Using quality improvement methodology to improve paediatric surgery at Queen Elizabeth Central Hospital, Malawi.
Queen Elizabeth Central Hospital, Blantyre, is Malawi’s largest referral hospital. As such the majority of Malawi’s specialist medical services are found here.
The paediatric surgical unit is one of the biggest units in the department of surgery with three full time paediatric surgeons. We serve a population of about seven and a half million children under the age of fifteen. That’s one surgeon per two and a half million children compared to one per seventy thousand in the UK.
Queen’s is a very special place. Despite being understaffed, underfunded and undersupplied we still manage about 500 major cases per year in paediatric surgery alone. These commonly include surgery for large tumours and complex congenital deformities. While we regularly run out of supplies such as gauze, gloves and antibiotics, we have the support of a 4 bed ICU. While we occasionally struggle to get X-rays, we often have access to free MRI (largely funded through research grants and private fees).
However, despite the lack of physical resources I believe our main deficit is human resources. One nurse may be responsible for 40 children on the paediatric surgical ward. Often there are no nursing staff in recovery. Twelve anaesthetic clinical officers have to cover six operating theatres, an ICU, and run an on call rota to cover emergencies out of hours. There are times when we have no interns on our unit.
Due to the volume of patients, lack of staff, and poor systems, children may sit on our wards for over a month waiting for an operation. We have enough surgeons at present, what we lack is availability of operating time and staff to provide robust care on the wards. Our operating lists are often overbooked, resulting in cancelled cases and children fasted unnecessarily. Some patients catch malaria while waiting and are cancelled again. Others get more sinister infections and suffer. Some even die waiting. Families may decide they have waited too long, that they can no longer neglect their other children, crops or livelihoods. They lose faith in the country’s hospitals and return to the traditional healers. Once children do get through the theatre doors, they may arrive without their investigations, or blood is not available in blood bank. This can result in further cancellation or waste of precious theatre time. In theatre I had started chronicling a series of ‘never events’. Events that should never happen. Antibiotics proven to reduce post-operative infections were sometimes delayed or not given. This means that post-operative recovery was further hampered. Patients were staying longer than they had to. This resulted in our wards being even busier, infections more common, stretched staff stretched even further, and patients suffering avoidable complications and even death. A vicious cycle, not because of a lack of skill or dedication, but because of poor systems and lack of staff.
I do not wish to paint a grim picture of Queen’s. What we manage to achieve with limited resources is remarkable, and we have many successes. However, we recognise that there is room for improvement. It is not within our power to increase staffing levels. However by improving our systems could we operate on more patients, more safely and have them stay on our wards for less time with less complications?
So in September 2012 Isabeau Walker a consultant anaesthetist at Great Ormond Street Children’s Hospital and I applied for the Johnson and Johnson Strengthening Surgical Capacity Grant. We attended quality improvement training at Great Ormond Street Hospital, London. There we met Liz Ball, Quality Improvement Lead for Surgery. She became the third member of our team, and we recruited Mark Clement advanced nurse practitioner on the Children’s Acute Transport Service (CATS), London.
The grant allowed us to fly the UK team out to observe our practise and work with us to help improve our systems. They worked closely with myself, Sister Mallewa nurse in charge of paediatric surgical ward, Sister Chizombwe nurse in charge of main operating theatres, Mrs Rose Kapenda anaesthetic clinical officer and Sister Saka nurse in charge of theatre recovery, as well as many others. I suspect they have learnt as much from us as we have from them.
Quality improvement involves the study of performance and implementation of systemic efforts to improve it. Improvements are made in an on-going cyclical process, using a mix of systems engineering and work place psychology.
Quality improvement methodology will tell you that staff on the ground best know the problems, and best know the solutions. Some will be exasperated in their inability to give the care that they want to give to their patients. Some will work against the odds, in subtly different ways, to produce good results. These are the ‘positive deviants’; our job was to find these people and to support them in their initiatives.
So on the final day of the first visit of the UK team we held an interactive ‘Introduction To Quality Improvement Workshop’. This was a unique event at Queen’s. For the first time we had professors, nurses, anaesthetic clinical officers, doctors, theatre staff and clerical staff, all discussing how they could work better together. The aim was to improve the care of children having surgery in Queen’s; it was an inspirational afternoon, producing over 30 suggestions.
The next year was involved in making some of these suggestions a reality. We prioritised 5 key issues that had emerged from the Quality Improvement Workshop:
The main output was an integrated care pathway for paediatric surgery. A simple four page document designed by the people on the ground, in an iterative process. The first page is filled out before the patient leaves the ward for theatres. It ensures that the patient arrives in theatre with the correct information - demographics, blood results and investigations, consent and brief medical history. This is easily visible on a single page in an easy to find document. Use of the care pathway should result in fewer cancellations, safer operations and anaesthetics, and improved flow through theatre. It has also resulted in our doctors now spending more time consenting our patients. The second page is our own version of the WHO Surgical Safety Checklist. The third page is an operation note but with specific instructions for analgesia, drains and discharge information which we hope will improve safety and hasten discharge. The final page is a drug chart and forty eight hour observation chart. In our last audit the document is being used in 87% of elective cases, and while it is often not used well (a well reported phenomenon of checklists around the world), we are working on it.
We have adopted a new blood ordering protocol which we hope will mean fewer patients cancelled on the day because blood is not available and less wasted theatre time waiting for blood to be cross matched. We have a new reserve patient protocol, so children who have surgery cancelled are not fasted as long. We have a new protocol for dialysis patients undergoing fistula surgery and are developing a painful procedure protocol to manage pain on our wards.
We now have a spreadsheet of patients on our wards with demographics, diagnosis and plan, and a daily senior ward round. With up to 60 children reviewed on a ward round, this should improve flow and length of stay, and perhaps even morbidity and mortality. We have spent a lot of time designing a tablet based system to replace this spreadsheet. If this works well it will further improve our workflow, safety and data collection. Often files are lost on follow-up. It is not uncommon to see a patient in clinic with a scar but no notes. We do not know what operation was done. This database will help us understand what has happened to our patients, and better plan future care.
The Lifebox Foundation donated pulse oximeters which measure oxygen in the blood. Using money from the grant we purchased blood pressure, pulse and saturation monitors to help our nurses better monitor our patients post-operatively.
Finally we have improved communication by introducing weekly meetings within paediatric surgery as well as meetings with nurses, paediatricians, theatre staff and lab staff.
Have these changes made a difference? Data collection is difficult in our environment as we are overloaded with clinical work. Despite this limitation we have been able to show improvements in our length of stay, timing of perioperative antibiotics and an encouraging trend in our mortality. We hope to present these results in detail in a scientific paper.
So what does the future hold? We must continue with our quality improvement work. The integrated care pathway is by no means embedded in our culture. If we stop now all the good work we have done will be undone. We must also complete development of the tablet based patient management system, something for which we have high hopes. We must continue with new developments. We need to find funding for all of these and to formalise the link with Great Ormond Street hospital, without whose assistance none of this would have been possible. I wish to thank them. I also wish to thank our staff who have committed to this process, the UNV staff at UNDP Lilongwe who have been supporting me, and THET and Johnson and Johnson who have made the project possible.
Dr Bip Nandi
United Nations Volunteer Surgeon, Consultant Paediatric Surgeon, Queen Elizabeth Central Hospital, Blantyre, Malawi