How can we make the patient with an individual disease more visible?

This blog post starts with an admission of guilt. Its 6:00 at Connaught Hospital and I have become accustomed to taking advantage of the early hours to slip into the clinical office to steal a little of the Kenyan coffee that a recently returned volunteer has brought. I choose the shortcut through Ward 9, where normally I pass past the 20 or so bodies lying in bed without a second glance. However, this time a patient becomes visible. I see them because they are illuminated by a doctor and a nurse, a few pieces of simple medical equipment, and the patient notes by the bedside. I hurry on, arm myself with a caffetiere, and check back in with the nurse in charge on my return to enquire about the patient in bed 14. “Low BP” is the curt response I receive back. Gentle probing reveals that the night nurses had performed their routine vital signs monitoring, and upon discovering a patient with abnormal vitals had asked a doctor to review the patient. These simple steps are a small demonstration of a system that we have been supporting to embed in the hospital, aimed at identifying the deteriorating patient. At the core of this, is an attempt to make the very sick patient visible.

How else can we continue to make the individual patient visible amongst the multitude of sick? A clear diagnosis helps. It enables patients to access resources, slot neatly into algorithms, and become pleasing to the physician’s gaze. This leads to a second admission: the personal (and I guess shared) frustration of clinicians unable to diagnose and treat patients in the manner we have been trained due to structural barriers. In a low resource setting where diagnostics are less available and patients often have limited resources to access diagnostics, this makes the easy win of knowing what to treat, how to treat it, and the satisfaction of having cured a patient much harder to come by. It often leads to these patients being labelled “generally sick,” and if a patient gets better or worse, it is hard for a clinician to judge what intervention may have helped or hindered. This creates an unstable foundation for developing our learning and for attaining that natural satisfaction of having helped a patient.

How can we make the patient with an individual disease more visible? This is partly about increasing access to diagnostics, and we are very lucky to welcome our new Laboratory Volunteer, Ed Choi, who is working with Connaught laboratory to improve the access to and quality of basic haematology and biochemistry diagnostics for all patients. Secondly, we can focus on improving diagnostics for specific high burden diseases. We are delighted to announce a new partnership with the National AIDS Secretariat, National AIDS Control Programme, and Global Fund providing funding to increase access to HIV Rapid Diagnostic Tests, improved HIV counselling and improved quality of care and staff training at Connaught. In a setting where stigma, difficulties in accessing services, and loss to follow up remain high, increasing the visibility of this group both at the individual patient level and at the broader policy level is key.

As clinicians in a high workload environment, we are prone to devote more of our time to patients who have a natural advocate for their care, normally in the form of a relative. In this setting, we recognise that relatives perform a much greater role than in higher resource settings; they act as both basic care providers and agents ready mobilise the financial resources patients need to receive care. Building on the successful experiences of employing referral coordinators and survivor advocates to ensure higher quality care for EVD survivors through the CPES programme, we have submitted a new bid to UK Aid Direct that focuses on providing patient advocates for those who do not have a relative to advocate on their behalf. This is complimented by ongoing work to solidify the destitute policy and support Connaught’s social worker Ini, to draw the gaze to this marginalised group.

And whilst patients remain the key focus we must also ask how do we make healthcare workers visible? Next month we will see the roll out of a nursing newsletter highlighting the impact of individuals as they continue to innovate to improve care. This month KSLP Volunteer Danny McLernon-Billows supported the first induction session for newly graduated house officers working within the Teaching Hospital Complex. This event was not only key for knowledge transfer and orientation, but also an opportunity to ensure that these young professionals are more visible. Small tokens, such as ID badges, engender a sense of belonging. Larger gestures, such as the provision of a forum that encourages feedback and incorporates them in to the decision making processes of the institutions they are joining, increases their visibility, participation and is key to driving systemic change.

– Dr Daniel Youkee, Country Director

#Resilience in Action

Our latest photo essay captures some of our favourite moments from the recent #ResilienceInAction campaign, which highlights the progress our partners have achieved since the end of the Ebola outbreak.

New Year, New Partners, New Opportunities

By Dr Daniel Youkee, Acting Country Director

As the new year begins, I first want to look back and thank Francis for his sterling work as Country Director. He managed the growth of the organisation, cemented our internal policies, and maintained close relationships with our Ministry of Health partners.  He will be fondly remembered and we look forward to working closely with him in his new role as Country Director for Restless Development Sierra Leone.

January also marks the last month of the Infection Prevention & Control (IPC) grant. The team has been working tirelessly to protect patients and health workers across Connaught, King Harman Rd, and Lumley hospitals. While the achievements of the IPC programme are immediately recognisable – visitors line up to wash hands, gloves sit neatly on the ward round trolley, and water flows from taps – what impresses most is the way in which progress has been achieved. There are now fiercely independent IPC focal points and we are seeing our staff draw back and Saloneans step up in the gravitational dance of partnership.  A huge thank you to Natalie, Hannah and all of you who worked on this grant previously (Sachiko, Dominic, Annabel, Ambrose, Gilbert, Becca).

As the IPC project winds down, we are gearing up to focus on a new 20 month (~$800k) mental health and neurology project. Funded through John Snow International, this will develop mental health services nationally, provide a pathway to accreditation for mental health nurses, and develop the neurology training and services available at Connaught Hospital. Hannah and Hege are working hard to ensure that the KSLP ethos is embedded throughout all elements of the programme design and to ensure maximum impact of the grant.

Over the past three months we have witnessed tangible gains across the hospital – from the implementation of the country’s first viral load monitoring in the Connaught HIV clinic, the regular Quality Improvement Committee meetings starting to deliver system change, the arrival of surgical trainee residents, the development of antimicrobial guidelines through consensus, and supporting our partners in the roll out and quality assurance of national malaria treatment guidelines.

The team based approach to Sierra Leone Early Warning Scores (SLEWS) implementation continues to integrate our work from undergraduate through to postgraduate education. SLEWS drives the recognition of and response to acute illness, improves communication between nurses and doctors, and supports the development of an ICU outreach service. SLEWS is the vehicle for driving improved patient care and health worker accountability and is a key component of KSLP’s framework for achieving behaviour and system change. On the ward trainings are bridging the gap from theory to practice and will culminate in the hospital-wide SLEWS launch on Thursday 27th January.

Internally, we continue to increase our engagement and alignment with KCL, with Martha, Max, Steve and Molly strengthening and developing our financial and recruitment processes.  Academic engagement with KCL appears to have reached a critical mass, with ongoing joint research proposals ranging from surgery to HIV, and from stroke care through to epidemiology.

Finally, we are entering a new era of partner relations as the Teaching Hospital Complex Act draws the College of Medicine and Allied Health Sciences (COMAHS) together with the four tertiary hospitals in Freetown under a new Nigerian-led administration. Autonomous from the Ministry of Health and Sanitation, it is a radical redesign of existing governance structures. We welcome Dr Deen as the new Medical Superintendent of Connaught Hospital and salute Dr TB Kamara for his long and distinguished service as he moves to take the role of Postgraduate Training Coordinator. As an academic health science centre partnership, we are uniquely poised to support our partners to seize this opportunity and drive sustainable system wide change.

Designing a Development Programme for the Faculty of Nursing Lecturers

The King’s Sierra Leone Partnership is moving into an exciting phase with our partners at the Faculty of Nursing at the College of Medicine and Allied Health Sciences (COMAHS), University of Sierra Leone.

On 3rd November 2016, Sister Alicia Wilson-Taylor, Senior Nurse Lecturer at COMAHS, and Dr Matthew Vandy, Dean of the Faculty, co-led an interactive workshop with the support of Linda Jenkins, KSLP’s Nurse Educator. The workshop built on teaching sessions started with COMAHS in 2013/14, before the Ebola outbreak halted this work, and outlined current plans to design a development programme for the faculty of nursing lecturers.

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Topics of discussion included developing skills in carrying out teaching observations, peer evaluation of teaching, student assessment, ward teaching, research, and the use of IT. The session was attended by 8 of the faculty lecturers.

Sister Wilson-Taylor shared with the group an inspiring example of using interactive learning in a teaching session the previous day where students had been asked to work in pairs to define the characteristics of a nurse and feedback to the group. Sister Wilson-Taylor said the session had been very successful and that the students came up with great ideas and the team is looking forward to future sessions.

kslp-and-faculty-of-nursing-at-comahs-photo-1 Dr Vandy, Sister Wilson-Taylor, and colleagues will be working over the next 10 months, supported by Linda, to develop the nursing curriculum, teaching, and assessment methods and use the learning from similar work that has already taken place in the Faculty of Medicine, also supported by KSLP’s Education Manager Suzanne Thomas.

IPC Campaign Week

As part of our ongoing work with the Infection Prevention & Control (IPC) Programme, KSLP IPC nurse mentors have been supporting partners at Connaught, Lumley and King Harman Road Hospitals to implement regular IPC campaign weeks. These weeks have proven effective in building and maintaining enthusiasm among hospital staff about the importance of following IPC protocols.

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Hand washing during one of Connaught’s IPC weeks in May

Each IPC week is different, but typically each day of the week has a particular theme for which the IPC Focal Person collaborates with the link nurses to focus the day’s training and monitoring on one particular component of IPC.

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Bobson Fofanah explaining the correct disposal of sharps

For instance, this September featured Sharps Safety Day at King Harman Road Hospital. Assistant IPC Focal Person Bobson Fofanah visited each ward to ensure that sharps bins were assembled correctly and located in safe places in each ward. He also checked to see if there are instructional posters in place and to make sure every staff member is aware of the importance of proper sharps disposal.

IPC campaign weeks build a strong sense of teamwork and enthusiasm about IPC across the hospitals. The week ends with a celebration, with awards given to the wards showing improvement in IPC practices.

IPC weeks also give the team opportunities to show off their creativity!

King Harman Road Nurses sing the IPC Song from King’s Sierra Leone Partnership on Vimeo.

#anotherdayatKSLP

As the KSLP team has grown over the years, our work has expanded to include activities across a wide range of programme areas. These activities are unified by the overarching vision of the partnership: to work alongside local partners to build a strong and resilient health system in Sierra Leone. We showcased the breadth of our partnership’s work in a month-long social media campaign #anotherdayatKSLP, the highlights of which you can see in this photo essay.

New Developments, by Richard Lowsby

It has been a turbulent few weeks; the country’s leader has resigned and been replaced, senior politicians have been stabbing each other in the back and the opposition are in turmoil.  The population are divided after a bitter referendum, promises have already been broken and the rest of the continent look on in concern.  The health system is in financial crisis with concerns over sustainability, resources are stretched to the limit and morale is at an all-time low.   Patients are suffering and the staff that care for them are engaged in a battle with the health secretary with no signs of a resolution or solution.  I refer of course, to the UK and not Sierra Leone.

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Dr Rich Lowsby with final year medical students, photo by Ibrahim Kabia

I have been home for a few weeks, a trip slightly longer than planned, but have left the political turmoil behind and now arrived back in Freetown to experience the full assault of the rainy season. Gone is the dust and in its place, a damp humidity but at least it is slightly cooler now.  The large majority of my time before leaving last month was spent supporting the development of the hospital’s new acute surgical and trauma assessment unit.  This was the second phase of the new A&E development following the opening of the new department in March.  The unit opened while I was away and I am keen to see how it is going.

I was told that the ward had opened in a bit of a hurry when several seriously injured patients arrived simultaneously following a major traffic accident.  The staff had coped admirably and had continued to do so.  The sister and staff nurse in charge have the ward running smoothly, there is a list of responsibilities for each nurse on duty for each shift of the day.  Each bed has a chart on the wall above it with a plan for the patient.

The high dependency bed currently has a patient being monitored and provided with oxygen after admission for a gunshot wound and collapsed lung.  The lung is now re-inflated after placement of a drain and he is improving.  A patient with a significant head injury has just arrived in the trauma resuscitation room after an assault and the staff are assessing him, supported by the medical officer.  The surgical team are reviewing patients admitted overnight after their morning meeting, a man with a suspected perforated ulcer and a child with an infected wound after a snake bite may need to go to theatre.

Some of my colleagues have been conducting training to support the opening of the ward and have worked tirelessly alongside the staff to ensure it functions effectively.  I am thrilled to see how things are progressing and I have realised how important good relationships and team effort are in moving things forward.  Work initially began over 6 months ago and is now complete, the hospital has a new Emergency Department.  This has been in the planning for a while, well before my time and I feel fortunate to have played a part in it.

It is not only hospital management, doctors and nurses that have contributed, but we have been working alongside builders, biomedical sciences, cleaners, engineers, infection control, hospital stores, maintenance, Ministry of Health and Sanitation as well as the UK Department for International Development.  As a result of everyone’s efforts, the hospital now has a department that is geared to assessing and managing acutely unwell and injured patients, that staff can be proud of and patients can trust.  It is everyone’s responsibility to sustain this good work.

Published, with permission, from Dr Rich’s Lowsby’s blog, Sierra Leone Emergency

Enhancing Resilience: supporting the next generation of health workers in Sierra Leone

Freetown’s College of Medicine and Allied Health Sciences (COMAHS) was forced to shut its doors for nine months during the Ebola outbreak. Finally reopening in June 2015, COMAHS is critical for rebuilding Sierra Leone’s health workforce, despite its limited training capacity, poor learning facilities, and a major shortage of teaching staff in most areas. This essay tells the story of the partnership between COMAHS and KSLP, formed with the goal of building capacity and resilience in post-graduate education in Sierra Leone.

All photos © Katherine Wise/Momenta Workshops 2015

A Day in Connaught Hospital’s Intensive Care Unit

Today we are in the Intensive Care Unit (ICU) at Connaught Hospital where the nurses are conducting their afternoon handover. Alongside Sister Elizabeth Kamara, the ICU sister-in-charge, KSLP’s Dr Ruth is leading today’s handover.

DSC_0071 It’s is a quiet day in ICU so Dr Ruth is taking time to test everyone’s knowledge on the importance of fluids and how to provide oxygen. Her energy is contagious as she asks about each patient:

“Ok, so why might this patient’s condition have changed?”

“Fever?”

“Chest Infection?”

“Reaction to the blood?”

“Exactly, it could be any of those things, so if there is a change in the patient condition, we need to think about what might be the cause and what you need to tell the doctor in charge.”

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ICU sister-in-charge, Sister Elizabeth Kamara,

Such on the job learning is highly valued in this unit. The daily handover is appreciated as much for ensuring the consistency of patient care, as it is for the opportunity to receive further training.

“Mentoring other nurses is the best part of this job,” said Sister Elizabeth. “It’s great to be able to share my knowledge and understanding with others.”

A close relationship builds between the nurses and their patients. In ICU, they provide ‘complete nursing,’ which includes everything the patient like feeding, fluids, and pain management. Any and every change in the patient’s condition must be recorded. This is a major responsibility, but all of the nurses shoulder it professionally.

DSC_0015 Each provides a detailed history of every patient at the end of the shift. Histories include details of why the patient was admitted, when he or she was last seen, and the critical points in his/her care and management. Despite seeing some tragic cases, optimism abounds in the unit. After all, “ICU is where we treat critically ill patients,” said Sister Elizabeth. They are the ones we know we can revive again and bring back to life.”

From Ebola Isolation Unit to Modern A&E Unit: Transformation at Connaught Hospital

KSLP Emergency Medicine Doctor Rich shares his reflections on the recent A&E refurbishment at Connaught Hospital

The entrance doors were unlocked, revealing dark corridors and empty rooms illuminated only by slivers of sunlight stretching out across the bare floor through broken panes of glass.  My eyes struggle to adjust, pupils dilating as I peer into the shadows. It’s humid and I can already feel beads of perspiration forming at the back of my neck.  The tiles have faded after repeated dousing in chlorine and a fine layer of dust has settled to give the ward an eerie, long-abandoned feel.  This was once part of the red zone, a place of fear and tragedy for many, a place where local staff worked alongside foreigners doing the best they could in a period of great uncertainty.  It is now silent, no one has been here for quite some time.

By the time the epidemic reached Freetown, hundreds of cases a day were being diagnosed across the country and the staff at Connaught needed to act fast to establish an Ebola isolation unit in an attempt to contain the virus and protect its healthcare workers.  Prior to the epidemic King’s had a program in place to help strengthen the emergency services at the hospital and had already introduced a triage system to expedite assessment of the sicker patients that presented to the hospital.   The outpatient department was re-branded as the Accident and Emergency unit to re-inforce the need for timely and effective urgent care for the critically ill and injured patients that attend there on a frequent basis.  An emergency that no one expected subsequently swept across the country at alarming speed and the Accident and Emergency ward was transformed into an Ebola holding unit.

In time, a purpose designed isolation unit was established alongside the hospital and the old unit, after decontamination, became redundant and stood empty; a dark reminder of painful recent events.  When I arrived, just over six months ago, we were isolating and managing suspect patients in the new unit.  I had heard some very upsetting accounts from colleagues, from both Freetown and abroad, that were around at the height of the epidemic and I struggled to imagine how challenging the conditions must have been. Before Christmas, it was opened up and I was able to enter inside.  Renovation work would soon be starting on a new A&E Department and I was curious to see what would be required to transform a place where the grief was still tangible into a facility that will aim to revolutionise emergency care for inhabitants of the city and beyond.

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Dr Rich working on the A&E refurbishment at Connaught Hospital

During the epidemic, the emphasis of the government and international agencies was focused out of necessity in containing the disease.  This was no doubt to the detriment of other health related issues.  Maternal and child mortality rates will have increased, surgery throughout the country was suspended and I have seen many HIV and TB patients that defaulted on treatment.  Most health facilities shut down but Connaught remained open, providing a much needed service to those that were sick but not suffering from Ebola.  The A&E, in its temporary facility, continued to deliver essential care at the front door, at great personal risk to the brave staff that served throughout.

We have seen the country declared free of Ebola twice now since I arrived and with recent cases in Guinea, it seems unlikely that the country will never see another case.  The skill and expertise now exists in Sierra Leone to manage the situation and gain control rapidly, the focus is now on re-building and strengthening the health care system.  This is now the main emphasis of the work of King’s at Connaught and of my role in the Emergency Department.  The lasts few months have seen huge steps forward in the delivery of emergency care and much of the credit should be given to my colleague Ling who has worked tirelessly over several years now to develop the A&E in conjunction with the hospital staff and Ministry of Health.

Before: the future A&E unit pre-refurbishment

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After: Dr. Ling stands in the newly refurbished A&E unit

The end of February saw work complete on the old isolation unit and the new A&E, along with resus and medical admissions units opened to patients. Equipment and patients were transferred seamlessly, coordinated by Sister Kamara, in under 2 hours and there was impressively no delay or impact on patient care and safety. Several of the staff came in early of their own volition to prepare the department and I was told off for being late by one irate nurse who had been there since 6am.

Ling is now back in the UK and is sorely missed by all the staff she worked with at Connaught, although she has left a strong legacy.  Several high profile figures have visited the department in the last few weeks including the deputy health minister, chief medical officer and chief nurse; all have been impressed.  The staff are revitalised and proud of their new department, they are eager to learn how to use the new facilities and equipment.  We have a new enthusiastic and motivated medical officer and Emergency medicine is enjoying a raised profile in Sierra Leone currently.  I’m sure that this is all having a positive impact on the care of the patients, who seem to be attending in ever increasing numbers. The big challenge now will be to sustain and build on this momentum and ensure that the ministry can support the hospital to develop systems and maintain a supply chain that will keep the acute care facilities functioning effectively for the benefit of the patients.

A lot has taken place over six months and a great deal more is to come. While work has the potential to become all-consuming at times, it is the down-time and the support of those who are close that is important to maintain a sense of balance and perspective. My personal highlight has been the visit of Alice, who arrived in Freetown last month as my girlfriend and went home as my fiancée. I was really pleased to be able to share my experiences and show her the highlights of what can be, at times, a beautiful country. In a place that offers tropical islands and idyllic beaches in abundance, I felt the most appropriate spot for a proposal would be in the jungle surrounded by howling chimpanzees. Fortunately, my gamble paid off and she agreed to marry me!