Simulation Training as a Learning Tool at Connaught Hospital

Alistair Cranfield, Anaesthetist and KSLP volunteer writes about the simulation training courses he delivered to healthcare workers at Connaught Hospital in Freetown. Using artificial aids to replicate real-life scenarios, health workers gain practical skills to ensure safe and effective patient care.

“This course will help me to give good quality care to my patients,” said nurse Ramatu, after participating in a simulation-based training course facilitated by King’s Sierra Leone Partnership (KSLP). The course uses scenarios to help teach the real-life skills required to manage the acutely unwell patients who routinely attend Connaught Hospital in Freetown.

Simulation for real-life scenarios

As the main medical, surgical and referral centre in Sierra Leone many of the newly trained nurses and doctors begin their working careers at Connaught Hospital. As students, most nurses and doctors gain a sound theoretical knowledge of healthcare but have very little practical skills training, so they lack the vital skills required to work effectively within the hospital environment. Part of our mission at KSLP is to work in partnership with teams at Connaught Hospital to ensure staff can apply theoretical knowledge towards safe, effective patient care. Simulation-based training is a proven way to do this, which is increasingly being used in such settings.

Simulation training uses artificial aides to replicate real-life scenarios, creating a learning environment in which patient care is not compromised. Using patient models, spare equipment and tools for patient observations, simulations allow students to experience clinical situations, developing the knowledge and skills required to manage them. It can be particularly useful in developing the ‘non-technical skills’ – including communication, team working, leadership and task coordination – which are essential for improving patient care and preventing errors. Research shows that up to 80 per cent of anaesthetic incidents occur because of failure of non-technical skills.

Assistance from the Royal College of Anaesthetists (RCOA)

Simulation is a valuable tool in medical education, but it is less commonly used in low-resource settings. High costs coupled with significant human and logistical barriers contribute to this. Since 2018, the UK Royal College of Anaesthetists (RCOA) has supported simulation as an educational tool at Connaught Hospital. By funding volunteers to be placed here we have been able to establish regular simulation training through specially designed and tailored educational courses. Connaught Hospital has also benefitted from the donation of a high-fidelity simulation manikin and equipment by the RCOA. With real-time speech, breath sounds and respiratory effort, the manikin provides an immersive experience for trainees and facilitates learning by creating more realistic clinical scenarios.

Healthcare workers take part in a training with a high-fidelity simulation manikin

Simulation as an essential part of staff training

KSLP has helped to ensure that simulation forms an increasing part of training at Connaught Hospital, and complements other education delivered in the form of lectures, practical sessions and clinical mentorship. Courses have been developed and delivered by subsequent volunteers, ensuring continuity and an ongoing educational presence within Connaught.

One of the most established training courses, the RATES Course (Recognition and Treatment of Emergencies in Sierra Leone) uses simulation to underpin many of the key teaching points. Through five scenarios, junior doctors lead and manage simulated medical emergencies in a safe environment, developing leadership and task prioritisation skills. They also learn to manage specific emergency medical conditions which they may not yet have encountered or had to treat independently in clinical practice.

One scenario focuses on the management of the seizing patient, a situation doctors often report feeling unsure of how to handle. These sessions provide a chance for them to practice administering basic management in a safe environment, with feedback provided on areas they might improve on. It allows discussion as a group of any areas they may be unsure and a chance to discuss any particular local issues or preconceptions that may hamper treatment.

Another of our scenarios focuses on sepsis, which remains a global killer and is a common reason for admission. Through the use of simulation, we are able to reinforce the key management goal and the time critical nature of treatment for sepsis if good outcomes are to be achieved. It also allows us to provide additional education through discussion such as linking into the antibiotic guidelines that KSLP has helped develop within the hospital, and the importance of prompt clear referral for senior or intensive care support.

Nurses are also benefiting from simulation training at Connaught. The ‘mini-RATES for nurses’ course has been designed to help nurses build confidence in assessing the unwell patient and develop the skills required to help manage critically unwell patients. Other courses are multi-disciplinary, with doctors and nurses training together. The Primary Trauma Care (PTC) course and a newly implemented Resuscitation Course teach basic life support skills. Both courses have core simulation elements, where doctors and nurses of all specialties train in tandem, promoting teamworking and interpersonal communication.

At KSLP we aim to work in partnership with local staff at Connaught Hospital. Several staff have now been trained to help conduct simulated scenarios for the RATES, mini-RATES and PTC courses. These facilitators are now being integrated into the training courses, receiving further mentorship during each session.

Feedback from participants on courses has been very positive, reinforcing the importance of using simulation alongside traditional techniques. Participants find it a useful tool for the hospital setting, helping to build confidence and teamworking.

Building my skills as a volunteer

As a KSLP volunteer, undertaking simulation training has been a fantastic way to engage with the staff at Connaught Hospital. Working with so many different staff at different stages of their training with different levels of experience has helped me to develop my teaching skills, becoming adaptable to the trainees present and sensitive to the specific needs of the group. It has also been a great way of understanding many of the issues that are faced by staff within the hospital and allowed us to engage in discussion after the simulation scenarios on ways these could be overcome.

Volunteer, Chris Curry delivers simulation training to staff at Connaught Hospital

As an emerging learning technique, simulation has been embraced by medical professionals at Connaught Hospital. Looking to the future we hope it will play a continued and important role in improving the safety of patient care within the hospital. In addition to regular courses to facilitate quality care of the medical and trauma patient, we aim to offer regular simulation training courses in surgery and critical care and anaesthesia, building on a recently delivered Safer Anaesthesia from Education (SAFE) course. We aim to develop a formalised training and mentorship scheme to train simulation facilitators from the hospital. Most of all, we hope that the use of simulation will continue to be embraced at Connaught Hospital and across Sierra Leone.

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 – http://www.who.int/antimicrobial-resistance/en/

And you can also make your stewardship pledge and become an Antibiotic Guardian here – http://antibioticguardian.com

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 volunteer@kslp.org.uk 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

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.

kslp-and-faculty-of-nursing-at-comahs-photo-2

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.