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. <a href="http://archive.nepalitimes.com/news.php?id=17851#.ZA7O-3ZBy3A" target="_blank">Another survey in 2011</a> had shown that only two of the hospitals in Kathmandu Valley at the time had earthquake resistant buildings.
&nbsp;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.&nbsp;
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.&nbsp;
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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.&nbsp;
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.&nbsp;
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.&nbsp;
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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 <a href="https://www.nepalitimes.com/editorial/poor-health-makes-nepalis-poorer">good patient care.</a>”
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.”
Read also: <a href="https://archive.nepalitimes.com/article/editorial/health-tip-editorial,4032">Health tip</a>, Editorial

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Emergencies in Nepal's Emergency Rooms

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109101132/636b73eb9c7e80680e062365jpeg.jpg" alt="" width="1500" height="911"/><figcaption>Photo: NATIONAL TRAUMA CENTRE</figcaption></figure>Speeding along a narrow winding mountain road in Dhading, a heavily intoxicated truck driver lost control of the <a href="https://www.nepalitimes.com/banner/nepals-deadly-roads-take-their-toll/" target="_blank" rel="noopener">vehicle</a> and it overturned, killing seven and severely injuring 34 passengers hitching a ride.This was a mass trauma incident that required immediate attention, but <a href="http://nationaltraumacenter.gov.np/" target="_blank" rel="noopener">Nepal’s only trauma care centre</a> was located in Kathmandu, 90km away via bumpy roads jammed with traffic.Read also: <a href="https://www.nepalitimes.com/?p=40249&amp;preview_nonce=aefd82ecbe&amp;preview=true" target="_blank" rel="noopener">injured use Internet to reach physiotherapists in Nepal</a>, Sonia AwaleMost passengers from the truck accident were taken to nearby hospitals in Dhading, but the 21 most critical patients were airlifted or driven in ambulances to the National Trauma Centre in Kathmandu.“It had already taken a while to bring the patients to the Trauma Centre, so we had to act quickly once they were here,’’ recalls Pramod Yadav, acting medical superintendent at the facility.The standard protocol for trauma care is the triage system -- determining the priority of treatment based on the severity of injury. Doctors at the National Trauma Centre quickly designated yellow, green and red codes to patients to ensure that those in critical condition were taken care of first, and fast.Read also: <a href="https://archive.nepalitimes.com/article/nation/accident-prone-Mugling-Narayangadi-highway,3828" target="_blank" rel="noopener">Unblocking an artery</a>, Sanjeev SharmaOn-call doctors were contacted and began assessing the patient’s injuries. But without a functioning MRI and a faulty CT machine, some had to be sent to private clinics and later returned to the hospital.This is a recurring event for patients seeking immediate care at the government-run Trauma Centre where patients in critical condition have to be moved about from one facility to another for tests.“We cannot afford an MRI machine, it is very expensive to repair our CT machines, we have limited trolley beds and only 11 ICU beds when we need more than 50,” says Yadav. “We are requesting the government for Rs420 million to become a real trauma centre, especially since we are the only one in the country.”There were 60,000 severe trauma injuries in Nepal in the last year, a 3,000 increase from the previous year, and a whopping 27,000 over the year before that. Like with all government-run medical centres, the Trauma Centre lacks resources, is under-staffed, and is incapable of handling this exponential increase.“In the last two, three years, falls, physical assault, <a href="https://www.nepalitimes.com/banner/nepals-deadly-roads-take-their-toll/" target="_blank" rel="noopener">road traffic accidents</a>, sports injuries and <a href="https://archive.nepalitimes.com/article/nation/burning-in-the-aftermath,3757" target="_blank" rel="noopener">burns</a> have been the leading causes of trauma,” lists  Siddhartha Dhungana, the Medical Record Officer at the National Trauma Centre. “Head injuries and multi-organ failures have been the highest causes of death in these cases.”Most hospitals in Nepal, like the National Trauma Centre, follow the World Health Organisation’s trauma protocol. During a trauma case, medical personnel are contacted as soon as possible, patients are screened, their needs are identified and necessary care is given.Although the government has not developed a standard care protocol for trauma like it has for cancer patients, private hospitals have implemented and refined their own systems based on WHO guidelines.<a href="http://archive.nepalitimes.com/article/nation/politics-behind-epidemic-of-hospital-vandalism,3578" target="_blank" rel="noopener">Om Hospital</a>’s Continuing Medical Education Program is at the forefront of teaching trauma care to new doctors and providing courses on improved techniques to existing doctors.“We make sure that the ABCs of trauma care are followed strictly and that blood is readily available be it from our blood bank or staff-chain blood donors,” says Binod Adhikari of Om, which handles dozens of cases every day and has systems in place to coordinate between doctors, nurses and critical care anesthesiologists to provide emergency care to patients.<h2>Ambulance chasers</h2><figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109101132/636b73ee9c7e80680e062366jpeg.jpg" alt="" width="1500" height="1125"><figcaption>Photo : SANJAYA KARKI/ FACEBOOK</figcaption></figure>Most of Nepal's ambulances are just jeeps with stretchers, with no life-support systems or medical attendants. It was only in 2011 that Nepal’s first emergency medical service was established. Supported by the Patan Academy of Health Sciences and the Stanford University School of Medicine, Nepal Ambulance Service (NAS) has since trained more than 100 emergency medical technicians (EMTs) and ambulance drivers and operates the <a href="http://archive.nepalitimes.com/news.php?id=18888#.XjvhpTIzaUk" target="_blank" rel="noopener">'Dial 102' service</a>. NAS operates mainly in Kathmandu Valley, Pokhara, Chitwan, Butwal and Bhairawa.“Before this, only few private hospitals had ambulances and they were used mainly for patient transfer rather than pre-hospital care,” says Hari Khadka, a paramedic at <a href="https://www.grandehospital.com/" target="_blank" rel="noopener">Grande International Hospital</a> and a member of the first EMT batch of NAS. “Ten years ago, there was simply no concept of pre-hospital care or paramedics in Nepal.”Now, many hospitals have their own EMS systems with mostly Type 3 ambulances that have first aid kits and basic medical supplies. <a href="https://www.nrcs.org/" target="_blank" rel="noopener">Nepal Red Cross Society</a> (NRCS) operates 283 ambulances nationwide. Although not every ambulance carries a paramedic, every driver has received first aid training.“We have five Type 2 ambulances and a paramedic in each vehicle,” says Bipul Neupane of NRCS. “We send these ambulances to patients who need basic life support systems.”But for patients needing critical care in remote areas, there is no recourse but expensive helicopter medical evacuation.Like Type 1 ambulances, some of these helicopters can have doctors, ventilators, advanced life support, and EMTs.“EMS has helped save many lives in Nepal but it isn’t always the best option considering the geography of Nepal and the condition of the roads,” says Sanjaya Karki, Head of the Emergency Department at <a href="https://www.nepalmediciti.com/" target="_blank" rel="noopener">Nepal Mediciti Hospital</a>. “Helicopter Emergency Medical Services ensure that we can get to critical patients as quickly as possible and provide the best pre-hospital care.”

It’s an emergency: Nepal needs to improve trauma care

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Emergencies in Nepal's Emergency Rooms

It’s an emergency: Nepal needs to improve trauma care