The malaria season got worse, then better when the rains stopped in mid-May. The president died just before Easter and the fuel situation got better (making it easier for staff to get to work). The kwacha was devalued in early May (raising the cost of transportation for staff and making them unhappy with current pay). A CT scanner has been recently installed (but is not yet operational).
More importantly, we have initiated several changes to improve the quality of care—especially for the sickest and especially after hours.
What exactly are these improvement projects?
Since I came in February, there have been 4 or 5 major, sustainable changes in practice or the practice environment that we think have made and will make a difference in morbidity and mortality. Note, in addition to recent changes, a couple of years ago a physician from Baylor restructured the clinic/intake process and we are still seeing benefit of that intervention.
First, the physical environment of the highest acuity area on the ward has been changed. When I came too much happened in one small room consisting of a bench and 5 beds– all sick new inpatients were initially evaluated and observed , all new IVs placed, all blood draws for labs, and all IV medication administrations and blood transfusions were started. What this really meant was that most sick patients were quickly sent to a general ward with a much lower level of observation and ability to intervene if something went wrong. The change consisted of creating a separate observation area of 12 beds for the 25 or 30 sickest patients. This has allowed us to put the medications and resuscitation equipment in easy reach of patients and has given us more room to respond. By also trying to place a nurse and clinician always in that room, patients with convulsions and breathing difficulties are identified sooner and therapy started sooner.
Second, the staffing schedule has changed. In January one experienced clinical officer slot was moved from days to a noon to 8p shift, joining the two overnight staff (medical intern and clinical officer intern). Since May, a second experienced clinical officer slot has been moved to join that shift. Evenings are very busy but until now the number of staff have been limited by the need for staff to leave by 4p to get home safely before dark. Some additional funding has incentivized these employees and the hospital provides a ride home at 8p. Having 4 Malawian staff at this busy time helps with flow and with addressing emergencies quickly.
Third, CPAP has come to KCH. CPAP stands for continuous positive airway pressure and it is a technique to give more oxygen support to sick children since we don’t have a ventilator (we can’t place a tube in a child’s lungs to breathe for them). This technique uses very simple technology. It has been embraced by our staff—they know when it’s needed and set it up without our involvement! It has made a life or death change in several kids.
Fourth, we have started a “blood book” to track transfusions. We write in the names of kids from whom we send samples and so know who to keep calling about until we get the blood. Since we transfuse 25-30 kids a day in the malaria season, and sometimes one to two per day die waiting for a transfusion, improving delivery can make a huge difference.
Fifth, we can’t ignore the fact that my partner, Hans, and I have made a difference thorough our experience and presence. We are both Western trained and “not young”. We stay 10-12 hours per day, 7 days a week, and are personally engaged all day with the sickest patients. It is a lot for just two of us but we hope to expand this (so it is sustainable—more in a minute).
One of the Children’s fellows, Michelle Eckerle, is looking at this using admission and death logs to compare this years’ malaria season with recent years. Our impression however, is that mortality is significantly reduced. The numbers are down on a daily basis, maybe close to half, but, of course we don’t know how the admissions this year compare with other years or if other factors are involved (maybe deaths were less well recorded in the past if parents just left with their child at night). Also, with our bigger “observation ward”, staff are not being called to other wards only to find a child has already died. The sickest are in one place and we can give them the best care possible within the limits of our system.
Do you have other changes planned?
First, Hans and I are excited that Rachel Mlotha, our young, Malawian “Head of Department” will return from 6 months of maternity leave in August. That should boost the senior level staffing from 2 to about 3.5 as recently we have also added a British pediatrician 8a to noon M-F. The ministry has assigned another pediatrician, Agip Phiri, starting mid August (4.5). It also looks like the German government will fund a second medical school related pediatric supervisor position with us (Hans is their first) in the person of a Northern Irish pediatrician with Malawi experience(5.0 or 5.5). I will talk about Children’s “after me” in a minute (maybe up to 6 total!!).
Hans has been in discussion with the hospital leadership (and Ministry of Health) to add core staff—more full time clinical officers and even assigning general physicians interested in pediatrics, just out of internship–and nursing staff. We think a smaller number of dedicated-to- us staff (as opposed to a roster of part-timers) and better paid staff could manage the load and raise quality. We would love to have one core staff (not just trainees) on overnight. There are no guarantees these ideas will be accepted and if so, that the positions will be funded and filled.
We are also hopeful that the ministry will find a way to obtain Artemether as a replacement for quinine. Studies in African children show that this change in treatment can reduce mortality of severe malaria by 22% by using artemether instead of quinine. Severe malaria accounts for the largest portion of our deaths.
In another blog it was said that you are hoping to work in Burundi. Some have asked “What does this mean for Malawi, Cincinnati Children’s involvement at Kamuzu Central Hospital and those who are employed where you are living?”
I only came to start Children’s program at KCH, not to be there long term—and by start I will hopefully be the first of a stable rotation of pediatricians. Right now Children’s is looking at which faculty could come and when (as well as big picture and cost of course). They are also looking to cooperate with other American hospitals and NGOs to enhance the number of senior supervisory pediatricians at KCH. From our perspective it would be great if Children’s ongoing participation included use of our current house and employment of the staff. We are centrally located, close to the hospital and well looked after by those who work here. It made our transition to Malawi all the easier and would make a good consistent base for those coming in the future. Children’s has already made an impact through those who have come, my hope is that it will continue.