• Strengthen the organization of emergency medical care within the Republic of Armenia.
• Develop a model trauma center at the Emergency Scientific Medical Center.
• Establish of a model municipal teaching hospital system.
• Prepare Armenian pediatric emergency physicians to conduct the pediatric emergency medicine courses.
• Provide ongoing training and quality assurance at the Pediatric Hospital and other possible sites using a pediatric emergency medicine curriculum.
• Integrate nuclear accident preparedness into the National Disaster Medicine Center through the training of the Metzamor Hospital staff.

• Improve hospital infection control protocols and practices at ESMC.

• Develop the professional role and leadership skills of nurses.
• Establish a Nursing Resource Center to train nurses in a variety of areas including physical assessment skills, specifically cardiac, pulmonary, and neurological assessment.
• Assess nurses' teaching and evaluation capabilities.
• Expand the influence of the Nursing Learning Resource Center and its existing nursing faculty to health-care facilities outside of Yerevan.

• Develop standards for medical education and training.
• Create three new international medical electives offered at the Emergency Scientific Medical Center.

• Upgrade hospital equipment, particularly in radiology and intensive care, and provide training in biomedical engineering.
• Improve efficiency in areas of hospital administration.

1993

• Partners signed the Memorandum of Understanding between Boston University School of Medicine and the Emergency Scientific Medical Center in May.
• In June, the Armenian government classified ESMC as a Level I-type trauma center, indicating the center is registered as a regional specialty care institute.
• Through a July decree, the government of Armenia established the Emergency Scientific Medical Center as an institute of the Armenian National Institute of Health.
• The Yerevan partners created a new Emergency Department in December, based upon the Western model of care.
  

1994

• Partners celebrated the September opening of the Yerevan Regional EMS Training Center.
• In December, the Yerevan partners deployed four trauma ambulances as training and field units.
• The ESMC opened a department of vascular surgery.

• In January, partners identified and trained a cadre of Armenian teaching faculty to provide EMS training.
• The Yerevan partners established a two-year emergency physician residency program in January.
• BUSM co-sponsored the 6th Armenian Medical World Congress in Boston in July.
• Key Armenian-American nurses with an interest in the partnership's nursing programs created the Council of American Armenian Nurses to advise ANA and to represent the partnership and Armenian communities in the Eastern United States.

• The partners contributed to the creation in June of an Armenian Nursing Association (ANA), the first Armenian professional nursing association.
• The partnership celebrated the establishment of a Nursing Resource Center in June at the ESMC.
• In June, the first resident completed the emergency physician residency program.
• Partnership representatives assisted the Armenian National Institute of Health in the development of continuing medical education programs and a plan for reform of continuing medical education.

• In February, US partners installed a CT scanner through a joint effort of the AIHA partnership and The United Armenian Fund.
• The Yerevan partners negotiated a contract with the International Atomic Energy Agency to nuclear preparedness programs.
• In October the Yerevan partners, in cooperation with counterparts from Tbilisi, Georgia, established an Inter-regional EMS Association, comprised of members of the Armenian and Georgian Regional Training Centers. This association was named a "sister" organization of the American College of Emergency Physicians' meeting that same month.
• The partners established satellite EMS training centers in additional districts around Yerevan.
• Two Armenian nurses participated in the International Council of Nurses meeting in June.
• In October, Armenian partners at the ESMC developed and launched a center web-site.

• In June, the Armenian Ministry of Health established the position of Emergency and Disaster Medicine Chairperson, within the National Institute of Health.
• Trainers from the EMS center participated in a radiation accident preparedness trainer course at the Radiation Emergency Assistance Center and Training Site, a U.S. Department of Energy facility in Oak Ridge, Tennessee. Following the training, the trainers returned to Yerevan and incorporated a new course on radiation accident preparedness at the center.

• The Nursing Resource Center was established and named a Center for Post-Graduate Nursing Education of the NIH. Partners conducted the first outreach program at Etchmiadzin Hospital in March 1999; it was the first time nurses taught other nurses about physical assessment.
• BUSM won the 1999 Award of Excellence in March for Best Application in Audiographics/Multimedia at the International Teleconferencing Association.
• The Memorandum of Understanding between ANIH and BUSM was updated and re-signed in April.
• The NIS Partnership Coordinator was invited to speak for the International EMS conference in Boston in May 2000.
• In August, the Yerevan Regional EMS Training Center served as host for the innovative radiation accident preparedness exercise involving seven sites and four training centers in a web-based teleconference network (Partially funded by the International Atomic Energy Agency (IAEA)).
• In November at the Annual Conference, ESMC's Director of Nursing was inducted into the prestigious international nursing honor society, Sigma Theta Tau.
• Four ESMC and two BUMC partners attended the AIHA annual conference.

Emergency Medicine (Training)

• In 1993, a comprehensive, staged training program was implemented for physicians, nurses and drivers of the Yerevan Emergency Ambulance Service, comprised of basic and hospital-based emergency medicine training. Out of this program, the Yerevan Regional Emergency Medical Services Training Center at Emergency Scientific Medical Center officially opened in September 1994. The Center is one of 15 EMS training centers established by AIHA, which use standardized, partnership-developed curricula. Since they began, the Armenian partners have trained 5077 physicians, physician's assistants, nurses, ambulance drivers, medical students, military cadets, police officers, and firefighters in over 150 training cycles and 12 types of courses. Trainees and observers have come from Yerevan and outlying districts such as Echmiadzin, Chorentsavan, and Vanadzor, Armenia, as well as Georgia, Hungary, Lithuania, Slovak Republic, and Bulgaria. Partners developed pre- and post-test evaluation instruments to assess the EMS training courses. The partnership oversaw the standardization and translation of curricula into Russian and Armenian languages.
• Partners updated the EMS training curricula to include courses in pediatric emergency medicine and emergency nursing (1994-1998). The instructors attended train-the-trainers workshops in the United States to develop specific training and teaching skills for the new curriculum areas. Each workshop addressed emergency medicine and first-responder protocols, disaster planning, principles of adult learning, case-based learning, utilization of print and multi-media resources for teaching, and equipment maintenance and repair.
• An emergency residency program was established at Emergency Scientific Medical Center to improve clinical competencies in recent university graduates. As of June 1998, 12 residents have completed the 24-month residency program.
• The Center instructors developed a two-month emergency training and certification course that is a prerequisite for licensure of ambulance, emergency department, and intensive care physicians throughout Armenia. The licensing exam is given in computerized and oral formats, and complies with national standards developed by the Ministry of Health.
• In conjunction with the IAEA, partners conducted a radiation accident preparedness course at the Metzamor Hospital, the receiving facility for accidents at the Metzamor Nuclear Power Plant. Instructors from Georgia, Estonia, Moldova, Russia and Ukraine also participated in the event, thus working toward an integrated approach to nuclear preparedness and response at the national, regional, and international levels.

Improved Emergency Care

• Access to emergency medical services in Yerevan has increased through the utilization of the trained health professionals. In addition, the establishment of an Emergency Department and deployment of four trauma ambulances has increased access to services. Emergency Department utilization is currently from 170-200 patients per month, or 35-60 patients per week.
• The Emergency Scientific Medical Center standardized a list of equipment to be used in all ambulances.
• Through a joint effort between Hart Technologies and the University of Massachusetts, the partners installed 50 Oxylator respiratory devices for oxygen regulation in ambulances, the emergency department, intensive care unit, and six area hospitals.
• Early in the partnership, Emergency Scientific Medical Center conducted a self-assessment with the assistance of BUSM and determined that it would be categorized as a Level II trauma center (local institution providing acute care), according to the American College of Surgeons' criteria. Steps were outlined by which Emergency Hospital could develop into a Level I-type trauma center (regional institution providing specialty care). The Emergency Scientific Medical Center achieved the Level I-type designation through increasing the number of general resuscitation teams by 30%, reorganizing ambulance services to dispatch resuscitation teams to trauma calls, establishing an emergency department, and publishing its scientific findings. All the above mentioned steps were completed by June 1993.
• Partners published a manual on traumatic damage to blood vessels to assist trauma physicians in the diagnosis and treatment of trauma patients.
• In 1994, the partnership installed a computerized database for collecting and analyzing data on ambulance calls from their ambulance services. One of the trauma ambulances was designated as a field training and data collection unit, in addition to serving as a response unit. The Center Director, who heads Substation #5 of the Ambulance Service, is designated to assist with data collection. Key indicators are routinely collected and analyzed, including call volume, patient destination, mechanism of injury, anatomic injury patterns, surgical services involved in patient care, ambulance procedures, and equipment utilization. Hospital administrators use the database to identify areas for improvement of EMS services and training.
• The addition of mechanical lung ventilators and MD and nurse training in their use led to a 3-fold decrease in mortality rate of multiple trauma patients. In addition, the use of modern ventilating systems reduced the length of stay by approximately one month.
• Intensive on-site training in critical care was conducted throughout the partnership. The telemedicine initiative (see below) allowed the partners to hold regular updates and clinical presentations on surgical, critical care, emergency care, and intensive care topics with their US partners.
• Armenian instructors from the Yerevan Regional EMS Training Center and the Pediatric Hospital taught the pediatric emergency medicine course three times.

Infection Control

• The partnership conducted special infection control training for emergency room nurses, trauma department staff and intensive care unit nurses. As a result, the Emergency Scientific Medical Center established an oversight committee for nosocomial infection control and assigned a responsible person from each department to monitor and oversee these issues within his or her department.
• Following a series of infection control workshops, the rate of post-operative complications caused by infection decreased by 15% in 1993.

Medical Education

• In 1991, BUSM signed an affiliation agreement with the Yerevan State Medical Institute, the Post-graduate Medical Institute of Armenia and the Armenian Ministry of Health to address areas of curriculum development and medical education reform. BUSM established an International Health elective that enables fourth-year medical students from accredited US medical schools to participate in a month-long externship at Emergency Hospital. In the past four years, eleven medical students, one group per year, have successfully completed this elective in Armenia.
• In July 1995, the BUSM co-sponsored the 6th Armenian Medical World Congress, which featured presentations on medical and nursing education. During the meeting, participants proposed several significant recommendations and eventually reached consensus on the following issues: an increase in the clinical experiences of Armenian medical students, the development of licensing standards and postgraduate physician activities, an assessment of the status of continuing medical education in Armenia, and the coordination of diaspora programs in continuing medical education. The Council of American-Armenian Nurses was formed at this time and plans were made for the establishment of an Armenian Nursing Association.

Nursing

• As of December 1997, 876 nurses had completed training programs and many nursing leaders have been able to participate in AIHA-led nursing conferences held in Moscow, Russia; Almaty, Kazakhstan; and Kiev, Ukraine. Nurses from Emergency Scientific Medical Center received training in critical care medicine, physical assessment skills, and nursing leadership and management.
• A new clinical nurse educator role was introduced in 1997 and its first incumbent, a nurse who had completed all levels of partnership nursing training, completed a four-month internship at BUSM.
• Continuing education reforms were implemented as a result of partnership interventions. One notable example is the institution of nurse instructors. Previously, nursing education was provided by physicians. Under the nurse educator model, nurses are starting to teach nurses in Armenia.
• The Armenian Nursing Association was created in April 1996 with support from the partnership and sister organizations, including the Council of American Armenian Nurses. The Association co-sponsored international meetings in June 1996, June 1997 and June 1998.
• In June 1997, partners opened the AIHA-funded Nursing Resource Center. It was later formally recognized as a branch of the Armenian National Institute of Health. Since it was opened, the NRC has conducted training and supervised the licensing of 120 nurses.
• Nursing leadership was advanced with the recent appointment of Emergency Scientific Medical Center's Director of Nursing as Chief Nurse of the Armenian Ministry of Health. The Nursing Director was instrumental in the improvement of hospital infection control practices and the establishment of regular nursing professional rounds. She also supported the creation of an electronic journal club through which Armenian and US partners share information on the nursing profession.
• One hundred twenty (120) Armenian nurses completed training in physical assessment, critical care medicine, nursing leadership and management, and infection control, offered at the NLRC in June.
• During the partnership sustainability period (1999), partners conducted six outreach programs at regional hospitals located in the Armenian districts of Echmiadzin, Ararat, Armavir, Metsamor, Sevan, and Charentsavan. Ninety nurses were taught and evaluated from March to September 1999. The BUMC monitors observed that the nurse/teachers demonstrated an 80% average retention rate six months after participation in the course. Practical testing showed that all nurses were able to demonstrate their skills accurately.
• National criteria for nursing re-licensure were established in September.
• ESMC's director of nursing was named Chair of Clinical Nursing of the ANIH (May 1998) and held that position during the period of the sustainability project. This followed her successful tenure as Chief Nurse of the Republic in 1997 and 1998.
• In January, the Nursing Journal Club was initiated by teleconference.
• In summary, the partnership's objectives to teach nursing programs, expand nursing influence, and quantify the outcomes of nursing teaching have been met.
  

Hospital Adminstration and Equipment

• Two key Armenian participants in the partnership program were promoted to positions within the public health administration. The chairman of the Emergency Scientific Medical Center and partnership coordinator was appointed the equivalent of Public Health Commissioner for Yerevan in 1998-1999. The Director of Nursing was appointed Chief Nurse of the Armenian Ministry of Health, as mentioned above. These two individuals are expected to bring to bear their partnership experiences in their new roles.
• Since the partnership's inception, the value of donated equipment from the US partners has reached nearly $4.5 million. Donations include computers, medical equipment, educational materials and supplies. Much of the equipment was sent to Yerevan through a combined effort between AIHA and the United Armenian Fund (UAF). The UAF sent its 100th airlift to Armenia, which included many BUSM donations. A joint venture between BUSM and the UAF was successful in installing a Picker CT scanner at the Emergency Scientific Medical Center Radiology Department. BUSM provided a series of in-service training workshops to radiology staff and hospital biomedical engineers. In addition, the department's director came to BUSM for clinical training on two separate occasions. As a result, from February 1997 to October 1999, 2,500 patients were tested using the CT scanner. This level of utilization led to 70% referral rate to Armenian medical institutions.
• Other departments at the Emergency Scientific Medical Center have also been upgraded through generous donations over the course of the partnership. The intensive care department created a computerized patient registry as a result of Hewlett-Packard's donation of a Patient Information Center. This was made possible through the efforts of Boston Medical Center's biomedical engineer, who returned to Emergency Hospital several times to connect the system, provide maintenance and repair, and conduct staff training. The trauma center has increased efficiency in the department through the use of a cell saver, made possible through donations from individual Armenian donors.
• The donation of computers enabled Emergency Hospital to computerize bookkeeping functions at the hospital and increase efficiency of the finance staff.
  

Other

• A telemedicine project was initiated in March 1995, when specialized equipment was installed at ESMC. Twenty-six telemedicine programs have been conducted since the program was established, representing 81 contact hours of instruction and patient consultation. With the recent installation of web-based teleconferencing among several Regional EMS Training Centers, Yerevan now has a forum for regional exchange. Among the teleconferences was an eight-part series on disaster preparedness. Over 100 participants attended the conferences, including the Armenian Minister of Health and health professionals from non-partner hospitals in Yerevan and Boston. One teleconference, "Expert Panel Discussion of an Airport Disaster," linked the presenters with a panel of Armenian experts and provided an opportunity for commentary and feedback. To broaden the dissemination of information, these teleconferences are displayed on the two partnership web-sites.
• The new administrative role of Information Coordinator, to support information technology applications, was introduced by AIHA in 1996 as part of the Learning Resource Center Project. The Information Coordinator has been trained under AIHA-led initiatives and has traveled to BUSM to learn web-site creation and design. The ESMC web-site was launched in October 1997. The Information Coordinator has been a significant contributor to the success of teleconferences by researching and presenting cases in relevant formats for clinical discussion.
• Telecommunications and distance learning have been important partnership methodologies, with events numbering 37 programs to date. A program held in October 1998 was the debut of an electronic network linking regional training centers in Yerevan, Chisinau, Tallinn, Moscow, and Kiev with BUMC, AIHA, and the International Atomic Energy Agency (IAEA). For novel application of telecommunications technologies and establishment of a new method of peer collaboration, the partnership was awarded the 1999 Award of Excellence for Best Application in Audiographics/Multimedia of the International Teleconferencing Association.
• An anonymous foundation donated $20,000 to renovate and convert the fourth floor of the Tuberculosis Clinic into an inpatient unit. This grant was incorporated into a previous grant by this foundation for the purchase of tuberculosis and Familial Mediterranean Fever medications. Three medical students participated in the medical elective offered at the Emergency Scientific Medical Center. They were from Wright State University, University of Calif. San Francisco Medical School, and University of Hawaii, bringing to 13 the number of medical students who have participated in this elective.
• Partner from Emergency Hospital supported the development of the new PHC partnership between Armavir and Galveston; the partnership coordinator participated in the MOU signing ceremony.
• Partners have frequently published results in academic journals such as the Journal of Public Health, the Annals of Emergency Medicine, the Journal of Nursing Staff Development, and the Journal of Medical Systems. Seven articles appeared during the period 1994-2001.