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