THE 2013/2014 MZUZU CENTRAL HOSPITAL INTERNAL file · Web viewTHE 2013/2014 MZUZU CENTRAL HOSPITAL INTERNAL MEDICINE DEPARTMENT ANNUAL REPORT. Summary. This report is the 2013-2014

THE 2013/2014 MZUZU CENTRAL HOSPITAL INTERNAL MEDICINE DEPARTMENT ANNUAL REPORT

SummaryThis report is the 2013-2014 annual report for the Internal Medicine Department of Mzuzu Central Hospital, Malawi, for July 2013 till June 2014. Found within the report’s introduction is a description of the Internal Medicine department, its mission statement, core functions, objectives, strategies implemented this year, and the planned activities for the year for the financial 2013-2014. It then moves towards discussion of the annual data of the general medical wards and the TB wards, specifically looking at numbers of admissions, diagnoses, mortality, length of stay and HIV status assessment. It provides a description of the challenges along with possible solutions to those challenges. It then concludes with our plans for the 2014-2015 financial year.

To summarise the data provided below the department as a whole saw 3141 patients as inpatients. The overall mortality was 15.6%. The proportion staying less than 5 days was 66%, the number staying less than 10 days was 89% with 11% staying 10 days or over. The HIV status was 61% unknown, 19% non-reactive and 20% reactive. The bacterial infections accounted for 32% of infections, whereas the cardiovascular diseases comprised 19% and malaria 12% of admissions over the year. Anaemia, heart failure, pneumonia and tuberculosis accounted for most of the patients with long stays.

The data provided in this report was compiled by the nursing officers and the matron and was analysed and created by Dr Jonarthan Thevanayagam, but all of the senior team were involved in its discussion and recommendations.

MCZH Internal Medicine Annual Report 2013-2014 Page 1 of 19

IntroductionInfrastructure and human resourcesThe Internal Medicine Department of Mzuzu Central Hospital comprises 3 wards (Male Medical Ward, Female Medical Ward and Tuberculosis [TB] Ward) with a total bed capacity of 102 (34 in each). The department also runs a busy Tuesday General Medical and Thursday Diabetic and Hypertension Outpatient clinics.

There is one principal nursing officer, 6 nursing officers, 16 midwife technicians, 14 patient attendants and 2 data clerks, however, the numbers have varied throughout the year. For example the principal nursing officer was on maternity leave for half of the year, and the chief nursing officer has been at school throughout the year. During the day shift the roistered nurse: bed ratio is about 1:10-12 and at night 1:16.

There have been 4 medical officers for most of the year, (the chief medical officer, two medical officers and a member of the Chinese medical team). There was an addition of a voluntary doctor from the UK who has worked on the team since March 2014.

The Mission of Mzuzu Central Hospital Department of Internal Medicine Providing cost efficient driven health services to our patients and clients with attention to

clinical excellence, patient safety and a health promoting environment.

Core Functions of the departmentThe department’s core business includes:

Provision of specialized in-patient services Provision of specialized out-patient services (specialized medical clinics)

The Strategic Objectives of Mzuzu Central Hospital Department of Internal Medicine

To ensure that there is increased percentage of definitive diagnosis of an in and out-patients in the medical patients so that they are on correct treatment.

To make sure that most of the medically diagnosed patients are managed within the department so as to reduce the cost incurred by both patients and the hospital.

To ensure that the medical department achieve infection prevention status so as to reduce the morbidity and mortality caused by hospital acquired infection.

Objectives setDuring the period under review the department set out to achieve the following:

The use of data to guide in the setting of action objectives. The reduction of the length of hospital stay for clients admitted to medical wards Increase the coverage of provider- initiated HIV testing and counseling (PITC) for in-patients Increase staff development through Continuous Professional Development (CPD).


The re-organization of Tuesday and Thursday ambulatory clinics of cardiac, general, Diabetic and hypertension into Tuesday General Medical Clinic and Thursday Diabetic/Hypertension Clinic.

Strategies implementedIn order to achieve the set objectives, the internal medicine department employed the following strategies:

Implementation of Performance Appraisal Management. Conduction of morning report meetings for case management discussion for both groups of

nurses and clinicians. Re-organization of medical department. Conduction of biannual dissemination of reports of the department to all members the

department and management of Mzuzu Central Hospital.

Planned Activities from Central Hospital Implementation PlanActivity Completed or not?Training clinicians and nurses in endoscopy Not doneTraining clinicians and nurses in doing biopsies Not doneConduct training in Oncology for nurses and clinicians

Not done

Establish orderly hypertension and diabetes clinics

Done

Conduct training on diabetic management DoneReferral of patients to specialized hospitals DoneFacilitate procurement of screens, glucometers, ECG paper, specimen trays, procedure trolleys, bedside stools, patient benches, filing cabinets, nebulizers, bone marrow aspiration needles and trephine biopsy needles

Partly done – only ECG paper and glucometers bought

Orientation of medical department to standards of clinical care in the medical department

Done

Finalizing and dissemination for clinical care standards

Done

Conducting CPDs in the medical department DoneConduct research activities in medicine Not DoneConducting departmental review meetings and death audits

Not done

Provide 24 hour service for both nursing and clinical divisions

Done

Maintain Infection Prevention Standards DoneConduct refresher in PQI/IP to technical and support for medical department

Done


2013-2014 Annual DataMethodologyData elements of interest on patients admitted to Mzuzu Central Hospital internal medicine department wards were extracted from patient files in the wards or the records office where they are filed by month for the reported period of 2013-4. These were compiled on paper, or directly onto an Excel spreadsheet by the nursing officers. Data from previous years has been taken from the previous annual reports. Data was analyzed using Microsoft Office Excel 2013 by a medical doctor.

Data for General Medical Wards (Male and Female)Total admissions and Annual differencesThe general medical wards had 2846 admissions to the medical wards and 295 to the TB ward. Female admissions accounted for 53% (1332) compared to 47% male (1514).

It is difficult to compare the data between different years since the way the data is collected has changed. However, it can be seen that in general terms admissions are falling. Reasons for this fall may be several, including less inappropriate admissions facilitated by better outpatient facilities; better preventative healthcare; higher use of private health care; introduction of fees etc.

Year

General Ward

Admissions

TB Ward admissions

Total admissions

General ward

Deaths

TB Ward

deaths

Total deaths

Mortality general wards

TB ward Mortality

Overall mortality

2010-11 5997 478 478 8.0

2011-12 4666 248 4914 538 65 603 11.5 26.2 12.3

2012-13 3668 419 4087 552 75 627 15.0 17.9 15.3

2013-14 2846 295 3141 407 83 490 14.3 28.1 15.6

Seasonal variationThere was seasonal variability of admissions with a substantial increase in the 3 rd quarter of the year (Jan-March), while much of this are malaria admissions, other admissions also rose at this time such as sepsis, anaemia and CCF during this quarter. This could be due to nutritional problems during this ‘hungry’ season or the interplay between malaria and these conditions. It is difficult to ascertain an exact cause as this variation is not suggested by 2012-13 data whereby the first half of the year had more admissions (2054) than the second half of the year (1614), and so it is possible that recording bias, or change in diagnosing habits may have occurred affecting the data, although this shouldn’t affect absolute numbers.


Q 1 Q 2 Q 3 Q 4

113 93 107 94

536 573

741

589

Quarterly deaths with admissions minus Deaths

Deaths Admissions

Sepsis

Pneumonia

Malaria CCF

Anaemia CVA GEPUD

Psych DM

ABM TBHTN

Malignancy

Epilepsy

Asthma

Alcohol

Poisoning

Crypto

Renal failu

re

Liver f

ailure

0

20

40

60

80

100

120

140

160

Cases per quarter

Q1 Q2 Q3 Q4


Case Mix of Admissions2010-11 % 2011-12 % 2012-13 % 2013-14 %

Total 5997 4666 3668 2846

Sepsis 343 5.73 883 18.9 513 14.0 360 12.6

Malaria 1660 27.7 755 16.2 624 17.0 362 12.7

Pneumonia 757 12.6 616 13.2 550 15.0 330 11.6

Heart disease 262 4.4 264 5.7 220 6.0 233 8.2

Anaemia 245 4.1 0 121 3.3 195 6.9

Stroke 104 2.2 183 5.0 116 4.1

HTN 205 3.4 0 110 3.0 98 3.4

The top causes of admission were malaria (12.7%), sepsis (12.6%), pneumonia (11.6%), cardiac failure (8.2%) and anaemia (6.9%) accounting accumulatively for 52% of total admissions. The next 5 were gastroenteritis (5.2%), CVA (4.1%), peptic ulcer disease (3.8%), diabetes (3.6%), hypertension (3.4%) and tuberculosis (3.4%). In total, these 10 conditions account for 72% of the conditions seen. The top 20 conditions account for 92% of cases, these include in addition to the top ten above: psychosis, bacterial meningitis, malignancies, epilepsy, asthma, liver failure, alcohol related diseases, poisonings and cryptococcal meningitis.

Therefore, it can be seen that the bacterial infections (pneumonia, sepsis, bacterial meningitis and gastroenteritis) accounted for 32.1% of total admission; cardiovascular related disease (cardiac failure, stroke, hypertension and diabetes mellitus) accounted for 19.2%, while malaria accounted for 12.7%. This is in comparison with last year’s figures of 36% for the bacterial infections, 17% for malaria and 19% for cardiovascular related diseases. We are therefore seeing a reduction in malaria cases warranting admission and pneumonias but a steady level of cardiovascular admissions which are therefore increasing their percentage of admissions due to the falling admissions generally. This trend is difficult to analyze over the years due to data sources however.

S e p s i s M a l a r i a P n e u m o n i a H e a r t d i s e a s e

A n a e m i a S t r o k e H T N

343

1660

757

262

245

205

883

755

616

264

104

513 62

4

550

220

121 18

3

110

360

362

330

233

195

116

98

Cases by year2010-11 2011-12 2012-13 2013-14


MortalityThe total mortality rate was 14.3% on the medical wards, which is slightly lower than last year’s 15%, but still unacceptably high. The top causes of death were cardiac failure (caused 16.7% of total deaths: 29.2% disease specific mortality), sepsis (14:15.8), pneumonia (14:17.3), CVA (7.4:25.9), tuberculosis (7.1:29.9) and malignancy (7.1: 48.3). Followed by anaemia (6.1:12.8), bacterial meningitis (4.9:27.0), acute or chronic liver failure (3.4:36.9) and hypertensive disease (2.5:10.2) in total accounting for 83% of the total 407 deaths. The data does not capture the patients who have gone through the medical wards with a diagnosis of TB and then go on to be admitted to the TB ward.

The diagnoses with over 20% mortality and over 12 admissions include malignancy (48.3% mortality), liver failure (36.8), Kaposi’s sarcoma (35%), TB (29.9), cardiac failure (29.2), cryptococcal meningitis (28%), acute bacterial meningitis (27.0), CVA (25.9), renal failure (22.7).

We must look into why

mortality rates are high in this hospital, while it is believed to be about the national average, it is higher than some other poorly-resourced countries. In addition to lack of more advanced medical treatments, like cardiac surgery for rheumatic heart disease and chemotherapy /radiotherapy for malignancies it is possible that less highly resourced treatments are not being delivered, such as oxygen and frequent stock outs of certain drugs like steroids which have proven benefits in particular tuberculosis conditions, and omeprazole for gastric bleeding. In addition, inaccurate timely diagnosis and management may play a part due to delays in initial review, expertise of those


CCFSepsis

Pneumonia CVA TB

Malignancy

AnaemiaABM

Liver f

ailure

HTN GE

Malaria

Cryptoco

ccus KS DM

Renal Failu

rePUD

Psych

Alcohol

Poisoning

Epilepsy

Asthma

0

50

100

150

200

250

300

350

400

Deaths and Discharges by Diagnosis

Deaths Discharges

performing initial review and delays in senior review. It is also hampered by lack of access and delays to diagnostic tests.

Length of stayThere are only results from the 2012-2013 that allow comparison in length of stay. In this field the department have made remarkable improvement. 66.5% of our admissions stay less than 5 days, and 88.9% of patients say less than 10 days. This is a significant improvement on the previous year’s figures of 60% staying less than 5 days and 85% staying less than 10 days.

Strategies we have used to improve this are the continuing morning reports allowing us to discuss new admissions, thrice weekly ward rounds, an improved system of outpatients to allow more clients to be managed as outpatients.

Length of stay by diagnosisThe diseases which accounted for the longest stays in hospital (over 10 days) were anaemia (11.2% of total over 10 day admissions), heart failure (10.5%), pneumonia (8.2%), tuberculosis (8.2%), diabetes (7.8%), and CVA (6.7%).

Of the diseases which had over one admission a month (12 admissions), the conditions with highest proportion of over 10 day stays, and therefore likely to have the longest stay were renal failure (31.2%), polyneuropathies (28.6%), tuberculosis (25.8%), malignancy (25%), diabetes (23.5%), bacterial meningitis (23%), cryptococcus and Kaposi’s sarcoma (20%), liver failure (18.4%), anaemia (17.4%) and CVA (17.2%). While poisoning, asthma, malaria had no stays of over 10 day, peptic ulcer disease, gastroenteritis, alcohol related diseases and sepsis had 5% or under admissions of under 10 days.

Referral rateThe data captured 169 referrals from other districts in the Northern Region where Mzuzu Central Hospital is the official catchment area representing 6% of our admissions. 94% are therefore self-referrals. This low number may be because patients arrive without any referral documentation, or clear record in the files and therefore for data purposes are recorded as self-referred. This does however represent an increase in referrals from last year’s number of 147 (4%).


2012-3 Proportion of stays under 5, 5-10 and over 10 days

Stay<5 Stay5-10 Stay>10

2013-4 Proportion of stays under 5, 5-5-10 and over 10 days

STAY<5 STAY<10 STAY>10

2.1% of admissions (60 patients) were transferred out. This low number may well be due to data capturing issues. These may arise as when patients are referred we often fail to keep a copy of the referral and also we rarely receive written feedback in order to collate and act on these results. 35% (21 patients) of these admissions were for ongoing psychiatric evaluation and management at St John of God hospital. Other patients went to Kamuzu Central Hospital for management of their anaemia (7), malignancies (6), dialysis (4) and imaging especially neurological problems. 1 patient went for management of trypanosomiasis at Rumphi.

We continue to have delays and prolonged stay of patients awaiting transfer due to transport issues. While some patients are able to wait for transport, such as those awaiting imaging, some require more emergency treatment for example dialysis, and this may be a cause of our mortality in those with renal failure.

HIV status assessment

In

2012-2013 63% of patients had their HIV status not known, with 40% being HIV non-reactive in those with known status in 2012-2013. In 2013-2014, the HIV unknown rate was 61%, a reduction of 2%. Of those with HIV status known about 48% were reactive and 52% were non-reactive. It can also be seen that there was an improvement in coverage in the last quarter by looking at the quarterly HIV unknown percentage which was 62.3% in Q1, 63.4% in Q2, 68.5% Q3 and 48.6% in Q4.

Q1 Q2 Q3 Q40

200

400

600

800

HIV status by Quarter

HIV/NR HIV/R HIV/UK

However, in absolute terms 1357 patients had a known status in 2012-3 whereas 1110 were known in 2013-4. Therefore there has been a slight improvement in percentage determined HIV status, but not in absolute numbers and still not near our objective of 100%. Furthermore, it is important to


15%

22%63%

HIV status breakdown 2012-2013

HIV/NR HIV/R HIV/UK

19%

21%61%

HIV status breakdown 2013-2014

HIV/NR HIV/R HIV/UK

note that the data records all those with known HIV status (documented within the last 3 months) and not the number of HIV tests performed in the department. Therefore the coverage of inpatient testing within the department may be far less than these figures suggest.

Difficulties in HIV testing and counselling have arisen due to the lack of trained counselors and the lack of provision of counselling training for our staff. Therefore, we are heavily reliant on the few patients. Verbal results and are recorded as unknown if there is no documented evidence, as are results over 3 months old. Therefore some of the improvement may be due to increasing awareness amongst clinicians and nursing staff to look through patients’ health passport to look for a record of testing within 3 months.

Data for TB wardDuring 2013-4 the TB ward had 295 admissions. Of these patients 96.6% had their HIV status known, with only 10 being unknown (3.4%). Almost 70% (205) were HIV reactive, and 27% (80) were HIV non-reactive. This is an improvement from last year which had a HIV status known percentage of 90, and close to the 100% target that has been set.

July-December 2013 January-June 2014

Number of patients

Percentage total

Mortality Number of patients

Percentage total

Mortality

Smear positive Pulmonary TB

29 17.4% 17.2 25 19.5% 20%

Smear negative pulmonary TB

45 26.9% 31.1% 13 10.1% 7.7%

Extra pulmonary TB

95 56.9% 34.1% 90 70% 25%

Overall 169 32.3% 128 22.3%

The length of stay on the TB ward was high with 15% staying less than 5 days, 35% staying less than 10 days and 64% staying over 10 days. However, most of the admissions to the TB ward come via the general medical wards, and unfortunately the data is unable to capture the length of stay on the TB ward distinguished from how long they were in the general wards.


P TB -ve

P TB +v e

Mi l i

a r y TB

D i ssem

i na t ed T

B

TB l ym

p h a d en i tis

TB Pl e

u r a l effu s i o

n

TB men i n

g i tis

TB Asc i t

es

TB sp i ne

P er i ca r d i a

l effu s i o

n

1510 10 14

9 7 83 3 4

4344

3117

15 16 1314 13

6

TB admissions with deaths by diagnosisDeaths Admissions excluding deaths

83 patients died this year in the TB ward, giving an overall mortality of 28.3%. This should be compared to a mortality rate of 17% last year, where there were a 42% more patients (419) seen on the TB ward. The data also may well be flawed by diagnosis recording, as many of these patients with diagnoses like TB lymphadenitis, probably had disseminated TB which also accounts for its mortality of over 30%. It would be unlikely for such patients to require such prolonged stay and have such mortality. It should also be said that apart from the stay before diagnosis of TB is made we should also consider the necessity of prolonged admission for patients who are on regimen 2 TB treatment, requiring daily streptomycin injections. Much of the admissions on the TB ward are on this regimen, which necessitates prolonged inpatient stay. The other point to make is the hospitalization rate of patients with smear positive TB, who before TB-HIV coexisted would not require a long stay, but are now slower to improve. It has also to be remembered that this data does not capture the number of patients who are seen on the TB ward via outpatients, and are started on outpatient treatments. The TB registry will have access to this data, which were not available on the surmising of this report, but it has to be said that the department treats the vast


majority of TB patients as outpatients.

P TB -ve

P TB +v e

Mi l i

a r y TB

D i ssem

i na t ed T

B

TB l ym

p h a d en i tis

TB Pl e

u r a l effu s i o

n

TB men i n

g i tis

TB Asc i t

es

TB sp i ne

P er i ca r d i a

l effu s i o

n

2420

16 146

13

2 4 16

3434

25

17

1810

19 1315 4

TB admission Length of Stay by TB diagnosisAdmissions under 10 days Admissions 10 days ad over


Achievements with regards to Objectives set The use of data to guide in the setting of action objectives.

o This has not happened as the data has not been analyzed in a timely manner and we hope to improve this in the future.

The reduction of the length of hospital stay for clients admitted to medical wardso The department performed well in this aspect. There are now 6% more overall

patients staying less than 5 days and only 11% staying over 10 days on the general medical wards. Useful strategies that were implemented have worked and include ward rounds three times a week and the daily morning report of medical admissions.

Increase the coverage of provider- initiated HIV testing and counseling (PITC) for in-patientso We have made a small improvement in this from 37% to 39%o Substantial improvement in Mar-June to 51% coverage

Increase staff development through Continuous Professional Development (CPD).o Most staff attended the morning reports which acted as CPDs at times with several

PowerPoint presentations and daily discussion of medical cases.o The nurses collect data on whether staff are attending.

The re-organization of Tuesday and Thursday ambulatory clinics of cardiac, general, Diabetic and hypertension into Tuesday General Medical Clinic and Thursday Diabetic/Hypertension Clinic.

o This has happened to some extent. However, some of our patients have travelled great distances to seek healthcare and cannot morally turn them away if they come on the wrong days.


Challenges and Possible SolutionsHighlighted by the data and the report there are a number of challenges the department face, which are discussed below.

Poor provider initiated testing and counselling coverageDespite improvement in the percentage of admissions with known HIV status we are far short of the 100% target. The reasons behind this are primarily the lack of adequate counselors stationed on the wards. There has been a lack of training of new counselors and so we are reliant on about 3 counselors for the whole department, and so there are often times when there will not be any counsellors on the wards. Another reason is clinicians not checking in health passports for those who have already been tested. We also have to consider why there is such discrepancy between the TB ward coverage rate and the general medical wards. It is possible that the tests were done while on the general wards and were not attributed to them due to movement to the TB ward. Reasons may be due to the long length of stay in the TB wards which allows provider initiate testing and counselling to occur. Even still, it is surprising to see such discrepancy between the wards and we need to look to see if we can learn from the TB ward. In order to improve HIV status determination, we need to:

1. Ensure that more nurses are trained to carry out provider initiated counseling and testing.2. Make sure that clinicians are prompted to check in the health passport as we design a new

admissions proforma.3. Ensure that DCT is carried out on those patients unable to give consent.4. Cultural shift towards normalizing, and reducing the stigma of HIV testing, so that HIV testing

should become a standard test on admission like full blood count and malaria testing.

Speed of diagnostic testsDelays in definitive diagnostic tests have contributed to the prolonged length of stay of patients with for example anaemia, TB and malignancies to name a few. These are primarily problems with getting histopathology results. These arise because the department is reliant on the surgical department in order to do biopsies which occur once a week. They then have to be sent to Blantyre and results take around 2-3 weeks. Many of our patients travel from a distance and may be frail therefore we prefer to keep them in hospital while awaiting these results in order to plan their further management and possible onward referral to Lilongwe or Blantyre.

Difficulties with basic laboratory tests still provide delays. There have been periods of times when even full blood counts and differentials are not working. In addition, the normal turnover of renal function and liver function tests causes delays and difficulties in managing sick patients and no doubt contributes to our mortality. Renal function results from several days ago and without creatinine are not very useful and this has become the standard. Also, the turnaround time of sputum results also contributes to delays in treatments.

In order to tackle these we suggest:

1. Use of the MZCH laboratory department who have started analyzing peripheral blood smears themselves.


2. We have a new UN volunteer doctor who is capable of looking at peripheral blood smears and we should ensure he passes on his skills to others while here to improve capacity.

3. Discussions with the surgical team to see if we can streamline the process of reviews and excision biopsies or even carrying out some biopsies under local anaesthetic and sedation in alternative minor theatres such as that in the emergency department.

4. Discussions with laboratory regarding when delays in basic laboratory tests may be rectified

Data analysis and accuracyThe data collection has been a difficult and tedious job done at the last minute. There are also some errors that occur due to loss of paperwork, mistakes in inputting on the paper form, mistakes entering onto the computerized form. There may also be errors in the final diagnosis of patients which are inputted into the data and could be due to lack of understanding of certain conditions by staff such as sepsis which has a precise definition, which is often not followed.

In order to improve we suggest that:

1. Designing a new Microsoft Excel spreadsheet to be used, or Microsoft Access database to help analyse the data and teaching on how to use it.

2. The production of a discharge letter will also allow for easy input of the data. It should contain referral data, diagnosis, and the HIV status of the patients on discharge and allow working out of the length of stay. This can also be scrutinized by the seniors on the wards.

3. Monthly data reviews in conjunction with a morbidity and mortality meeting. The data will be inputted by a nurse in conjunction with a clinician every month. With smaller numbers the chances of errors being rectified are easier. This will also provide us with a useful tool to pick up on problems as all deaths occurring in the month can be analysed and also an opportunity for learning and possibly research. Discharge letters can also be scrutinized to see if there has been any errors, or lacking information.

Disease specific managementOur mortality rates for certain conditions are high, and our length of stay for some conditions are high. The non-communicable diseases are increasing in significance and are becoming a higher proportion of our admissions, and contribute significantly to our mortality. As stated above also is the possible lack of accurate diagnosis by staff which may present problems analyzing data. Furthermore, there are several interventions that are time critical and have positive impact on mortality, such as antibiotics for infections, and aspirin for stroke and myocardial infarction. Therefore we suggest:

1. Purchase of the clinical guidelines from QECH to be provided to all clinicians, and copies available on the ward for nursing reference. We have started a rolling fund to buy these at cost-price.

2. Production of our own guidelines and treatment algorithms with an emphasis on multidisciplinary approach and timeliness.

3. Conduction of CPD sessions for all staff on priority conditions.4. Clinicians to review all admissions thoroughly within 1 hour of arrival into the hospital, and

to initiate timely management.


Access to higher level careThe department still has episodes where basic nursing observation equipment is non-functioning. This therefore leads to lack of basic observations and therefore recognition of the sick patient. There is also a problem with important observations not being performed like heart rate and respiratory rate. Oxygen delivery is also a problem, with only 2 concentrators per ward. The lack of oxygen availability surely impacts on our mortality for many conditions. As does our lack of access to higher level of care. This can arise due to the lack of a working HDU and an intensive care unit which cannot provide much more than services available on the ward, except for a higher nurse: patient ratio.

Plans to improve this are

1. Production of a new observation chart2. Discussions with the ICU staff regarding creation of an admissions policy to streamline

access to higher level care

Tuberculosis speed of diagnosis and mortalityWe have managed to formally orient nursing and clinical staff on the TB guidelines in terms of reading guidelines to staff in the morning report and by promoting discussion between colleagues on cases. However in addition to time taken or pathology discussed above there is also other difficulties. These include the TB/HIV interplay making presentations more unusual and the high mortality due the late presentation of disease. In addition, there is need to synchronize the TB/ART system which does not capture who is a TB suspect or not.

To improve these we will discuss with the Rainbow clinic and colleagues about whether the system can be changed or not. We understand that this may be difficult due to the difficulties in changing a computerized system.


Strategies to Plan and Implement in 2014-15Based on the challenges raised above, and other challenges our department feels are important we have come to decide on some strategies or plans to implement this year. In order to plan changes and improvements to the department we have thought of simple system solutions to complex problems. The ideas presented are based on neglected processes which are difficult to measure, low cost, but of undisputed benefit. However, they have no cost-recovery mechanism and require synergy across the department and other departments to work together towards a common goal of improving healthcare to our population. The department feels that much improvement can be made by tackling these systematic issues.

1. Improve Admission Proforma and combine with a Discharge lettera. This will improve clinical diagnosis and prompt interns to ask appropriate

questions.b. There will be space for senior review by a medical officer which will ensure more

appropriate management of patientsc. It will also allow better data collection by using the discharge letter and the

admission.d. It will reduce the unnecessary duplication of tests like ultrasounds and

echocardiograms and provide baseline blood tests in cases of re-admission.e. If we have carbon copy paper, patients can also keep a copy of the discharge

letter in their health passport to reduce the need for duplication of work but allows patients to keep copies for continuity of care.

2. Improve recognition of the sick patienta. This will improve triage of our patients to ensure regular review of patients.b. This will require clocks with second hands in each bay to ease the taking of vital

observations like heart and respiratory rate.c. We plan to introduce an early warning system (EWS) based on simple patient

observations and to improve the regularity of observations.d. It will allow earlier pick up of problems and so trigger reviews and earlier

management of problems while they may be reversible.e. Oxygen saturation monitoring would be very helpful to do help with triage and

to allow oxygen to be given if available.f. Oxygen would be a simple treatment if available, and we should aim to increase

its availability by increasing the number of concentrators as well as the using oxygen pressure regulators on oxygen cylinders.

g. We plan to introduce training for on the EWS in order to train those taking observations.

3. With changes to the observation chart we will take the opportunity to change the drug chart.

a. This will allow more responsible prescribing, so that a duration and indication for antibiotics should be clearly stated.

b. There will be clear guidelines on the use of the treatment chart. 4. Improve Documentation

a. By providing enough files for the wards with dividers for every patient.


b. Designing a standard filing system in order to keep track of investigations.5. Improving access to information and guidelines

a. We can do this by providing cost-price guidelines book from QECH.b. Writing our own guidelines.c. Writing patient information leaflets in order to educate our patients and the

public. This will be preventative medicine and will hopefully decrease readmission and complications as well as educate the population.

6. Increasing Continuation of Professional Developmenta. We hope to provide at least weekly bedside/clinical teaching to the clinical

officers.b. We hope to provide hospital wide multidisciplinary CPD sessions addressing

primarily the initial assessment and management of acute situations commonly found throughout the hospital.

7. Improving regulation of the clinical internsa. By providing a logbook, in order for interns to learn and be assessed on their

clinical encountersb. Providing regulations about where interns and officers should be during their

calls – outpatients during the day and emergency during the night.8. As a medical department we also plan to split the wards between the clinicians.

a. This will allow clear accountability and responsibility for patients, so that nursing staff know exactly who to call regarding patients.

b. It will promote better handover of patients and therefore deeper knowledge.c. The main obstacle to this is the number of clinical staff available at any given

time. There are as they may be times when there is only one or two seniors on the wards, and also only one or two juniors.

9. In order to move forward as a united multidisciplinary team, we must have involvement of the nursing staff.

a. This will include increasing the frequency of observations, aided by the new chart above.

b. The ward managers will come together to discuss what is needed to develop nursing care plans.

c. These nursing care plans will become part of our routine admission proforma, and we may combine the clinical admission proforma, with a nursing proforma.

d. The nurses will join on rounds with the clinicians, and move towards knowing in detail all the patients on the ward and will present patients on rounds and specific problems that the multidisciplinary team can try to solve together.

10. We also hope to do monthly morbidity and mortality meetingsa. We aim to have a nurse and a clinician each month to look at the previous

month’s data and present in the last week of the month.b. This will also improve the regular data collection.

11. In order to work collectively within the hospital, we are reliant on other departments and aim to educate and sensitize these departments to our patient’s needs.

a. Intensive care – with the production of the EWS system it will be easier to recognize the sick patient and decide whether higher level care is required.


i. We should equip the ICU with the tools to provide higher level care such as increased oxygen delivery, the possibility of ventilating patients including nursing aspects, pumps for infusion of drugs like insulin, inotropes and sedatives.

ii. We should train the anaesthetic and nursing staff about the above if available.

iii. We should review these patients at least daily including the weekend, and will expect ICU staff to call for reviews if not happened.

b. Outpatients departmenti. We need to work together to produce streamlined outpatients clinics

ii. We can design clinical tools based on guidelines to streamline NCD treatment of hypertension, diabetes, stroke, asthma and cardiac failure.

iii. We will design and distribute Patient Information Leaflets to distribute to the public.

iv. We shall discuss the best way to analyse and capture data from our clinics for use in audit, research and analysis, and work together with the systems already in place.

c. Surgical department – we require their co-operation for the collection of histology samples in order to improve length of stay, and we should discuss this with them.

d. Pharmacy – we require knowledge of what medications are available especially if making guidelines based on or different to the Malawi standard treatment guideline, where there are sometime problems with provision of drugs.

e. Laboratory i. As discussed in the report, we have to work together with this

department to resolve problems with delays. ii. We should also ensure that we do not request inappropriate tests.

f. Radiology i. We have to ensure that inappropriate tests are not requested such as

abdominal radiographs if not needed.ii. We need to develop a system of tracking old results so we do not have

to repeat radiographs or scans, and this will be helped by the discharge summary.

iii. Communications between the departments regarding delays in scans to try to alleviate problems that may arise

g. Records department – we require speed of retrieval of patient notes, and ensure results are kept in case of need at a later time-point.

h. Administration i. In order to financially budget our modest plans, we require knowledge

of the financial system and what is financially available.ii. In order to reduce length of stay and speed of referral to specialist

centres, we require co-operation with the transport office.12. Improve liaison with our referring health centres and district hospitals

a. We aim to provide a discharge letter on discharge, with a plan that can be implemented by the referring clinicians.


b. We will continue district visits, to educate clinicians in the district about what conditions are important to refer or not.

c. We can also use these as specialty clinics if it is well organized in the districti. This will allow diagnosis and treatment of conditions in the district

without patients requiring inpatient stays at MZCH and also speedier refer onto specialist centres if needed.

13. We hope to foster a culture of continual improvement through audit, quality improvement and research within the department in order to track and improve quality of care provided by the department.

i. We can put this into the intern logbook, and encourage the nursing side to develop this also.

Final NoteThis report has highlighted and analysed several issues facing the medical department in 2013-2014. It is hoped that if we can tackle these problems together and implement the plans suggested we can foster a culture of continual improvement and by the next year there may be a decrease the overall hospital mortality, reduced length of stay and provision of better quality healthcare for the population we serve.

Report written and created by Dr Jonarthan Toney Hugh Thevanayagam, BA (Hons), BMBCh, MRCP (UK), DTMH, Volunteer medical doctor.

Data was compiled by the Matron and the Nursing officers of the Internal Medicine department.

The report was checked and ratified by all senior staff in the Department.



Documents

THE 2013/2014 MZUZU CENTRAL HOSPITAL INTERNAL file · Web viewTHE 2013/2014 MZUZU CENTRAL HOSPITAL INTERNAL MEDICINE DEPARTMENT ANNUAL REPORT. Summary. This report is the 2013-2014