We’ve been observing emergency and routine ward work for a couple of days now, so I thought it was about time I discussed some of the professional aspects of our stay here.
Our role here is still developing, but over the past few days of clinical observation, discussions and meetings with the seniors here in both medicine and surgery, a few common strands are emerging. In brief, we feel that the main way we can be of use here is in the teaching and training of the junior doctors, both in formal settings and by modelling our approach to them in our clinical work.
There are several issues to be addressed, but one of the most important is the quality of emergency care (medical and surgical) delivered in the acute setting. It would be useful at this stage to describe the current system:
Description of the Accident and Emergency department
The outpatients department has become one of Juba teaching hospital's biggest challenges. It functions as an Accident and Emergency, Outpatient Department and Primary Healthcare Clinic all rolled into one. However due to the sheer volume of patients (around 500 attend the unit every day) there are serious problems with fulfilling its roles.
There is a central seating area in the middle with disabled access that is flanked by the pharmacy, laboratory, and X-ray dept. In front is the Emergency Ward with 9 Emergency beds. There are no fluids, giving sets, cannulae or drugs. In the top right hand side and to the right are 6 small consulting rooms about 3m x 3m (some smaller). Medical Officers (SHO equivalent) from the specialties Pads, O&G, Medicine, and Surgery sit here and interview patients
A&E/OPDHow the department functions
There is no triage. Patients book themselves in at reception and depending on their presenting problems are sent to various specialties by an untrained receptionist. For example if the patient has a limb problem then they are sent to the surgeons. This system is often inaccurate. Worse still, sick and unstable patients are not being recognised. David described on his first visit how poorly patients, lying on the floor, were stepped over so that well patients with minor complaints were seen. He also found a patient whom no one knew, who hadn’t been seen by a doctor, had died on an examination couch.
From a surgical perspective, my observations have been very similar; the other day I went to the department and found three or four poly-trauma patients lying on and bleeding all over the floor unattended, one with a clearly fractured humorous. The doctors on duty at the time were in the office seeing the patients with hernias who registered first in the queue.
Part of the problem is the actual structure of the department, particularly the lack of triage. The doctors are very over-stretched given the sheer volume of patients they are seeing, and this is something we’ll be looking into helping to alter in the future.
Another issue is the acute care delivered to the emergency admissions in the medical and surgical assessment units. Basic observations are generally not completely done, history and examination documentation are usually rather scanty, and there seems to be an inability to distinguish and prioritise the haemodynamically unstable patients.
There is no triage. Patients book themselves in at reception and depending on their presenting problems are sent to various specialties by an untrained receptionist. For example if the patient has a limb problem then they are sent to the surgeons. This system is often inaccurate. Worse still, sick and unstable patients are not being recognised. David described on his first visit how poorly patients, lying on the floor, were stepped over so that well patients with minor complaints were seen. He also found a patient whom no one knew, who hadn’t been seen by a doctor, had died on an examination couch.
From a surgical perspective, my observations have been very similar; the other day I went to the department and found three or four poly-trauma patients lying on and bleeding all over the floor unattended, one with a clearly fractured humorous. The doctors on duty at the time were in the office seeing the patients with hernias who registered first in the queue.
Part of the problem is the actual structure of the department, particularly the lack of triage. The doctors are very over-stretched given the sheer volume of patients they are seeing, and this is something we’ll be looking into helping to alter in the future.
Another issue is the acute care delivered to the emergency admissions in the medical and surgical assessment units. Basic observations are generally not completely done, history and examination documentation are usually rather scanty, and there seems to be an inability to distinguish and prioritise the haemodynamically unstable patients.
David in part of the MAU- Organising formal teaching sessions to run over and reinforce the very basics of the ABCDE approach, including the necessity of measuring the basic physiological parameters, basic fluid management, when to call for help etc.
- Basic training on the importance of documentation
- The introduction of Obs charts, fluid charts etc. (Currently there are none.)
- Look into the restructuring of the A&E/OPD to include a triage system so critically ill or deteriorating patients aren’t unnecessarily left in a queue
- Audit the current system of recording and responding to obs on admission (and identifying and responding to the haemodynamically unstable) then re-audit after training/introduction of obs charts
- Model the approach to the House officers in our own clinical work and notes
I’m sorry if this was a bit of a long post but thanks for sticking with it. We’ll be keeping you updated on how it all pans out but I hope this sets out some of the big picture to put the rest of it in context. As I said, our role’s still emerging...
James (& Dave)
PS I promise the next post will have less text and more pictures!
Hi James, your dad told me what you were up to. will keep in touch - let me have your email.
ReplyDeleteLove, Ruth (Smith)