Two hospitals could insert central venous catheters and gain intraosseous access, which is important in shock management. In terms of resources, only two of the four had a separate triage area for emergency patients. All four hospitals had an isolation room, an obstetric/gynecologic area, and a decontamination room. We surveyed hospitals on their reasons for non-compliance with signal functions, asking them to choose from among five possible causal factors. The first was training issues, taking the form of a lack of education. The second factor was related to the lack of availability of appropriate supplies, equipment, and/ or drugs. The third pertained to management issues, such as the staff being unfamiliar with the functions, and cases where other equivalent procedures could have handled the conditions. The fourth factor was policy issues, referring to cases where the government or the facility itself does not allow for compliance with the signal functions. The fifth factor was designated as “no indication,” meaning that there was no patient group who needed this function. Supplemental Table 4 describes the reasons respondents provided on the survey for each unavailable signal function. Inappropriate supplies/equipment/drugs was the most common reason, as might be expected, and shortage of human resources was another causal factor. One intermediate hospital did not agree with the use of emergency signal functions for sentinel conditions, and answered “no indication” as their reason for non-compliance.It is widely recognized that there is a huge burden caused by trauma and non-communicable diseases in LMICs, where capability for emergency care is believed to be suboptimal.Many studies have tried to assess the state of emergency care in the health facilities of LMICs. Due to the accessibility issue,vertical farming racks most studies examined teaching hospitals located in urban areas. Assessment tools were not standardized and were usually developed by the researchers themselves.

Domains for assessment were usually related to the availability of resources, and functional aspects were surveyed with qualitative measures, if any. To our knowledge, this study is the first to survey urban and rural Myanmar hospitals using ECAT, the newly developed objective tool for assessing emergency care in health facilities. Our study demonstrated that the performance of emergency signal functions in Myanmar hospitals is inadequate, especially in trauma care. Trauma care in LMICs has been regarded as a role for large hospitals, and direct referral to upper-level facilities is a common practice. Burke et al. found that lack of readily accessible equipment for trauma care and shortage of skilled staff were the main reasons for poor quality trauma care in lower-level health facilities in LMICs.Another study pointed out the limited training opportunities for trauma management in LMICs.We found similar obstacles to trauma care in Myanmar hospitals, including the unavailability of items necessary for signal functions. Unlike other LMICs, Myanmar faces a singular geographic and demographic situation. Road conditions are poor. Almost 20 million people live in areas not connected by basic roads. The roads that do exist are unpaved and narrow, contributing to the overall lack of accessibility. The cause of this problem might be found in continuous armed conflicts. Since the independence of Myanmar in 1948, a continuing civil war has devastated the population and infrastructure of the rural areas, which has led to the deterioration of the health status of the country. In areas dominated by violence, residential zones are located away from road access, and the level of medical care is behind the times. Financial support is also lacking.For example, a referral and transport from Matupi Hospital to an adjacent upper-level facility takes as long as 16 hours during rainy seasons due to road damage . In this situation, timely management of patients in a critical condition is virtually impossible, and demands for higher levels of emergency care in basic-level facilities can be raised. Moreover, the results of our study show that some intermediate-level hospitals could not provide resuscitation for critical patients due to the lack of advanced airway management, mechanical ventilators, and defibrillation. Imbalances in the quality of emergency care in both basic- and intermediate-level facilities should be addressed carefully.

However, in Myanmar’s special situation where highway infrastructure is lacking and there are problems with long transport times, the ability to administer emergency medical care at a large hospital should be established based on skilled labor and resources. Ouma et al. emphasized that all countries should reach the international benchmark of more than 80% of their populations living within a two-hour travel time to the nearest hospital.20 Although it cannot be realized in the near future, measures to alleviate accessibility problems can be applied. Thorough gap analyses to address existing challenges in remote regions will be helpful for planning. In this regard, ECAT should be validated to include a time factor, such as the referral time to the nearest upper-level facility. We identified the following urgent issues in need of remediation: 1) improvement of trauma-related signal functions in basic-level facilities; 2) improvement of trauma and critical care-related signal functions in intermediate level facilities; and 3) implementation of a comprehensive nationwide survey to uncover emergency care deficiencies in rural areas, with emphasis on the time required for referral to higher-level facilities. Our suggestions to address the issues identified in our study can be summarized as relating to the reinforcement of infrastructure and human resources within each level of facility. In addition, prehospital care and care during inter-facility transportation should receive special attention considering the unique context of Myanmar, with its dispersed residences and extremely long transport times. There has been an effort to establish formal EM in Myanmar. In 2014, the Emergency Medicine Postgraduate Diploma course provided by Australia graduated Myanmar medical officers.8 These emergency providers will be an imperative asset to setting up a modern emergency medical care delivery system in Myanmar, although most of them will practice in advanced-level facilities. Measures to build the capacity to respond to medical emergencies in rural areas should be pursued in Myanmar. There have already been efforts to improve first-aid skills among local healthcare workers who have a high degree of understanding of the local context, and to employ them as community emergency responders.

These local healthcare workers are well informed about the population, hygiene, disease distribution, and the geographical and cultural characteristics of the area; thus, they are able to provide essential first aid and find appropriate health facilities for referrals. This practice has been expanded to the concept of out-of-hospital emergency care . It refers to a wide range of emergency treatments, from the process of recognizing an emergent care situation, to the initial emergency treatments outside the hospital, and transport to the hospital.The establishment of OHEC has played a role particularly in LMICs by reducing mortality rates by 80%, especially in trauma cases.Since 2000, several organizations have implemented the trauma training course program with non-physician clinicians in Eastern Myanmar.The program comprises various skills for carrying out the initial treatment of trauma, taught through simple simulations and feedback. The findings indicated that survival rates improved significantly among major trauma patients following the implementation of this program. We recognize that some skills covered in the TTC, such as surgical airway management, would be relatively dangerous for health workers to perform in the field, and believe that development and implementation of a training program focused on the operation of emergency signal functions would be more practical for the rural context. Those who are trained in this program could act as prehospital emergency care providers, and also aid basic-level facilities to fill the functional gaps identified in this study. In addition to the above suggestions, a national or provincial strategic plan for reinforcing emergency care in rural areas of Myanmar should be established and implemented. Following a thorough investigational survey,vertical racking system essential resources for each level of health facility should be supplemented. Public education to recognize emergency conditions is another area to be strengthened. In many LMICs, including Myanmar, folk remedies are still commonly attempted before people seek medical attention, especially in the field of obstetrics and gynecology.Recognizing the need for emergency care is crucial because it is the first step leading the patient to the emergency medical care system. Community education should play an important role in preventing delays in the detection of emergency situations.Traditional medicine providers have been the first to participate in this training thus far, and it has been reported to be effective.Point-of-care ultrasound has emerged as an essential diagnostic tool in emergency medicine .Several studies have demonstrated that a structured curriculum is both feasible and effective in training emergency physicians to obtain and accurately interpret images with test characteristics approaching or even exceeding those of dedicated radiology-performed scans.However, less is known about the penetrance of POCUS into daily EP practice.

The emergency department poses unique challenges to implementation of diagnostic POCUS not present in other specialties with broad adoption of POCUS such as cardiology, critical care, and obstetrics: 1) the time spent with an individual patient is limited compared to other specialties; 2) ED settings vary dramatically between academic, community, rural, and urban practices, and each environment has its own unique challenges with respect to availability of POCUS and training of clinicians in ultrasound and 3) the breadth of POCUS applications in the ED is considerably greater than in other specialties. Guidelines from the American College of Emergency Physicians endorse 12 core applications. The degree of experience necessary to obtain competency in image acquisition and interpretation, while not clear, appears to be highly variable between these applications.As a result, few EPs maintain competency in all 12 applications without further postgraduate fellowship training. This leads to a general reluctance to perform and rely on some POCUS exams, as EPs question the need to maintain competency in certain applications.9 Indeed, a survey of EPs in California found that most EPs do not use POCUS, and that EPs in academic environments use POCUS more regularly than their community counterparts.The challenges posed above apply both to established EPs and residents in training who are establishing practice patterns. Despite near-universal incorporation of ultrasound into resident training,a survey of recent residency graduates found limited use in daily clinical practice.This suggests that dedicated ultrasound training in most EM residency programs in North America progresses residents to the intermediate level, where they are able to effectively acquire and interpret images, but not to the level of the expert who is able to seamlessly incorporate the procedural skill into practice. We hypothesized that a number of perceived barriers may be leading to a gap in deliberate, on-shift practice, which is preventing trainees from advancing to expert levels. The goal of this study was to assess and address relevant barriers to POCUS performed on shift by residents at a single, three-year EM residency program. As such, the study had two phases. We first performed a voluntary residency-wide survey to address perceived attitudes and barriers to on-shift use of POCUS. Next we performed an intervention to address the primary barrier, namely the perceived lack of a proper charting and reporting policy.We conducted the study at an ED with an annual volume of 65,000 patients, which hosts a three-year EM residency program. The residency trains a total of 36 residents, with 12 residents per year. The study site uses the HealthLink/ EPIC electronic medical record , and all point-of-care ultrasounds are wirelessly uploaded to a middleware product . Quality assurance of all scans submitted for review is performed by ultrasound fellowship-trained EPs who rotate on a weekly basis. At the time of study performance, ultrasound training consisted of a four-hour introductory ultrasound course at the start of residency training, a four-week mandatory ultrasound rotation during the first year, and quarterly didactics with simulation and hands-on training during regularly scheduled mandatory conference. In addition, ultrasound fellowship trained faculty offered three-hour sessions, biweekly, which consisted of didactics, image review, and bedside scanning. These sessions were mandatory for the first-year resident who was on the dedicated POCUS rotation, as well as two second and third-year residents who were on a dedicated month of community ED practice. The study was performed as part of ongoing quality improvement program, not requiring institutional review board review at the study institution.At the beginning of the study, a departmental best practice, systematic, ultrasound documentation workflow was disseminated to faculty attending physicians. This workflow included saving ultrasound examinations performed or supervised by a faculty member credentialed in the relevant application.