Emergencies in Nepal's Emergency Rooms

Hospitals across Nepal need to urgently upgrade their ERs to prepare for disasters and for urgent treatment

Photo: Sonia Awale

Nepal’s major hospitals are not prepared for emergency response and care in an event of another earthquake or pandemic, according to a recent new study published in the International Journal of Emergency Medicine. The paper lists a serious lack of preparedness at emergency units of hospitals, and compares the capacity of private, government, and teaching hospitals in Kathmandu.

The study was the first of its kind conducted in Nepal and its investigators aimed to build on the Emergency Care Systems Assessment (ECSA) conducted by Nepal’s Health ministry the WHO in 2019. The ECSA report had identified 39 key items to improve emergency care in the country. Another survey in 2011 had shown that only two of the hospitals in Kathmandu Valley at the time had earthquake resistant buildings.

 The cross-sectional pilot study looked into seven tertiary hospitals in the Valley out of which three are academic, two are governmental, and two are private institutions. Included in the study are TU Teaching Hospital, Patan Hospital, Dhulikhel Hospital, Bir Hospital, the National Trauma Centre, Grande Hospital and HAMS Hospital. 

Researchers used a cross-sectional mixed-method study to gather data on facility characteristics, human resources, clinical services, and signal functions of seven major tertiary-level health facilities in the Kathmandu Valley. 

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Investigators identified three respondents from each of the seven institutions who are directly involved with the emergency department in a clinical care or administrative leadership role. Respondents included physicians, nurses, hospital administrators, and general hospital staff.

Emergency response—which is at the forefront of natural disasters and pandemics—during two major disaster events in the country, the 2015 Gorkha earthquake and the Covid19 Delta wave in 2021, showed that Nepal’s emergency response and care was subpar, write the authors.

“This study was designed and conducted so that we recognise our weaknesses, and start slowly improving them,” said Olita Shilpakar, an emergency physician at TUTH, and one of the authors.

The study concluded that while all the facilities surveyed had general availability of round-the-clock emergency services, there were significant gaps as well as differences in infrastructure, diagnostic, consultant, and human resource availability.

“The WHO estimates nearly 40% of lives can be saved with appropriate emergency care,” said Ramu Kharel, an assistant professor of emergency medicine at Brown University in the USA who led the study. “Improving emergency care is one of the most efficient public health interventions. Our study identified many opportunities for us to improve emergency care at hospital levels.”

Government hospitals were characterised by a lack of a designated triage area, as well as the unavailability of Obstetrics/Gynecology (Ob-Gyn), orthopaedics, paediatrics, or psychiatry consulting services.

Academic hospitals had limited isolation rooms or infectious diseases and were found to not have adequate access to toilet facilities. There was limited availability of social work services and security personnel. 

In private hospitals, protocols for time targets in triage, triage for children below five years of age, trauma care, and burn care among other services were found to be missing. Safety protocols for managing hazardous exposures were not there, and there was a lack of protection for staff and patients from violence. 

While government hospitals that typically care for low-income populations reported better availability of ancillary services and social care services, private hospitals not supririsngly scored the highest in access to and availability of health infrastructure.

Meanwhile, academic facilities were found to have more written protocols given their increased likelihood for research and teaching compared to governmental and private facilities. However, academic institutions were found to have the highest rating with greater availability of consulting services.

Common barriers across all institutions included a lack of training in key emergency procedures, written protocols, point-of-care testing, and ancillary patient services. 

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Researchers have recommendations regarding the triage system and time metrics, training and education, written protocols for emergency care, and health infrastructure in order for the health facilities included in the study to improve emergency care. Investigators also highlighted a need for specific training, and cross-collaboration between the institutions to strengthen Nepal’s emergency services.

“The findings of this study will allow us to find areas of collaboration between institutions as well. For example, some hospitals have better protocols, others have better triage systems,” said Kamal Thapa, one of the study investigators and an emergency consultant at Grande Hospital. “We need to work together to improve emergency care. Ultimately, our concern is good patient care.

Emergency medicine is a new field globally, and especially so for Nepal but evidence from other countries has shown that even simple interventions— like having a good triage system in hospitals— have a significant impact in saving lives.

Said Kharel: “The next step for these hospitals is to use the findings as a guide to take steps towards addressing gaps identified in this report. Furthermore, we need to conduct larger research around the country to look at gaps in emergency care in rural area facilities.”

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