Improvement

Working as a trainee in the UK, my focus had always been on practising medicine to the best of my abilities and to me this meant being a good clinician, making the correct diagnosis and providing effective evidence-based care.  That is what we are taught at medical school and it remains the focus throughout postgraduate training.  There was little emphasis placed on other skills such as teaching, management and service innovation.  Clinical audit was often a tick-box exercise and even if you identified a problem and wanted to make a change, there was not enough time to enact it and as a trainee, we were rarely empowered to have a significant impact.  This is slowly changing, there is a greater emphasis on clinical leadership as a result of widely publicised system failures in the UK and clinicians are being encouraged to re-engage in management.  This makes sense, we practice on the front-line, working with patients every day.  We know what the problems are so we should have a fair idea of how to solve them and improve delivery of care.

When I arrived in Sierra Leone, one of many new concepts that I was introduced to was monitoring and evaluation (M&E) and I spent several hours with my new team composing an M&E framework for the work we would be undertaking.  Although at times it felt a little tedious, it was actually useful in terms of devising a strategy for the year ahead and identifying objectives for research, training and service delivery that we wanted to achieve.  The really challenging part was deciding how we would measure success and deciding what our outcomes would be.  For example, we knew that we wanted to provide training to the nursing staff but how would we demonstrate that we had achieved what we set out to do and how could we determine whether we had been successful.  Results are all important in this business, the problem is that conducting the M&E could be a full-time job in itself.

This led me on to the topic of quality as I thought that a really interesting study would be to demonstrate that the A&E at Connaught is providing quality care to its patients and that this quality is continuously improving due to the work that we are doing alongside the local staff through our various projects.  It would be important for the organisation, positive for the staff and patients would value the service that they are receiving.  As I write this, it sounds very aspirational but I was fresh and full of enthusiasm.  I still believe it is possible eight months on but I am a little more realistic about how much can be achieved in the time I am here.  The challenge is not only in making improvements, but sustaining them and demonstrating that they have been effective, all in a resource constrained environment.

I began with a bit of a review of the literature and also considered UK emergency department quality indicators.  A review of quality measures in resource limited settings published last year in the International Journal of Emergency Medicine identified 180 different indicators of quality while a study set in South Africa using a panel of experts identified 77, of which only one was an outcome measure- that of missed injuries.    A similar process in Canada came to consensus on 48.  It strikes me that there is actually very little consensus at all and it is reassuring that far greater minds than my own have struggled to answer this question.

 

Quality measures are generally divided into structure, process and outcome. Outcome measures are arguably the most important to capture, although the hardest to measure.  For example, given the short time that patients spend in the emergency department, it is difficult to prove that our interventions have a direct impact on mortality.  The first UK quality measure, still with us but increasingly hard to achieve, is the four-hour target.  This has no doubt improved the experience of many patients attending UK A&Es but I have seen some questionable behaviour by departments to achieve this target acting under managerial pressure over the last 10 years- an unintended consequence.

 

Measures that tend to crop up regularly in the literature are time to antibiotics for patients with infection and time to treatment for patients with heart attacks.  In low-income countries such as Sierra Leone, once diagnosed with infection, patients need to buy their antibiotics as well as the cannula and drip for them to be administered.  They may not be able to afford this.  An ECG my not be available to make the diagnosis of a heart attack so most go unrecognised and the only treatment available is aspirin.  There is no formal ambulance service and it would be a long journey indeed to the nearest cardiac catheter lab so patients will present days later, or not at all.

Quality care, according to the Institute of Medicine should be safe, patient-centred, timely, effective, efficient and equitable.  Translating this to what is achievable and what can be measured in low-income settings is a real challenge but we should try our best and bear these factors in mind in whatever projects we undertake.  A lot of work has been put into developing triage at Connaught over the last few years by King’s and the hospital staff.  Taken for granted at home, triage has revolutionised care of sick patients in Freetown and has continued throughout the recent epidemic.  Emergency patients with severe traumatic injuries or life-threatening medical emergencies such as seizures and stroke may have waited hours to be seen in the past – this is not the case now.

I was fortunate to be able to present some of the work conducted on triage and represent the hospital at the International Conference for Emergency Medicine a few weeks ago in South Africa.  During this conference we took part in a consensus meeting to try and refine the list of quality indicators down and I await the final results with interest.  Meanwhile, back in Freetown, the staff are working hard, quality is improving and I have faith that there will be further progress over the next few years.

Triage team hard at work

Setting up for resus training

Quality

Mohamed (not his real name) presented overnight with progressive breathlessness.  He had been seen by the junior doctor on-call who had listened to Mohamed’s chest and heard crackles possibly suggesting some fluid in the lungs.  A diagnosis of heart failure was made and a prescription was written for a diuretic to help shift the fluid off his chest.  Resus had been full, mostly with stable patients and there were no beds available on the admission ward so he was placed on a trolley in the waiting room for the night.  No comment had been made in the notes about his high fever, low oxygen levels or the dangerously low blood pressure recorded on the triage sheet which would suggest an alternative diagnosis of sepsis. 

Because the patient was not in a medical bed, he was not seen on the ward round the following morning and was reviewed several hours later when the diagnosis was changed and appropriate treatment was prescribed.  Fortunately, he had not received the diuretic as he had no money with him to buy the drug, on the flip side he did not get vital antibiotics either.  It is reasonable to say that Mohamed did not receive quality care and may die as a result.  There are a multitude of factors that resulted in his inadequate care.

Before going any further, let me be clear that I am not intending to be critical, I am simply trying to analyse what happened.  Achieving quality care is a challenge in all health systems across the globe and I have encountered many of these issues in the UK.  I have been that junior doctor, in the middle of the night stretched to my limits with little support and have no doubt made diagnostic errors- no one is infallible.  Why was the diagnosis missed?  Maybe the junior doctor did not read the triage sheet, if he did perhaps he did not comprehend the significance of the vital signs recorded.  He may have been tired and over-worked and did not take a thorough history or perform an adequate examination.  If he was tired, it may have been because he had been working during the day in another job as the basic salary is not enough to support his family.  Perhaps he has not been paid.

It is possible that the patient did not give an accurate history and so misled the doctor; this may have been intentional or accidental.  Some patients will conceal a diagnosis of TB or HIV from medical staff and will not disclose the fact that they are currently on treatment or have stopped it for some reason.  They may fear stigmatisation or reprimand.  They have often seen the traditional healer, tried multiple remedies and self-medicated before presenting to hospital too late for cure in order to save money or due to cultural beliefs.

 

The patient was not reviewed by a more experienced doctor overnight; there may not have been a more senior doctor to consult or maybe they were in bed. Because he was not admitted into a bed, he was not reviewed by the nursing staff so his vital signs and deterioration were not identified.  The doctor was therefore not called back to review him.  The beds were full – this could have been a busy shift but perhaps patients were not reviewed on the previous day or the hospital was full so patients could not be transferred.  I could keep going, this is a complex scenario.  The bottom line is that we could have done better for Mohamed.

 

There is certainly no individual to blame in this story, but there are many lessons to be learnt and much to improve upon. It is also unfair to suggest that this reflects standard care in the hospital or to say that this is unique to the setting.  Many of these problems occur in UK hospitals and while systems are more sophisticated and governance stronger at home to minimise adverse events, we do not always achieve good quality care and patients may suffer as a result.  As an example, The Royal College of Emergency Medicine have highlighted that ‘exit block’ leads to excess mortality and this is one of the factors that is contributing to the current crisis in UK emergency medicine.  At the risk of going slightly off topic, I will conclude by saying that achieving quality care is a challenge globally.

 

Resource limitations in Sierra Leone, and many other low-income countries, make delivering quality care extremely difficult and challenging but many basic issues are shared by more developed health systems.  I often get frustrated and these frustrations are shared by my nursing and medical colleagues here – everyone wants to do the best for their patients, it is fundamental to why we enter the profession but after working in prolonged challenging conditions, I can see how morale can dip.  While not directly comparable, the current struggles of UK junior doctors indicate that the grass is certainly not greener at home currently.

Quality care is an international goal although measures of quality may be different depending on the setting and resources available. Quality can mean different things to different people and a health minister’s view of quality may be different to a doctor’s or nurse’s which in turn may have a different focus to that of the patient or their relative.  There are many definitions and no broad consensus on how to measure it but I would argue that it should focus on the experience of the patient as they are at the centre of everything that we do.