Hospice

• Develop the country's first hospice program to serve patients and their families.
• Establish inpatient hospice services for pediatric patients at Clinical Children's Hospital.

Pediatric Infectious Disease

• Develop a series of user-friendly protocols for triaging infectious disease patients, making diagnoses, applying appropriate tests, and selecting proper treatment.
• Study an outbreak of the bacterial infection Salmonella, which has plagued infants in Latvia since 1992. Identify the disease's source and mode of transmission, as well as effective treatments. Study the clinical features, epidemiology, and antibiotic susceptibility of this strain of Salmonella, with the ultimate goal of reducing cases among Latvian infants.

Obstetrics and Gynecology

• Improve the health care of Latvian women during pregnancy and childbirth.
• Create regional programs for managing gestational diabetes.
• Develop data exchange models for "real-time" international clinical consultations.

Leadership/Health Care Administration

• Provide training opportunities in the areas of strategic planning, management, finance, personnel management, security systems, marketing/communications, and total quality management, for leaders within the partnership institutions and for national-level managers and policymakers.
• Examine the relationship between teaching institutions and medical facilities in Riga, and strengthen their respective management systems and collaboration.
• Understand the financial aspects of managing an academic medical center, its information systems, and curriculum development.

Plant Security and Clinical Engineering

• Institute a program for biomedical engineering training for personnel within each Latvian partnership institution.
• Understand the role and development of a professional security officer in a health care setting.
• Learn crisis management and prevention for security officers and disaster planning and practice in a health care setting.
• Facilitate the distribution of donated medical equipment and supplies, with a program to maintain the equipment for long-term utilization.

Nursing

• Develop the leadership skills of nurses in the Latvian partnership institutions.
• Open a Nursing Resource Center, to provide updated education and training to nurses throughout Latvia.
• Enhance the role of nurses in the Latvian partnership institutions, so that they are more involved in the care and education of patients.

Community Health (added in 1996)

• Develop a model community health project in Tukums involving different sectors of the community - both public and private - in an inclusive process designed to educate the Tukums citizens, especially the community's youth, on methods to improve their health and wellbeing.
• Replicate the successful community health project in other locations in Latvia, and disseminate project achievements and methods to others throughout Latvia and the region.

• The St. Louis and Riga partners signed the partnership Memorandum of Understanding at the White House, on June 28 at the invitation of First Lady Hillary Rodham Clinton. The signing ceremony coincided with a visit by the First Lady of Latvia, Mrs. Aina Ulmane. As a sign of support by the Ministry of Health (MOH), State Minister of Health of Latvia, Dr. Peteris Apinis, signed on behalf of the MOH. Representatives from each of the Latvian and US institutions and AIHA also signed.
• Partners attended the AIHA Third Annual Partnership Conference for the New Independent States (NIS) of the former Soviet Union, entitled "Managing Quality for Healthy Outcomes," in St. Petersburg, Russia in October. Morning plenary sessions provided didactic overviews of continuous quality improvement (CQI).

• Twenty-five Estonian and Latvian nurses participated in a Baltic Nursing Workshop in Pirita, Estonia. The February workshop brought together 25 nurses from partner hospitals in Tallinn and Riga, Latvia. The workshop enabled partners to learn from each other about the status of nursing in the two countries and the role of the partnerships in effecting change in the profession. Participants identified joint nursing activities in the Baltics, exchanged nursing resources, and planned for a follow-up conference in Riga.
• US partners jointly sponsored with AIHA and the Association of University Programs in Health Administration (AUPHA) a management workshop entitled "Leadership in a Changing Health Care Environment." The course provided health care leaders from all districts in Latvia with opportunities to gain knowledge and practical experience in the management of human and material resources. Teams from each of the partnership hospitals developed projects and implemented them in their respective institutions. Examples included the implementation of a cost-accounting system and a hospice care program. Also, the faculty developed and distributed protocols for the treatment of common infectious diseases. Latvian First Lady Aina Ulmanis, USAID staff and US Ambassador Lawrence Napper, attended the workshop's closing ceremony.
• The St. Louis partners conducted a Pediatric Infectious Disease conference in Riga. Two hundred Latvian physicians, nurses, and laboratory professionals attended the three-day conference in April. The partners discussed the management of infections in children, prevention of nosocomial and community infections, and the structures and systems necessary to diagnose and treat acute pediatric infectious diseases. Five physicians and nurses from BJC Health System served as faculty at the conference.
• Partnership nurses attended the first meeting of the CEE Nursing Task Force in Budapest, Hungary, also in April. The meeting successfully created new bonds among the nurses, who learned that they share many common challenges, most notably in the areas of nursing education, in-hospital practice of nursing, economics and resources, and nursing as a profession. In a brainstorming session, the nurses identified areas for improvement, and they formed small discussion groups to refine ideas for an action plan.
• The partners attended the first AIHA Partnership Conference for Central and Eastern Europe in Budapest, Hungary. The May conference gave AIHA's CEE partnerships, health ministry officials, and other senior health care professionals an opportunity to explore the progress and challenges of health care and health reform.
• In May, the St. Louis-Riga partners initiated work on the development and implementation of a new activity to extend programmatic impact to the community level. After a series of visits to possible program sites, the partners decided to initiate this community-based project in the rural district of Tukums, west of Riga. The outreach project explored a variety of strategies to provide health education to families to improve the health status of the community, including preventing the spread of communicable pediatric diseases.
• The US partners conducted a Conference on Women's and Infant's Health in Jurmala, Latvia in June. Over 250 nurses, midwives, physicians, and other allied health workers from across Latvia attended the four-day conference. The conference addressed issues related to the improvement of health care during pregnancy and after childbirth. Latvian First Lady Aina Ulmane opened the conference, along with Mrs. Mary Napper, wife of the US Ambassador. Topics of interest included new advances in infertility treatment, cancer screening, patient and staff education, community health nursing, and psychological aspects of care for families with seriously ill infants.
• The three Latvian information coordinators participated in AIHA's first workshop for CEE information coordinators in Tallinn, Estonia. AIHA staff provided training on the use of Internet applications such as Netscape and Eudora, copies of which were distributed during the September workshop, Web searching and Web page design. During the workshop, information coordinators started creating Web pages for their own institutions. AIHA staff also introduced the Learning Resource Center Project workplan and led "training-of-trainers" exercises to enable information coordinators to train others within their institutions on Internet usage.
• US partners conducted a Nursing Leadership Conference in November for 35 Latvian nurses from the three partnership hospitals, the Tukums District community health outreach project, the Latvian Nursing Association, and the Municipal Health Department. Topics included the nurse-patient relationship, the nurse-manager (supervisor) relationship, stress management, safety in the workplace, meeting facilitation, and nursing status in Latvia. On the final two days of the ten-day conference, Latvian nurses presented their patient education projects and shared posters.
• The St. Louis and Riga partners presented a three-day conference on hospice care in Riga. Approximately 125 physicians, nurses, social workers, and religious leaders from across Latvia attended the November conference, entitled "Goal-Directed Care of Terminally Ill Patients and Their Families." Partners presented and led panel discussions on such topics as truth and truth telling, roles and reasons for hospice teams, pain control and symptom management, bereavement and aftercare, terminal care case studies, and funding strategies for hospice care.
• Partners from Barnes-Jewish Hospital conducted a two-day security and safety conference in Riga in November. The three Riga partner hospitals worked with their St. Louis counterparts at the conference to develop security plans and services. Twenty Latvian partners participated in this conference, covering topics like the evolving role of the professional security officer in a health care setting, crisis management and prevention for security officers, and disaster planning and practice for the health care setting.

• The Latvian partners received a donation of $140,940 worth of antibiotics from Eli Lilly and Company in April. Children's Hospital distributed some of the donated antibiotics to outlying district hospitals that have participated in the partnership's community outreach program.
• In May, the partners attended the annual CEE Nursing Task Force meeting and AIHA Second Partnership Conference for CEE in Zagreb, Croatia. The nurses shared reports of their partnership activities and participated in lectures on nursing education, management, and home care/hospice. Riga-St. Louis partnership representatives facilitated and/or served as panelists on sessions on measuring partnership success, health promotion, improving health care through patient/family education initiatives, home care and hospice.
• The US partners conducted a community health outreach workshop in Tukums in May. A clinical dietician, childcare manager, and nursing research specialist from St. Louis facilitated the workshop. The US partners worked with the leadership of the Tukums region to design the modules to be used in the community health project. They assisted the Tukums leadership team of approximately 30 people to move into the operational phase of the project.
• Two specialists in infectious disease from Washington University in St. Louis presented the partnership's work on Salmonella research at the Latvian Medical World Congress in May.
• In July, the St. Louis partners donated over $200,000 worth of medical equipment and supplies for distribution to the Children's Hospital in Riga. Items donated by Barnes-Jewish Hospital included syringes, adhesive bandages, hypodermic needles, thermometers, colostomy kits, and surgical sutures.
• The Latvian information coordinators participated in the Second CEE Information Coordinator Workshop in Krk, Croatia from July 21-25. The workshop focused on the role of the Learning Resource Centers interactive learning, conferencing, and communications. After the conference, the information coordinators conducted a survey amongst hospital staff to determine barriers and solutions to providing information access.
• In October, a Riga partner involved in the hospice initiative attended the World Congress on Home Care and Hospice in Boston, sponsored by the National Association for Home Care. Conference activities included reports on home care initiatives in various countries and a roundtable discussion of home care in Central and Eastern Europe.
• The partners opened a Nursing Resource Center (NRC) at the Latvian Nursing Association headquarters in Riga on September 9. Latvian First Lady Aina Ulmane, Ministry of Health officials, US Ambassador Larry Napper, USAID Representative Howard Handler, partners and AIHA staff, attended a ribbon-cutting ceremony. The first of AIHA's NRCs to be opened in CEE, the Riga center serves as a resource for nurses from all across Latvia.
• The Latvian Community Health team implemented the Community Health project in Tukums. As a kickoff activity, the community health project leaders designated October "The Month of First Aid," when first aid-related activities were held in various community settings, including kindergartens, a local fish factory, police department, and other institutions. Partners presented a total of ten lectures, each including didactic information as well as practical activities, such as role-plays. The program was successful not only in terms of educating the community, but also in actively engaging the community leaders in addressing health care needs and concerns.
• Senior managers from Barnes-Jewish Hospital conducted a financial management workshop in Riga in November, with the assistance of AIHA staff. Twenty Latvian physicians and nurses attended the course, which taught the basics of financial management and included sessions on database utilization.
• Partners attended and presented at the AIHA Healthy Communities Dissemination Conference in Banska Bystrica, Slovakia in November. The Tukums Healthy Community team learned about similar community outreach projects in Slovakia and showcased their own successes. A Latvian student, who helped adapt an American student skit on sexuality to a Latvian audience, spoke to the conference about her work as the leader of a team addressing the issue of sexual responsibility.

• Thirty Estonian and seventy Latvian nurses attended a Baltic Nursing Workshop in Riga in February. This meeting built upon previous Baltic nursing activities, and was particularly significant because it was planned and executed entirely by the CEE partner nurses. Topics included the role of the nurse and the midwife in pre- and post-natal care, preparation of mothers and families for childbirth, and non-traditional methods of childbirth.
• The partnership commemorated the opening of pediatric hospice care at Children's Hospital in March. Members of the US hospice team also assisted leaders of the newly established children's hospice in the education of Latvian hospice staff. The St. Louis partners gave several major lectures to hospice physicians, nurses, social workers, medical residents, and family doctors. The team also consulted on strategies for further developing hospice in Latvia.
• The partners participated in AIHA's Health Care Workforce Conference in Budapest in March. Relevant ministry officials, health care educators and practitioners from Latvia also participated in the conference, called Shaping the Infrastructure of Health Professions.
• Partnership nurses attended the third annual CEE Nursing Task Force meeting in Bucharest, Romania. Forty-five nurses from all partnerships in the region came together to share accomplishments and discuss Nursing Resource Centers, association building, and plans for future collaboration.
• The partners attended AIHA's third annual Partnership Conference for Central and Eastern Europe in Bucharest, Romania in May. This year's conference highlighted the partnership experience and issues of partnership sustainability. At the opening plenary session, the US partnership representative gave her perspective on the partnership experience, emphasizing the benefits derived by the St. Louis partners and community. Children's Hospital Pediatrician and Information Coordinator presented on "The Role of Communications Technology in Partnership Sustainability."
• The partners participated in a jointly sponsored AIHA/WHO Community Health Conference in Saldus and Tukums, Latvia in May. Municipal officials and active community health leaders from districts throughout Latvia discussed health promotion, community health, and establishing linkages between health professionals, municipal leaders and community representatives.
• The Riga partners hosted a three-day conference organized by AIHA, from June 14-17 entitled "Nursing Associations: Leadership and Organization for the 21st Century." The conference gathered nursing leaders from 16 countries in CEE and NIS, and from the US to discuss the role of nursing associations, organizational leadership, professional nursing development, nursing power and influence, policy development, and uses of technology. The nurses developed country action plans for implementation upon return to their respective countries.
• The Latvian information coordinators attended AIHA's third annual training workshop for Information Coordinators from the 36 AIHA-sponsored Learning Resource Centers (LRCs) in CEE. Information Coordinators from the three Riga partner institutions attended the training held in Kosice, Slovakia in July. The main themes of this workshop were information management and sustainability of the LRCs. Participants learned about database design, improving time management, developing annual budgets, and generating internal and external sources of funding.
• The Latvian partners held a ceremony on September 18 to celebrate the successes of the partnership and to mark the end of the AIHA-funded program. The Riga/St. Louis partners hosted the ceremony, press conference and reception at the Benjamin House in Riga. The First Lady of Latvia Aina Ulmane, USAID Representative Howard Handler, US Ambassador Larry Napper, and representatives of the partnership institutions participated.
• A Latvian physician spent three weeks training on ultrasound techniques at Sveti Duh Hospital in Zagreb, Croatia with an eminent physician who has developed model women's reproductive health services.
• A week prior to the closing ceremony, two clinical engineers from Barnes-Jewish Hospital traveled to Riga to meet a shipment of donated medical equipment from St. Louis and to assist its transition through customs to the warehouse. They distributed the donations (worth approximately $25,000) to district hospitals and trained on-site engineers in the maintenance and use of the equipment.
• On December 10, the US partners held their own partnership celebration at Barnes-Jewish Hospital in St. Louis. The President of Barnes-Jewish Hospital introduced two videotaped addresses, the first from First Lady Hillary Rodham Clinton, congratulating the partners on the many successes of the Riga-St. Louis partnership. The second presentation was the videotaped address of Latvian First Lady Aina Ulmane, made at the September partnership celebration in Riga. After the First Lady presentations, partners from Washington University Medical School in St. Louis and Bikur Holim Hospital in Riga gave a summary of partnership achievements and commented on the mutual benefits of collaboration. The three US partner institutions were awarded plaques of recognition by AIHA for their contributions to the partnership. A reception and dinner followed the ceremony, where future collaboration beyond the AIHA-sponsored relationship was discussed.

Hospice

• The partners worked together with religious leaders, families, and the medical community to develop a fully functional hospice program. Located at Bikur Holim Hospital in Riga, the hospice program served over 200 patients and families in its first year of operation. The hospital created the post of Assistant Hospice Nurse to help administer this program.
• The Latvian Medical Academy (LMA) Clinical Children's Hospital opened a pediatric hospice unit in the spring of 1998. The new director of the pediatric hospice unit gained ideas from staff at Barnes-Jewish Hospital for incorporation in Riga.
• At Bikur Holim Hospital, staff combined the hospice and gerontology units into one department of 75 beds. This combined department has been reorganized as a separate branch hospital. A newly appointed chief administrator leads the hospice/gerontology branch, while the Bikur Holim general director supervises the administrator.
• As a result of the partnership, the Riga hospitals realized improvements in pain management. Doctors have been trained in treadmill use and how to chronicle and manage pain. Technical personnel received training in the use of modern equipment, some of which was donated by the US partner institutions. Bikur Holim Hospital established a Pain Center, designed to administer pain relief to those patients needing it the most.
• Through the work of the partnership institutions, the Latvian health care system introduced the new specialty of palliative therapy. Partners were instrumental in the establishment of the Latvian Association of Palliative Therapy. Within this association is a special section for nurses of terminal patients.

Pediatric Infectious Disease

• Two Latvian pediatricians specializing in laboratory research studied an outbreak of Salmonella, which has had an increased incidence among Latvia's pediatric population since 1992. The researchers examined the epidemiology and antibiotic susceptibility of the disease. Through this work, they discovered an enzyme unique to the Latvian strain of Salmonella. This is of particular interest to Latvians, but also has applicability to other researchers because of the enzyme's link to antibiotic resistance.
• Over the partnership period, the incidence of Salmonellosis has decreased in Latvia. In 1997 there were 358 documented cases of Salmonella infection, down from 425 in 1996. In 1996 three patients died at Clinical Children's Hospital from Salmonella. No deaths were reported in 1997. This decrease can be attributed to the partnership's focus on improved diagnostic and laboratory testing procedures, new infection control procedures, the use of more appropriate antibiotics, and new patient education and prevention programs.
• Vast improvement was achieved in Clinical Children's Hospital's ability to prevent, detect, diagnose, and manage children with infectious diseases. The partners developed epidemiological data, instituted prevention programs, and increased diagnostic capabilities. The Riga hospitals improved their ability to treat acutely ill children with bacterial and viral infectious diseases.
• An Infection Control Team was created in the Maternity Hospital that is responsible for all nosocomial infection cases and that works hand-in-hand with the hospital microbiology lab to track patient progress. Doctors at Maternity Hospital cooperate with this team to find the best isolation methods, and with the microbiology lab to formulate the most effective treatments.
• BJC Health System, Riga Children's Hospital, and zoos in St. Louis and Riga initiated a zoo project. The impetus for the project development was the inability of laboratories in Latvia to identify and effectively treat bacterial infections in children because of the lack of pure (i.e., free from antibiotic treatment) animal blood auger plates. In this project that clearly benefits all parties involved, the St. Louis Zoo contributed to the establishment of a petting zoo area at Riga's zoo. In the petting zoo, sheep are kept free of antibiotic-added feed. These sheep are bled on a regular basis to produce much needed blood auger plates that are used in the diagnostic laboratory of Children's Hospital.

Obstetrics and Gynecology

• A major initiative in maternal/child health resulted in the following: improved use of ultrasound to determine neonatal outcomes, renovation of pediatric units to enhance patient care, and re-design of administrative and operational processes to enhance quality and reduce costs.
• Latvian physicians capitalized on new diagnostic capabilities to produce better risk assessments and link those assessments to better management of mothers and babies during perinatal and neonatal care.

Leadership/Health Care Administration

• As a result of the partnership, several organizational changes were made at the partner institutions. For example, at Bikur Holim Hospital, teams of physicians, nurses, and administrators were formed to develop best practices in specific specialties, such as hospice, pain management, rehabilitation, and cardiology. Latvian partner hospitals changed the functional duties of department heads, incorporating suggestions from the management training courses.
• Bikur Holim reduced its operating expenses by approximately 20-25% over the course of the partnership by instituting many administrative and operational changes introduced through training workshops and consultations. The hospital introduced a computerized system to track and control daily telephone expenses. With the help of partners and knowledge gained through financial management workshops, hospital staff installed a computerized financial accounting system. Management reduced or reassigned staff when necessary, including a reduction of staff in the rehabilitation department and reorganization of the gerontology and hospice units. Latvian partners introduced functioning controls over medication purchases and materials procurement.

Clinical Engineering/Information Systems

• A major component of the partnership was infrastructure enhancement. Over the course of the three-year program, the St. Louis partners donated over $500,000 worth of medical equipment and supplies. The partnership established computer resource centers with Internet access in four of the partner institutions. Also, the US partners donated approximately $250,000 worth of pharmaceuticals.
• The partnership established computer resource centers with Internet access in four of the partner institutions. Each institution created their own Web site, utilizing techniques learned at the AIHA Information Coordinator workshops.

Community Health

• As a result of the healthy communities project in Tukums, the partners formed a community coalition to plan community activities and address health problems in Tukums. A local padoma (council) meets regularly. The padoma includes the municipal government; preschools and the primary, elementary, and high schools; the creation center (child development center); psychological center; churches; social workers; and common citizens of Tukums. The entire council meets every two months. Individual teams meet more often, to work on specific issues.
• The Latvian partners actively disseminated the successes of the Tukums community health project. The partners participated in a jointly sponsored AIHA/WHO Community Health Conference and attended and presented at the AIHA Healthy Communities Dissemination Conference in Banska Bystrica, Slovakia. The partners also developed a program to replicate the Tukums model in other communities in Latvia.

Nursing

• Partners developed a program for teaching nursing systems theory and practice to nurses in Latvia. They compiled a "how-to" guide, with a series of self-learning modules, including nurse/physician joint documentation, evidence-based nursing practice, developing quality improvement and re-engineering teams, and conducting in-service training.
• The Latvian nurses worked with their Estonian counterparts, with US partner support, to develop stronger regional ties. The nurses held a series of Baltic Nursing Workshops, where participants discussed the status of nursing in the two countries and the role of partnerships in affecting change in the profession. Participants also discussed the role of the nurse and the midwife in prenatal and postnatal care, preparation of mother and family for childbirth, psychological aspects of care, and non-traditional childbirth methods.

Additional Developments Since Partnership Graduation

• The St. Louis partners received private donor funding for a joint project between Bikur Holim Hospital and the Riga Jewish Community Center for an adult wellness program.
• USAID awarded the partnership with a separate $270,000 grant to develop, model, and implement standards and performance measures that would allow faith based organizations to be reimbursed for providing gap services (home care, home based hospice, meals-on-wheels) to the elderly and medically frail. The lead agency in St. Louis will be the Jewish Family and Children's will link with Bikur Holim, the Jewish Community Center, the Latvian Theological Accademy and the Childrens Hospice and Childrens Hospital in Riga.
• A student from Riga completed three years of study in St. Louis working towards a degree in pastoral care. This initiative grew out of the partnership's work in hospice care and is unique to Latvia. The trainee will return to Riga to teach at the Divinity School in Riga and to work in both hospice and women and infants pastoral care settings.
• With ongoing support and encouragement from the US partners, the Children's Hospital in Riga has increased its affiliation and collaboration with the medical university in Riga. This has resulted in improvements in teaching, delivery of care and research coordination, particularly in the area of pediatric infectious disease.