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.
