The overall objective of the partnership was to improve maternal and child health in Eastern Slovakia. In the four clinical areas of perinatal, neonatal, pediatric and gynecological medicine, partners focused on education modules, delivery system reform, and technology transfer.

Neonatal

• Improve intensive care for critically ill very low birthweight (VLBW) and extremely low birthweight (ELBW) infants by: developing more effective teamwork in the neonatal intensive care unit (NICU); improving transport team skills; and upgrading nursing assessment and technical skills in the NICU.
• Improve infection control procedures in the NICU by: developing protocols for infection control in NICU; training a nurse to be responsible for infection control; and improving strategies for antibiotic therapy.
• Introduce new diagnostic and treatment protocols for infants suffering from intrauterine hypoxia, fetal distress, and intrauterine growth retardation (IUGR).
• Improve diagnosis, treatment, and follow-up of hypoxia by: preparing and disseminating a study guide throughout Slovakia; exploring diagnosis and treatment protocols; and establishing follow-up procedures.
• Improve prematurity prevention programs by: assessing the existing program; reviewing regional initiatives; and implementing a prematurity program.
• Develop a team approach to neonatal intensive care by: assessing the NICU nursing practice; examining interaction of members of the NICU team; designing protocols for team responsibility and team training for nurses and physicians.

Obstetrical

• Improve identification of IUGR by: improving screening and early diagnostic procedures for high risk mothers; refining monitoring of infants in utero using improved invasive and non-invasive methods; and developing more effective screening methods to identify risk earlier.
• Improve treatment protocols for high risk mothers including intrauterine hypoxia and distress by: improving screening methods; upgrading nursing assessment and patient care management in LDR; and developing a more effective framework in caring for the high risk mother.
• Develop more effective prematurity programs by: developing educational programs for outlying areas in Eastern Slovakia to help identify better referral of high risk mothers; identifying cultural and financial barriers that prevent early identification of risk; and creating nurse training programs throughout Eastern Slovakia for "social nursing" to better serve the high risk population.
• Introduce new diagnostic and treatment protocols for perinatal medicine by: assessing treatment protocols for prostaglandin and examining new techniques to treat IUGR, hypoxia, and related problems.
• Improve infection control procedures by: identifying the role of infection control nurse and developing control protocols.
• Improve care of high risk pregnant women by: developing protocols for OB referral; developing risk indicators; and implementing a regional referral plan for Eastern Slovakia.
• Improve hospital care of diabetic mothers by: assessing present programs and recommending appropriate protocols.
• Explore new techniques in the diagnosis of prematurity by: establishing a physician training program for physicians throughout Eastern Slovakia.

Gynecology

• Improve screening programs for cervical cancer by: assessing problems in screening, diagnosis and treatment of cervical cancer and assessing laboratory protocols in cytology screening.
• Improve delivery of gynecological oncology services by: reviewing present screening for cervical and ovarian cancer and developing, implementing and disseminating regional screening protocols for Eastern Slovakia.

Pediatric

• Reduce hospitalization of children with chronic illness by: examining management of patients with upper respiratory problems and improving treatment for children with renal insufficiency.
• Improve the delivery of emergency and intensive care by: improving infection control in delivery of emergency and intensive care; improving nurse training in these specialized areas; and developing better linkages among pediatric sub-specialties.
• Improve the diagnostic techniques for respiratory illness by: developing treatment protocols to shorten hospitalization; reviewing new diagnostic techniques; and disseminating protocols throughout Eastern Slovakia.
• Improve organizational relationships by: assessing organizational issues and providing recommendations.
• Improve the identification and intervention techniques related to child abuse by: assessing the present program and identifying weaknesses; establishing an in-service training program to assist in the identification effort for hospital professionals; expanding the training program to the Eastern Slovak region; and conducting a regional child abuse conference for the CEE region.
• Improve pediatric intensive care (PIC) by: assessing the present PIC program and identifying deficiencies and developing and implementing program enhancements.
• Improve program in endocrinology and immunology by: exploring the present program design and introducing new advances in the fields.

Administrative (all clinical areas)

• Improve management and fiscal control by: assessing systems deficiencies; preparing, implementing, and monitoring strategies for correcting deficiencies; developing a guide for dissemination nationally; and conducting two conferences on issues related to cost effectiveness and quality of care education.
• Improve nursing education program by: assessing current nursing practice; assessing the existing nursing education program; and developing and monitoring new approaches to nursing education.
• Improve information services by: assessing the present information system and its financial and clinical programs; identifying deficiencies in the system structure and recommend remedies; and developing, monitoring, and implementing a plan for system improvement.
• Improve nurse training by: developing specialty training programs in perinatal clinical care and exploring ways to make program content accepted nationally.
• Improve clinical care model in obstetrics and newborn medicine by: outlining effective clinical path processes; identifying "program champions"; organizing practice team; monitoring progress of clinical path process; and developing guide for dissemination nationally.

• Representatives from Kosice made their first visit to Providence in September, 1995. The Regional Director of Health accompanied four physicians, a nurse, and an administrator from Kosice Faculty Hospital. Together with their US partners, the Slovaks developed the partnership work plan and planned activities in the areas of obstetrics, neonatology, pediatrics, nursing, and management. They signed the Memorandum of Understanding in the State Room of the Rhode Island Capitol; the ceremony was hosted by Governor Lincoln Almond.

• In January, a nurse/physician team introduced to the Faculty Hospital the nurse/physician team concept. As a result of this initiative the Kosice Faculty Hospital began 24 hour staffing and services in their neonatal and obstetrical units.
• US partners traveled to Slovakia for exchange in nephrology which resulted in the creation of a research program in a scientific field of nephrology in the Kosice Faculty Hospital.
• The gynecological and obstetric clinic of Kosice Faculty Hospital hosted an international conference on problems related to high risk obstetrics and high risk neonatal care in March.
• In May US and CEE partners participated in the first annual CEE conference in Budapest.
• The partners held the first nurse training course for obstetrical, gynecologic, pediatric and neonatal nurses, also in May.
• In July the partners developed recommendations for the pathology department, the cytology lab, microbiology lab, and biochemistry lab for improving all procedures.
• Kosice Faculty Hospital launched infection control committees in neonatal and obstetric departments in September.
• Also in September, five non-partnership hospitals begin cooperation with Kosice Faculty Hospital using protocols related to perinatal care and initiating transfer of high risk infants and high risk mothers to Faculty Hospital.
• Using SWOT analysis in October, the Slovak partners identified strengths, weaknesses, opportunities, and threats in budget planning, staffing, and clinical innovations within their departments and within the hospital.
• In November, the Slovak partners reviewed pediatric intensive care and emergency care for children, resulting in new guidelines for the admission and care of infants in pediatric intensive care.

• The partners participated in the second annual CEE conference in Zagreb, Croatia in May.
• In May the CEE partners attended the Conference of Slovak Association of Microbiologists, giving a presentation on nosocomial infection in NICUs.
• Approximately 100 nurses and managers attended the partnership-sponsored seminar for pediatric nurses and midwives in June.
• Kosice Faculty Hospital renovated the Pediatric Intensive Care Unit and initiated parent rooming in.
• The Slovak partners introduced techniques for monitoring arterial blood pressure and blood gas in the Pediatric Intensive Care Unit.
• In July the partners held a conference on prematurity for Eastern Slovakia.
• US partner hospitals initiated nurse training for improved teamwork in perinatal care in September. The training concluded in Kosice in November.
• The partners began to utilize videoconferencing, holding two conferences in September on team building and ambulatory care.

• In January Kosice Faculty Hospital identified nurse infection control officers.
• The Slovak partners developed pediatric intensive care practice protocols.
• In March the partners hosted a seminar on child abuse in Slovakia attended by over 150 physicians, nurses, and other health professional from Slovakia.
• The partners participated in the third annual CEE conference in Bucharest in May.
• Also in May, the Kosice partners held a regional conference on perinatal regionalization.
• In June the CEE partners gave a "Hospital in Crisis" presentation of management procedures for reducing cost and improving quality in hospitals in Slovakia.
• The partners held 15 videoconferences this year, on a variety of clinical and administrative topics, including, neonatology, nursing education, pain management, infection control, and pediatric diabetes.

• In March and April, the newly appointed director of Kosice Faculty Hospital made his first visit to Providence, with a team that focused on pediatric intensive care, including patient assessment techniques used in the emergency room and in clinical management.
• The US and Slovak partners made a presentation about partnership activities at the regional Neonatal Conference in Nove Zamky, Slovakia in May.
• The Slovak partners conducted a training course for staff operating the Children Security Line, in September in Kosice. The workshop participants learned about the special needs of children and their problems and became more familiar with various interventions to be employed through the Children Security Line to help resolve these problems.
• The partners held 13 videoconferences this year, on a variety of clinical and administrative topics, including pediatrics, obstetrics, neonatology, pharmacy management, prospective budgeting, and negotiation skills.

Neonatal

• Dramatic reductions occurred in mortality for very low birthweight and extremely low birthweight infants both in the Faculty Hospital and in Eastern Slovakia. The decline of mortality for infants in the neonatal intensive care unit of the Faculty Hospital between 1995 and 1997 was already documented; however, in Eastern Slovakia early neonatal mortality from 1995 to 1997, as a result of the influence of the Faculty Hospital, went from 6.9 per 1,000 live births to 4.1 per 1,000 live births. This influenced the total infant mortality rate with a reduction from 14 per 1,000 to 10.9 per 1,000 live births. In addition, during 1996, high-risk neonatal referrals to the Faculty Hospital more than doubled, 39 in-utero transports and 66 infants transported to the hospital in this period of time. During the same time period there was a 67% reduction in neonatal deaths among low birthweight infants in the hospital.
• Not only have the neonatologists from the Faculty Hospital reduced the infant mortality rates for Eastern Slovakia area but they have also changed the way in which regionalization of perinatal care occurs in the entire republic. A proposal was submitted and accepted by the Ministry of Health and recorded as a legislative edict to establish networks of care in Slovakia that are comparable to the levels of care used in the United States. This has further encouraged the development of referral for both high-risk mothers and infants to Level III centers within Slovakia.
• Of equal interest in the neonatal area was the improvement in infection control procedures. This resulted in a significant reduction of infections that had plagued the neonatal intensive care unit. The unit not only introduced preventive activities to reduce neonatal infections but also created the means to identify the type of infection and, therefore, to more carefully identify the antibiotic to be used in the infection control. As a result, antibiotics of a lower generation and at less cost were able to maintain control over neonatal infections. The result was a significant cost savings of almost $9,000 USD in just one year. Finally, treatment protocols were introduced that have dramatically improved the care of infants in the neonatal unit over the past two years also resulting in a reduction of morbidity.

Obstetrics

• There has been a rapid decrease in perinatal mortality in the Faculty Hospital as well as in other hospitals in the city and in the surrounding regions. From 1995 to 1997 the perinatal mortality rate in Kosice Faculty Hospital declined from 19.1% to 5.15%; neonatal mortality rate excluding congenital anomalies declined from 24.2% in 1995 to 7.2% in 1997. There has been a corresponding increase of high-risk transfers to the Faculty Hospital for delivery, which is an indication of the success of the regionalization program sponsored by the hospital. As a result of interventions by the partnership, there is better identification of high-risk problems within the patients treated antenatally and improved treatment protocols for high-risk mothers. Also as a result of intense activity in the area of infection control, a new system of nursing was developed in which prevention of nosocomial infections was encouraged with improved hand washing, single use paper towels, and improved suturing materials. There was also a responsible nurse assigned as the infection control officer for the department. Improved nursing documentation helped to track the patient throughout the system and reduce levels of hospitalization for periods of up to 2-4 days.

Gynecology

• The most dramatic improvement in gynecology was the introduction of a much more expansive cervical screening program. Approximately 1,500 screens per year are now done routinely on patients that meet qualifications that were established on a national level. These qualifications for screening, which were introduced as regulations in the Ministry of Health, were actively supported by the partnership hospital.

Pediatrics

• The most significant improvement in the pediatric area was the introduction of a series of new technologies in the delivery of emergency and intensive care. These included new approaches for parenteral nutrition, intercranial pressurized monitoring, and new invasive monitoring using arterial blood pressure and blood gases on critically ill patients. As a result, patients received better care and the department used less oxygen concentrates in critically ill patients and improved the treatment for shock. Of equal importance was improved nursing care for ventilated patients in which nurses were taking an active role in monitoring patients undergoing ventilation within the intensive care unit. Finally in the area of infection control, various protocols and procedures were used for hand washing, single use towel, liquid soaps and disinfections and also monitoring of infections within the unit.
• The introduction of the increase in the number of physicians and nurses working in the pediatric intensive care unit allowed for 24-hour coverage in this department. The number of physicians increased from 2 in 1995 to 3 in 1997; nurses increased from 14 in 1995 to 17 in 1997.
• Of singular note in the pediatric area, as outlined in the objectives, was the development of a program in child abuse prevention and identification. In March, 1998, the partnership held a two-day conference on child abuse and domestic violence in Kosice, the first of its kind in Slovakia. Slovak and US medical professionals, social workers, and community health leaders gathered to discuss the medical, legal and social ramifications of violence occurring in the home. This effort resulted in a national focus on child abuse as both a societal problem as well as a medical problem. As an outcome of the conference, a group of concerned physicians, nurses and attorneys in Kosice formed a committee to work to change the current child protection legislation and to increase the rights of the child and develop a crisis hotline for victims of abuse.
• Finally, in the pediatric area, negotiations were undertaken with the Ministry of Health to identify key hospitals in the three regions responsible for intensive and resuscitative care for all children (Bratislava, Banska Bystrica, and Kosice). This was done under the aegis of the partnership and with support from the American partners.

Nursing

• Significant improvements were made in the area of nursing, including nursing protocol and nursing education. A Nursing Resource Center was established in the Kosice Faculty Hospital to serve as an information and technology resource and training site for all nurses in eastern Slovakia. The Nursing Resource Center holds monthly nursing meetings that are attended by nurses from around the region. Topics discussed include infection control, the nursing process and the role of the nurse.
• During the second half of 1996 nurses in the post surgery department of gynecology introduced new nursing protocols and a new nursing care check list for each particular operation. A curriculum for nursing education was developed in conjunction with Slovak nurses in the Providence facilities.
• As part of a collaborative effort with other nurses throughout Slovakia, the Kosice and Providence nurses participated in the first Slovak national nursing conference on "Out-of-Hospital Nursing." The conference provided a forum for discussion and health system planning between hospital-based and community-based nurses, with presentations on health insurance and home care agencies, nursing care of terminally ill patients, and volunteerism in nursing.

Administrative

• A key result of the interventions that occurred on the management level is the improvements in the budgeting process of the Faculty Hospital. Prospective budgeting now occurs in at least one of the three departments. Of equal note is the emphasis on appropriate staffing and the relationship of staffing to patient acuity in all three of the departments that were part of the partnership initiative. Finally, with the introduction of information systems, there has been significant upgrading of the use of computers within the hospital both in terms of management for staffing and budgeting and more importantly for the quality of care using such nationally and internationally recognized software programs such as the Cochrane Library.
• The partnership has had a significant influence on the Ministry of Health in changing both legislation and regulations around the delivery of care of mothers, infants, and children. Included in this is the heightened interest in child abuse and domestic violence. As a result, Faculty Hospital has continued country-wide dissemination of a model child abuse and domestic violence programs initiated in Kosice.
• Of equal note is the initiation of a perinatal regionalization program built along the lines of the United States program. In just 2 1/2 years the impact on outcomes is equivalent to what occurred in the United States over almost a decade and a half. In May 1998 the partners held a two-day perinatal regionalization conference for health care providers which focused on the impact of regionalization of perinatal and neonatal care in eastern Slovakia.
• In another arena, the utilization of teleconferencing capabilities has inspired the medical school to look at the potential for maintaining linkages with the United States and the Brown University Medical School. The establishment of a relationship to the Brown University Medical School similar to that which has occurred in the partnership itself, would expand the video conferencing capability to include the original partnership departments as well broaden the focus to other clinical departments.