Development and Implementation of a Longitudinal Global Acute Care and Systems Strengthening Program

EVENT DESCRIPTION	STUDENT INVOLVEMENT	DESCRIPTION
RESEARCH
Participation in Global Health Research	16 students	Virginia Global Surgery Symposium: 5 oral presentations 2 poster presentations American College of Surgeons Clinical Congress: 1 oral presentation 3 poster presentations
EDUCATION
Global Surgery Seminar Series	360 attendees over series duration	18 events with approximately 20 attendees on average
Virginia Global Surgery Symposium	27 Volunteers 250 symposium attendees	3-day event
Journal Clubs	41 attendances	3 events
TEAM Workshop	19 participants	1 workshop
Richmond Ambulance Authority Ride-Along^a	6	6
COMMUNITY OUTREACH
Hands-Only CPR Instructors	9 Student Instructors	2 Community Teaching Events
Stop the Bleed Instructors	17 Student Instructors	2 Community Teaching Events

Table 2

Preclinical Curriculum Sessions: Focus Description and Objectives by Year.

SESSION TITLE	SESSION DESCRIPTION AND OBJECTIVE
M1 – FIRST PRECLINICAL YEAR (8 MONTHS)
Session M1-1: Global Burden of Disease (Domain 1)	Focus Description: Through an interactive presentation and small group or case discussion, students will develop a basic understanding of the major causes of global morbidity and mortality and variations among high-, middle-, and low-income countries, especially in regards to acute surgical or medical disease. Specific Objectives: Identify the major causes of morbidity and mortality around the world as they pertain to acute care, and how risk factors and health determinants vary by world region.
Session M1-2: Globalization of Health and Health Care (Domain 2)	Focus description: Through an interactive presentation and small group or case discussion, students will develop a basic understanding of how globalization has impacted the spread of both chronic and acute disease, and be presented with an overview of healthcare systems that differ from our own. Specific Objectives: Describe how travel and trade contribute to the spread of communicable and non-communicable diseases, with special attention to diseases that require acute intervention.
Session M1-3: Professional Practice: Access to Health care, Challenges in Local and Global Pre-hospital Healthcare Systems (Domains 2, 7)	Focus Description: Through a presentation and open question session, representatives from Richmond Ambulance Authority will discuss the operation of a local prehospital care system and prepare students for a ride-along experience with their service. Next, faculty and student co-leader(s) will use an interactive presentation and small group or case discussion to discuss access to healthcare in emergencies and prehospital care in low-resource settings. Specific Objectives: Describe different national models or health systems for provision of health care. Develop a basic understanding of a local prehospital care system. Articulate barriers to health and health care in low-resource settings locally and globally, including in the delivery of emergency care in the prehospital care environment.
Session M1-4: Global Research Ethics and Introduction to Journal Clubs (Domain 6)	Focus Description: Through an interactive presentation and small group or case discussion, students will discuss common ethical issues that arise in global acute care and systems research, how it affects local communities, and what can be done to address these issues and build international collaborative partnerships. Specific Objective: Develop an understanding of common ethical issues and challenges that arise when working in service delivery and/or research of acute disease conducted in or applicable to low-resource settings, vulnerable populations, and within diverse economic, political, and cultural contexts.
Session M1-5: Understanding Social and Environmental Determinants of Health (Domain 3)	Focus Description: Through an interactive presentation and small group or case discussion, students will learn what social, economic, and environmental factors contribute to health in the acute setting. Specific Objective Identify major social and economic determinants of health, how they influence acute healthcare needs, and their effects on the access to and quality of health services.
Session M1-6: Professional Practice and Preparing for a Global Health Experience (Domain 7)	Description: Through an interactive presentation and small group or case discussion, students will discuss various clinical activities related to the delivery of acute care and surgery in low-resource settings. Students will also be presented with practical knowledge that directly prepares them for a global health experience. Specific Objectives: Become familiar with common health problems, especially those requiring acute care, and chief complaints in regions where VCU has participated with medical and surgical trips. Present a practical checklist to prepare students to embark on global health experiences.
Session M1-7: Strategic Analysis for Healthcare in Low Resource Settings: The Basics of a Needs Assessment (Domain 11)	Focus Description: Students will be presented with a systematic process for determining the acute care needs of a community, and a basic understanding of how a formal Needs Assessment fits into a planning and improvement process to strengthen healthcare systems. Specific Objective: Describe the steps for conducting a needs assessment at facility or health systems levels for care delivery in low resource settings.
Session M1-8: Building Sustainable Emergency and Acute Care Programs in Low-Resource Settings (Domain 4)	Focus Description: In this session, students will engage in a group discussion about two pillars of strengthening and building essential and sustainable emergency and acute care services: a skilled acute care and surgical workforce and the establishment of local partnerships. Specific Objective: Learn how the global acute care workforce shortage crisis impacts capacity building initiatives worldwide. Appreciate the importance of collaboration with a host or partner organization to assess an organization’s operational capacity.
M2 – SECOND PRECLINICAL YEAR (5 MONTHS)
Session M2-1: Understanding Health Policy in Low Resource Settings and Introduction to NSOAPs (Domain 9)	Focus Description: Through an interactive presentation and small group or case discussion of the implementation of a National Surgical Obstetric and Anesthesia Plan (NSOAP) in Ethiopia, students will gain insight into the design, implementation, and evaluation of global surgery, anesthesia, obstetric services in low resource settings. Specific Objectives: Identify effective project management techniques used throughout NSOAP and other program planning, implementation, and evaluation. (Domain 9)
Session M2-2: Social Justice: Strategies for Addressing Inequity in Low Resource Settings (Domain 8)	Focus Description: Through an interactive presentation and small group or case discussion, students will learn about fundamental vulnerable populations; health and human rights; and health inequalities, especially as they relate to acute and critical care needs. Specific Objectives: Acquire a basic understanding of the relationships between health, human rights, global inequities, and acute care needs. Discuss strategies to engage marginalized and vulnerable populations in making decisions that affect their health and well-being in both the acute and chronic setting.
Session M2-3: Sociocultural and Political Awareness (Domain 10)	Focus Description: Through an interactive presentation and small group or case discussion, students will develop an understanding of how limited resources are assessed and utilized when planning national surgical plans. Specific Objective: Develop an understanding and awareness of the healthcare workforce crisis in the developing world, the factors that contribute to this, and strategies to address this problem. (Domain 8)

Table 3

Passing Requirements of the ACCESS Program.

YEAR	REQUIREMENT
1	Attend 6 of 8 interactive sessions with completion of the corresponding pre- and post- session materials Participation in 2 of 6 journal clubs Attendance at 4 of 10 monthly global seminar series Participation in at least one community engagement event (e.g. instructing Hands-Only CPR or Stop the Bleed) with satisfactory evaluation from local partners
2	Attend 2 of 3 interactive sessions with completion of the corresponding pre- and post- session materials Participation in 2 of 6 journal clubs 24 hours of preceptorship with a global health experienced faculty preceptor Capstone project proposal
3	Participate in 4 specialty-specific interactive sessions with completion of any relevant pre- and post- session materials
4	Support faculty as a Senior co-leader for at least one session for junior students Present Capstone project at the Global Medicine and Surgery Research Day with a minimum score of 70% of the points awarded by a faculty panel Moderate at least one journal club for underclassmen Submit Capstone project for presentation or publication to at least one national or international platform Comprehensive assessments of the global competencies

Fall 2019 Semester Sessions Objective Understanding Scores.
In the first fall semester of the ACCESS curriculum, students improved in self-reported understanding of all session objectives (3.13/5 vs. 3.82/5, p = 0.03), with the overall significance driven by evaluations of objectives learned in Session M1-4: Global Research Ethics and Introduction to Journal Clubs and Session M1-6: Professional Practice and Preparing for a Global Health Experience.

Appendix 1

Third Year Session Objectives in the Surgery Emphasis.

ACCESS SURGERY EMPHASIS
SESSION TITLE	SESSION DESCRIPTION AND OBJECTIVE
Session M3-General Session: Designing a Meaningful Global Surgery Capstone Project	Specific Objectives: Designing of capstone proposal allows students to apply and demonstrate their knowledge acquired during the ACCESS elective course. This session will teach students how to identify feasible potential projects, organize ideas, define research methodology, and design an action plan. The project outcomes will be presented on the VCU Research day. Students will be encouraged to draft abstracts, submit the results to national conferences and convene their project’s findings/outcomes into an academic manuscript. Specific Objective: The proposal will include a research question or project objective and its importance, relevant background information and prior work, planned methodology, and a feasible timeline for completion of the project. The student will have received feedback and approval by their faculty mentor before proposal submission. Students will also complete selected CITI Online Research Ethics training modules by the date of proposal submission.
Session M3-1: Strategic Analysis for Health Surgical Services in Low Resource Settings: The Basics of a Health Needs Assessment and Situational Analysis	Focus Description: Strategic analysis refers to the process of analyzing existing information to formulate a strategy. A Health Needs Assessment and Situational Analysis are tools used to identify and analyze community health needs and the broad societal context. The process helps not only on the identification and prioritization of health needs but also in planning actions upon unmet needs. Surgeons and acute care providers working in international settings must possess a basic understanding of how a formal community needs assessment fits into the strategic planning of interventions for local surgical systems. Specific Objective: Each learner will possess a foundational understanding of what is involved in a needs assessment and SWOT (strengths, weakness, opportunities, threats) Analysis and how they can be used to draft an effective project proposal.
Session M3-2: Ethical Challenges for delivery of surgical care in low-resources settings abroad.	Focus Description: Given the many ethical issues and considerations arise when providing essential and/or elective surgery procedures in low-resources settings abroad, this session will offer students the opportunity to learned and to explore options on how best to address them. Being aware of common ethical challenges is the first step for self- awareness of own and others’ actions and when facing ethical decision-making situations. We will discuss ethical challenges such as: Belief of ‘good enough’ or ‘better than what they had’ White savior complex in missions Patient selection and follow-up for elective surgeries in LMICs Dilemma of disposable vs reusable surgical materials Use of limited resources to help just one patient (e.g. CT scan) Specific Objective: Each learner will possess a solid awareness and foundational understanding of common ethical challenges that impact the delivery of essential and elective surgeries in low-constraints settings.
Session M3-3: Basic Surgical Skills Valuable in Resource-Constrained Settings	Focus Description: The ability to perform and adapt surgical clinical skills in limited-resource settings is essential to provide quality care. Adaptability includes the use of essential clinical skills in settings with limited surgical providers and medical supplies. Instrument handling knot tying and suturing techniques IV access infusion Chest tube insertion Bleeding control techniques Specific Objective: Each learner will learn basic surgical skills needed when participating in global surgery activities
Session M3-4: Common Emotional Challenges When Facing Prevalent Surgical Conditions in Low-Resource Settings	Focus Description: Discussion of common surgical scenarios will prepare medical trainees for common challenges (both practical and emotional) faced when working in resource-limited settings. During this session, students will have the opportunity to analyze cases that would mimic challenging and realistic situations and would allow them to explore negative emotions related to the lack of adequate resources. Orthopedic Injury (Frustration) Abdominal Mass (Floundering) Rabies (Futility) Hypovolemic Shock (Frustration) Acute Appendicitis (Failure) Specific Objective: Each learner will participate in surgery-related simulation cases commonly encountered abroad to explore emotions of how they might feel when they don’t have the resources they are used to having at their disposal.
Session M3-5: Educational Opportunities and Challenges in Global Surgery	Focus Description: During this session, students will understand different strategies to reach out to different audiences or populations groups in LMICs with the goal of facilitating knowledge transfer and exchange. Principles of “knowledge sharing” and “knowledge exchange” can be used to educate patients and their families, colleagues, health policymakers, community members on topics related to the delivery of surgical care. Students would understand that educational strategies are bidirectional, and the realities of the local communities must be taken into consideration when designing and delivering them (e.g. low literacy). Sharing knowledge can be possible through different methods. Software platforms that offer telehealth and online chat services Oral presentations and talks Written materials: pamphlets, pictographs, Specific Objective: Each learner will understand the importance of educating patients, families, and communities with the use of simple educational strategies.

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DOI: https://doi.org/10.5334/aogh.3385 | Journal eISSN: 2214-9996

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Language: English

Published on: Dec 22, 2021

Published by: Ubiquity Press

In partnership with: Paradigm Publishing Services

Publication frequency: 1 issue per year

© 2021 Cybil S. Stingl, Kyle J. Alexander, James M. Dittman, Noah J. Hillerbrand, Karishma Popli, Amira Dalmazio, Nancy Valencia-Rojas, Aline Baghdassarian, Sudha Jayaraman, Edgar B. Rodas, published by Ubiquity Press
This work is licensed under the Creative Commons Attribution 4.0 License.

Volume 87 (2021): Issue 1

Development and Implementation of a Longitudinal Global Acute Care and Systems Strengthening Program

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