1993

1994

1995

1996

1997

Neonatology and Neonatal Resuscitation

• Established a collaborative daily patient care rounding system at L'viv Oblast Clinical Hospital (LOCH) in September 1994 patterned after rounds at Henry Ford Hospital (HFH); the purpose of the rounds at LOCH is to discuss patient management issues with physicians, professors, medical students and nurses.
• Developed a comprehensive and detailed computerized data collection methodology to assist in identifying clinical issues and measure progress in clinical care (October 1994); data on all patients is included in this database. A new information system to register neonatal resuscitation data has been developed and a corresponding database is currently being developed.
• Developed and translated a series of guidelines for clinical practice for use by physicians and nurses at the bedside.
• Creation of educational and training programs for LOCH's medical staff as well as interns and students of L'viv Medical University.
• Introduced the practice and established a training program in mechanical ventilation for newborns in May 1995.
• Designed a program to support broader family involvement in the care of their neonates from breast-feeding to family visitation and established a program of parent education and a Committee of Parents.
• Created or adopted and translated into Ukrainian a series of documents to better record patient care processes including a Respiratory Flow Sheet, a Patient Care Flowsheet, a Physician Presentation and Sign Out Sheet, a Laboratory Flow Sheet, Admission Orders, Transfer/Discharge Data Form, the Ballard Assessment Form and a Nursing Report and Communication Form.
• Obtained approval to create a nurse educator position on the LOCH unit in order to maintain the teaching momentum established by the neonatal partnership, including staff training and quality assurance.
• Improved the technical aspects of care (mechanical ventilation, cardio-respiratory monitoring, oxygen saturation monitoring, blood gas analysis, use of central catheters, fluid and electrolyte management, nutrition and infection control) and developed specific guidelines for clinical practice (antibiotic usage, flow management, nursing of intensive care infants, etc.).
• Through a number of meetings with hospital and ancillary service heads, improved the delivery of support services essential to quality care, including a constant and secure oxygen supply, availability of blood gases within the unit, pharmacy support and more accessible laboratory and radiology services.
• Established a six-bed Neonatal Intensive Care Unit at LOCH.
• Provided outreach education through a series of lectures to providers of neonatal care in rural areas of the oblast beginning in mid-1995, in support of LOCH's position as a regional resource; promotion of the idea of regionalization of neonatal care for the oblast. More than 100 providers from Lviv oblast were trained.
• As mandated by the L'viv Oblast Health Administration, certificates confirming professional training in L'viv Regional Neonatal Center is obligatory for certification of medical staff in birth houses of L'viv Region.
• Meetings with the L'viv Oblast Health Administration resulted in new rules regarding the timely transfer of infants to the regional center at LOCH. The number of infants who were admitted to the LOCH on the first day of life increased from 29 in 1995 to 221 in 2000. In 1995 the unit had 54 urgent admissions in comparison with 334 in the year 2000.
• Developed a formal Quality Assurance Program utilizing the data collected on the forms and entered into the computerized data bank.
• Noticed a trend in the Fall of 1995 that tiny babies were being transported to LOCH earlier (less that 5 days of age and many during the first day of life) as LOCH became recognized as the regional resource.
• Developed two videos about the unit and the transport of high-risk infants from the region to LOCH.
• An Emergency Card for Neonatal Resuscitation, developed by the HFHS Division of Neonatology, was translated into Ukrainian, printed by HFHS and presented to the LOCH unit as well as sold to attendees of the conference.
• LOCH is currently working towards receiving established sponsorship support for the NICU. Sponsorship funds obtained in 1997 exceeded 3,000 Ukrainian Hryvnas (approximately 1,500 USD) from families and businessmen in L'viv. In 1998-2000 this total amount received from the sponsors was 32,000 Hryvnas (approximately 6,500 USD) The L'viv Regional Charitable Foundation "Infant" was established to support the Unit.
• A National Association of Neonatologists has been created, and now it has more than 100 members.
• In 1998, LOCH medical staff provided 152 consultations to hospitals and birth houses in the region, compared to 102 in 1997, 20 in 1996 and 5 in 1995. This number continued to grow - 152 in 1998, 242 in 1999 and 372 consultations in 2000.
• In 2000, the average length of stay in the neonatal unit of LOCH was 26.7 days, which represents a significant reduction from 32.0 days in 1995.
• Evidence of a measurable increase in technical skills can be shown by review of data on mechanical ventilation and catheterization procedures from the annual reports of the L'viv Oblast Clinical Hospital. Data from 1995 showed a 33.3 percent survival rate after mechanical ventilation; in 1996 this percentage increased to 39.9, in 1997 the survival rate rose to 41.4%, and in 1998 to 56.9%. Because of an increased number of critically ill infants admitted to the unit on the first day of life this value went down by 10% in 1999 but rose again in 2000 up to 50%. LOCH reports also show an increase in the number of central blood vessel catheterization procedures performed each year - the number per year rose from 0 in 1995, to 74 in 1998, 92 in 1999, and 80 in 2000.
• The Neonatal Resuscitation Program has been introduced into all birth houses of L'viv Region. In 1997 alone, 266 medical staff from different medical institutions of the region underwent professional training in the field of neonatal resuscitation. The total number of certified persons trained at the center has exceeded 850. As a direct result of this, the rates of poor early neonatal neurologic outcome and early neonatal mortality have decreased.
• Since 1995, significant changes in the mortality rates in the L'viv Oblast have been recorded. From 1998-1999 more VLBW infants were born in the region which affected the mortality rates. The partners from L'viv attribute the 1997 reductions to the regionalization of perinatal care, effective functioning of the L'viv Regional Neonatal Center, the other perinatal institutions of the region, and implementation of a neonatal resuscitation training program in the oblast with a donation of 1-year sets of basic neonatal resuscitation equipment and supplies by AIHA. The data below was obtained from the Department of Statistics of L'viv Regional Health Administration.

• The neonatal partners have also collaborated with the Children's Medical Foundation of California to assist in sending physicians from L'viv to Poland for training. The US partners formally met with the representatives from this foundation in September 1998 in L'viv to discuss further outreach of such an effort in the L'viv region.

Rheumatic Fever and Rheumatic Heart Disease

• Developed and received acceptance of a single set of definitions regarding the diagnosis of rheumatic heart disease and specific diagnostic criteria for rheumatic fever as proposed by the World Health Organization (July 1994).
• Established a unique database containing data on all patients treated since 1993. This database assists in correct diagnoses and proper decision-making in therapy planning, changes in clinical practices, management, etc.
• Created a patient care abstract form, with the assistance of the HFHS Epidemiology and research staffs, to be used to develop a rheumatic fever project data base to collect, computerize and analyze data of the incidence and location of newly diagnosed cases of rheumatic fever and rheumatic heart disease and to direct efforts in primary and secondary prophylaxis and education to specific geographical locations within the L'viv oblast.
• Brought the microbiologic and serologic capability of the laboratories at LOCH up to World Health Organization Standards as regards the diagnosis of streptococcal disease.
• Established a Scientific Advisory Committee of medical representatives from L'viv to assist in planning and coordinating the gathering and analysis of data and advising on the dissemination of recommended protocols.
• Established a local Rheumatic Fever Control Program Committee comprised of clinical, public health and community representatives to assist in guiding the program and establish clinical and public educational programs directed towards the lay public, public health officials and practicing physicians.
• As early as June 1995, a preliminary analysis of both government statistics and the LOCH data base indicated a dramatic increase in antibiotic treatment of children with sore throats, and dentists in the region were noted to be doing some subacute bacterial endocarditis prophylaxis in patients with valvular heart disease. Also, data from the LOCH bacteriology lab documented an increase in the number of throat cultures and blood cultures.
• A Center for Rheumatology has been established at LOCH. Staff of the center include the Chief Pediatric and Adult rheumatologists, one member of L'viv Medical University and representatives of Oblast Departments of Statistics and Information.
• A number of new techniques have been introduced into the practices of pre-hospital medical care, including more active use of ultrasound diagnostics in the detection of cardiac pathologies.
• Due to its role in anti-rheumatism care, management of streptococcal infection is now an area of focus at LOCH.
• The L'viv Oblast Health Administration has issued a special order regarding how best to facilitate implementation of the Rheumatic Heart Disease Prevention Program at a regional level.
• Significant reductions have been recorded in the average length of stay for patients in the Cardiac Surgery Unit and the Pediatric Rheumatological Unit. In the Cardiac Surgery Unit, from 1993 to 1997, the pre-operative length of stay decreased from 17.2 to 5.6 days and the post-operative length of stay was reduced from 25 to 12.6 days. During the same period, the average length of stay in the Pediatric Rheumatological Unit was reduced from 24.9 to 23.2 days.
• As a result of the program, according to the L'viv Oblast Department of Statistics, there was an increase in early diagnoses of rheumatism in children and a decrease in chronic rheumatological cardiac pathologies from 126 in 1993 to 75 in 1997. Proper diagnoses and rational treatment of active rheumatism in adolescents resulted in a decline in chronic rheumatological cardiac pathologies from 80 in 1993 to 57 in 1997.
• Other positive outcomes resulting from the project include a change in physician and patient attitudes toward sore throats; increased and earlier use of antibiotics; fewer complications of rheumatic fever; earlier diagnosis of rheumatic fever in children; and a decrease in resulting chronic cardiac pathologies due to improved diagnostic methods and earlier treatment.

Urology

• During an April 1994 visit to L'viv, training for physicians, residents and nurses in the transurethral resection surgery of the prostate and bladder and post-operative management skills and sterile technique for endoscopic bladder surgery was conducted.
• Since the inception of the urology training program in 1995, approximately 1950 transurethral operations have been performed.
• Reductions in average length of stay for patients with prostatic adenoma was reduced from 21 to 7.5 days and for cystic cancer from 27 to 10.3 days, both during the period from 1993 to 2000. The decreased length of patient stay and the use of less invasive techniques have improved the general psychological state of patients.
• Acquired knowledge has been disseminated throughout the oblast through the training at LOCH of 15 surgeons from the L'viv Emergency and Railway Hospitals and the Hospital of Veterans of the War. Additional urologists from Khmelnitzk, Cherkassy, Volyn and other oblasts have also been trained at LOCH. By the year 2000 fifty urologist from Lviv oblast and 20 urologists of other oblasts of the Ukraine were trained.
• Improved diagnosis of early bladder cancer and improved surgical treatment have reduced the recurrence of the disease from 30 percent in 1995 to the 1997 rate of 11.8 percent, for patients at two years post-operative.
• New technologies introduced into the department as a result of the program include transurethral resection of prosthetic and bladder cancers and new parameters for diagnostics have been established (e.g. urine flow rate and transrectal multi-positional ultrasound diagnostics). These transurethral invasive techniques have been included in the professional training program for medical staff.
• According to data available from the Ministry of Health of Ukraine, the Urological Unit of LOCH is one of the country's top five units performing transurethral surgery.

Laparoscopic Surgery

• In August 1994 the HFHS team presented lectures to the LOCH surgical staff and demonstrated and supervised the laparoscopic removal of gall bladders which resulted in a shortening of the length of stay to 5 days from 20 days after open surgery; this was accompanied by reductions in associated pain, trauma and costs.
• As a result of partnership activity, nearly 200 endoscopic operations are currently carried out each year at LOCH. By the year 2001, 1817 operations were carried out.

 
Ophthalmology

• Current techniques in cataract surgery were implemented in L'viv, resulting in reduced average length of stay for cataract patients from 14 to 4 days.

Other

• Relationship which developed between HFHS and World Medical Relief, Inc., a non-profit organization in Detroit staffed largely by volunteers that collects, cleans, packages and ships equipment and supplies all over the world. Over the last five years, WMR shipped four 40-foot containers to the partners in L'viv. The local Rotary Clubs and the Rotary District Governor have been very supportive in contributing toward the costs incurred by World Medical Relief.
• A close relationship developed between HFHS and Ukrainian Village, Inc., a non-profit housing and social center in one of the Detroit suburbs organized to serve the sizeable Ukrainian- American community in southeastern Michigan. The members of Ukrainian Village have adopted the partnership as a special project (replacing the Chernobyl Hospital) and have purchased for LOCH an infant transporter for use in the ambulance, a ventilator, a transport monitor, and a chemical analyzer, representing donations of $37,000.
• An unanticipated outcome of the partnership was the opportunity to collaborate with a group of physicians from Nashville, Tennessee in developing a neonatal resuscitation training program in Vinnytsia, Ukraine. One of the Nashville physicians, a neonatologist, contacted the US partners who collaborated to ensure the program would continue to be uniform throughout Ukraine. Six neonatologists from Vinnytsia were trained in L'viv as providers and then as instructors during the visit to L'viv in May 1998. The materials (slides, tests) that had been translated into Ukrainian were provided by the Detroit partners as well as an overview of the course format.