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.