Recommendations for development at Ishaka Hospital

Feedback to Ishaka Adventist Hospital

The hospital is a friendly and welcoming place to work. We have enjoyed our short time here enormously, have learned a great deal and are sad to be leaving. We hope this feedback will be useful.

Facilities
The hospital facilities are adequate and will improve when the new outpatient department opens. The wards are clean and tidy. Access to diagnostic tests and medicines is adequate.
Staffing levels with the exception of the female and paediatric ward also seem adequate. The calibre of staff is good.
The nurse training school and laboratory technicians school are a positive presence within the Hospital.

Vocational commitment and Morning Prayers
The principles of the Adventist Mission underpin a positive approach to healthcare work. Morning Prayers are an upbeat start to the day and provide a forum for announcements. They encourage punctuality and should run to time finishing at 8.30 prompt.

Clinical Officers
The clinical officers are bright, reliable and conscientious. The hospital suffers for lack of a generalist physician to provide leadership and guidance for them in the outpatient department and on the wards. Without that guidance their practice will become increasingly idiosyncratic.
The Clinical Officers do not adhere closely enough to the sound and sensible advice of the Uganda Clinical Guidelines. They perform many unnecessary investigations. They over-prescribe medication causing unnecessary cost to the patients and exposing them to unnecessary and potentially dangerous adverse drug reactions. They are not used to working to protocols and tend to ignore them even when they are present and very clear. They should be frequently reminded of and urged to follow protocols and the Uganda Clinical Guidelines.

The Clinical Officers should meet every week with one of the Medical Officers for Continuing Medical Education (CME) and to discuss best practice for common conditions. The Clinical Officers should be encouraged to write brief, relevant and legible notes. Patient care would be best served if one clinical officer was attached to the wards for a week at a time.
We are actively seeking a replacement for us and would suggest to the hospital that they make this a financial priority.

Wards
The wards are clean, and not overcrowded. The semi-private ward is the much less busy of the two wards, yet they seem to have similar staffing levels. The women’s and children’s ward is in reality two wards and is dangerously understaffed. Through no fault of the staff this results in children dying needlessly. This needs to be addressed as a priority.
The staff do a handover between shifts and there is a ward book in which decisions and orders from the ward round are written. However, these decisions are not always acted upon. This system needs to be reviewed and improved if possible.
There are no protocols in place. We suggest protocols are introduced and adhered to in at least the following areas
Routine weighing and measuring of children under 5 on accurate scales
Routine voluntary HIV counselling and testing on all admissions
The management of unconscious patients
The management of shock
Fluid balance charts, orders for BP checks
The management of anaphylaxis and transfusion reactions
Blood transfusion chart
Removal of cannulae after IV drugs administration has stopped
Nasogastric tube positioning needs to be checked on each occasion by listening for air in the stomach. At present the ward has no stethoscope to do this.
Although already very busy, we believe matron should prioritise participation in the rounds at least once a week.
There should be access to clean drinking water on the wards for patients. Mosquito nets should be provided, at least on all the children’s beds.

Outpatients
Outpatients runs efficiently and waiting times are reasonable. We have introduced some simple protocols for management of common conditions. These should be kept up to date and added to over time.
The scales are inaccurate and need to be replaced. The department needs scales for weighing children less than 10kg. There are height measures but they are broken and need to be repaired or replaced.
It is unavoidable that people are sometimes waiting for hours, for investigation results for example. There should be access to clean drinking water in the department.
The staff in outpatients need customer care training; they should see patients attending as valued customers who they want to encourage to return.

Laboratory
There are an unacceptably large number of problems with lost specimens, inaccurate labelling and samples being collected in the wrong containers. This causes friction between the wards and the laboratory and teamwork between the lab and the wards is poor. Turn round of the tests and communication of the results to the ward is slow, and this has resulted in at least one death whilst we have been here. There is no system in place for monitoring or ordering of stock, so the lab runs out of reagents and cannot offer testing. Whilst we have been here the lab has run out of reagents for TPHA, FBC, HIV testing (first determine and then unigold) and CD4.
Stock control and ordering procedures are clearly inadequate and need to be improved as a matter of priority. We are often without blood for at least 24 hours before the stock is refreshed. The protocol for blood transfusion does not adhere to the Uganda Clinical Guidelines and this may contribute to the problem of running out of blood.
The laboratory continues to perform tests which are outdated and clinically unhelpful, despite the knowledge that the test is pointless. An example is the Widal Test. The senior staff are aware that the test has no merit, yet continue to order and perform the test, leading to inaccurate diagnosis and treatment of typhoid. They should participate in the CME sessions and pass on their knowledge, to alter clinical practice.
We suggest that the lab staff attend the wards on a daily basis and draw the bloods for testing or train the ward staff on a regular basis. This will ensure correct labelling and container use and we believe will improve communication between these departments.
In our opinion Sunday should be a normal working day. The laboratory staff are reluctant to perform tests on Sundays.

HIV service
The HIV service is relatively new and has great potential. However, the standard of service currently being provided is unacceptably low. HIV testing is rarely available on Fridays and not at all on Saturdays and Sundays. This means that for nearly half the week there is no testing at all. On other days there have been no counsellors and out-stocking of testing kits has been a continual problem. We estimate that testing has actually been available for less than 25% of the time in the 6 weeks we have spent here. All permanent lab staff should perform HIV testing and CD4 counts. It is a mistake for this to remain the preserve of only Duncan and occasionally Vicent. The consequence of a delayed diagnosis of HIV is often fatal when many patients are reluctant to come back to test.
Duncan’s performance as the in charge of HIV testing needs to improve dramatically otherwise the job should be given to someone else. The CD4 machine is capable of giving CD4 percentages, vital in the management of children, but the machine has not been calibrated and the staff member responsible has not arranged for this to happen despite requests.
The service should be redesigned, with a system introduced for timely ordering of test kits and CD4 reagents. Different and more reliable staff should be allocated to this vital area if necessary and sensitisation work undertaken with all staff members and students.
The clinical department suffers for lack of protocols. Starting people on ARVs is often unnecessarily delayed. Liaison with the wards and monitoring of inpatients with HIV/AIDS does not happen, and inpatients are only rarely started on ARV’s.
There remains some uneasiness and stigma amongst ward and outpatient staff about talking to patients about HIV and testing. There is a need for some training for the entire staff here and the HIV department should take the lead on this.

Drugs
Drugs and supplies are generally available, and easily on hand. The pharmacy is efficient and works well. Outstocking should not be tolerated and can be avoided by the introduction of a weekly stock check and never allowing stock on any item to fall below one months maximum usage before reordering. A simple Excel spreadsheet would make this task straightforward. We have placed an example on the computer in the records office which you are welcome to amend and use. The drug stock list needs to be updated to include;
W1050 Salbutamol inhalers
T0014 Aciclovir tablets 200mg
I0138 Cloxacillin 500mg IV vials
W0078 Aqueous cream
R1497 Soft paraffin
W0281 Clotrimazole pessaries
Something for prostatic hypertrophy (doxazosin, prazosin)
W1080 Silver nitrate cautery sticks
W0940 Podophylline solution
T1260 Spironolactone 25mg tabs
W0775 Oramorph solution
R0677 Gentian violet 25g
W0848 Paracetamol 250mg suppositories

Charges
Staff and patients are unaware of the charges in operation in the hospital. The clinical officers need to know the cost of items they prescribe, and charges for supplies and other items. Patients are often anxious about the size of their bills and this affects their decisions to discharge, sometimes earlier than we would recommend. We suggest price lists are displayed prominently on wards and in outpatients and given to clinical officers. Over prescription of intravenous fluids and intravenous drugs can dramatically increase costs.
For as long as the hospital service is so dependent on user charges for income the poorest and sickest members of the community will be discriminated against. Witness the lack of a feeding programme for malnourished children.
The hospital must look elsewhere for income if it is to discharge its obligations to the most needy members of the community.

Continuing education
The presence of the nursing school and laboratory training school is a great asset for the hospital. There is a clear desire to learn from nearly all staff, both those in training and qualified staff members. Regular evening weekly training sessions which are open to all should be introduced and we believe would be popular.

Income generation and investment
The hospital should work closely with VSO and other organisations to explore creative ways to generate income. Presently the hospital operates financially on a hand to mouth basis. There is an atmosphere of continual crisis within management. The service to patients suffers through an unacceptable toleration of out-stocking and no flexibility with charging to the poorest and sickest patients (e.g. malnourished babies).
The danger of underinvestment is worsening of patient services and falling staff morale and commitment. This will threaten the viability of IAH when KIU Hospital is fully operational.
Serious attempts should be made to generate income. The local health insurance plan needs to be reviewed. The cost and quality of private care offered should be increased (whilst maintaining a cheap and efficient service to the majority). Vehicles and facilities should be hired out. More attention should be paid to fundraising in the local and wider community.
The hospital needs a full time fundraiser skilled at negotiating for funds with the District, NGOs and international charities. Such a person should be able to generate an additional income of $50,000 pa. VSO may be able to help with such an appointment.
The hospital and church should use its land holdings to build houses for rent in the booming local market. This would provide long term income.
The hospital could advertise more extensively for medical student and other health professionals to visit from affluent countries and impose higher charges for use of the guest house and transport from and to Entebbe.

Priority areas of review
Increase staffing level on the female and paediatric ward.
Explore innovative fundraising possibilities to create more financial security.
Canvas VSO and other organisations to provide key personnel to develop the clinical service and generate funds for investment in the service.
Provide some staff training on high quality customer care. IAH will need to provide an excellent service if it is to compete with KIU.
Overhaul the HIV service to guarantee good service on 6 days of every week.
Protocols and guidelines to be established and adhered to for all common conditions
Weekly staff education sessions
Stock checking and ordering system put in place to ensure that there are no stockouts of essential items. Outstocking should be regarded as a disciplinary offence.


Jan Power, Mark Russell
February 2007