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Poole Africa Link Visit to Lira University, October 2015

 

Report from Poole Africa Link Visit to Lira University, Uganda: October 2015

 

Contents Page Number
Introduction 2
Logistics Report 2
Lira University 3
Lira Referral Hospital 4
Midwifery Perspective 4-6
Paediatric Perspective 6
Surgical Perspective 7-8
Links between Lira and Wau 8
Suggestions for future Visits 8-9
Conclusion 9
Appendix 1. Teaching Program for Week 2 10

 

Introduction

 

Team Members:

Frankie Dormon: Consultant Anaesthetist and Team Leader

Pamela Dumashie: Senior Midwife

Antoinette McAulay: Consultant Paediatrician

Judy Mella: Associate Specialist in Surgery

 

Following the unsettled period in South Sudan, and closure every weekend of Juba Airport, a decision was taken during August to cancel the planned trip to Wau Hospital and take a smaller team to Lira University instead.  Frankie Dorman and Peter McEwan had already made a preliminary brief visit to Lira in 2014 following the recommendation of Tim Beacon

 

The overall aims of the trip were as follows:

 

  • To investigate the possibility of establishing a second link with Lira University
  • To develop a working relationship with Lira district Hospital
  • To teach students at Lira University  and if possible staff at Lira Hospital
  • To investigate the possibility of inviting staff from Wau hospital to Lira University to attend clinical courses run jointly by PAL and the university

 

Logistics Report

 

There is no doubt that Uganda is far safer than South Sudan. Our journey from Kampala was by road which is in good condition.  We stayed in Kampala for the first night to ensure that our journey took place during daylight hours and this should be done where possible.  We also met with two contacts in Kampala, so that we had friends who were aware of our presence in the country, as a safety precaution.  It was easy to get sim cards and we remained in contact with each other and have developed a significant network of friends in the country.

In Lira, Hotel Kanberra was clean and enclosed/locked at night with a security guard.  The food was good and plentiful.  We were able to source lunch snacks safely at the market enabling us to maintain a degree of independence. None of the team suffered any illness during the stay. Accommodation is cheaper in Uganda in comparison to South Sudan.

We had a driver who met us at the airport and stayed with us throughout the trip.  He was very attentive and added to our security.  We would recommend that teams have a driver for the trip to enable free movement between the university and hospital when required.  There is a large university bus, but the journey is about 20 minutes and the bus only goes between the hospital and university twice a day.   

 

Lira University

 

Chancellor: Professor Jasper Ogwal-Okeng    

Dean: Dr Tom Otim (Obstetrician and Gynaecologist)

Prinicipal midwifery and Nursing Lecturer: Dr Anna Agnes

SEED lecturer: Cherrie Clark

 

Lira University was initially established as a college of Gulu University to train degree level midwifes. It is envisaged that these midwifes will have an advanced role, also being trained as nurse practitioners and able to carry out caesarean sections. This is part of an initiative to address maternal mortality in developing countries with populations having limited access to qualified healthcare practitioners.  The first intake of students was in 2013 and there are now three years intakes of the 4 year course. The University also has degree courses in public health and hospital administration. Further degree courses in Nursing and Medicine are planned. The university now has its own licence from the Ministry of Education. There is also a student accommodation block and a brand new University coach to take students to Lira Hospital. The teaching staff are predominately from Uganda, who have been supported by lecturers provided by the Peace Corps SEED organisation. There are spacious facilities for teaching, computer facilities and a well-stocked library.  Most tutors had experience in nursing and/or midwifery, and mainly holding degrees, in a science or in nursing/midwifery. Some had additional skills or were working towards MA.

 

Maternity hospital facilities have been built including two wards, a nursery, a delivery suite and an operating theatre. Opening the hospital has been delayed due to administrative problems but the University is expecting to receive its hospital licence in the next week, and shortly start to take patients. Plans and procurement are already well-developed for a 200 bedded hospital with full facilities to be built over the next 3 years. Future plans include training medical and midwifery interns.

Currently second and third year students are receiving their clinical experience at Lira District Hospital. Their clinical training includes placements in paediatrics, medicine, surgery, out-patients and the psychiatry unit as well at maternity. They also have placement at smaller (level 4) facilities such as Aboki hospital. The academic, age and work experience levels of students  varied immensely, ranging from eighteen year old A level students straight from school, to mature students, some of whom already held diplomas and many of whom had been working as nurses, midwives, medical officers as well as in other areas.

 

At our several meetings with Professor Jasper Ogwal-Okeng  and with Dr Tom Otim, it became clear that the Government are highly supportive of the University.  Initial funding for the University has come mainly from the African Development Bank., but the government is now supporting the institution financially. The government are also are providing scholarships for many of the current students.  Professor Jasper  felt there would be almost 100% government scholarships for the 2016 intake. The relationship with Lira Referral Hospital will stay strong and it was confirmed to us that we would be able to work in both facilities, even though we plan to have a formal MOU with the University in the first instance.

 

Lira Referral Hospital

Medical Director: Dr James Elima

Lira District Hospital is the main health facility for the Lira region. It has male and female medical and surgical wards, paediatric and therapeutic feeding ward, a maternity unit, TB ward, eye unit and large out-patient department including a well-run HIV clinic. There were two currently used theatres, a laboratory for haematology, blood bank, basic biochemistry, microscopy and HIV testing, and pharmacy. There is a radiology department with X-ray machine and ultrasound run by a radiographer. Radiology services however were limited by lack of X-ray film. The facilities are regularly cleaned and the areas in-between wards are beautifully laid out with grass and neat hedges.

The level of hospital administration far exceeded what we have observed in Wau, with a hospital board and highly effective senior management team. Weekly well attended CME meetings are held. There are hospital notes and hospital numbers for all patients, with excellent ministry of health admission sheets. The notes contain prescription charts and observation chart.

There are however still considerable challenges.  In particular there is currently no Consultant Obstetrician or medical anaesthetist.  Consultant appointments are made by the Ministry of health rather than hospital board and there is often a considerable delay. Medical input to the wards is mainly very junior (interns and staff grades). There are 1 or 2 trained nurses on each wards but the wards are extremely busy and rely heavily on student nurses (certificate and diploma level as well as Lira university students).

Electricity is available via mains and a back-up hospital generator. Water was piped in some areas but in some available via Jerry cans, including the maternity unit. Wards were very cramped. Food for patients is provided by relatives. The medical director is keen to develop library and educational facilities. There is already internet facility in the resource room, but it is often weak and not open out of hours; often the only time when busy staff can go to use it. There is no budget for journal subscriptions and therefore any good up to date text books, or digital articles would be welcome.. There may be a route for approaching international protocol to help with free journal access – e.g. through COSECSA and other colleges.

 

Midwifery Perspective

The maternity unit at Lira hospital is somewhat outdated and under resourced, with the infrastructure in a dilapidated condition.   A look at the birth register, suggests the unit is handling in the region of 6000 deliveries per annum.  The Caesarean section rate appears to be around 25%, most of which are emergencies.  In the past six months, there were no assisted deliveries either forceps, or ventouse although I did see the equipment in the labour room storage area.  I was not able to obtain figures of maternal or neonatal morbidity for the unit, however in the two weeks I was there, I knew of three hysterectomies, two fresh stillbirths, a neonatal death of an infant with severe malformations, and no maternal deaths.

The small delivery room consists of four delivery tables with lithotomy poles, in a single room without privacy screens.  There is a large sink, but mostly no running water, so water is supplied by jerry cans being carried in.  There is a small table/stool for neonatal resuscitation; it has no light source and no heat source.  Instruments are kept on a trolley, in large canisters, having been autoclaved in the onsite facility.  They are then removed as needed, one by one by opening the lid and using tongs.  Women in labour are required to bring in a plastic sheet to lie on and a razor blade for cord cutting. There were some wall posters of management of obstetric emergencies. Care at this hospital is without charge and if available, patients are administered IV fluids, antibiotics and clinical items used as needed, e.g. swabs, gloves, Indwelling catheters etc.   The unit does not have any gases or suction and is woefully short of instruments.

Part of the same building has a single side room, which is the ‘eclampsia room’ but is often used as a general side room, and is not in an easily observed position. There is a second room used as an ‘overspill’ delivery/antenatal room.  Adjoining with no entrance door is a main ward that is used as a postnatal ward, for caesarean sections.  This is a 20 bedded ward, with a single sink, and no privacy screening.  Toilet and washing facilities are off the ward and patients’ hygiene and dietary needs, and support with their infants is by their relatives. A separate building houses an 8 bed postnatal normal delivery/antenatal ward.  There are just beds with no other facilities or nursing staff on this ward.

The operating theatre, for emergency caesarean sections is a separate building, a hundred yards along an open path through the hospital grounds.  The Neonatal intensive care is also a separate building 50 yards away, and if an infant needs paediatric input, staff must run carrying the infant to NICU

Patients attending for labour assessment or antenatal care, wait outside the single main entrance which leads directly across the hall into the labour room.  They line up along the inside of the hall and are seen at a desk outside the labour room entrance.

Usually, the maternity unit is staffed by two qualified midwives, who are responsible for managing the ward as well as deliveries, working with attending doctors and attending theatre for emergencies.  A considerable number of students, I saw from five to twelve, from three different nurse training institutions, take up the bulk of the work on the unit.

The operating theatre is basic but sufficient.  However there is not a dedicated clean scrub area and does not necessarily have theatre staff for emergency caesarean sections. Pre- and post-op women have little dedicated care, partly due to staffing and partly due to lack of skilled attendants.

On the whole, the midwives manage low and high risk women and call a doctor for emergencies.  Intern doctor is usually working on the unit or on gynaecology, and a senior doctor can be called from clinic duties.  Otherwise an on call doctor must be called if needed, I was informed this can sometimes take many hours.  

Fetal monitoring is limited to listening in via pinnards at antenatal visit, at onset of labour and occasionally during labour.  Documentation in labour is limited In other areas, it is adequate but not always accurate.  Notes are kept in a box on the table.  Take up of full antenatal care is quite low, but there is good engagement by women, with busy HIV and Diabetes clinics.

Midwifery Training needs

Access to the maternity unit was easily available, however it was difficult to gain staff time due to their workload, and not having been introduced. Students were given various clinical tasks to do but were poorly supervised and senior or experienced students seemed to teach juniors. Everyone was busy, albeit in an un-streamlined manner, and so care and teaching, for staff and students, was on an ‘as-it-presents’ basis.

The midwife in charge has recently instigated a dedicated CME session once a week, on the unit, which enables maternity staff to attend as it is impossible for them to leave the unit unstaffed.  There is no other formal in house training.  She is keen to improve the unit and negotiated a change to the forthcoming programme so that I could facilitate the next session.

Communication is reasonable but the resourcing needs of maternity, are not being addressed.

Staffing, best practice training and equipment are all in real need.  However, some simple, low cost changes in practice could make some difference to outcomes.

Paediatric Perspective

There are two children’s wards at Lira Hospital. There is a Therapeutic Feeding Ward, which is run strictly following the UNICEF guidelines, as we have seen in Wau, although observations are not carried out regularly following admission. The main Children’s ward is very crowded, tightly packed with cots and serving predominately the under 5s. The wards are cleaned every morning and all cots have a mosquito net.

Older children, who are far less likely to be admitted, are on the adult wards. By far the most common condition is Malaria, but there are many children with other infectious diseases and sickle cell anaemia. Each patient has set of well organised medical notes that are completed daily and contain the drug chart. Ward stock drugs and IV fluids are provided free of cost, parents only have to buy more unusual drugs. There is only one oxygen concentrator used for two children and one oximeter, which means children have to be prioritised for this life-saving treatment. Observations are not being done regularly and thermometers are only available if doctors and nurses have their own to use! Plastic gloves were always used for bloods/ cannula insertion; and I saw some evidence of alcohol gel being used but not strictly between examining every patient

Staffing in Lira is a challenge. For instance there are only 1 or 2 permanent nursing staff, the vast bulk of duties including venepuncture, cannula insertion and giving IV drugs being done by the student nurses. There are plenty of student nurses from different schools, although the Lira University students are at a much more advanced level. There was not much evidence of student nurses receiving structured education on the wards.  Ward rounds seem to be mainly led by interns (just-graduated doctor) and are never-ending. We didn’t meet the consultant paediatrician who apparently is more or less constantly available for advice by mobile phone.

Surgical perspective

 

There are two 25-30 bedded wards, one male and one female, children from 5 years of age included.  There are 2 surgical interns and 1 or 2 middle grade surgeons and 1 senior surgeon (who appears  to be permanently on call).  The doctors come promptly when called to the ward. Blood and fluid are available, antibiotics and drugs too, but supplies are sporadic. All are free at the point of access. There was always a trained nurse on the surgical ward when I was there, but the ward is totally dependent on the student nurses for wound rounds and jobs, and staff are too busy to do more than teaching them practical necessities.

 

The 4 new theatres are fabulous – and will be for all surgery including obstetrics and gynaecology. The new ITU al also very well set up and equipped. The hospital plans to start training 8 ITU nurses and build up to staff the unit. They would welcome managerial input and training from us.  The anaesthetic practioners use ketamine and thiopentone, and also do spinals. There are no anaesthetic doctors.  Circumcision, hernias and minor operations are done under local anaesthesia +/- ketamine in an outpatient theatre.

Histology: There is a good well equipped lab (USAID). However there is no histopathology. Apparently there is pathologist in Northern Uganda. Patients coming into the surgical ward with a suspected tumour can have a biopsy. However only if they can afford it does the specimen get sent to Kampala, if not, it sits in a cupboard. Often patients don’t come back for results. There is definite scope for cytology telemedicine – either national or international. The hospital needs either a digital photographic eyepiece for the path lab microscope or a new microscope with in-built photography. Histology is more complex, but it would be a start to get the cytology up and running.

Specialist procedures:  The set up would easily entertain a visiting specialist surgical group. Cleft lip and vesico-vaginal fistula (VVF) teams are already coming from time to time.

Operating tools: In particular the hospital desperately needs some good orthopaedic instruments.

Emergency Department:  Emergencies in hours tend to present and get triaged in outpatients, or find their way to the surgical ward, but not in an organized fashion. The hospital would benefit from an A&E reception with a resus room and minor trauma surgery away from the routine circumcisions and hernias. The recycled surgical sets would be very useful here.

Surgical safety: The hospital has received life box training and has pulse oximetry in theatres. However the surgical safety check still needs instigating and we have given them lovely big acetates and also entrusted one of the obstetric interns to set up a name tag system for caesarian sections, so mothers and babies are name tagged.

Radiology: There is a radiographer, but no radiologist. There is a digital machine – but the reality is that the X-rays are then not viewed on the ward. Hard copies are often not available – or the patients go outside for X-rays and the quality can be very poor. One solution is to set up a PACS type system so that digital viewing can take place on the ward. This should be very feasible. Pro-tem a good viewing box would be helpful – one on each ward. Ultrasound is used fairly comprehensively during weekdays 9am-5pm.

 

Links between Lira and Wau

Frankie Dorman explored the possibility of joint teaching between Lira and Wau, facilitated by Poole Africa Link; in particular examining what we had to offer the students and doctors in Lira as well as looking to see whether the University would be a suitable site for training doctors and nurses from South Sudan.  Transport would not be difficult as the border is only 3 hours away by car,  and Juba a further 3 hours’ drive.  Both Dr Danga from South Sudan (whom we spoke to in Kampala) and Professor Jasper Ogwal-Okeng   were very positive.  Professor Jasper felt that this would be a valuable development for the University. We were also informed that the Ugandan Government are very keen to develop systems for supporting the South Sudanese in Uganda.  They are already providing some training in Kampala and wish to extend this

 

Suggestions for Future Visits

Strategic

  • Agree and sign a Memorandum of Understanding with Lira. A draft copy is currently with Professor Jasper Ogwal-Okeng    .
  • Carry out assessment of Lira university hospital once it is up and running – this will enable a training needs analysis that is relevant for them.
  • Investigate the possibility of longer term visits. In particular to facilitate the development of the Intensive Care Unit at Lira Hospital
  • Investigate the possibility of senior trainees spending 2-3 months in Lira (via Wessex Deanery and Royal Colleges)

 

Equipment

  • Both the university and the hospital need further instruments, for delivery and for perineal repair.
  • Assist Lira maternity unit to equip practical neonatal resuscitation areas, in labour room and in theatre: each needs a light source, a heat source, stethoscope, ambu bag.
  • Consider how to address provision of water for hand washing in labour room. ? provide a pump to use with jerry cans?
  • Help provide basic equipment for both hospitals: thermometers, blood pressure cuffs, watches, laryngoscopes etc.
  • Provide further teaching resources for the University, especially resuscitation models
  • Support the development of library resources for both institutions.

 

Teaching/ Mentoring

  • Continue to support with training courses including resuscitation
  • Provide and facilitate a dedicated perineal repair workshop for students.
  • Formulate and support specific short training programme for theatre staff. Include scrub practice, swab and sharps management
  • Look at digital packages for teaching anatomy for University students
  • Online teaching between Poole and Lira Hospital

 

Conclusion

The team returned extremely enthusiastic about the potential for a rewarding link between the Poole Africa Link and Lira University, alongside close working with Lira Referral Hospital.  Visiting Uganda is far easier, the travelling is more reliable and time spent in Lira will be more predictable than in Wau.  Our welcome both at the University and the Hospital was fantastic and we were able to teach on the wards without causing any conflict. We had some frustration during the first week that our skills were not being adequately utilised.  In future we would need to give the tutors more time to prepare for our visit to ensure that we are included in their timetables to maximise our teaching for the students at the University. We have however been very gratified by the very positive feedback received.

 

Pami Frankie Judy Antoinette Resources needed at University
Monday Am University Yr2

10.30-11.30
Magnesium and PET

Hospital Yr3

OPD/Theatre

Hospital Yr3

Surgical Ward round

University Yr 2

10.30-11.30
Congenital Abnormalities

2 rooms and 2 power-point projection
Monday pm

2-4pm

Students in 2 groups

4-5pm

Students choosing 2 sessions

University

2-4pm Yr 3
Post-Op Care and Hand-washing
4-5pm Yr 2

Post-Op Care and Hand-washing

University

2-4pm Yr 3
ABC using AIM laminates
4-5pm Yr 2

ABC using AIM laminates

University

2-4pm  Yr 3
Paediatric Surgical Conditions
4-5 pm Yr 2

Surgical Checklist

Laminates and Team work

University

2-4pm Yr 3
Congenital Abnormalities

4-5pm Yr 2

Practical session on Blood glucose

2 rooms and 1 power-point

2-4 rooms

Tuesday am Hospital Yr 3

Maternity Unit

University

10.30- 12.30 Yr 2

Oxygen and Life Box

University

10.30-12.30 Yr 2

Paediatric Surgical Conditions

Hospital Yr 3

Paediatric Ward/OP

2 rooms and 2 power-points
Tuesday pm
Yr 2 and 3 Students to have 2x 1 hour sessions
University

Yr 2

PPH

University

Yr 3

Oxygen and Life Box  

University

Yr 3

Surgical Checklist

Laminates and Team work

University

Yr 2

Care of Preterm Infants

4 rooms if possible and 2 power points
Wednesday am Hospital

Yr 2 and 3

Hospital

Yr 2 and 3

Hospital

Yr 2 and 3

Hospital

Yr 2 and 3

Wednesday pm

Students to choose 2x 40 minute sessions
All Yr 3 students to attend Feedback Session

University Yr 3

Perineal Trauma

Feedback Session

University Yr 3

Sepsis and ABC

Feedback Session

University Yr 3

Blood Transfusion

Feedback Session

University Yr 3

Anaemia

Feedback Session for Yr 3

4 rooms and ? power-point
Thursday am Hospital

Yr3

Hospital

Yr3

Hospital

Yr3

Hospital

Yr3

Thursday pm

Students to choose 2x 40 minute sessions
All Yr 2 students to attend Feedback Session

Mama Natalie

Yr 2

Feedback Session

Maternal Anaesthetic

Emergencies

Yr 2

Feedback Session  

Fistula Repair

Yr 2

Feedback Session  

Recap Neonatal Resuscitation/ Special Situations

Yr 2
Feedback Session

2-4 rooms and 2 power-point

 

Appendix 1: Teaching Program for Week 2 at Lira University



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