ANZGITATrainingProgram2017EndoscopyUnit,HospitalNacionalGuidoValadares,Dili,Timor-Leste

CenterDirector&ANZGITACountryProgramLeader:DrChrisKielyCo-Director&Co-CountryProgramLeader:DrChristopherHair

Introduction

ANZGITA partnered with Hospital Nacional GuidoValadares(HNGV)in2016toprovideassistanceforthefurtherdevelopmentoftheirendoscopyunitandthedeliveryof training for themedicalandnursingstaffworking at the unit. This partnership came via arequest from Dr Chris Kiely, an Australian trainedgastroenterologistbasedinDilifrom2016-2018.

As the national hospital, HNGV is the largest healthfacility inthecountry. Itconsistsof250bedsand islocatedinthenation'scapital,Dili.Inpatientservicescovergeneralmedicine(80beds),generalsurgery(80beds), paediatrics, obstetrics and emergency. The busy emergency department seesapproximately150patientsdaily.

PatientsareadmittedtoHNGVforelectivesurgicalproceduresthroughoutpatientclinics,andarereferredtoHNGV(astheonlytertiarylevelproviderinthecountry)fromhealth-carefacilitiesinthedistrictsofTimor-Leste.Complexcasesarereferredout-of-country,toeitherreceivetreatmentinSingapore,IndonesiaorAustralia.

Theresourcesavailableat thehospitalare limitedandunreliable. Difficultieswithsupplychainmanagementandlimitedresourcesmeanthatsimplemedicationssuchasantibioticsbecomeunavailablefromtime-to-time.

Background

Timor-Leste,adevelopingnationwithapopulationof1.2million, is located450kmnorth-west ofDarwin.Despite being so close toAustralia its health outcomes are poor. Infantmortalityisimproving,butremainsathighlevels:57childrenper1000live-birthsdiebytheageof5yearswhichis5timestheWHOEuropeanRegionrateof11per1000live-births,andwellabovetheglobalaverageof43per1000livebirths.1,2

Malariarateshavedeclinedbyover90%inthepastdecade,duetoaconcertedeffortbytheMinistryofHealthinconjunctionwiththeWorldHealthOrganisation(WHO).3

HepatitisBiscommoninTimor-Leste.ArecentstudyrevealedaHepBSAgpositivierateof2.8%inthe755womenwhoattendedtheBairoPiteClinicinDiliforantenatalandpost-natalcare.4HepatitisBtreatmentandvaccinationprogramsarebeingdeveloped:currentlyaround60%ofchildrenreceivethethreeHepatitisBvaccineinjectionsby1year.Thereiscurrentlynoaccesstoantiviraltreatment.

MainentrancetoHNGV

Othergastrointestinaldiseases

TheWHO reports colorectal cancer as the secondmost common cause of cancer-relatedmortalityinmenandfifthmostcommonforwomeninTimor-Leste.Ofthe350gastroscopiesperformedatHNGVfromMay-November2016,therewere22malignanciesdiagnosed(14oesophagealand7gastric)–analarminglyhighrate.Patientstendtopresentatanadvancedstageofdiseaseandthustreatmentoptionsarelimited.Therateofhelicobacterinfectioninpatientsrequiringgastroscopywas33%onanauditfromtheEndoscopyUnit(May-November2016). Antibiotic resistancepatterns areunknown. Malnutrition iswidespread,mainly aconsequence of inadequate diets. However, chronic GI infection and malabsorption alsocontribute. The prevalence of chronic liver disease is estimated at 10.8 per 100,000population(17.8formales,9.6infemales),threetimesthatofAustralia(3.7overall;6.8formales,2.8infemales).

Increasedknowledgeabouttheidentificationandtreatmentofpatientswiththeseconditionsiscritical,andisakeyoutcomeoftheprogram.

GastrointestinalservicesatHNGV

A full-time Cuban-trained gastroenterologist isemployedbythehospital,andprovidesinpatientand outpatient services. Prior to 2016, basicdiagnosticgastroscopywasperformedusinganolder fibre-optic Olympus system (model GIF-XQ30).Thisservicestoppedinlate2015whenthecountry’sonlygastroenterologistatthetime-aCubandoctor-left.

AfunctionalOlympus180seriesprocessor,alongwithonegastroscope,wasdonatedtoHNGVinearly2016byProfessorSydneyChung.Followingthis, reprocessing protocols and a standardoperatingprocedureweredeveloped,andthreeadditional nurses were hired. Upper GIendoscopywasrecommencedinMay2016byDrChris Kiely. Two colonoscopes were donated in December 2016, which allowed thecommencementof lowerGI endoscopy. Thereare currently two trainedendoscopists (DrAcostaandDrKiely)andonetrainee(DrSantos)performingendoscopyatHNGV.Therearefourendoscopynursesemployedintheunit:threeTimoresenursesandoneCubannurse.

TheEndoscopyUnitatHNGVconsistsofoneprocedureroom,athree-bedrecoveryareaanda smallendoscope reprocessing room. Thegastroenterologyservice isavailable toadultsover15yearsofage.Thisincludesinpatients,outpatients,emergenciesandtertiaryreferralpatients.TheunitisopenMonday–Friday,between8am–4pm,withflexibilityforadditionalsessions as required depending upon demand. After-hours emergency endoscopy

DrYunierAcosta,DrCeliaSantosandDrChrisKiely

procedurescanbeperformedonpatientswithacute upper GI bleeding and food bolusimpaction.

Outpatient clinics include generalgastroenterology, hepatology and generalmedicine.

Histopathology is not routinely available, andthe hospital’s CT scanner regularly breaksdown,whichlimitsthediagnosticcapabilities.

HelicobacterpyloriantibioticsensitivitytestingisunderwaythroughapartnershipwiththeAustralianNationalUniversity.

Equipment

1. Endoscopyequipment

• Olympus180seriesprocessor

• Twogastroscopes

• Twocolonoscopes

• Onefootpump

• OneERBEdiathermymachine

2. EndoscopicAccessories:bandingdevices,sclerotherapyneedles,forceps(disposableandre-useable),polypsnares,endo-loops,clips,andPEGtubes. Maintainingthesestocksisoneoftheobjectivesoftheprogram.

3. Medication: proton pump inhibitors, topical lignocaine and bowel preparation(glycoprep).Theformularythatthehospitalworkstoisbasic.

4. Reprocessingiscurrentlyundertakenusingmanualtechniques,developedfromtheWorldGastroenterologyAssociationguidelines. In2016,Whitleysdonateda largeamountofenzymaticdetergentandglutaraldehyde.Thereareplansafoottoupgradethereprocessingroomin2017.

5. Reportsarecurrentlyhand-writtenintriplicate.

MainObjectivesandGoals

Todevelopasafe,sustainableandeffectiveendoscopyunitatHNGV,bypromotingthehigheststandardsofevidence-basedpractice.

Thiswillbeachievedthrough:

a. Provisionofawell-designedfacilitythatstreamlinespatientmovementandcareandallowssafeandefficientendoscopicinvestigationandtherapy.

b. EstablishmentofahighqualityEndoscopyUnitwitheffectiveadministration,includingregularaudit.

c. Promotingtheapplicationofbestpracticeguidelinesfortheprevention,detectionandmanagementofdigestivedisorders.

TheANZGITAProgram2017willbethefirstyearthatANZGITAhassentamedicaltrainertoTimor-Leste.Assuch,itisexpectedthattherewillbesomeflexibilityinthedeliveryoftheprogram.

ClinicalProgramEndoscopy:TheHNGVEndoscopyUnitisinitsinfancy.Majoreffortsneedtobedirectedatimprovingbasicendoscopyservices.Endoscopysessionsareheldeachmorning.Theteacherwill be involved in undertaking and teaching both gastroscopy and colonoscopy. Patientselection,preparation,sedation, instrument insertiontechniquesandimageinterpretationwillallneedtobeaddressed.Thereiscurrentlyonetrainee(DrCeliaSantos)andoneCuban-trainedGastroenterologist(DrYunierAcosta),whowillpartakeintraining.

Due to capacity constraints, the trainer should expect to undertake fewer procedurescomparedtoAustralianhospitals.

Sedationisprovidedwithfentanylandmidazolamunderthecontroloftheendoscopist.InTimor-Leste, smaller doses are given than those required in Australia (average of 2mg ofmidazolamand37.5mcgoffentanylattherecentaudit).

Thetrainerwilladdressanumberofclinicalproblemsanddifficultendoscopyissues,includingdiagnosing malignancies, amoebic colitis and managing bleeding ulcers and varices, longcausticstrictures,theplacementofPEGtubesandperformingpolypectomies.

WardRounds:TheTrainerisencouragedtoattendwardroundswiththeclinicalteaminthewards of HNGV most mornings. The Trainer will be encouraged to contribute to themanagementof thepatients, however theymay find that theywill learnmore than theyteach!TheadvancedstateofpathologyisverydifferenttoAustraliaorNewZealand.Equally,accesstoadvancedinvestigativemodalitiesandtherapeuticoptionsismuchmoredifficult.Toseehowthelocalspecialistsandtraineespracticeintheseconditionsisamostimpressiveexperience.Alotofveryfinemedicineispracticedwithgreatingenuityanddedication.

AcademicTrainingProgramGrandroundlecture:AGrandRoundisheldweeklyintheRACSbuilding(Friday12pm).Theaudience of around 30-40 consists of seniormedical staff, registrars, interns andmedicalstudents. During theANZGITAprogram the trainerswill give the lecture at thismeeting.Relevant topics include: updates on chronic hepatitis B, gastrointestinal bleeding, acutehepatitisandmanagementofchronicliverdisease.

Physiciantraining:AseriesoftutorialsaredeliveredintheRACSBuildingfrom3-4pm.Thetopicscoverarangeofgeneralgastroenterologyandhepatology.

Nursingeducation:Followingthesuccessof the first ANZGITA visit in 2016,educationofendoscopynursingstaffwasflagged as a priority. Nursing trainingembracesallaspectsofendoscopy,mostimportant being infection control,instrument reprocessing and patientsafety. In addition to these, tutorialsabout patient preparation,communication, accuratedocumentation, the use of endoscopicaccessories and management of thesedated patient are critically important.An interactive tutorial is scheduled foreach afternoon (3pm in the EndoscopyUnit).

References

1 http://www.unicef.org/infobycountry/Timorleste_statistics.html accessed 25 April 2016 2 http://www.who.int/gho/child_health/mortality/mortality_under_five_text/en/ accessed 25 April 2016 3 Manel AMG et al, Evidence-based malaria control in Timor Leste from 2006 to 2012, Malar J. 2015; 14: 109. 4 Hall C et al, Prevalence of hepatitis B infection in women delivering at a community health centre in Dili, Timor-Leste and discussion of programmatic challenges, Trans R Soc Trop Med Hyg. 2015 Apr;109(4):280-2

DiJonesdemonstratingtheuseofendoscopicaccessoriesin2016