donation and its positive effects on the health of blood donor, also who can be a blood donor and how to avoid the side effects of donation.

Within the project, it is planned to reconstruct the blood donor room of "Blood Transfusion Station" equip it with specially designed blood donor chairs and modern technology to create a safe environment and to make donating a comfortable experience for donors.