Evaluating the effectiveness and utilization of the primary emergency care training in Nepal: a longitudinal mixed methods study

BACKGROUND: Emergency care is essential for the management of the growing burden of disease and traffic injuries in low- and middle-income countries (LMICs). In Nepal, nearly one in ten deaths in 2017 were attributed to injury. The Primary Emergency Care (PEC) training package of 6 days duration was developed to equip the various health care cadres with knowledge and skills to deliver emergency response. The study evaluates the effectiveness of the training, skill utilization, and the significance of an enabling work environment on application of acquired knowledge and skills. METHODS: A mixed-methods evaluation was conducted using the four-level Kirkpatrick Model (KM) to assess the PEC training. Participant details and training scores were obtained from training records of 295 training graduates for level one results. Pre/post-knowledge tests were compared using paired t-tests. Eleven health facilities were purposively selected for follow up, assessing 48 PEC graduates via knowledge assessments, structured clinical skills assessments, and simulations. Qualitative data were collected via 19 in-depth interviews, 10 key informant interviews with hospital leadership, and 11 focus group discussions (FGDs) with non-PEC-trained staff. These qualitative data were thematically analyzed using Ms-excel. RESULTS: There was a significant 35.9% ± 17.3% increase in knowledge after the PEC training (p = 0.001), with a significant 7.2% ± 12.9% decline at study follow up (p = 0.001), although there was no significant difference by length of time since the training (p = 0.652). Paramedics showed the greatest loss in knowledge compared to other health cadres (p = 0.005). Trainees reported increased confidence, and workplace observations indicated a positive "ripple effect" of peer-to-peer knowledge sharing among PEC and non-PEC staff. CONCLUSIONS: The PEC training significantly improved knowledge and skills with evidence of sustained knowledge retention although a modest but significant decline was observed over time along with evidence of workplace application of skills. Limitations existed in measuring patient level outcomes as per the KM, positive spillover effects along with an enabling environment were reported in emergency departments as result of the training. The training is a feasible, low-cost approach to strengthening emergency care in resource-limited settings like Nepal.