Simulation Education to Advance Emergency Medicine and Pediatric Critical Care in Nepal CURRENT STATUS: POSTED

Background: Internationally emergency medicine is a relatively young specialty that is increasingly recognized for its potential for growth. In low middle-income (LMICs) like 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, and simulation participation environments in critical care procedures and decision making for both adult and pediatric emergencies. In these two workshops a total of 71 participants, including Nepalese emergency care providers ranging from pre-hospital personnel to faculty, engaged in these sessions. Results: Pre and post-workshop surveys were provided and this subjective data showed significant improvement in confidence levels along with procedural skills technique and knowledge as a result of the educational sessions provided. Conclusion: Multidisciplinary education and workshops to LMIC are necessary for development of emergency medicine and pediatric critical care. Simulation education and workshop training are highly valuable “hands on” methods to educate these healthcare providers. Highly developed healthcare systems in emergency and critical care must assist in the world wide development acute care management in these poorly resourced countries

Conclusion: Multidisciplinary education and workshops to LMIC are necessary for development of emergency medicine and pediatric critical care. Simulation education and workshop training are highly valuable "hands on" methods to educate these healthcare providers. Highly developed healthcare systems in emergency and critical care must assist in the world wide development acute care management in these poorly resourced countries Background Internationally, emergency medicine is a relatively young specialty that is increasingly recognized for its potential for growth. Almost uniformly it is under-resourced and underdeveloped. This is especially true in low middle-income countries (LMICs), like Nepal. 1. Even in established centers, emergency care in both adult and pediatric patients is delivered by providers that may have little or no additional training in emergency medicine. In recent years the concept of quality emergency care is flourishing in Nepal and various pathways to emergency medicine specialization have been accredited. 2.
However, no specialized training programs for pediatric emergencies and procedures exist yet to date.
In most well-resourced countries there has been a move toward providing seamless, efficient critical care that has been established specifically for pediatric patients. 3 For the most part, however, pediatric critical care remains in its infancy in most hospitals across most LMICs. The majority of hospitals lack pediatric emergency care units dedicated to the pediatric age group, healthcare staff trained to care for critically ill children and rapid access to necessary medications, supplies and equipment. Perhaps one of the most important stumbling blocks in most LMICs is the lack of established training programs for healthcare providers working in clinical environments with a high volume of pediatric patients like emergency departments. 4 The formalization of emergency care education is an important first step, as skill specialization may enhance the blossoming specialty of emergency medicine in Nepal. As a way to provide emergency care education from a system with established emergency care protocols, several workshops were organized in collaboration with the University of Toledo Medical Center at Dhulikhel Hospital-Kathmandu University Hospital (DH-KUH). These emergency care conferences were focused on the teaching of knowledge, skills and approaches to common adult and pediatric emergencies and critical care situations. These conferences utilized didactic lectures, hands-on skills sessions and simulationbased scenarios as educational tools to fortify knowledge and enhance the confidence of participating health care providers. Furthermore, they focused on multidisciplinary participation of healthcare providers. These providers included attendings, residents, medical officers, nurses and paramedics who would work as a team.
The workshops also utilized "simulation-based" learning models rather than the antiquated "see one, do one, teach one" which has previously been shown to put patients at risk 5. Experiential learning, deliberate practice and the ability to provide immediate feedback are the primary advantages of simulation-based medical education. It is an effective way to develop new skills, identify knowledge gaps, reduce medical errors, practice teamwork communication and maintain infrequently used clinical skills with the overall goal of improving patient care.6 Although simulation cannot replace clinical exposure as a form of experiential learning, it replicates real life situation and promotes learning without compromising patient safety. In essence, "simulation-based" education allows providers to practice case management and procedures many times, improving their competency before they actually manage a real patient. Therefore, our objective of the workshops was to promote experiential learning, practice procedural skills, review common errors via debriefing and practice multidisciplinary teamwork dynamics. Furthermore, 78% noted that they are managing emergency or critical pediatric patients on a limited basis. 24.4 % had never participated and 31.3 % had participated only occasionally in the simulationbased learning sessions. Table 3 demonstrates subjective data improvement in self-reported confidence of the participants in various domains. The most significant improvement was noted in the management of sepsis and intraosseous access. The participants still felt least confident regarding pediatric drug calculation.

Discussion
Educational sessions like these can be excellent tools to educate individual providers in the standard of care for emergency medicine from nations where the specialty is more established. The distribution of levels of training and specialty indicate that providers interested in emergency medicine exist across all levels of training from pre-hospital to emergency medicine facility. Currently, the avenue to becoming an emergency specialist in Nepal is variable, whether it be through fellowship or residency.
1. Due to non-standardized training there is wide variability of knowledge across providers7,8.
The evaluations of these educational sessions demonstrated the participants benefited from practicing hands on procedures and simulation cases by actively learning the essential skills necessary in emergency based critical care. The perceived confidence level increased significantly in various skills. As such, "hands-on" experience provides the essential confidence needed which greatly reduces the learner's stress when they encounter difficult cases in the emergency department.
Evaluating their actions, and more importantly their behavior, teaches them valuable lessons in improving muscle memory, reducing reluctance to act, and ultimately improving situational response. The objective data gathered bears out the conclusion that theses workshops improved provider confidence in managing critically ill patients.
As indicated by tables one and two, the prior training and experience of these learners was widely variable. However, the multidisciplinary nature of participants accurately simulates the actual emergency department environment, where providers in Nepal interact with consultants, paramedics, and interns on a case to case basis. The simulation experience reinforced a collaborative approach to critically ill cases with engagement from all levels of healthcare providers. It is of our opinion that simulation education currently is the optimal tool to reinforce this collaborative care model in most high stress and high acuity patient care situations. Therefore, the results of these workshops support a didactic/hands-on learning experience to improve both medical care knowledge and clinical skills.
Limitations of this study include a highly variable participant demographic from paramedics to physicians. Education was not stratified to each different learner group within this workshop with all attendees attending the same sessions. Therefore, educational content may have been too advanced for certain participant groups and outside their scope of practice in an actual emergency department.
Future workshops may have more impact if groups are separated based on roles in clinical practice.
This could provide focused education tailored to the responsibilities and education of each participant. Clearly, though, multidisciplinary engagement of all providers in practicing simulation scenarios is the most effective, more accurate method to simulate "the actual patient care environment." Additional workshops are planned to not only expand our educational footprint, but to reinforce and identify the retention of critical emergency skills and pediatric education for the emergency providers of Nepal.

Conclusion And Future Direction
Ultimately what can be accomplished in several short sessions is limited compared to the establishment of emergency medicine as a specialty or pediatric emergency medicine as a subspecialty. The results of our study indicate that the potential for growth may not be so steep.
Emergency critical care in Nepal is typically outsourced to consultants. The conferences conducted help to validate the practice of emergen-cy medicine providers as specialty specific. The University of Toledo Medical Center plans to continue its investment of significant time and resources into growing med-ical education in Emergency Medicine and Pediatrics in Nepal through similar edu-cational sessions and the cultural exchange of residents and students. Further follow up with the participants to explore their behavioral change and out-come needs to be planned.

Ethics approval and consent to participate
IRB waived and exempted the study at Dhulikhel Hospital in Dhulikhel Nepal due to lack of patient identifier information in this study. Only subjective survey information was included.

Consent for publication
Consent was obtained from all authors and participants. Consent though, not indicated due to educational format from workshop participants and no publication of individual personalized data.

Availability of data and materials
All data generated or analyzed during this study are included in this published article [and its supplementary information files].

Competing interests
The authors declare that they have no competing interests

Funding
No funding was provided for this research