key: cord-0078904-bmka4cwm
authors: Jackson, Peter; Siddharthan, Trishul; Cordoba Torres, Ivet T.; Green, Barth A.; Policard, Chantal Jean-Pierre; Degraff, Jerry; Padalkar, Roma; Logothetis, Kathryn B.; Gold, Jeffrey A.; Fort, Alexander C.
title: Developing and Implementing Noninvasive Ventilator Training in Haiti during the COVID-19 Pandemic
date: 2022-02-17
journal: nan
DOI: 10.34197/ats-scholar.2021-0070oc
sha: 735162bae7ef872ce8df15f85fbb0bc4e526fd21
doc_id: 78904
cord_uid: bmka4cwm

BACKGROUND: Noninvasive ventilation (NIV) is an important component of respiratory therapy for a range of cardiopulmonary conditions. The World Health Organization recommends NIV use to decrease the use of intensive care unit resources and improve outcomes among patients with respiratory failure during periods of high patient capacity from coronavirus disease (COVID-19). However, healthcare providers in many low- and middle-income countries, including Haiti, do not have experience with NIV. We conducted NIV training and evaluation in Port-au-Prince, Haiti. OBJECTIVES: To design and implement a multimodal NIV training program in Haiti that would improve confidence and knowledge of NIV use for respiratory failure. METHODS: In January 2021, we conducted a 3-day multimodal NIV training consisting of didactic sessions, team-based learning, and multistation simulation for 36 Haitian healthcare workers. The course included 5 didactic session and 10 problem-based and simulation sessions. All course material was independently created by the study team on the basis of Accreditation Council for Continuing Medical Education–approved content and review of available evidence. All participants completed pre- and post-training knowledge-based examinations and confidence surveys, which used a 5-point Likert scale. RESULTS: A total of 36 participants were included in the training and analysis, mean age was 39.94 years (standard deviation [SD] = 9.45), and participants had an average of 14.32 years (SD = 1.21) of clinical experience. Most trainees (75%, n = 27) were physicians. Other specialties included nursing (19%, n = 7), nurse anesthesia (3%, n = 1), and respiratory therapy (3%, n = 1). Fifty percent (n = 18) of participants stated they had previous experience with NIV. The majority of trainees (77%) had an increase in confidence survey score; the mean confidence survey score increased significantly after training from 2.75 (SD = 0.77) to 3.70 (SD = 0.85) (P < 0.05). The mean knowledge examination score increased by 39.63% (SD = 15.99%) after training, which was also significant (P < 0.001). CONCLUSION: This multimodal NIV training, which included didactic, simulation, and team-based learning, was feasible and resulted in significant increases in trainee confidence and knowledge with NIV. This curriculum has the potential to provide NIV training to numerous low- and middle-income countries as they manage the ongoing COVID-19 pandemic and rising burden of noncommunicable disease. Further research is necessary to ensure the sustainability of these improvements and adaptability to other low- and middle-income settings.

Noninvasive ventilation (NIV) is a method of providing respiratory support through the application of oxygen and positive airway pressure via a nasal or facial mask or, occasionally, a helmet delivery system. NIV is considered the standard of care for the initial treatment of exacerbations of chronic obstructive pulmonary disease (COPD) with hypercapnia and acute pulmonary edema from congestive heart failure (CHF) (1, 2) . Although the role of NIV is less clear in acute respiratory failure (ARF) due to viral or bacterial pneumonia, data suggest that NIV use in selected patients with close monitoring is of likely benefit (1, 3, 4) .

The COVID-19 pandemic has created challenges in the management of respiratory disease globally because of high rates of COVID-19-induced ARF and limitations in resources and hospital capacity. In low-and middle-income countries (LMICs), such as Haiti, there is a longstanding shortage of critical care staff, beds, and equipment at baseline; estimates suggest that many LMICs have fewer than 5 intensive care unit (ICU) beds per 100,000 people as compared with 35 per 100,000 in the United States (5) . NIV can provide temporizing and destination therapy for patients with respiratory failure due to a range of etiologies; therefore, NIV may mitigate the effects of COVID-19 outbreaks on fragile healthcare systems in LMICs (1, 3, 6) . Recently, NIV was conditionally recommended for ARF in COVID-19 by the World Health Organization, likely because of its clinical efficacy for select patients and to reduce strain on ICU resources during the pandemic (6) .

The COVID-19 pandemic provides a rationale for urgently increasing NIV capability in LMICs, and the ongoing rise of noncommunicable diseases, including COPD and heart failure, suggest that NIV capacity will have durable benefits (7) . More than 90% of COPD deaths now occur in LMICs, where the prevalence of COPD has continued to increase; meanwhile, CHF prevalence doubled from approximately 33 million in 1990 to 66 million in 2017 and carries the highest mortality in LMICs (7, 8) . NIV is proven to decrease mortality during exacerbations of both CHF and COPD (1, 9) . In addition, there is possible benefit of NIV for ARF in patients with human immunodeficiency virus (HIV); HIV remains most prevalent in LMICs, and ARF is the leading cause of death in patients with HIV (2, (10) (11) (12) . Given the urgent need for NIV for COVID-19 in LMICs and its utility in diseases endemic to these settings, programs to improve NIV capacity are clearly warranted.

Despite the clinical benefits and need for NIV in LMICs, its use is not common in these settings (13) . This is likely due to numerous barriers to NIV uptake. Although cost is one consideration, studies have generally shown NIV to be cost effective (14, 15) . There is no research on limitations for NIV use in LMICs; however, studies evaluating general care for patients with ARF in LMICs identify staff training as a significant limitation to appropriate care of critically ill patients with ARF (13, 16, 17) . Studies in highincome countries that evaluated barriers specific to NIV use also found staff familiarity and adequate NIV training are important predictors of use (18) (19) (20) . Furthermore, research on how to best deliver training to improve staff familiarity and competence with NIV suggests that didactic education together with in-person simulation is most effective (21) (22) (23) .

Given the urgent need to increase critical care capacity and the large potential benefit of NIV use within Haiti and other LMICs, we created a multimodal NIV curriculum to improve NIV user confidence and knowledge. This training was in conjunction with a previously planned distribution of bilevel positive airway pressure (BPAP) and continuous positive airway pressure (CPAP) machines within the country by the Ministry of Public Health and Population (MSPP).

Haiti is a low-income country located in the Caribbean with approximately 11 million people, divided into 10 administrative units or "departments." The country has a shortage of physicians, with only 25 per 100,000 people. In addition, there is a severe lack of critical care resources. A survey in 2019 of 51 health facilities in

Haiti revealed only 124 ICU beds and the capacity to ventilate just 66 patients throughout the entire country (24) . Before training, discussion with Haitian physicians identified key personnel involved in NIV administration. Nurses and physicians are both involved in NIV application and troubleshooting; initiation of NIV and all NIV settings are directed by physicians, as there is a severe lack of respiratory therapists. This informed the inclusion of a range of healthcare workers in the training (Table 1) .

In January 2021, three anesthesia critical care physicians (A.C.F., I.T.C.T., and C.J.-P.P.), two pulmonary and critical care physicians (T.S. and P.J.), and one respiratory therapist (J.D.) conducted a 3-day multimodal NIV course consisting of didactic sessions, team-based learning, and multistation simulation training.

Didactic sessions were delivered in English with real-time translation to French with occasional clarifications in Haitian Creole. There were five didactic sessions: NIV indications, choosing and titrating NIV settings, machine and mask setup, physiology of NIV, and expanded NIV use and NIV failure. All didactic sessions were created by the aforementioned trainers and were based on literature review and Accreditation Council for Continuing Medical Education (ACCME)-accredited open-source content from medmastery.com (25) .

Simulation and team-based learning problems were independently created by the trainers and reviewed by the study team. Study team review focused on ensuring all content was evidence based, addressed within didactic sessions, and reflected in the knowledge-based assessments. 

Simulation consisted of 10 stations ranging from hands-on application of NIV on a low-fidelity simulation mannequin to a megacase with real-time narrative feedback on trainee decisions. Specific attention was given to trainees' recognition of NIV contraindications and failure during simulation. All simulation and team-based learning included native Haitian translators for real-time feedback and teambased discussion.

Trainees were asked to complete pre-and post-training surveys to assess their confidence with NIV in a clinical setting. Confidence surveys consisted of 12 items using a Likert scale to reflect participants' comfort with various aspects of initiating and managing patients on NIV. Likert scores ranged from 1 to 5, with 1 indicating a participant was "very uncomfortable" and 5 indicating the participant was "very comfortable" with an aspect of care. Trainees also completed a pre-and posttraining knowledge examination. This examination was based on the didactic sessions and modified assessments from medmastery.com, which produces opensource ACCME-approved content (25 (26) . Imputation of means was also calculated to ensure no large differences and is reported. For included subjects, missing values on confidence surveys were excluded in the calculation of means. Given an approximate normal distribution for Likert scale data, paired parametric t tests were used to assess differences between groups on both knowledge and confidence assessments. All associations were considered statistically significant at P values of 0.05 or less. Data were analyzed using R version 3.6.1.

A total of 36 participants participated in the study ( Table 1) domain's post-training average was not significantly different from post-training scores in other domains with the exception of "general use" (P , 0.001) (Figure 3 ).

In this study, we describe the development and implementation of a multimodal NIV training over 3 days in Haiti, an LMIC in the Caribbean. Among 36 participants, there was significant improvement in confidence using NIV and NIV knowledge measured in five domains. After the removal of confidence surveys with five or more missing values, we noted a significant improvement in the mean confidence score after training (0.95 points), and the majority of trainees (24 of 31, 77%) demonstrated improved confidence scores. The knowledge examination also demonstrated marked improvement in all five measured domains, with an overall mean improvement of approximately 40%. It is difficult to determine whether this will translate to improved application of NIV, and this will require long-term follow-up.

It is worth noting that these postcurriculum improvements are in line with previous work detailing trainings of similar content and in similar settings. In one recent study in the United States, a 3-day, multi-institutional, ventilator waveform training showed improvement in post-training knowledge examination of 37% (27) . Another study of short-term, multimodal, advanced cardiac life support training, which occurred in Haiti, demonstrated postcurriculum knowledge improvement of 22% after one training (28) . This suggests that our training was of similar efficacy in knowledge transfer to other well-designed curricula.

In the knowledge examination, the domain with the largest improvement tested general uses of NIV, including COPD and CHF, diseases with high prevalence in LMICs and strong evidence for benefit with NIV treatment (7). This domain had a significantly higher posttraining average than all other domains. The reason for this is likely related to a concerted effort during training to encourage use of NIV in clinical conditions with the best evidence for efficacy. Conversely, the domain testing modes of ventilation had the lowest pretraining and posttraining average and demonstrated the least improvement. It is reassuring that post-training improvement in the modes of ventilation domain remained statistically significant and did not differ significantly from other post-training domain averages, with the exception of general use. The reasons for lower scores in the domain evaluating mode selection in NIV are not clear, and additional attention should be paid to this content in future trainings. It may also be of benefit to and evaluate individual questions, in the modes domain and others, to reveal outliers that may be modified or excluded in future testing. Overall, the average percentage correct was relatively low, even after training. It is important to note, however, that the questions used were modified from ACCMEbased content and represented advanced concepts. Further work is necessary to ensure there is ongoing education and that knowledge is retained.

One potential limitation of our training was that the increase in confidence, 2.75 (SD = 0.77) to 3.70 (SD = 0.85), was not as great as that in some related studies in the region. For example, in a study evaluating a multimodal emergency medical service skills course conducted in Port-au-Prince over 4 days, there was an improvement in "self-efficacy" Likert scale scores from 1.5 to 4.25 after the training, an improvement of 2.75 ± 0.93 (28) . The reasons for only 77% of our trainees noting improvement in confidence are also not clear. As noted previously, we elected to exclude confidence surveys with five or more missing values. These scores were omitted because it is not possible to ascertain whether missing values suggested high or low confidence of the participant, and the high number of missing values increased risk of bias with imputation (26) . It may be that missing values indicated low confidence, which would have underestimated our training's overall effect. In addition, our pretraining average value was higher at baseline (2.7 vs. 1.5); this makes comparison of relative increases difficult to interpret. Regardless, in-depth interviews after subsequent trainings to understand participants' confidence in using NIV would be of value.

This study has several other limitations. First, although we were able to train a diverse group of providers from across Haiti, the intervention was held at a single site; this may limit the external validity of our results. In addition, the training period was short-the optimal length of NIV training curriculum cannot be concluded from our work. It is possible that shorter curricula provide equivalent improvements in confidence and knowledge, and if so, the short duration of our training may allow similar content to be delivered quickly during periods of increased need. In addition, whereas the focus of this training concerned knowledge and practical skills, any intervention requires longitudinal follow-up to ascertain implementation, sustainability, and the complex enablers and barriers to adoption in resource-limited settings.

Lack of local language fluency is another limitation we encountered. Despite these limitations, this study showed notable improvement in NIV confidence and knowledge after the delivery of a short and targeted curriculum. The study also provides important insights into the implementation of formal training in NIV in a low-resource setting during the COVID-19 pandemic and provides a framework for future educational efforts as LMICs continue to face the rising burden of respiratory failure. Given the positive feedback from the attendees and requests for future training, additional educational initiatives are being discussed. Needs assessments conducted while in Haiti, which included stakeholder interviews and resource assessments, provided insight into future training and infrastructure needs. These gaps included a need for mechanical ventilation education and respiratory equipment, particularly disposable items such as ventilator tubing, masks, viral filters, and heat moisture exchangers. We intend to continue to provide training and capacity building to Haiti in the future.

The decision to provide in-person learning and simulation during the COVID-19 pandemic was based on several factors. Although there is limited research on modalities of NIV training, previous work evaluating methods of ventilator training found that simulation and in-person training have clear advantages (23) . In fact, simulation-based testing for ventilator management has been incorporated and validated in Israel for anesthesia board examinations (29) . The data on remote ventilator learning are less robust. One critical review of virtual training platforms concluded that there was no scientific evidence to show the efficacy of virtual ventilator training; furthermore, in our review of the literature, we did not find any virtual simulations for NIV (21) . Virtual training has been necessary in the pandemic era, but coordination with hospitals lacking infrastructure in telemedicine poses real limitations and challenges. Although there is a risk to in-person training during the COVID-19 pandemic, all our trainers were vaccinated, masks were always required during the training, and health screening was performed by site staff before entry into the facility. Importantly, the Haitian medical community was directly involved during planning of this curriculum and specifically requested this NIV training for the successful rollout of the NIV program.

This study demonstrates the design and implementation of an NIV training program over 3 days in Haiti, a lowresource setting, with testing and confidence surveys demonstrating significant improvements after training. Ongoing work to establish a sustainable national NIV program in Haiti beyond training will be necessary to improve outcomes related to respiratory failure. The COVID-19 pandemic has highlighted gaps in care that exist in LMICs with significant increases in morbidity and mortality attributable to a lack of resources and knowledge in the treatment of respiratory failure (30) . Unfortunately, given the slow rate of vaccination in LMICs, it is reasonable to assume that the effects of COVID-19 and increased need for NIV in these countries are likely to persist for some time. This initial medical training curriculum in NIV can inform future trainings to improve respiratory care not only in Haiti but in other LMICs across the globe.

Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure

Noninvasive ventilation in immunosuppressed patients with pulmonary infiltrates, fever, and acute respiratory failure

Noninvasive ventilation in acute respiratory failure: which recipe for success?

H1N1 GTEI/ SEMICYUC Investigators. Early non-invasive ventilation treatment for severe influenza pneumonia

Critical care capacity during the COVID-19 pandemic: global availability of intensive care beds

World Health Organization. COVID-19 Clinical management: living guidance. World Health Organization

Projections of global mortality and burden of disease from 2002 to 2030

Burden of heart failure and underlying causes in 195 countries and territories from 1990 to 2017

British Thoracic Society Standards of Care Committee. Non-invasive ventilation in acute respiratory failure

Beyond the guidelines for noninvasive ventilation in acute respiratory failure: implications for practice

Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia

Groupe de Recherche en R eanimation Respiratoire du patient d'Onco-H ematologie (GRRR-OH). Effect of noninvasive ventilation vs oxygen therapy on mortality among immunocompromised patients with acute respiratory failure: a randomized clinical trial

Non-invasive ventilation in children and adults in low-and low-middle income countries: a systematic review and meta-analysis

Cost effectiveness of ward based non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease: economic analysis of randomised controlled trial

Cost-effectiveness of noninvasive ventilation for chronic obstructive pulmonary disease-related respiratory failure in Indian hospitals without ICU facilities

Optimizing respiratory management in resource-limited settings

Emergency and critical care services in Tanzania: a survey of ten hospitals

Utilization of noninvasive ventilation in acute care hospitals: a regional survey

How to initiate a noninvasive ventilation program: bringing the evidence to the bedside

A European survey of noninvasive ventilation practices

A critical review of mechanical ventilation virtual simulators: is it time to use them

Simulation training for residents focused on mechanical ventilation: a randomized trial using mannequin-based versus computer-based simulation

Mechanical ventilation training during graduate medical education: perspectives and review of the literature

Research and Education consortium for Acute Care in Haiti (REACH) Study Group. Critical care capacity in Haiti: a nationwide cross-sectional survey

Noninvasive ventilation masterclass. Medmastery

Missing data in Likert ratings: a comparison of replacement methods

Impact of novel multiinstitutional curriculum on critical care fellow ventilator knowledge

Near-peer emergency medicine for medical students in Port-au-Prince, Haiti: an example of rethinking global health interventions in developing countries

Incorporating simulation-based objective structured clinical examination into the Israeli National Board Examination in Anesthesiology

African COVID-19 Critical Care Outcomes Study Investigators Patient care and clinical outcomes for patients with COVID-19 infection admitted to African high-care or intensive care units (ACCCOS): a multicentre, prospective, observational cohort study

Collaboration in the time of COVID 19 noninvasive ventilation training in Haiti

Author disclosures are available with the text of this article at www.atsjournals.org.