Pioneering enhanced hospital referral coordination in Sierra Leone

Our Hospital Performance Monitor volunteer, Lucy Hartshorn, describes her experience working as part of the referral coordination team.



At the beginning of October last year, the Sierra Leone Ministry of Health launched a new national referral system, building on successful elements of previous Ebola survivor-targeted efforts, to support broader access to health services for the population of Sierra Leone. Critical to this system are the 17 KSLP-supported referral coordinators. A new cadre of specialist health workers, the referral coordinators are based in each district’s government secondary hospital and in the specialist, tertiary hospitals in Freetown. They use their clinical backgrounds to support incoming and outgoing patient referrals at the facility and make sure patients are at the right place at the right time.

Patients in Sierra Leone face a myriad of obstacles when they get sick, from knowing who to visit for a diagnosis or navigating where they need to get to receive treatment, to the availability of health care workers who are trained and able to provide the specific care a patient may need. In Sierra Leone, this is complicated by significant resource constraints – on both individuals and the health system. For the hospitals, doctors, nurses, midwives and laboratory staff that work in the government hospitals across Sierra Leone, getting each patient the care they need is often accomplished through a clever mix of compassion, teamwork and communication. As the Hospital Performance Monitor Volunteer, I lead the referral coordination team in training and supporting our Referral Coordinators (RCs) and working with the Ministry of Health.

Lucy and the KSLP Referral Coordinator mentors, Sorie Samura and Hassan Shaw, recently supported district level leadership meetings in Makeni.

It is exciting, if not initially intimidating, to be able to work with King’s Sierra Leone Partnership! I am not clinical and instead have a background in ‘global health’, spanning biomedical sciences, public health and health partnerships. While much of KSLP focuses on overcoming challenges in clinical care, which you can read more about here, the referral coordination work is pioneering a new model of enhanced hospital coordination to overcome wider Sierra Leone health system challenges. The two KSLP RC Mentors, Sorie Samura and Hassan Shaw, and myself make up the Referral Coordination support team. They both bring clinical experience and a near-unlimited understanding of the Sierra Leone health system to our project, while I bring the baked goods (sometimes) and Americanisms. Together, we support the RCs spread across the country – mainly from the KSLP ‘Clinical Office’ tucked the end of the hall after Ward 10 in Connaught Hospital.

By referral coordination, we mean the networks, information and communication that helps clinicians direct patients to the right places, where they can get the right services, at the right time. This is different than the ambulance networks patients use, although the RCs link closely with emergency alert systems in each district to help notify hospitals of patient details prior to arrival, helping them prepare. For incoming referrals, this means receiving calls from Peripheral Health Units (PHUs), District Emergency Alert Systems or NGO and private facilities wanting to send patients to the government hospital; notifying clinical and laboratory staff of incoming patient diagnosis, needs and estimated time of arrival; and advocating for access to facility services for Free Health Care Initiative (FHCI) patients. For outgoing referrals, the RCs play a critical role in helping patients navigate the complex landscape of service delivery in Sierra Leone – a patchwork of government, private and NGO offerings. The RCs work with clinicians, patients and patient caretakers to determine which other facilities have the services the patient needs and their availability, and then contacts the next facility’s referral coordinator, who supports patients from the receiving end.

RCs are also hugely beneficial to the facilities that they work within, supporting hospital preparedness and improving patient flow. What is innovative about the RC-based referral coordination system is it’s ability to make huge impact and improvement within the space and resources available. Success has so far been build on small-small changes- the use of standardized referral forms, a designated hospital employee to take over a role often ad-hoc filled by clinicians, sharing of phone numbers with information on different hospital service offerings, a system of reporting these referrals on a weekly basis – to name a few. The referral system has given the MoH its most comprehensive understanding of patient referral numbers, needs and flow – fed back in KSLP-produced weekly and monthly reports. This is used by the Referral Coordinator’s hospitals, District Health Management Teams and the Ministry of Health and Sanitation for prioritising resources, visualizing system gaps and demand and advocacy for more accessible, high-quality health service provision across the country.

The referral coordination team is made up of 17 KSLP-supported referral coordinators, working at facilities across the country.

It is exciting to impact on this innovative creation – a national network providing individual patient, facility and system benefits. My role focuses on studying the referral system in real-time. I use the information produced by our RCs and RC Mentors for not only improved referral project implementation, but also through newly created feedback loops to help hospitals and the Ministry of Health plan, to advocate for services and resources for patients and facilities, and to enhance the global health sector’s understanding of patient access to care. It’s a process of constantly learning. New and updated patient referral information is compiled every week – a truly incredible feat and something which exists in few countries! From this, I get to think about interesting questions like: what challenges hospitals are facing, how to share the information to best visualizes these challenges, how the referral coordinators are impacting patient outcomes, and what the different benefits of referral coordinators in each unique facility and district are. What I think makes KSLP different from many other organisations is that we focus beyond just enhancing the understanding of the patients, hospitals and health system. For me, it’s about turning that knowledge of patient referrals and system access into action – informing policy, projects and research for better patient care.

Just as patients in Sierra Leone benefit from the teamwork and compassion of their health workers, I depend on the skill, expertise, collegiality and unrelenting commitment of the two KSLP RC Mentors, seventeen referral coordinators and the team at the MoH program implementation unit. They are responsible for the success of the referral system so far. As we approach the end of February, they can boast of having trained almost twenty specialist referral coordinators, supported over 4,200 referrals and helped patients navigate over 500 facilities!

New Nursing Curriculum – Update

Before she heads back to the UK at the end of her 15 month placement, our Nurse Educator Linda provides an overview of the curriculum implementation planning.


Nursing education leads at COMAHS are making good progress with designing their new curriculum for registered nurses. They have been working with me for the last year and the journey has been long and winding but is really taking shape now.

On Friday 20th November, I assisted the Faculty of Nursing team to work on an implementation plan for the new programmes which will start in 2018. It is quite a challenge to develop the detail of a plan such as this. The faculty staff welcomed the opportunity to get started, building on their expertise in delivering the current nurse education programmes. One example of a change in the new curriculum plans came from the feeling that degree students had plenty of theory base but less clinical experience. The new curriculum is focused on introducing clinical practice for degree nurse students earlier in their training. For Diploma students they will experience a good balance between sufficient theory to match the clinical experience that forms a core part of their programme.

Each lecturer has a responsibility for a subject area depending on their clinical background. Here they are hard at work devising lesson plans for units in their subject (below). This work is the start of building a bank of accessible documents for use by all lecturing staff both full and part time. I wish them well in their endeavours as I head back to the UK this week. KSLP will continue to support the role of nurse educator at COMAHS so watch this space for updates!

Happy World AIDS Day!

Our infectious diseases volunteer Hannah unravels the complex picture of HIV in Sierra Leone and explains how KSLP are supporting the National HIV/AIDS Control Programme to improve diagnostics and testing.


Happy World AIDS Day. Maybe an odd thing to say on a day that commemorates a disease which has killed 70 million people worldwide. But despite the ongoing tragedy of the HIV pandemic, in 2017 there is lots to celebrate.

While a vaccine or a cure remain distant prospects, we now have incredibly effective treatment for HIV. Antiretroviral therapy (ART) can suppress the activity of the virus in the body to the point that it is undetectable and people show absolutely no symptoms or signs of the disease. Many people living with HIV can now take a single, well-tolerated pill each day, and live a normal healthy life. Perhaps even more impressively, we now understand that people with HIV who are taking effective treatment with a suppressed viral load cannot transmit the virus to other people.

With such powerful weapons to fight this disease, reversing the growth of the pandemic now seems possible. UNAIDS has adopted the ambitious 90-90-90 targets – that by 2020, 90% of people living with HIV should know their status, 90% of those should be on treatment, and 90% of those on treatment should have a suppressed viral load. This has driven a huge global scale-up of ART provision, and data from severely-affected countries such as Swaziland is beginning to show the benefits.

So what about Sierra Leone? In Western Africa the picture is complex. On the one hand, fortunately, levels of infection have not reached the levels seen in Southern and Eastern Africa. Sierra Leone’s 2013 Demographic Health Survey found a prevalence of 1.5%, with up-to-date results due in 2018. However, the lower burden of infection means that HIV has previously been afforded a lower priority and less international donor support than in other countries. There is an increasing recognition that Western and Central Africa are being “left out” of the HIV progress seen elsewhere in the continent.

The problem is multifactorial. In the highest-burden countries, almost everyone will know a friend or neighbour who is affected by HIV, which has some effect on normalising the disease. In Sierra Leone, despite the support of counsellors and peer networks, the majority of people living with HIV have not disclosed their status to anyone, for fear of discrimination or even abandonment. As a result, many people believe HIV to be a rare problem, or one that is confined to certain marginalised groups such as men who have sex with men or commercial sex workers. Most sexually-active young adults do not perceive themselves as being at risk of infection, and condom use is low. Fear of HIV affects testing rates, while infected people who are hiding their HIV status from their families find it very difficult to access care and take treatment regularly.

While ART medications are provided free to patients through the Global Fund, people living with HIV face multiple other barriers to care. Limited human and physical resources mean that patients may have to travel some distance to an ART site, and the cost in time and money may be prohibitive. In the rainy season, it can be difficult for supplies to reach remote clinics and stock-outs may occur. This is particularly problematic because excellent adherence is required for ART to successfully suppress the virus. Missed doses because of stock-outs or financial problems, or interruption of care during the Ebola outbreak, can lead to irreversible drug resistance developing.

This formidable challenge means that many people living with HIV in Sierra Leone are not benefiting from prompt diagnosis and effective suppressive ART, and instead develop weakened immune systems and infections such as tuberculosis and cryptococcal meningitis. People living with HIV therefore make up a very high proportion of medical inpatients in Connaught Hospital, with associated high mortality.

Recognising the scale of the challenge facing Sierra Leone, in 2017 the National HIV/AIDS Secretariat launched the ambitious “Catch Up Plan”, which aims to rapidly scale-up HIV testing and treatment across the country. Along with other NGOs, KSLP has been working with the National HIV/AIDS Control Programme to support implementation of the plan.

As part of the national HIV Technical Working Group, KSLP members have been centrally involved in updating the 2017 ART Guidelines to reflec,t the WHO’s 2015 “Test and Treat” recommendation – that all people living with HIV should initiate ART, rather than just those who have evidence of a weakened immune system. We have also been supporting national training sessions on these new guidelines for HIV workers across Sierra Leone, mentoring and supervising staff in Connaught to ensure their implementation, and working on translating these guidelines into a more accessible format which can be disseminated by smartphone app.

In Connaught we have been working with the hospital management and HIV counsellors to increase testing through provider-initiated testing and counselling for patients attending the hospital. This strategy, which is recommended by the WHO, takes advantage of a person’s contact with health services to offer them HIV testing, regardless of the reason for presentation. This has led to a dramatic increase in the rates of HIV testing, particularly amongst medical inpatients. We support care for these inpatients through clinical work with the junior doctors and regular HIV ward rounds with Connaught’s clinicians, and by improving systems to promote access to important tests such as CD4 and TB screening. We are collaborating with a local infectious disease specialist to pilot screening for cryptococcal disease in HIV patients with advanced immunosuppression , and to learn more about the prevalence of cryptococcosis in Sierra Leone.

Treating HIV in Sierra Leone can involve witnessing a tragic loss of young lives when people present with very advanced disease. However, the amazing effects of the treatment mean that it can also be extremely rewarding. A few months ago, I reviewed a lady in her twenties who presented with speech difficulty and complete paralysis of the right side of her body. She had initially been diagnosed with a stroke, but when her admission HIV test was positive we decided to treat her empirically for cerebral toxoplasmosis, a parasitic brain infection seen in people with advanced HIV. The improvement was remarkable. She regained her ability to walk and talk, started ART, and now just has some mild hand weakness. I regularly bump into her and her mother waiting outside the physiotherapy department for her appointment, gaining weight and looking healthy.

In addition to individual success stories there is definite progress following the Catch Up Plan, on both concrete targets and more subtle indicators. When I first arrived in Sierra Leone in January I found many people reluctant to talk about HIV. Healthcare workers adopt euphemistic acronyms – RVS (retroviral syndrome) or ISD (immunosuppressive disease) rather than utter those other three letters. One of the aims of provider-initiated HIV testing was to normalise HIV as “just another disease”, like hypertension or diabetes. Now it feels like the dialogue is changing, with a noticeable increase in awareness and willingness to discuss the problem. Connaught’s young doctors are passionate advocates for their HIV patients, and gain a lot of knowledge and experience about HIV management. While there is still a long way to go in tackling stigma, it feels like people are talking more openly about it.

HIV progress starts with openness and advocacy. So, Happy World AIDS Day! Celebrate by telling one other person the news that people who are on treatment with a suppressed viral load live a normal healthy life and are unable to transmit the virus. We’re looking forward to continuing to work with Connaught and the National HIV/AIDS Secretariat to make that a reality for more people living with HIV in Sierra Leone.

Hannah and Dr Lakoh teaching a session on scaling up HIV services across Sierra Leone last week.

Antibiotic Awareness Week: Guideline Launch!

In this post, our infectious diseases volunteer Imogen offers some insight into the issue of antimicrobial resistance in Sierra Leone and describes the antimicrobial guidelines project which was launched during World Antibiotic Awareness Week.



This week is World Antibiotic Awareness Week and around the world there has been a focus on promoting both awareness of antimicrobial resistance and the need for antimicrobial stewardship, i.e. responsible usage by clinicians and patients alike. During this time, the KSLP infectious diseases team oversaw the launch of the University of Sierra Leone Teaching Hospitals Complex (USLTHC) Connaught Hospital Anti Microbial Guideline. This is the fruit of over a year’s work, drawing on expertise from a variety of local and international partners. We hope this will be a useful reference for junior doctors at Connaught Hospital, who requested guidelines like these to improve their ability in prescribing as they report not much formal teaching about prescribing in their undergraduate training. Following graduation, they bear huge levels of responsibility, especially as due to well documented human resource constraints, they can find themselves operating fairly independently very early in their careers.

Audit data from Connaught Hospital from March 2016 showed that 76% of medical admissions through the emergency department were prescribed antibiotics, and of those prescribed, 88% had an inappropriate dose, route or frequency. It is evident there was a clear need for simple guidance to help those who provide frontline medical services here with prescribing decisions around this crucial area, especially when it is known that the use of broad spectrum antibiotics (those that target a number of different types of bacteria) drives resistance.  This guideline serves as the first formal promotion of antimicrobial stewardship in Sierra Leone but there is much more work to be done – firstly, in improving surveillance data. Without a robust laboratory service in the country, anti-microbial resistance goes largely unrecognised with an ‘out of sight, out of mind’ attitude. However, we know there is widespread, indiscriminate use of broad spectrum antibiotics (e.g ciprofloxacin and ceftriaxone) in the community, so it is unsurprising that worrying levels of resistance are starting to be seen with improved surveillance.

The guidelines were drafted by a committee of clinical and pharmacists from Connaught Hospital and KSLP, drawing on national and international guidelines, and local resistance data (where available). The draft was reviewed by stakeholders in Sierra Leone as well as KSLP technical advisors based in the UK, before being presented to the Drugs and Therapeutics Committee at Connaught Hospital. We know the guideline is not perfect, but we hope the recommendations are an improvement on the current practice. One major constraint is the lack of reliable local sensitivity data, and also data about what are the prevalent pathogens. Consideration was given not only to likely pathogens and resistance mechanisms, but also the affordability of drugs to patients – in the interests of best antimicrobial stewardship principles, we would like to always recommend the most narrow spectrum option available for any given condition, but from our experience in clinical practice, we know if this means going from a once daily administered drug to a four times a day administered drug, the price may quadruple, and become unaffordable.

Tests to confirm diagnosis, either pathological or radiological, are also expensive, and therefore a luxury the junior doctors often have to do without. For this reason, we have not emphasised the antibiotic review in this first edition of the guideline as this principle relies so much on good diagnostic support. This principle states that the antibiotics should be reviewed ideally at 48 hours to see if they can be stopped, changed or stepped down from IV to oral.  We have encouraged oral step down, but if there is no additional information to confirm or refute an assumed diagnosis, it is difficult to advocate strongly the other courses of action. In addition, there is the recognition that counterfeit drugs are common in this part of the world, so it is easy to blame the drugs rather than the bugs if the patient is not improving. As a doctor, it is a disheartening environment in which to practice medicine, as you rarely get feedback on whether the right course of action was taken, making it difficult to learn and improve in the crucial early postgraduate stages of training.

It was decided to make use of the smartphone app format, making the resource easily accessible to junior doctors (who all have a smartphone, or perhaps even more than one) and reducing the risk of the documents deteriorating in quality over the years or indeed going missing altogether as we often see in the UK too! To achieve this, we worked with Essential Medical Guidance, based in South Africa, who agreed to host the content on their platform. We hope that using this format will allow changes to be made to content as surveillance data and knowledge evolves in Sierra Leone. We’re very grateful for their support in hosting the guidelines and adapting into the app format and are very proud of the outcome. If the implementation and dissemination is successful then we hope to develop similar guidelines for internal medicine and opportunistic infections which can also be hosted through the Essential Medicine Guidance platform.

So after many months of work, this week we finally launched the app, accompanied by a training session for junior doctors at Connaught Hospital to provide an introduction to antimicrobial resistance and stewardship as well as the functionality of the app. The initial feedback from Junior Doctors was very positive. This launch event also facilitated dialogue between senior clinicians and members of the Pharmacy Board of Sierra Leone, who are leading the delivery of the National Strategic Plan for Combating Antimicrobial Resistance.

Looking to the future, the next steps will be to promote use of the app during mentoring sessions with the junior doctors, complete another audit after implementation, and ultimately continue to develop the ongoing research capacity building projects which are essential to generate local resistance data and inform the next iteration of the guideline. It is also essential to recognise the importance of infection prevention and control (IPC)  – with a reduced level of infections there will be less need for antibiotic use. During the launch of the guidelines, we took the opportunity to strengthen messages around IPC best practices, reminding doctors that IPC exists not only to protect the workforce from the patients, but vice versa as well. Ultimately, we hope that by developing a culture of antimicrobial stewardship in Connaught Hospital, it will be possible to reduce the emergence of antimicrobial resistant infections and consequently reduce avoidable deaths from hospital and community acquired infections.

You can read more about antimicrobial resistance on the WHO website –

And you can also make your stewardship pledge and become an Antibiotic Guardian here –

World Mental Health Day 2017

By Dawn Harris, Mental Health Coordinator



On November 10th, we will be celebrating World Mental Health Day with the theme of ‘Mental Health in the Workplace’. The concept of mental health in Sierra Leone is poorly understood by many and often highly stigmatised. Discrimination against mental illness is common and I imagine that conversations about mental health at work are almost non-existent. Any opportunities to raise awareness need to be embraced.

A large amount of my time in Sierra Leone is spent working with the national team of twenty Mental Health Nurses. These nurses run mental health clinics throughout the country, often working in isolation in their respective units but together they form a vital work force.

On the 14th August 2017 Sierra Leone experienced a deadly mudslide and widespread flooding. Over 500 people lost their lives and an estimated 8000 people were displaced. On the morning of the disaster the mental health nurses had all travelled to Freetown for a training week. Anticipating that the mental health needs of the affected population could rise, the Ministry of Health and Sanitation called upon these nurses to work directly at the worst affected sites as part of the disaster response efforts. My work at KSLP suddenly altered from delivering a teaching week to assisting with the coordination of this response.

Over the following weeks the team worked tirelessly to provide psychological support to thousands of individuals. The environment on the ground was initially very chaotic, with many distressed individuals still searching for loved ones. I heard tragic stories of individuals losing their entire families as they had left the house early to go to work while the rest of the family slept. I witnessed many people sheltering in half-built houses that were not fit for human habitation, with people sleeping directly on dirty floors and with poor sanitation. It was so overwhelming I found it hard to emotionally comprehend the enormity of it all. The burden of carrying out this work on the mental health nurses was vast. They spoke directly with many affected individuals each day, showing continued compassion and empathy. It was almost impossible not to become emotionally invested.


In the wake of this tragedy I must remind myself to focus on the positives so that we can move forwards in a meaningful way. Despite the devastating circumstances there have been moments of relief; children laughing and playing together in the half-built houses, people singing and dancing while sheltering in a church, a young female smiling after receiving potentially lifesaving epilepsy treatment when she had been left untreated for over ten years, and a lone child reunited with family members who they thought had been lost. This, in no way makes up for the enormous losses but has given me a new sense of hope and recovery for these affected individuals.

It has been a privilege working closely with the mental health nurses over this time. There seems to be a renewed enthusiasm within the team for the delivery of mental health support in spite of the daily challenges they face. The nurses have been able to spend more time together, strengthening their bond as a team and building their confidence. It has been inspiring to watch the team grow over this time, despite being stretched to their absolute maximum.


I have been inspired by one health worker in particular who often talks of her passion for mental health and wanting to raise awareness. She lost family members in the mudslide but worked together with the nurses to deliver psychosocial support. Her input on the ground with knowledge of the area was crucial for the success of the intervention, particularly while the environment was so chaotic. I hope that this passion continues and we can harness it to drive forward this outreach service that will now be vital so for this devastated community.

For me personally, this experience has also been a reminder that any of us can be affected by mental health issues at any time. Life can suddenly be altered in ways we cannot predict and potentially trigger mental illness. Even as a mental health worker I am not immune and will acknowledge that this has been a stressful time for everyone involved. Some of the group work carried out in the response has involved talking with the nurses, psychosocial support workers and domestic staff at the camps to raise awareness of stress and its management. The sense of team work, with a sharing of experience and burden has been vital to maintaining each other’s mental health. This can be said of almost any circumstance.

Unfortunately, as a result of the disaster and prioritisation of the response, events to commemorate World Mental Health Day in Sierra Leone may not be as large as previously hoped. At Connaught Hospital the team of Mental Health Link Nurses will visit each ward to raise awareness. At the Ministry level and nationally we are seeing greater recognition of mental health issues. This progress has been achieved as the result of many years of advocacy work by multiple organisations, plus a willingness within the government to improve mental health services. It will take time for this progress to filter outwards to the wider population, when mental illness may be openly talked about in the work place but I believe this is something that will happen. It is exciting to be in Sierra Leone at a time when we have a real opportunity to continue this momentum and build on what has already been achieved.

Life in Freetown

 by Linda Jenkins, KSLP Nurse Educator



I came to Freetown in August 2016 hoping to use my training skills and nursing/midwifery knowledge to work with partners at the faculty of nursing but wasn’t at all sure what the role entailed as I was this was the first KSLP volunteer post in nurse education. Joining a team of skilled medical volunteers seemed daunting at first, but the sense of camaraderie and fun was good as we adjusted to conditions and challenges but also enjoyed the benefits of Salone life (beaches, bars and fresh fish & seafood). I found common ground with some of the nurses who had worked through the Ebola epidemic which helped us create a voice for nursing amongst the medics and researchers!

Linda Blog Banner

It is strange for me to feel that though it’s been many years since I worked in West Africa (I spent three years in a village in Burkina and two in The Gambia) some things are still the same – the heat; the noise; the colours; the music; the pace of life. The welcome for us all is big here although the country has suffered a great deal. Before I arrived, I had some insights through listening to my partner who has spent many years working with Sierra Leone Red Cross and from my daughter who spent time here too. My colleagues at the faculty of nursing are inventive when dealing with the challenges that face them – poor conditions in offices and classrooms; no electricity or water and plenty of students. They accepted me as a partner and I enjoyed getting to know them as friends too. I feel having experience of living in Africa helped me and them to communicate and build relationships, which is the core to partnership working. There are naturally challenges for me and for them. For me it’s taking time to understand and see how things work. It’s never time wasted. For them it’s understanding that Kings doesn’t always bring money but offers skills and connections.

There is no doubt the role that Kings played during Ebola created a positive attitude towards Kings volunteers and this helps forge relationships. I’ve both enjoyed and been frustrated when working here but possibly no more than in my previous NHS role! The work on the curriculum development, sharing the frustrations of the nursing lecturers, meeting the students and invigilating at exams are all highlights of my working time here. The beaches, developing a suntan and being able to work near my partner were highlights of my home life here. There are plenty of outlets for activities outside work like beach walks, (watching) running, swimming, bars and a large international church group to be involved with. As anywhere in low resource countries, it’s getting your head around the obvious contrasts in contexts of poverty and the rural/urban split that is hard. Despite this, the experience is huge and rewarding.

We are currently looking for a new Nurse Educator to replace Linda as she moves onto pastures new – please check our Volunteer page for more details. To apply, please submit a covering letter (maximum 2 pages) and CV (maximum 4 pages) to before midnight on Sunday 24th September.

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.

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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.

Partnership for change: first impressions in Freetown

I’d always wanted to volunteer in a developing country, motivated like many by an interest in applying my skills to help a place in great need. I was attracted to the strong partnership ethos of King’s Sierra Leone Partnership (KSLP) and delighted to have the chance to come and work with Connaught Hospital colleagues.

I joined the NHS as a graduate general management trainee in 2009, after which I worked in various operational and strategic roles including most recently as Programme Director for Diabetes & Stroke Prevention at Health Innovation Network (HIN), the South London Academic Health Science Network. I am grateful to my managers at HIN for kindly allowing me a six month career break to come to KSLP in Freetown.

During my first month at Connaught I was struck by how hospital life is on the one hand of course so totally different, and yet on the other hand many of the issues are similar to the ones that NHS managers devote their careers to solving.

laura-at-connaughtProbably the most striking difference is the spectrum of common diseases. Infectious diseases (such as TB, malaria, HIV, measles, meningitis, pneumonia and others) are very prevalent. Spending time observing in an outpatient clinic during my second week here I was also taken aback by the severity of advanced disease that Connaught staff are treating. In my years in UK hospitals I have never seen so many patients so poorly as I have seen here in just a few weeks.

But while there is what sometimes feels like an overwhelming amount of suffering, there is also a good deal of hope. Patients, relatives and staff are incredibly warm and friendly, greeting strangers they pass in the corridor and one person who I hadn’t met before thanked me profusely for my work! I have met some incredibly strong and resilient people here who have survived some terrible times and are committed to working towards a better healthcare system. The work they do every day is truly impressive and humbling, particularly when you remember that they have far fewer resources of all types than we do in the NHS.

The issues that Connaught has in common with the NHS that I’ve discovered so far are as follows (I’m sure there are more!):

  1. Issues around flow of patients through the hospital – together with Connaught doctors and nurses we’ve started some process mapping to better understand the problems before co-designing solutions
  2. Rotas and handover processes
  3. Ways to embed effective multi-disciplinary working
  4. Estates and maintenance issues
  5. Effective management of outpatient services and ensuring patients do not become lost to follow up
  6. Health records management
  7. Robust systems for audit and quality improvement

And it’s the last two issues where I am focussing my energies for now.

There’s a great deal of enthusiasm in the hospital for improving the health records system, both to improve patient safety and care quality as well as enabling staff to undertake meaningful clinical audits and quality improvement projects. The records office staff in particular are fantastic and we have been working together on the first stages of our improvement plan.

It’s also a fascinating process working with colleagues to start up a rolling programme of quality improvement projects. We’ve established a committee where projects can be proposed, registered and reported on when completed. Our first two projects are about implementing the new international guidelines for the treatment of malaria and improving antibiotic prescribing. We’re going to be running some multi-disciplinary training sessions soon on quality improvement tools and methods. I am learning a lot from colleagues here showing me what is likely to be effective and what is not, and why.

My third project is an evaluation of a major educational programme working with the medical, nursing and pharmacy schools at the College of Medical and Allied Health Sciences (COMAHS). I’m developing some new skills in designing qualitative evaluations and it will be interesting to hear the views of staff and students in the focus groups and interviews early next year.

I’ve always thought that the role of an effective healthcare manager is to provide the best possible environment and conditions for clinicians and patients, so that the best possible patient outcomes are achieved. This means making sure that systems work and that staff have the right skills, equipment and support to meet patients’ needs. As one of my first managers in the NHS memorably put it, “you have to be the glue” that brings the various parts of the system together. These principles are exactly the same here. I’m enjoying learning about how the Connaught management team is approaching this task and trying to make the best contribution I can.

Volunteering overseas is a “less trodden path” for healthcare managers than it is for clinicians, but I would encourage anyone who has an interest to pursue it and get in touch via if you would like to know more. Whilst there are some tough times, it’s an incredible and very worthwhile experience.

Laura Spratling, Hospital management volunteer