Context This work was performed at St Francis Hospital, Zambia between February and July 2010. St Francis is a 340 bed hospital in rural Zambia. The number of Medical Staff at the hospital varies from 4 to 20 relying predominantly on volunteers. Zambian Clinical Officers perform a role similar to an Advanced Nurse Practitioner and there are many Midwives, Nurses and students.
The Paediatric ward has an Intensive Care (IC) area with eight beds, two oxygen concentrators, one suction machine and no infusion pumps. There are 28 malnutrition beds, 68 general beds and 18 cots. Inpatient numbers range from 3 to 300 depending on seasonal variation.
Problem My intention was to investigate antibiotic sensitivity to respiratory pathogens. In reality, performing such a study in five months is impossible. You have to manage the acute workload, overcome cultural and language barriers whilst gaining the trust of the staff. My agenda quickly changed.
The admission of a child would typically entail a journey on foot to the hospital, a queue at Outpatients, an assessment by a Clinical Officer then a queue for a cannula. Very sick children would be placed in an IC bed meaning they were reviewed twice a day. New admissions would be seen by a doctor the following morning. No child would have observations recorded.
Intervention Firstly we addressed the problem of children arriving at the ward in a hypoglycaemic coma. We made glucose water and cups available to anyone waiting in the queue at outpatients. Secondly, when possible we assigned a Clinical Officer to paediatric triage so that children were a priority. We rearranged the Intensive Care area to create more beds and introduced an incubator for the acutely unwell babies with malnutrition. We created a portable emergency trolley from a disused wooden cart.
The biggest change was a medical presence on the ward from 08.00–18.00. A daily ward round was conducted and the afternoons spent reviewing those in the IC area and new admissions. The aim was to ensure patients had a nasogastric tube sited with regular glucose water and other appropriate medication. A national blood shortage meant provisions were made for parent to child or staff to child transfusions. We gave tutorials on recognising the acutely unwell child and Neonatal teaching.
Results Results were assessed by examining mortality statistics over the 5 month period as can be seen in Table 1. We presented these results to the hospital and the statistics were used in a Government bid for funding for a permanent Paediatric Clinical Officer.
Discussion Projects attempted in developing countries require time and planning. Advance contact with the hospital and knowledge of resources is essential but can be difficult with poor internet access and work pressures. Current Specialist Training does not lend itself easily to significant time out of programme. However in a short period of time, by addressing small problems and setting achievable goals, quality improvement measures can be made and have a lasting effect.
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