EM is an emerging specialty in Colombia, where the demand for emergency providers is staggering. Two Colombian institutions offer accredited residency training in EM, and these programs are the primary supply of EM physicians for the country. The few physicians who are already practicing EM face the challenges of defining this young specialty and tackling immense problems such as ED overcrowding, excessive wait times, and high patient to provider ratios. I will work at Hospital Fundacion Santa Fe de Bogota (FSFB), both clinically and from within the FSFB EM residency to improve education and clinical care. Over four weeks, I will initiate a project that will be team focused and generate potential for long-term international collaboration. I will continue this work as a fourth year resident, via telecommunication and return visits. This will be my first time working in Colombia in the capacity of a physician, and will be the first time I have independently led a project aimed at improving EM education and research internationally - the two primary goals of my career. My goals are as follows: 1) To enhance resident education through implementation of a research cirriculum that promotes increased faculty engagement and faculty-resident collaboration; 2) To build research confidence through group completion of primary research projects and preparation of results for publication; and 3) To improve clinical operations at FSFB by focusing research questions on current operational challenges. Due to strong support from faculty at Hopkins and FSFB, this initiative has high probability of success and sustainability.
The FSFB Emergency Department (Clinica de Urgencias). Top: Exterior of the building looking west, toward the Andes which loom above the hospital. Bottom Left: Looking east, a view of the ambulance bay and patient entrance. The FSFB ED has 3 floors and sees more than 70,000 adult and pediatric patients per year. Bottom Right: A rare early morning glimpse into an empty FSFB ED waiting room.
The immediate goals of my project in the emergency department (ED) at Fundación Santa Fe de Bogotá (FSFB) in Bogotá, Colombia were to increase academic capacity and emergency medicine (EM) faculty engagement in the education of FSFB EM residents, while assisting in the initiation of resident-led and faculty mentored research projects with a focus on departmental operations. To do this I spent four weeks teaching about basic operations management, quality improvement, and emergency research methodology. Residents were divided into four groups, each with residents of varying experience led by an EM faculty physician. Each group selected a unique operational or patient safety challenge within the department, and developed a research or quality improvement project that directly related to that problem.
My time at FSFB was immediately rewarding. I found that residents and faculty alike were empowered by the opportunity to address challenges within their own department, and by a sense of institutional support to do so. Many of the problems faced by emergency clinicians in Colombia are very similar to the problems we face in the United States: ED crowding and long wait times due to poor access to primary care, inefficiency of hospital operations that lead to a backlog of patients in the ED, and burnout of ED physicians and nurses due to an unrelentingly hectic work environment. The scale of these problems, however, is far beyond what is typically experienced in the US. Resident groups focused on ED boarding, rapid triage assessment and up-front processing to decrease throughput time, increasing efficiency of laboratory processing, and reduction of EM workforce burnout. They are currently working on these projects independently, with a goal of not only improving their work environments but also publishing in academic journals. In this respect, the project has been a success.
The project has met several challenges as well. While it was easy to engage residents and attending physicians while I was on the ground, it has been more difficult since my return to the United States. The ultimate success of these projects depends on the ongoing efforts of residents at FSFB, and my ability to remain involved has been limited – even with regularly scheduled videoconferences and email communication. Resident engagement and follow-through has also waned since my departure, but with good reason. Resident physicians do not earn salaries in Colombia, but instead pay to complete residencies. Many residents work 40 hours per week at other hospitals as generalists, after completing the more than 50 hours per week required by their residency program – just to be able to make ends meet. Regardless of interest level and commitment to the projects, many residents are left with little time to invest in the projects – and the burden falls to the few who remain committed. This was not a challenge I had anticipated.
Overall, the project has been a success, and it remains my hope that our four projects will each result in positive departmental changes, as well as opportunity for academic publication. We are currently striving toward a goal of project completion with sufficient time to prepare preliminary results for poster presentation at the annual international meeting of the Society of Academic Emergency Medicine in New Orleans, LA in May, 2016.
Figure 1. Emergency medicine (EM) residents and clinical instructors from Universidad del Rosario at our first weekly educational conference at Hospital Fundación Santa Fe de Bogotá (FSFB) in Bogotá, Colombia. These instructors graduated from the first class of EM residency in the region in 2008, and their residents will join a very small group of EM-trained physicians in the country.
Figure 2. EM residents work in groups with a faculty mentor to develop four unique projects focused on improvement of operations, patient safety and quality of care in the FSFB ED. Project plans were developed over four weeks and focused on ED boarding, advanced triage protocols, process improvement and physician and staff burnout.
Figure 3. A group of FSFB residents works together with Hopkins EM resident Jeremiah Hinson (standing) to develop their project. They plan to utilize Lean Sigma tools including value stream mapping to identify areas for improvement in ED processing of laboratory studies, and introduce time-saving interventions based on their results.
Figure 4. The on-site educational component of this project culminated in a symposium with poster presentations of each group’s proposal. The symposium was attended by nurses and physicians and by administrators and educators throughout the hospital. Here, a third year resident, Diego Vivas, explains his team’s plan to reduce wait times and improve patient experience by initiating advanced care protocols on arrival of patients to the waiting room.