Quality and Safety in Emergency Care in Resource-Constrained S ettings

1. Quality and Safety in Emergency Carein Resource-Constrained Settings Elizabeth Molyneux Queen Elizabeth Central Hospital College of Medicine Malawi

2. Background • Emergency Medicine is seldom recognisedas a specialty • Services are fragmented • Vertical programmes – malaria, TB, HIV • little or no collaboration, • compete for funds • Very few trained staff in emergency care • Funding is tight • (Malawi US$16.2/per capital annually on health)

3. Assessment of quality • Centrally driven • Mostly by looking at mortality figures • Little or no feedback

4. In the hospital Problems Short staffed Staff rotations Little supervision or training Lack of equipment/drugs Poor morale Very little feedback Infection prevention problems – overcrowding, disposal etc

6. Malawi

11. Clinical Standard of Care WHO ‘blue book’

12. Assessment of Quality of Care WHO Assessment Tool a 3600 tool • hospital: numbers admissions, discharges. deaths, cleanliness, supervision drugs, equipment department: staffing levels, allocation, patient flow, job charts, team work staff : knowledge attitude actions guardians: understanding on discharge

13. Assessment results in Malawi 51 government and 16 not-for-profit health units Mortality 6.2% (1.4-12.7%) 51% deaths in <24 hours admission • 83% (44) no triage • Incomplete initial assessment 65.5% • Poorly organised drugs • Poor patient flow • Only 9/53 used ETAT (emergency triage assessment and treatment)

14. Case Management Audit Correct classification Pneumonia 39% Diarrhoea 31% Neonatal history and exam 31.2% Fever 66% Reassessment of seriously ill 7%

15. Efforts to Improve Quality of Care

20. TRIAGE P2 P3 P1 IMMEDIATE CARE PRIORITY CARE NON URGENT CARE CLINICAL AREA 1 RESUSCITATION INITIALCONSULTATION 1. Triage: ETAT Validated Frontloaded Dynamic 2. Monitoring until stable: Convulsions Fluid resuscitation Blood transfusion 4. Interface: seamless Communication In-hospital transfer Senior supervision

23. Triage/ETAT Admissions Case fatality rate 2001 2002 2003

24. 50 40 30 20 10 No of deaths In paed A&E respiratory coma/ fits sepsis 2001-2 2003-4

25. 50 40 30 20 10 No of deaths In paed A&E anaemia respiratory coma/ fits sepsis shock 2001-2 2003-4

28. DEATHS WITHIN 24 HOURS OF ADMISSION: 2003 – patients admitted between 0900 – 0900: 36% 2004 – patients admitted between 0800 – 1700 via RESUS 12.5%

29. OVERALL TOTAL INPATIENT MORTALITY: Effects of Paediatric Emergency Department Pre:10 – 18% (median 12.4%) Post: 4 – 8% (median 5.7%)

30. ROLL OUT OF ETAT & PHI IN MALAWI • 2004 Assessments in 8 hospitals • Adapted WHO Blue Book • Support from PaedDept, College of Medicine • Local support from 2 hospital coordinators • Financial support from URC • Monthly visits from central hospital • 3 monthly meetings of coordinators and activities reported and actions agreed

31. 2006 -2008 PaedsDeptcontinued to support 8 districts • Clinical visits • ETAT training and retraining • Data collection and reporting • Scottish funding for 4 trainings in northern and central region • Monitoring and evaluation

32. 2008 Ministry of Health adopted a paediatric inpatient improvement plan through the ARI unit • 10 districts – pilot 53 hospitals in 16 districts • - Stakeholders meetings and feedback to MOH • - Assessors chosen • - Training of assessors • - ETAT all senior staff • - Assessments done • - The referral management book adapted • 2009Training of trainers • 2010 Extended to 53 hospitals

34. Hospital Measures to Improve Care • Departmental • Mortality meetings/daily meetings • Triage: time and accuracy • Audits and feedback • Data collection streamlined - feedback • Case management • Patient flow • Available equipment/drugs/diagnostics/staff • Leadership • Team work • Multitasking • Advocacy with management

35. Measures to improve and maintain quality • Individual staff • Training ETAT courses modules and case management • Feedback • Leadership • Supervision • Hand washing, hand sprays • Job charts

36. Giving IV fluids How do I make up a 10% glucose solution when I only have 50% glucose 1 part 50% glucose 4 parts of water

37. Giving IV fluids Should I label every bag YES! YES! YES! Label any added solutions; what, when, how much Put a label along the place where the volumes are written on the bag Line + time when it started and what volume Put a line + time at the volume you want in several hours Label the rate you want the drip to run 50MLS 50% GLUCOSE 5PM 2/7 X i- 60mls/hr = 20 drops/min

38. ----- ----8am------ -----10am----- ----12 md----- ----2pm ----- -----4pm----- -----6pm----- ----8pm----- - - - - - - - This is a label with the times at which you expect the fluid level to have Reached that mark

39. How do we assess quality • For patient • Access • Timely help • Pain control • Good notes • Immunisations • Infection control • {Kindness helpfulness • Culture of care • Privacy}

40. OPERATIONS OF THE COMPLAINTS BOXESAT QECHBYL. NYIRENDAMATRON - PAEDIATRICS

41. Critical Care Pathways (CCPs) Less forgotten: history +exam, medications, tests monitoring Good admission notes Nursing, medical notes and lab results together on one page Better team work Better communication Better patient care Fill CCP in regularly at least 2 x a day Better monitoring Better care

42. AUDIT critical care forms Were the correct drugs given? At the correct time and dose? Were vital signs taken? Is fluid rate written and given correctly? Was monitoring done? If a child had a seizure was glucose checked?

43. Global Status on QoC Improvement at Referral Level • By end of 2009: • 40 had introduced quality of referral care activities • 32 conducted hospital assessment • 24 introduced/adapted pocket book • 17 conducted at least 1 ETAT course • 24 had some activities QoC improvement.

44. Global Status of Referral Care Improvement, July 2009 AFRO - 13 AMRO - 4 EMRO - 2 EURO - 11 SEARO - 3 WPRO - 4

45. To improve and embed quality in our services We need • Recognition as a specialty • Have senior supervision • Think about task re-allocations • Include managers

48. To improve and embed quality in our services We need • Pre service training • Less re-allocation staff outside the unit • Assessments • Audits • Training • Equipment • Data

49. To improve and embed quality in our services We need • Trauma care improved • Pre hospital care and transport • Standards eg WHO blue book • Critical Care Pathways • Hub of care

50. Important steps towards long term successful implementation Ownership by the MoH through an already functional unit Leadershipat central and local level