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