Thursday, 27 March 2014

Improving Paediatric Surgery through Quality Improvement Methodology

Strengthening Surgical Capacity is a programme funded by Johnson & Johnson and managed by THET. Under the programme, a partnership between Great Ormond Street Hospital NHS Trust, UK and Queen Elizabeth Central Hospital, Malawi is using quality improvement methodology to improve paediatric surgery at QECH. 

In this blog, Dr. Bip Nandi, a United Nations Volunteer Surgeon and Consultant Paediatric Surgeon at QECH, details the work of the project and highlights the difference it is making. 

Queen Elizabeth Central Hospital, Blantyre, is Malawi’s largest referral hospital. As such the majority of Malawi’s specialist medical services are found here.

The paediatric surgical unit is one of the biggest units in the department of surgery with three full time paediatric surgeons. We serve a population of about seven and a half million children under the age of fifteen. That’s one surgeon per two and a half million children compared to one per seventy thousand in the UK.

Queen’s is a very special place. Despite being understaffed, underfunded and undersupplied we still manage about 500 major cases per year in paediatric surgery alone. These commonly include surgery for large tumours and complex congenital deformities. While we regularly run out of supplies such as gauze, gloves and antibiotics, we have the support of a 4 bed ICU. While we occasionally struggle to get X-rays, we often have access to free MRI (largely funded through research grants and private fees).

However, despite the lack of physical resources I believe our main deficit is human resources. One nurse may be responsible for 40 children on the paediatric surgical ward. Often there are no nursing staff in recovery. Twelve anaesthetic clinical officers have to cover six operating theatres, an ICU, and run an on call rota to cover emergencies out of hours. There are times when we have no interns on our unit.

Due to the volume of patients, lack of staff, and poor systems, children may sit on our wards for over a month waiting for an operation. We have enough surgeons at present, what we lack is availability of operating time and staff to provide robust care on the wards. Our operating lists are often overbooked, resulting in cancelled cases and children fasted unnecessarily. Some patients catch malaria while waiting and are cancelled again. Others get more sinister infections and suffer. Some even die waiting. Families may decide they have waited too long, that they can no longer neglect their other children, crops or livelihoods. They lose faith in the country’s hospitals and return to the traditional healers. Once children do get through the theatre doors, they may arrive without their investigations, or blood is not available in blood bank. This can result in further cancellation or waste of precious theatre time. In theatre I had started chronicling a series of ‘never events’. Events that should never happen. Antibiotics proven to reduce post-operative infections were sometimes delayed or not given. This means that post-operative recovery was further hampered. Patients were staying longer than they had to. This resulted in our wards being even busier, infections more common, stretched staff stretched even further, and patients suffering avoidable complications and even death. A vicious cycle, not because of a lack of skill or dedication, but because of poor systems and lack of staff.

I do not wish to paint a grim picture of Queen’s. What we manage to achieve with limited resources is remarkable, and we have many successes. However, we recognise that there is room for improvement. It is not within our power to increase staffing levels. However by improving our systems could we operate on more patients, more safely and have them stay on our wards for less time with less complications?

So in September 2012 Isabeau Walker a consultant anaesthetist at Great Ormond Street Children’s Hospital and I applied for the Johnson and Johnson Strengthening Surgical Capacity Grant. We attended quality improvement training at Great Ormond Street Hospital, London. There we met Liz Ball, Quality Improvement Lead for Surgery. She became the third member of our team, and we recruited Mark Clement advanced nurse practitioner on the Children’s Acute Transport Service (CATS), London.

The grant allowed us to fly the UK team out to observe our practise and work with us to help improve our systems. They worked closely with myself, Sister Mallewa nurse in charge of paediatric surgical ward, Sister Chizombwe nurse in charge of main operating theatres, Mrs Rose Kapenda anaesthetic clinical officer and Sister Saka nurse in charge of theatre recovery, as well as many others. I suspect they have learnt as much from us as we have from them.

Quality improvement involves the study of performance and implementation of systemic efforts to improve it. Improvements are made in an on-going cyclical process, using a mix of systems engineering and work place psychology.

Quality improvement methodology will tell you that staff on the ground best know the problems, and best know the solutions. Some will be exasperated in their inability to give the care that they want to give to their patients. Some will work against the odds, in subtly different ways, to produce good results. These are the ‘positive deviants’; our job was to find these people and to support them in their initiatives.

So on the final day of the first visit of the UK team we held an interactive ‘Introduction To Quality Improvement Workshop’. This was a unique event at Queen’s. For the first time we had professors, nurses, anaesthetic clinical officers, doctors, theatre staff and clerical staff, all discussing how they could work better together. The aim was to improve the care of children having surgery in Queen’s; it was an inspirational afternoon, producing over 30 suggestions.

The next year was involved in making some of these suggestions a reality. We prioritised 5 key issues that had emerged from the Quality Improvement Workshop:

1.       An integrated care pathway:
The main output was an integrated care pathway for paediatric surgery. A simple four page document designed by the people on the ground, in an iterative process. The first page is filled out before the patient leaves the ward for theatres. It ensures that the patient arrives in theatre with the correct information - demographics, blood results and investigations, consent and brief medical history. This is easily visible on a single page in an easy to find document. Use of the care pathway should result in fewer cancellations, safer operations and anaesthetics, and improved flow through theatre. It has also resulted in our doctors now spending more time consenting our patients. The second page is our own version of the WHO Surgical Safety Checklist. The third page is an operation note but with specific instructions for analgesia, drains and discharge information which we hope will improve safety and hasten discharge. The final page is a drug chart and forty eight hour observation chart. In our last audit the document is being used in 87% of elective cases, and while it is often not used well (a well reported phenomenon of checklists around the world), we are working on it.

2.       New Protocols:
We have adopted a new blood ordering protocol which we hope will mean fewer patients cancelled on the day because blood is not available and less wasted theatre time waiting for blood to be cross matched. We have a new reserve patient protocol, so children who have surgery cancelled are not fasted as long. We have a new protocol for dialysis patients undergoing fistula surgery and are developing a painful procedure protocol to manage pain on our wards.  

3.       Ward data and note keeping:
We now have a spreadsheet of patients on our wards with demographics, diagnosis and plan, and a daily senior ward round. With up to 60 children reviewed on a ward round, this should improve flow and length of stay, and perhaps even morbidity and mortality. We have spent a lot of time designing a tablet based system to replace this spreadsheet. If this works well it will further improve our workflow, safety and data collection. Often files are lost on follow-up. It is not uncommon to see a patient in clinic with a scar but no notes. We do not know what operation was done. This database will help us understand what has happened to our patients, and better plan future care.

4.       Basic equipment:
The Lifebox Foundation donated pulse oximeters which measure oxygen in the blood. Using money from the grant we purchased blood pressure, pulse and saturation monitors to help our nurses better monitor our patients post-operatively.

5.       Communication
Finally we have improved communication by introducing weekly meetings within paediatric surgery as well as meetings with nurses, paediatricians, theatre staff and lab staff.

Have these changes made a difference? Data collection is difficult in our environment as we are overloaded with clinical work. Despite this limitation we have been able to show improvements in our length of stay, timing of perioperative antibiotics and an encouraging trend in our mortality. We hope to present these results in detail in a scientific paper.

So what does the future hold? We must continue with our quality improvement work. The integrated care pathway is by no means embedded in our culture. If we stop now all the good work we have done will be undone. We must also complete development of the tablet based patient management system, something for which we have high hopes. We must continue with new developments. We need to find funding for all of these and to formalise the link with Great Ormond Street hospital, without whose assistance none of this would have been possible. I wish to thank them. I also wish to thank our staff who have committed to this process, the UNV staff at UNDP Lilongwe who have been supporting me, and THET and Johnson and Johnson who have made the project possible.

Tuesday, 25 March 2014

Ending the Isolation: Creating an Epilepsy Hub in Sierra Leone

In the last in our series of blogs about health partnership projects in Sierra Leone, THET's Communications Officer, Timur Bekir, visits an epilepsy clinic and training session to document the work of the Basildon-Lumley Partnership.

A health partnership between Basildon & Thurrock NHS Trust and Lumley Government Hospital in Sierra Leone, working closely with The Epilepsy Association of Sierra Leone, is improving epilepsy care by training healthcare workers around the country and creating an epilepsy hub to reach rural communities.

Connaught Hospital in Sierra Leone’s capital, Freetown, sits to the north of the city, not far from the Cotton Tree, a famous landmark that is over 200 years old and marks the spot of a settlement built by freed African American slaves in the late 1700s. 

It’s first thing on a Thursday morning and I’ve been invited by project leader Dr. Radcliffe Lisk, a Consultant Neurologist at Basildon, to sit in on an epilepsy clinic. Patients quickly fill the room and a queue snakes out of the door. The service is obviously much needed.

The clinic starts with patients and health practitioners singing and praying then a Q&A follows. Patients asks questions about their condition and any issues they are having trouble with. For many, this is the first time they are seeking treatment for their epilepsy.

Epilepsy clinic at Connaught Hospital, Freetown, Sierra Leone. Photo: Timur Bekir/THET

50 million people have epilepsy worldwide, but around 80% are found in developing countries. Dr. Lisk explained why:

‘The reason why epilepsy is more common in developing countries than it is in developed is because of additional causes such as poor obstetric practice. A lot children are born with brain damage because of prolonged labour and these are the children at risk of epilepsy in later life. And cerebral malaria has been shown to be one of the main causes of epilepsy in children. Trauma from war and high levels of road traffic accidents also contribute. Most of the prevalence studies that have been done in Africa show that epilepsy is about 2-3 times more common than it is in Europe or America so it is a big problem.’ 

The most reliable data suggests 60,000 people in Sierra Leone have epilepsy. But inadequate health provisions and long-held views among the population that epilepsy is a result of witch craft or demonic possession means that 80-90% of people with the condition will never receive the treatment they need.

During the session I get a chance to speak with some patients who have benefitted from the project. When describing their experience of having epilepsy, patients describe similar difficulties they’ve faced such as stigma, isolation and the general belief that they are ‘crazy’. Jeneba Kabba has had epilepsy for 14 years now and described her ordeal:

‘They gave me kerosene to drink and said that is the way to treat epilepsy. I had this treatment for three years. People were laughing at me and saying I was crazy.’

Jeneba found out about the work of the partnership three years ago and has been able to manage her epilepsy ever since. She is a mother and teacher, and works with the partnership to raise awareness and reduce the kind of stigma she faced for so long.

A health worker administers drugs to epilepsy patients at a clinic in Connaught Hospital. Photo: Timur Bekir/THET

As well as the sessions at Connaught, the partnership is expanding its activities across the country. The project, currently funded under the health partnership scheme, is creating a national epilepsy hub to reach isolated rural communities. Previously, rural patients had to travel long distances or wait for the monthly provincial visits to access any sort of epilepsy service.  To reach the vast majority of patients, the project is training all levels of rural health worker in epilepsy diagnosis and management. Training health workers in the Peripheral Health Units (PHUs) that serve the villages and chiefdoms is a key activity for the project and essential to increasing access for patients.

To see the training first-hand, I travel to Moyamba District in the north of the country. The two hour journey takes five. Slowed down by a never-ending caravan of traffic coming out of Freetown and terrible road conditions once into the district. This helps to highlight how difficult it is for rural communities to access services in Freetown, add to this the cost, and some individuals and families have no chance of accessing healthcare.

Once at the workshop, I watch as Dr. Lisk and his team run through a full days teaching, covering everything from diagnosis, clinical treatment, and breaking down the traditional beliefs that claim epilepsy is demonic possession or witch craft.

To date, 439 health workers have received training, including 6 district medical officers, 89 Community Health Officers and 254 Community Health Nurses & Community Health Assistants. Trainees have reacted positively to the training with the majority acquiring new knowledge such as different types of epilepsy, its association with depression and recognising that the majority of seizures can be controlled with medication. Many trainees are now local focal points for the project.

Along with the training sessions, the partnership has produced a handbook that includes protocols on the management of various aspects of epilepsy. In tandem with this, the partnership continues to raise awareness about epilepsy through TV and radio appearances and newspaper articles. All essential activities in breaking down the long-held but misplaced beliefs about epilepsy in Sierra Leone.

‘The advocacy work is extremely important,’ states Dr. Lisk, ‘because that's how you get them into the clinics in the first place. If you don't change their beliefs you won't get them to the clinics. It's a slow process but our programme also goes into schools so we can educate the new generation. We talk about epilepsy and have our posters in schools too.’ 

Patients receive drugs from a health worker at Connaught Hospital. Photo: Timur Bekir/THET

Back in Freetown, I sit in on an EEG session in the neurology department of Connaught Hospital. The EEG machine used by Dr. Lisk and his team has been acquired with funding from THET. The project has been able to purchase three machines and train four technicians to perform EEG recordings. 

A technician carries out an EEG test for a patient at Connaught Hospital. Photo: Timur Bekir/THET.

A technician assess the EEG reading. Photo: Timur Bekir/THET.

A patient receiving an EEG test. Photo: Timur Bekir/THET.

A patient receiving an EEG test. Photo: Timur Bekir/THET.

I ask Dr. Lisk about the sustainability of the project and he explains that the programme has worked closely with the Ministry of Health from the start to help ensure the future of the project:

‘One of the keys to sustainability is integration into the Ministry's programme. That's why, from the onset, we made sure this wasn't a parallel programme. So by actually training the staff employed by the Ministry of Health they then have the knowledge to carry on the work after the project ends.’ 

In fact, epilepsy has received further recognition from the government and a focal point for epilepsy in the Ministry of Health has been appointed. This is an important development for a project that is really gaining momentum and, from the amount of patients I’ve seen attend clinics, is much needed.

One thing is for sure, the partnership has already been able to produce strong advocates for the project. Over just a couple of days I’ve met health and social workers, teachers and patients who have responded positively to the training and are now advocates engaging in awareness raising and sensitization in their districts. A great example of how training and education can have life changing results far beyond the classroom. 

Find out more about the partnership at

Find out more about epilepsy in Sierra Leone on the Epilepsy Association of Sierra Leone website. 

THET has produced a short film documenting the work of the project. Dr. Lisk, trainees and patients are interviewed about their experience of epilepsy in Sierra Leone and the impact of the project. Help support the work of the partnership and share the video with friends, family and colleagues.

Monday, 3 March 2014

Giving Children a Chance: Reducing Child Mortality in Sierra Leone

In the second in a series of blogs focusing on THET funded health partnerships in Sierra Leone, THET's Communications Officer, Timur Bekir, visits Ola During Children's Hospital in Freetown to document the work of the Global Links project. 

It’s a stifling November day (the locals will later laugh and tell me that November is a cool month) and at Ola During Children’s Hospital in Sierra Leone patients crowd the corridors waiting patiently by the Emergency Room. In the Special Care Unit babies struggle to adjust to their new world. And in the ICU a mother tenderly reassures her child. In each of these vital wards is a volunteer from the UK working with local staff to help improve healthcare for Sierra Leone’s youngest residents. 

The volunteers: Paul Gibson, Liza Waldegrave & Gareth Lewis are part of the THET funded Global Links project, a health partnership between the Royal College of Paediatrics & Child Health and the West African College of Physicians. The THET funded Global Links project places long-term volunteers in five African countries: Sierra Leone, Ghana, Kenya, Nigeria & Uganda. The partnership is working with staff and institutions in each of these countries to establish a consortium of UK and East & West African central and district hospitals that will work to reduce child mortality and help meet Millennium Development Goal 4.

The 8 Millennium Development Goals.
Global Links seeks to address MDG4.
The volunteers work closely with the staff at Ola During, the main referral hospital for the whole of Sierra Leone, to provide clinical support, develop protocols and train staff. And, by all accounts, the relationship between the volunteers and their Sierra Leone colleagues is strong. Gareth Lewis, a Paediatric Registrar and Senior Resident at Ola During, highlights the relationship between volunteers and local staff:

‘All the doctors have been great. I’ve been working with one doctor in particular in the Child Protection Unit and she has been really helpful in teaching me bits of Krio here and there. They’ll help with translation. In general they have been very supportive and you never feel excluded as an outsider here.’

Walking around the wards I can see this inclusivity first-hand. The local staff and volunteers have a professional, but easy manner with each other, undoubtedly vital in ensuring a positive and productive working relationship.

Gareth Lewis in the SPU. Photo: Timur Bekir

Gareth Lewis with House Officer. Photo: Timur Bekir

There’s a huge need for support at Ola During, as Dr. Baion, Medical Superintendent, highlights starkly:

‘We have nine wards which means, at the least, we need nine doctors, but we have only two doctors in this hospital. So even having just one person from Global Links helps a lot. They are covering so many areas that we cannot do on our own.’

Paul Gibson, a Consultant Paediatrician in Lancaster, is midway through his twelve month placement. He kindly spends the day showing me around the hospital and introducing me to staff and patients, his energy and enthusiasm doesn't flag for a second. Dr. Gibson is well aware of the need he’s here to address:

‘When last measured, the mortality in Sierra Leone was approximately 170 per 1000 so about 17% of children died before their fifth birthday. What that means at Ola During Hospital is that approximately 10-14% of our admissions die, which is tough on the staff and the whole operation.’

Dr. Paul Gibson. Photo: Timur Bekir

Dr. Gibson and local team. Photo: Timur Bekir

Typical cases at Ola During include malnutrition, malaria and respiratory tract infections. And it’s a constant numbers game – not enough skilled health workers to deal with the cases that come in on a daily basis. As Dr. Gibson notes:

‘One of the features of health and healthcare in Sierra Leone is simply a shortage of numbers of health workers. Then there’s also the quality of skills those health workers have. If you start with the nurses, often they feel poorly paid and unrecognised. And training isn't just about giving people new knowledge and new skills, it’s about giving people a reward. So one of the things that external people like Global Links, funded by THET, can do is bring that in and send a message to nurses or nurse aides that what you do is valuable,  and it’s important to invest in you and your training.’

Emergency Room. Photo: Timur Bekir

Local nursing staff. Photo: Timur Bekir

Nurse attending to a patient in the ER. Photo: Timur Bekir

Patient in the ER. Photo: Timur Bekir

During my two days at Ola During it’s encouraging to see the emphasis placed on evaluating and measuring impact. Away from the wards and in the classroom I sit in on the weekly Mortality & Morbidity session. These meetings are not only a chance for the team to analyse and improve mortality rates in the hospital, but are also the start in rebuilding a much needed medical postgraduate life for the institution.  

The addition of ‘speed learning’ at the end of each day on ICU is helping to supporting and nurture leadership, team working, and improvements to clinical governance, team development and clinical leadership too. Led by the local Staff Nurse, these fifteen minute sessions are a chance for staff to get answers to questions that come up on ward rounds. The sessions foster a culture of sharing and learning as each member of staff contributes by imparting the knowledge they have to answer daily queries.

In addition to these sessions, the volunteers are helping to deliver more training, including twenty hours of undergraduate lectures and a regular, weekly, Continuing Professional Development programme for paediatric staff, including sessions on HIV testing, clinical assessment, and treatment of shock and dehydration.

Liza Waldegrave with nurse in the ICU. Photo: Timur Bekir

Dr. Gibson with patient in the ER. Photo: Timur Bekir

A mother feeds her child in the ER. Photo: Timur Bekir

Dr. Gibson tends to a patient. Photo: Timur Bekir

As my time at Ola During draws to a close, I reflect on spending the day with a really motivated team who clearly care passionately about their role. The challenges are numerous and can sometimes seem overwhelming. But the local staff, with support from UK volunteers, are making gains in a large number of areas. The RCPCH Global Links project is forging a relationship with Ola During and other hospitals around Africa in order to work together to train health workers and improve healthcare for children far into the future. As Dr. Gibson states:

‘Success for colleagues in Sierra Leone would be that in five years there would be an internal self-sustaining confidence that nurses, doctors and midwives actual felt that they were the leaders, that they could control things and come up with ideas. And that the workforce is self-sustaining.’

It’s that emphasis on long-term, sustainable healthcare that is fundamental to the health partnership approach, and why training and developing the skills of local health workers, not just delivering services, is key to realising that approach for real in hospitals in Sierra Leone and around the world.

Dr. Gibson with nurse and mother in the ER. Photo: Timur Bekir

Record keeping in the ER. Photo: Timur Bekir

Patients rest in the ER. Photo: Timur Bekir

House Officer in the SCU. Photo: Timur Bekir

A mother with her child waits to be seen in the ER. Photo: Timur Bekir

To find out more about health partnerships in Sierra Leone and around the world, visit 

To find out more about Global Links and how you can volunteer, visit the RCPCH website.