Lean nursing: a foreign concept in EC and ICU?

“Here is Edward Bear, coming downstairs now, bump, bump, bump, on the back of his head, behind Christopher Robin. It is, as far as he knows, the only way of coming downstairs, but sometimes he feels that there really is another way, if only he could stop bumping for a moment and think of it. And then he feels that perhaps there isn’t.”                                                                                                                            – A.A. Milne, Winnie-the-Pooh

Recently I started doing some in-hospital shifts again. Since my first shift, I’ve been pondering whether I should say something or if I should just suffer in silence. This blog is about my experience in one private hospital group. I’m well aware that, by posting this blog, I’m exposing myself to not working in said hospital group again. So, why risk future shifts and cash flow by posting this blog? Because I feel that I have to be true to me and what I stand for. And I don’t think that these experiences are specific to the hospital group or applicable to only nurses.
It’s my experience that most nurses working in hospitals feel like Edward Bear: they have a feeling that maybe their working conditions could be different, that there should be another way than the daily struggle that has been normalized. Maybe because I have worked outside of the industry, and as manager within the industry, I know that the daily conditions of clinical nurses can and should be different.
In his book Lean Hospitals, Mark Graban says that healthcare providers often think that our job or the value that we bring to the hospital is our ability to deal with problems and just work around the issues and get on with things, to improvise and cope. We think that it makes us heroes to go home broken after a tough shift. We do things that should not be done; we work hard at the workarounds that adds no value to the facility, to us or most importantly to the patient. I think that it’s especially true about nursing. Here is why:
1) Inefficient systems and waste within nursing
After being involved in LEAN projects, I look at most nursing processes and see them as beyond absurd. The amount of waste, workarounds and the inefficiencies are downright ridiculous. There is much more to LEAN than it being a process improvement philosophy, but I’m going to describe it as that for now. I do think that the LEAN approach at times tends to oversimplify complex issues, but it’s generally a good approach for linear problems. LEAN thinking categorizes wastes (inefficiencies) in the system that any organization should attempt to reduce such as:
The waste of unnecessary motion: Walking up and down to fetch medication, equipment, linen, water, bedpans, etc. are not always necessary. I’ve been tracking my kilometers walked per shift. My average over 2 months is 5.2km per 12 hour shift. To walk 5.2 km on a flat surface takes about an hour, implying that I spend one hour a day walking, not nursing. Most of my shifts have been in ICU, where the patients are within close proximity to each other and the ‘specialized nurse’ is supposed to be mostly at the patient bedside. Thus, one would expect that ICU nurses walk less than nurses in other units. So how much time do nurses in, say, surgical units spend walking versus nursing?
The waste of waiting: I also work in the emergency center (EC). A well-described concern in ECs across the world is access block. Yet, from a nursing perspective, there seem to be more constraints keeping the patient in EC, than processes that enables the flow of patients through the EC. The EC is at its busiest after hours and on weekends. Yet, this is typically when other services in private healthcare slow down and operates on skeleton staff– including radiology and pharmacy. Inevitably, the EC nurse becomes a gatekeeper for these systems, e.g. the EC nurse needs to call the radiographer prior to a patient going to X-rays. This increases the workload on the nurse and waiting time in the EC, and not to mention that after hours the patients are only allowed to X-rays one at a time.
The waste of overproduction: Again in EC, we overdo the administration. Why, for a follow up patient that only needs to see the doctor for a quick checkup requiring no nursing input, does the nurse need to complete a 4 page document? And, for admission, does the nurse need to copy 8 pages of nursing notes and the doctor’s notes? I know it’s for auditing purposes, but what is the value? With only one printer shared amongst EC and reception staff another delay is created for no obvious reason.
To transfer a patient from ICU to the ward requires similar overproduction of nursing notes. There is the implementation record, the transfer record and the ICU chart. Then, there is the ward documentation that some wards insist that the ICU nurse should complete. Again, overkill. Ordering simple blood tests is another complicated process. The doctor writes up the request (this can be on one of two places, so the nurse better check both!). Then, the nurse ticks it off on the blood request form, writes the bloods, patient name and bed number into a diary for pathology and has to write it into her notes. Re-writing the blood request that might be written in two places into three places increases the chances of error or omission of a test (and it happens regularly, especially when the unit is busy).
The waste of overprocessing: Overprocessing means doing things not wanted by the client. In the EC, the patient is required to sign out at two places before they can be discharged (creating a delay): once to say that they did not handover any valuables or received them back and then to agree to discharge. Asking why we need to do this, the answers varied between ‘it’s the hospital’s rule’ ‘its proof of our input, should the patient complain’ and ‘it’s for auditing purposes’. Considering the risk/benefit profile, is it really true that the risk of a patient complaint is worth the time lost and the compromise on patient flow?
And why do the nurses need to rewrite everything that the doctor wrote down? Would a simple nursing checklist on the doctor’s notes, especially in EC, not improve patient flow?
2) Conflict between job description and client expectation
Patients in private healthcare often state that they are paying a premium for the care that they receive and, as such, they have a right to demand a certain level of care. More often than not, the nurse is responsible for meeting these patient demands. Often, these requests are in conflict with the described nursing functions. In a way, this has created a reverse incentive, where, if the nurse meets the patient’s demands, then on paper it will appear as if the nurse didn’t do their job. But, meeting the job description and doing the job on paper means not meeting the patient’s expectations. Is the exhausting paper trail that nurses must leave (which, it seems, is mostly for auditing purposes) really patient centric and valuable?
It’s a core nursing function to coordinate all other service providers (e.g. physiotherapy, dietician, food requests, and radiology) and all of these services have preconceived ideas of what the nurse’s function and responsibility is. So, it is not surprising that nurses’ end up feeling pulled in every direction and is consistently told that they are not meeting someone’s expectation of what they were supposed to do that day.
3) Doctors behaving like toddlers
Doctors still throw their toys out of the cot…and nurses are still required to pick it the toys. I count quite a few doctors as close friends, so I felt apprehensive making such a blanket statement. But, hear me out – there is no formal process that prevents doctors (and other service providers) from behaving poorly towards nurses. When I worked on the cruise ships, there was a guest vacation policy. Guests could be asked to disembark or leave a public space if they behaved rudely towards the ship’s staff. Perhaps hospitals need to implement a similar kind of policy for inappropriate behavior towards nurses. Nurses are at the core of service delivery in private healthcare and, as such, the hospital and nursing management should ensure the psychological safety of their nurses.
On a recent shift, a doctor behaved poorly in front of patients, visitors, and other staff by shouting at a nurse. He had the nurse in tears for something that was completely out of her control. When he eventually left, even the patient was in tears. How is this patient-centered? And, why should the nurses still be expected to cover for this type of behavior, smooth things over and apologize on behalf of the doctors to the patients and their families?
Another LEAN principle is respect for people…nurses are also people and should be treated as such.
4) My time is valuable
This has probably been the toughest part of returning to clinical nursing. Covering the unit is the most important aspect of a nurse’s life. Family events or plans after work simply need to be adjusted according to the unit’s needs. Fulltime staff members’ shifts change regularly, sometimes at incredibly short notice. If a shift change happens late, the other shift just needs to stay on, no explanation needed. Even though a part of me gets that, a part of me also rebels against the frequency with which it happens.
As an agency nurse, there is the opportunity cost of being booked for a shift. The agencies have the right to cancel your shift up to 2 hours before your shift was due with no financial compensation. Yet, you probably said no to other work or gave up on other opportunities in order to be available for the agency. Taking into consideration that you are required to be on shift 15 minutes early and sometimes have a 30-60 minute travel time, they basically cancel you as you are already on your way to work. Not really fair….and, beware- should you cancel a shift, you are ‘punished’ by not being booked for a few days.
5) The absence of nursing leadership
There are good nursing managers out there. But, are they showing leadership and advocating for nursing care? As I’ve been told: you can see that the unit is busy because the unit manager is hiding in her office behind a closed door.
Why do they do hide? Are they ignorant of the issues on the floor? I think not. I think it’s more a case of the managers feeling as helpless and disempowered as their staff… and they are caught between the staff and the higher levels of management.
Again referring back to LEAN, ‘Go and See’ is crucial. What the nurses on the floor need is for the nursing managers (hospital managers, head office representation) to be there, to be involved, to produce policies that enable them to do their job, to remove constraints and workarounds, basically to operationally manage the unit. By going and seeing those positioned to improve circumstances can experience the current conditions and frustrations. Currently  they remain removed from the daily grind and they hide behind their audits, checklists and paperwork. Nursing and nursing management has become paper and audit driven rather than patient driven. Why this irrational fear of protection with administration?
6) Level of dissatisfaction
In the short time that I’ve been doing shifts again, I’ve really felt disheartened with the level of frustration expressed by nurses. Not to mention the lateral violence, where nurses take out their frustrations on peers or those lower qualified. I daresay that the lateral violence is a direct result of the daily frustrations with waste and inefficient processes, the behavior of doctors and lack of nursing leadership. There is very little psychological safety within the current nursing environment and, again, as someone told me: the managers don’t have our backs.
The LEAN philosophy describes another waste: the waste of human potential. It’s my belief that the current hospital environment wastes nursing potential and therefor is losing great nurses.

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Summary
A quick unscientific Facebook stalking of my university nursing friends revealed that maybe 3-5 of them are still clinically nursing in hospital. Something must be wrong. Especially seeing that people love telling us that nursing is a calling. If that is true, then we all seem to have lost our calling…
Or, is it that the environment has become so detrimental that nursing is no longer appealing or sustainable as a long-term career option? I wrote this blog because I believe that we can and should change the environment. But, it will take strong nursing leadership. Step one of being the patient’s advocate is by being a nursing advocate, advocating for better nursing conditions so that we can be better patient advocates.

Nursing in Africa

In large parts of Africa, decades of war, conflict and instability have left its people with limited access to basic healthcare services. This is aggravated by the fact that the continent carries 25% of the global disease burden and the lowest number of global healthcare worker per capita.
The challenges that impact healthcare service delivery in Africa include (but are obviously not limited to) lacking infrastructure, poor management, lacking equipment, variable care standards and supply chain issues. In 2001, in an attempt to address some of these challenges, the countries belonging to the African Union (AU) committed to allocate 15% of their fiscal budget to healthcare (Abuja declaration 2001). Sadly only six countries succeeded in doing that. It is estimated that even if all of the AU countries allocated 15%, the size of their budgets are simply not enough to address and overcome some of the challenges that face healthcare systems in Africa.
The budget size and lack of allocation or investment in healthcare leads to another problem: dependency on donor funding. Unfortunately donor funding comes with vested interests and may inadvertently contribute to the vertical development of disease specific fields at the expense of horizontal or strengthening of the whole health system. A good example of this is HIV research that across the continent is disproportionately represented and funded.
Because the burden of disease and the demand for healthcare services that’s continuously rising, larger budgets and more healthcare workers are required. Alarmingly statistics demonstrates that in some African countries there has been a decline in the number of healthcare workers over the past twenty years. In addition, there is a known distribution of healthcare workers towards urban areas, leaving rural areas without adequate healthcare delivery structures and staffing.
In most of Africa, the first healthcare worker to provide care to a patient is a nurse (WHO2008). With nurses being the mostly widely spread and available health professionals on the continent, their role cannot be overestimated. Creating more enabling environments for nurses to be educated and work in better conditions should be prioritized. A few issues that seem to be universal to the ability of nurses to perform in Africa are highlighted below. These issues draw on my experience and my conversations with local nurses in the settings in which I’ve worked.
Quality and appropriateness of nurse training
Formal nursing education was brought to Africa by imperialism. This implies that the people who brought formal nursing education to Africa introduced it in a similar way to how it was done in the countries that they came from. Most of these models were (and still are) based on training nurses in-hospital and where one of the primary roles of the nurse is as team member with a medical doctor and others. This is very different from community based care that’s prevalent and required in rural Africa. In most of Africa, the nurse is often a solo practitioner that’s far from hospitals and other team members. The training of the nurses should prepare them for such roles and situations.
Clinical and educational gaps can be identified by furthering research, especially nursing science research in Africa. This then allows the design of curriculum’s that are contextually relevant to the needs of the continent. This is, however, complicated by other issues, namely:

Limited research on indigenous diseases in Africa
Most of the infectious diseases that are endemic to Africa such as schistosomiasis or trypanosomiasis are not well-researched. With limited evidence based guidance, there can be no best nursing practice for these endemic diseases.
The fields that are researched are according to donor specialization and interest. Sun and Larson (2015) did a review of all nursing research from Africa that was published over a decade and found that the most studied areas were associated with funding resources. They also found that prevalent conditions in Africa e.g. malnutrition, diarrhoea disease and other common causes of death were not studied and/or published. This demonstrated a clear gap between the healthcare needs and the fields researched.
Nursing research needs to focus and address the glaring healthcare issues in Africa. Often care in villages is rendered by persons with no training in healthcare, and addressing issues like the need for reliable community based care when developing curriculums or conducting research could impact the health systems tremendously.

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Training facilities
Training facilities across Africa lack enough classrooms, electricity, running tap water and technological advances. Internet has been reported as a scarce resource across various training settings in Africa. The access to electronic resources is limiting for both students and educators. Open-access resources have helped to make science more accessible globally, but there is still a high cost to obtaining research and information making it incredibly tough to stay abreast of new guidelines, especially for nurses in Africa.
Clinical guidance in hospitals is lacking and there are limited simulation models at training facilities. At some of the facilities where I’ve conducted training there have been no CPR manikin’s or other additional models for training. In most places we had to innovate and make our own manikins and other adjuncts.
For healthcare workers in rural areas, obtaining further education or refresher training means uprooting and even leaving a healthcare facility unattended for the duration of their training. This should be considered when we think about educating and upskilling nurses.
Knock-on impact of the doctor shortage in Africa
The lack of doctors, especially in rural areas has resulted in task shifting. Task shifting occurs when tasks that would normally be seen as the doctors’ domain, are shifted to nurses. It increases the nurses’ workload and the nurses are expected to perform tasks that they have not received training for.
The distribution of health facilities and different tiers of care means that the large drainage areas in the rural districts are often manned by nurses without any further medical support close by. This means that the nurses working in rural areas are isolated when dealing with cases that are not within their scope of practice, limited clinical guidelines and difficulty in obtaining help. Telemedicine and technology may offer some solutions provided that it can be reliable in areas with limited electricity, currently no internet etc.

Regulatory issues
In many African countries, graduates are not subject to registration with a statutory body. There may be professional associations, but there is no compulsory registration process and professional licensing. In countries with no regulatory body, there is no representation to lobby for nursing rights or amendments to Acts of Parliament, salaries for nurses or to promote career progression.
Often healthcare worker salaries (including doctors) are not paid on time, if at all. This leads to some healthcare workers having secondary streams of income or funding their own incomes out of privately charging patients’ higher fees.
Gender inequality
In most African societies, gender equality has not yet been achieved. Women receive less education than men, they have less rights and their voice are not heard in the same way. Nursing remains a predominantly female profession and this limits the ability of nurses to assert themselves and it impacts on the ability of the profession to influence national policy.
There is a trend where even though the nurse workforce is mainly female at service delivery level, at top management and policy level it’s represented by men. In the DRC it was established that only 1% of the nurses are male, yet more than 90% of the top levels and education facilities positions are filled by men.
The social determinants allowing people to access healthcare includes basic primary education and gender equity amongst other factors. Sadly neither one of these has been achieved for nurses in Africa and it hampers the progress of nursing education and research across the continent.
Career progression
This tie in with the above, and the fact that because of the role of women in society, nurses being mostly female and the difficulties faced by nurses to render care, career progression may be stunted. Because healthcare workers in rural areas need to travel to further education and because nurses are predominantly women, it is hard for them to leave home and obligations at home to further their career.
Lack of mentorship and language barriers
There is a lack of mentorship to help nurses further themselves as researchers and educators. Organizations such as the AFEM Nurses Group developed a mentorship program with international mentorship support to African nurses. Another program is the Nursing Education Partnership Initiative (NEPI) that was formed in 2011 by PEPFAR to improve nursing and midwifery education in Africa. We need more programs like this.
Mentorship, inclusion into global healthcare networks, research and education are complicated by language barriers. Often nurses working in rural areas do not read or speak English; the language which much of the training material and research is presented in.
Conflict
It has been postulated that there’s a statistically significant relationship between accessibility to care and civil conflict (Rhode 2015). Unrest and conflict creates havoc on the ability to deliver healthcare, train providers, obtain supplies and in violent prone areas access may be restricted as patients are afraid of travelling. During periods of increased violence, the healthcare facilities are looted and healthcare workers intimidated. In violent prone areas, malnutrition is aggravated, harvests are regularly pillaged and access to fields is restricted due to security conditions.
Conclusion
There are various challenges to improving the fragile healthcare systems in Africa. Nurses form the backbone of healthcare service delivery in Africa. The difficulties faced by nurses across the continent are only one challenge; improving dilapidated health facilities and improving on the poor distribution of essential medicines and supplies are other challenges.
In order to improve healthcare systems, nurses needs to be more involved in policy-making, developing healthcare plans and research.

Please note: Africa is not a country and in some of the African countries, the health system is well-established and working. In other’s it’s not going that well. I’m aware that this blog makes blanket statements, however it refers to my experiences and conversations in the country’s that I have travelled to.

References
Munjana OK, Kibuka S, Dovlo D. (2005) The nursing workforce in Sub-Saharan Africa. Issue paper no 7. International Council of Nurses.
Sun C. Larson E. (2015) Clinical nursing and midwifery research in African countries: a scoping review. International Journal of Nursing Studies. 2015 May;52(5):1011-6. doi:10.1016/j.ijnurstu.2015.01.012.
http://www.our-africa.org/women
http://www.who.int/healthsystems/publications/abuja_declaration/en/
Rohde JT. (2015). The relationship between Access to Healthcare and Civil conflict. College of William and Mary. Honors Theses. Paper 99
Abuja Declaration 2001
Klopper HK, Uys LR. 2012. State of Nursing and Nursing Education in Africa: a country by country review. Sigma Theta Tau international
The nursing Education Partnership Initiative in the Democratic Republic of Congo. (2012). Assessment of nursing and midwifery education and training capacity at seven training institutes in the DRC. Synthesis report. Prepared by CapacityPlus, Intrahealth International

Emergency care in Africa: There is no free lunch…

Let hunger be ranked first because if you are hungry you cannot work! No, health is number one, because if you are ill you cannot work! – Discussion group ranking; Musanya Village, Zambia1

The basic economic premise states that our wants are unlimited but our resources to obtain our wants are limited. On an individual level this implies that we are constantly prioritising desires in order to afford the most important ones (I’m using the word desire as an umbrella term for needs and wants). Sometimes we prioritize in a conscious way through budgeting, negotiating with our partners, saving for large expenditures or investing. At other times it’s automatic and we are largely unaware of the process. These ‘automatic’ decisions are based on beliefs and values, rooted in our culture, community and environment.

Every so often the desires are mutually exclusive and choosing one option means giving up on another, thus we make trade-offs or sacrifices. Our willingness to make a trade-off depends on the perceived benefit of the chosen option. The trade-off is not always financial, convenience or time might be valued more than cost. If the benefit is unknown or uncertain, the trade-off is viewed as risky and not worth the effort or cost.

Economics 101

  • Humans have unlimited needs and limited resources
  • We can’t have everything that we need or want
  • What you are willing to give up depends on what you get out of it (the benefit)
  • The decision is not always easy

fsdfs

The relation between income, benefit and trade-off can be seen in the triangle. Income represents the ability to raise financial resources to pay for care and it includes savings, obtaining a loan, etc. Benefit refers to treatment outcome and adequacy of emergency care. The trade-off is the sacrifice made to afford the benefit.

For people living in Africa the benefit is murky and the cost high. Ambulance services are rudimentary limiting the ability to obtain care at the site of injury, transport to definitive care or care during transit. Upon arrival at the health facility, Africans are burdened with out-of-pocket payments prior to stabilisation, resuscitation or basic care. In addition, due to low government investment, healthcare facilities create alternative funding methods to afford supplies, staff etc. These methods generally involve requesting (demanding) supplementary payments, known as informal payments, bribes or gifts. Paying these allows the patient to skip the queue, get a bed and receive care. Other cost considerations are the ‘hidden’ or indirect costs including the travelling costs, transportation, carer accommodation, waiting time and lost income opportunities.

Sadly, these expenditures are incurred to obtain care in facilities where infrastructure is lacking. Running tap water, electricity, basic equipment or medication are not a given. Also healthcare providers are often not well-equipped with basic emergency care skills.

Trade-offs are made in order to afford the care and may include

  • Reducing the household’s food consumption and budget
  • Selling a girl child into underage marriage
  • Selling assets such as livestock or dwelling
  • Removing children from school
  • Child labour
  • Selling foodstuffs like maize
  • Taking out loans at a high interest rates
  • If there’s more than one patient, prioritising care for one member at the expense of another

Basically, accessing emergency care requires massive trade-offs for a very uncertain benefit. An alternative is to not access care and hope for the best. This becomes a reasonable option when one considers that each year approximately 25 million Africans are pushed into poverty due to healthcare expenditure. Catastrophic health expenditure is calculated in various ways; however most methods exclude informal, indirect costs and the depletive sacrifices. The entire household suffers the repercussions of financial ruin.

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Emergency care benefits only the patient. The household makes the sacrifice so that one person can potentially benefit. It’s further complicated due to the urgency, emergency care requires time-critical interventions and delaying care can be devastating. The decisions taken shortly after a traumatic incident are probably not well-thought through, rational or informed. Predicting the required sacrifices is confounded due to different types of cost, changing costing structures and a whole lot of unknowns. It’s a tough call.

When we are involved in developing and strengthening systems in other communities than our own, we need to be aware that as outsiders we don’t understand the daily reality of those we serve. We can’t assume the local needs, wants, trade-offs and norms. Our observations are clouded by our own bias. This can be overcome by establishing ways to enable community participation that allows the implementation of sustainable and locally owned interventions.

On another level, advocacy for the greater good of accessible care includes continued lobbying for universal access to healthcare. Emergency care, especially out-of-hospital systems can significantly reduce cost as a barrier to access care.

                        For me a good life is to be healthy1 – Old Man Ethiopia

This blog includes some aspects that I addressed at the BADem symposium regarding the trade-offs that people make in Africa to access healthcare.

  1. Dying for change, poor people’s experience of health and ill-health. World Bank Study 2000. www.worldbank.org/poverty/voices

 

 

 

BADEM2016

Yesterday I had the privilege to participate in the emergency medicine symposium held by BadEM in Cape Town.  Conferences, symposiums and workshops that attract big name-speakers are often expensive and definitely unaffordable to students.  This symposium not only attracted THE big names in Emergency Medicine in South Africa, it was also FREE allowing everyone to participate and it filled 400 seats.  

The BadEm team are great believers in the power of social media, especially free open access medical education (FOAMed) and the power of social media was once again demonstrated.  By mid-morning (if not earlier) #BADEM16 was trending on twitter.  Word about what is important in emergency care in Africa gained a global audience and tweets were flowing in from all over the world.  How brilliant!

The BADEM16 talks was thought –provoking and covered themes including to stop using first world solutions for the developing world; should we be training CPR in low resource settings; owning up and learning from mistakes, errors and omissions; how to have the difficult death conversation with the family and how to allow the patient to die with dignity.  And that we need new solutions for the same old problems. 

I found it refreshing that clinical expertise took a bit of backseat, allowing the conversation to be on things that I think really matters, such as how do we develop sustainable cost-effective systems that the patients can trust and where people actually want to and can effectively work in the system.

Emergency Medicine is leading the way to new frontiers.  By creating global awareness, the need for emergency care systems can become a priority, resulting in better resource allocation and investment into emergency care systems.

In conclusion, this is without doubt an exciting time in the development of emergency care in Africa.  I feel incredibly blessed to be part of the story that we are writing, the story of how emergency care in Africa was developed.  To the BADEM team, well done!

See some pics below

NS – a blog to follow shortly on my talk and the fact that there is no free lunch

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check out badem.co.za

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Prof Wallis talking about CPR

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Some of the speakers and the BADEM team

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One of the tweets during my talk

 

 

Gugu Zulu: Another story about the barriers to access emergency care in Africa

In Africa, surviving serious illness or injury is like participating in Survivor.  In order to survive, people need to outwit, outlast and outplay the health system.

The death of the fit, apparently healthy 38-year old Gugu Zulu made news headlines. The events leading to his death are tragic. Zulu, a well-known South African personality died during the Trek4Mandela Kilimanjaro expedition that raises awareness for the #keepingagirlchildinschool movement.

Details on the descent that were supposed to improve Zulu’s condition and allow for further care are sketchy. The timeline in the media reports differ, some saying that it took 4 hours to cover 32 km on a bicycle stretcher, others say 8 hours.  Still, how terrifying the experience must’ve been for his wife that remained at his side throughout the journey.  Despite discrepancies in timelines and the exact cause of death still pending autopsy results, it appears that the lack of timely access to further emergency care was a contributing factor leading to his death.

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Example of the bicycle stretchers used in Kilimanjaro

 

Gugu Zulu required urgent emergency care, and he died because he couldn’t get to care. Sadly, the story repeats itself in various African settings on a daily basis where people frequently die because of health system failures. They die because there is no available transport to the health facilities, which are too far apart and ill-equipped.  They die because care is unaffordable and healthcare staff are not trained to deal with emergencies.  And they die because there are no out-of-hospital care systems (see earlier blogs on access to care and EFAR).

In Zulu’s case (and depending on the route taken) the closest appropriate facility was about 50km away from the National Park. The Kilimanjaro Christian Medical Clinic (KCMC) is a 600 bed facility and it has an emergency care department that doubles as outpatient clinic. It serves the healthcare needs of 15 million people. Time, geographical accessibility and method of transport appears to have been bigger issues contributing to his death than only the availability of an appropriate facility.

The effectiveness of emergency care is dependent on time. The following definition for emergency care was agreed upon at the African Federation for Emergency Medicine (AFEM) consensus conference in April this year: ‘emergency health conditions are those requiring rapid intervention to avert death or disability, and those for which treatment delays of hours or less make interventions less effective.’

Obtaining care for emergency health conditions are a challenge in Tanzania.  The country has a doctor to patient ratio of 2 per 100 000 people. Another constraint as highlighted in this case is the lack of formal out-of-hospital services. Formal systems would facilitate the delivery of care at site of injury/illness and continued care during transportation.

That said, Tanzania is one of the very few African countries that has emergency medicine residency and emergency nursing programmes. Local emergency care practitioners have been supported by international faculty to share expertise.  In 2011 the Emergency Medicine Association of Tanzania (EMAT) was formed.  This organisation works closely with the government to prioritise emergency care and to development emergency care.  EMAT and AFEM works closely together to advocate for the unrestricted access to emergency health care.

Ensuring unrestricted access to emergency care by developing sustainable systems requires awareness and funding.  Sadly, emergency care does not yet share a similar status to that of high-profile diseases like HIV, TB and Malaria.  People are aware of the high-profile diseases and thus they are well-funded and promoted.

The death of Gugu Zulu begs the important question, can global stakeholders in health care continue to ignore the importance of developing strong emergency care and out-of-hospital care systems?

As Olive Kobusingye says,

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In future, the stories told in Africa will depend on how well we advocate and continue building emergency healthcare systems.

P.S. I would like to share an idea that we’ve been talking about since the WHO Basic Emergency Course last year. The idea is to travel from clinic to clinic through some countries that has ties with AFEM by cycling and/or using the method of transport that the different communities would use to access care. The purpose is to raise the awareness of how hard it is to obtain emergency care.  I would welcome some ideas on how we could make such an undertaking work. 

Further reading

Gugu Zulu

https://www.ecr.co.za/news-sport/news/small-medical-facility-needed-mount-kilimanjaro-letshego-zulu/

http://www.msn.com/en-za/news/localnews/gugu-zulus-wife-pleads-for-mini-medical-facility-to-be-erected-on-mount-kilimanjaro/ar-BBuZ6G2?li=AAaxc0E&ocid=spartandhp

https://www.researchgate.net/profile/David_Irwin3/publication/267102897_A_Retrospective_Study_of_Acute_Mountain_Sickness_on_Mt._Kilimanjaro_Using_Trekking_Company_Data/links/54da49c70cf233119bc29c23.pdf

http://www.iol.co.za/motoring/industry-news/gugu-zulus-death-is-a-blight-on-tanzania-2049525

http://www.iol.co.za/motoring/industry-news/kilimanjaro-tragedy-the-inside-story-2047032

Emergency care

http://www.afem.info/

http://www.emat.or.tz/

http://www.kcmc.ac.tz/index.php?q=casuality

http://www.epijournal.com/articles/167/hendry-sawe-young-leaders-bring-fresh-energy-to-african-emergency-medicine

Access to care: time to reconsider the concept?

Imagine the uncertainty and level of decision-making required to visit a healthcare facility for a cholesterol test, blood pressure check or the renewal of a script versus requiring care and transport at the scene of an accident where there’s multiple injured patients, some requiring urgent care.

The pressure to make decisions, the emotional intensity involved (fear, anxiety, anger, remorse) and the perceptions about the possible barriers to obtain emergency care seem more complex than those required when visiting a primary healthcare clinic. Injury, accidents, sudden illness and complications from non-communicable disease all fall under the umbrella of emergency care.  Because emergency care is a frequent entry point into the healthcare system, one would assume that the barriers to access emergency care have been well-described and explored.

I reviewed more than 50 of the most cited papers that describe access to care and only three mention emergency care. Another interesting observation is that most authors do not clarify what they mean when using the term ‘access to care’. Most articles do however refer to either the behaviour model of access to care or the 5A model.

Models in brief:

The behavioural model of access to care (Aday and Andersen, 1974) highlights the relationship between utilisation and access.  It suggests utilisation as a proxy to measure access.  The flaw of using utilisation as a proxy is that patients that died prior to reaching care are not captured in the measurement.  In emergency care those that could not access care and the reasons why they couldn’t or chose not to access care are incredibly important.

In the 5A model (Pechansky and Thomas, 1981) access to care is described as a best-fit between the characteristics of the health service, the provider and the patient.  (5A’s=Availability, accessibility, affordability, acceptability, accommodation).

In recent years, the approaches became more ‘holistic’ considering variables including culture, society and gender. Access to care has clearly become more than arriving at a healthcare facility.  But again, the ability to seek care during an emergency, at the site of injury/ out-of-hospital or during transit is not mentioned.

Most countries in Africa do not yet have emergency care systems or the infrastructure to support the development of emergency care. Functional and accessible emergency care systems would enable these countries to address the burden of disease, reduce the impact of road traffic accidents and under-5 mortality to name just a few.

In these countries, when a household member requires emergency care the household needs to make harsh decisions and weigh the risk of financial ruin against a family member’s life.  This can cause irrational decision-making or a delay to make the decision. How can this not be a consideration when describing access to care?

Why including emergency care in access to care discussions matter?

The terms emergency care and out-of-hospital care are relatively new and not included in discussions on access to care, especially not those building on the older, generic descriptions.  It makes it hard for policymakers and funders to actually understand what emergency care is, how it enables access to the rest of the healthcare system and why it matters.

If key stakeholders do not understand the terminology used, they are unlikely to prioritize it, promote it or fund it. Measurement and evaluation are important to stakeholders.  Emergency care does not lend itself to quick, affordable projects with measurable outcomes.  For instance to a politician or funder arriving in a village and vaccinating 500 children is measurable and can be promoted.  To develop emergency care takes time and is harder to define and measure and thus less likely to be funded. If we can clarify the concepts around access to emergency care better, we might be able to create measurable outcomes and thus obtain funding and prioritization.

Not including emergency care as a core aspect when defining access to care in general complicates the development and advocacy of emergency care.  Maybe it’s time to design a model similar to the 3D model used for maternal mortality to define the determinants of access to emergency care.

I would love to hear your thoughts:  how would you describe access to care and if you agree that emergency care deserve more mention (or am I just biased?).

Please note that due to space I’m not including all the article. I can send a spreadsheet if anyone would like to see it.  Some of the authors include Donabedian, Aday and Andersen, Frenk, Pechansky and Thomas, McCintyre et al., Ensor and Cooper, Dutton, Gulliford, Goddard and Smith, Hadid and Mohindra, Mooney, Culyer, van Doorslaer and Wagstaff, Peters, O’Donnel and others.

Making EFAR stick

There is no question about the need to develop better emergency care systems in low and middle income countries (LMIC).  However, the significant barriers to developing the systems may appear daunting and unattainable.  This is partially because any emergency care system need to start within the community or wherever incidents may occur, continue with care during transportation of the patient and allow early appropriate treatment at a healthcare facility.

Developing a system across the above continuum is complicated in LMIC’s.  It is expensive and requires the presence of enabling factors external to healthcare.  Examples of the enabling factors include sufficient technology and infrastructure such as telecommunications and roads.

As mentioned in a previous blog, an alternative and/or parallel strategy is to enhance the ability of the community to respond during an emergency.  This is feasible even in areas where healthcare facilities are scarce, roads non-existent and telecommunications lacking.

Developing community responder systems are based on a fundamental principle that developing a basic capacity to render emergency care can be simple, efficient and cost-effective. To ensure sustainability, the following should be considered:

  • Mismatching

The trained members need to either live or work within the community.  This might sound obvious, but often it is not.  Also, training economically active people may result in these people not being within the community most hours of the day.  Design should thus involve training the employed, pensioners, people who work within the community (they might even travel from outside the community to work there) and the unemployed.

  • Managing expectation

Training the unemployed and even the employed may lead to another problem: expectation.  People might participate with the expectation of getting a job or advancing their career and receiving job opportunities.  Expectations needs to be managed by being upfront about what the community responder program is about and what is required from trained community members.

Community members may experience a downer after the initial high of being equipped with life-saving skills, or they may be traumatised by exposure to critically ill and injured people.  Early attention to ways to keep members motivated, engaged and supported emotionally is required.

  • Integration of formal/informal system

If there is a formal ambulance system, the informal (community) and formal systems should be integrated. Community members may feel intimidated by formal emergency care practitioners, and the formal practitioners may not help the situation.  This seems to be a major difficulty when implementing community systems.

  • Equipment and innovation

The other barrier to sustaining community first aid responder programs is the availability of equipment and stock, including splints, bandages and gloves.  In LMIC’s even in healthcare facilities these are scarce items.  Yet if it was freely accessible, it may be impractical to carry stock around at all times.  This makes a case for training the community members ways to improvise and innovate.

A deterrent to continued participation is the cost of phones and airtime for telecommunications with formal emergency services and/or hospitals.

  • Other

Concerns from the community may include if and how good Samaritan legislation would protect them, the need for documentation and remaining current with training and skills.

one tier system

The two tier system.  Mould-Millan et al. 2014

Further discussion

Emergency care competes with an existing bias from foreign funders to fund vertical disease programs, with early and easy measurable outcomes.  For policy makers there is competing budgetary priorities and poor economic growth.

So when advocating for the development of emergency care systems, we need to motivate for cost-effective, easy to implement systems whilst simultaneously developing the more expensive formal systems. Formal systems would include tertiary training, specialization of medical practitioners etc.

Training community volunteers to provide early emergency care and stabilisation can save lives and prevent disability.  The training provided and subsequent informal system needs to be context-specific, defined by the community and their needs.  The greatest challenge after obtaining funding is integrating the participatory community system within formal more bureaucratic systems.

Read more

Jayamaran S, Mabweijano J, Lipnick M, et al. First things first: effectiveness and scalability of a basic prehospital trauma care program for lay first-responders in Kampala, Uganda.  PLoS One 2009; 4: e6955

Mould-Millman NK, et al. AFEM Consensus Conference, 2013.  AFEM out-of-hospital emergency care workgroup consensus paper: advancing out-of-hospital emergency care in Africa – advocacy and development.  African Journal of Emergency Medicine. 2014; 4:90-95

Sasser S, Varghese M, Kellerman A, Lormand JD. Prehospital trauma care systems. Geneva: World Health Organisation.

Tiska MA, et al. A model of prehospital trauma training for lay persons devised in Africa. Emergency Medicine Journal. 2004; 21:237 – 9

http://www.who.int/bulletin/volumes/84/7/editorial20706html/en/