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Report from Lira March 2019

Report from Lira March 2019

Dr Frankie Dormon

 

Background

This was the sixth team teaching visit to Lira.

 

The six man team consisted of two midwives, Sally Loven and Amy Tucker, two paediatric nurses, Ally Ahvee and Sophie Boot, a Surgeon, Sarah Clark and myself, an anaesthetist.  The teaching was much more efficiently organised with one day each week per year group at the University.   Lectures were broadly in line with the curriculum and agreed prior to the trip.  The rest of the time the midwives visited outlying clinics with the midwifery tutor and the paediatric nurses worked at Lira Regional Referral Hospital on the paediatric ward. Sarah and I spent more time with the newly appointed medical staff, encouraging them to set up policies for the new University Hospital, including drug charts, and safety issues around prescribing and infection control. We both also spent some time at LRRH where we provided teaching support.

 

Logistics

Flight and transport to and from Lira went extremely smoothly again this year. We arrive at 8.30 with plenty of time to get to Lira before dark, and fly home via Amsterdam, the long haul part being overnight.  We had the services of our regular driver, Arnold, who was his usual helpful self.  The team stayed at the Kanberra Hotel again where we are greeted like old friends and met with other charity groups. All team members were healthy throughout.   We managed 9 days of formal University teaching as we also taught a modified paediatric triage and treatment course on the Saturday (ETAT).  The rest of the time was flexible at the University, Hospital or Clinics.

 

University

We were pleased to see that the University Hospital is beginning to take patients although most of the equipment is still to arrive.  The Emergency department is functioning with about 2 patients being admitted daily for minor conditions, hernia repair, abscess treatment or medical conditions.   We had helped the Lira team to design a drug chart before our arrival and this was introduced to the doctors, pharmacists, medical records department and students.  Each group received separate 1 hour lectures on the chart and how to use it, there was some useful feedback and we will be making a few amendments over the summer. The IT manager is looking at ways of electronically scanning each drug chart to allow formal audits to be undertaken. Another area that we felt needed focus was Infection control, including the use of antibiotics.  We failed to win a bid for money for this, but we taught on Infection Control, with a formal lecture to the newly appointed doctors, and sessions for the students on hand washing, general infection control and theatre infection control. The need for a drug chart and thoughts about infection control was clear and discussed at their weekly CPD meetings,  where most of the doctors meet up to discuss various issues.  We also highlighted the opportunity to use the patients’ attendants to assist in some of the nursing care to make up for the shortages of staff across Uganda.  Hopefully the staff will use the time now, while there are few patients to set up ward protocols and systems and some guidance documents for attendants. We have advised that they need to create a Drug and Therapeutics Committee and an Infection Control committee, probably as subcommittees of a Quality Improvement committee which should be chaired by a very senior doctor who is able to make the necessary decisions.

 

The maternity wing is building up with a total of 80 deliveries since opening. We watched a couple of  caesarean sections performed under spinal anaesthesia and were pleased to see that they used the WHO safety checklist and that their management of sterility was far better than we have seen before in Lira.  The atmosphere in theatre was professional, calm and relaxed. The surgeon was excellent but some thought could be given to improving safety in regard to handling sharps and counting swabs and instruments.

 

Individual Reports.

Frankie Dormon.

 

I went out with a   long list of objectives, (In italics) as follows.

 

  1. Support the team and keep you all safe.

The team were really supportive of me and I was able to let them get on with their teaching without needing too much input from me.  We all achieved a huge amount. Everyone stayed safe.

 

  1. Discuss future plans with Professor Jasper, to contribute to our 5 year plan

                With particular reference to Medical School,

I had a long meeting with Professor Jasper, he was very supportive of our plans, especially the need for a drug chart and Infection control systems.

Drug supply and other consumables: Funding remains an issue but supply is pivotal to the hospital’s success, this led me to produce a minimum drug list for anaesthesia and we discussed how the anaesthetists might move forward with this.  I reiterated that antibiotic supply was pivotal to good infection control, there needs to be a robust system. He appreciates that we can only sow seeds and that his team need to take on our ideas and move them forward.

The Medical School will not be opening this year as the University Hospital does not yet have adequate equipment and patients, but this delay will hopefully be short.

Primary Trauma Course in October. He felt that this should be done on the University site and we should encourage his doctors, who are accredited trainers, to be part of the faculty.

Student Funding Project (See under objectives) was welcomed in principle.

Use of the attendants as part of the patient care; all patients have family who can help with care.  This has been developed in Mbale in their neonatal unit and reduced mortality from 50% to 12%.   Professor Jasper agrees that this should be explored.

Relationship with Regional Referral Hospital.  Some of the staff at the University have come from the Regional Referral Hospital.  We had met with the new Hospital Director Dr Stephen Obbo, and he felt that the University were taking away some of his expertise.  It was clear after discussions with Professor Jasper and The University Hospital Director, Tom Otim, that the University are keen to establish links with the Referral hospital and to work with them.  I re-iterated that as a charity we would wish to continue working across both sites and helping them to share developments.

The failed bid for Antimicrobial Stewardship: we were both disappointed about this, but we will be looking for future bids and I have introduced Professor Jasper to the THET lead in Kampala, so that we are made aware of future funding.  Although we cannot support a visit to UK financially, Professor is still keen to come to UK this summer to see how we manage a hospital, hospital staffing and the management structure.  I have agreed that he can stay with us and I would hope that Poole Africa Link can put together a useful programme during his week.  We just need to finalise a date.

 

3 Ensure that classroom teaching is relevant to the curriculum and environment

The planning worked well on this occasion and apart from losing the odd hour for exams at the beginning or end of the day, we taught a full day each week with each year group.

 

  1. Collate teaching hours and subjects

See Appendix 1.

                               

5 Teach the ETAT course with a view to identifying a small group as trainers (from the tutors)

We were unable to achieve this in full due to Student Guild Elections.  These are hugely important to the students and were being held on the Saturday all day,  We had advertised the course from the Wednesday on their notice board and had informed all the qualified staff at their CPD meeting,  but despite being told that many would come, we only managed 10 students instead of the hoped for 60. We taught the morning lectures but kept the scenarios for the following week in class.

 

6 Teach scenario based anaesthesia to year 3 and 4 (in theatre if possible).

The theatres were not as busy as we hoped at the University Hospital and apart from the maternity theatre there was still no equipment, so theatre teaching was not possible.

 

7 Explore dental services with a view to linking in with Dentaid in the future (this objective is up for grabs if anyone interested)

We have discovered that there is a very good dental clinic at the Orphanage, Otino Waa, with minimal services at the Government Hospital and some private clinics in Lira.  This project should stay active.

 

8 Provide training at the Regional Referral hospital to students, midwives and doctors as appropriate. 

On our first day we visited the Regional Referral Hospital to orientate team members, 4 members had not been to Lira before and I believe it is vital that team members are aware of the local situation before they start teaching the students in the University.  We met a new Hospital Director Dr Stephen Obbo, a Physician.  He has been in post about 5 weeks but was very welcoming and was happy for us to work at the hospital with nurses and doctors.  There has been a shift of staff from the Government hospital to the University Hospital and he only has 5 interns.  Clearly staffing is an issue.  (See discussion with Professor Jasper)

 

9 Collect feedback from tutors and students where possible.

We received a lovely wooden plaque from Year 4 in thanks for all our work over the years.  We felt that we had a close relationship with the tutors during our stay but did not collect any formal feedback.

 

10 Use opportunities to teach alongside local tutors as possible.

The midwives were able to visit several local clinics with Anna Grace, the midwifery tutor, where they worked closely together.

 

  1. Commission the Glostavent Anaesthetic Machine

The glostavent anaesthetic machine was taken out of its wooden box and checked over. The biomedical Engineer, Obio Daniel is familiar with the machine and seemed happy to provide engineering backup.  In addition the two anaesthetic nurses have both used the machine in the past.  We spent a morning going over the checklist and function but were unable to use it for a patient as there was no anaesthetic volatile agent for general anaesthesia and no muscle relaxant for ventilation.   Drug supply needs to be addressed and we produced a minimum drug list for anaesthesia based upon a list used in Mbale.

 

12.Discuss the student training programme with Jasper – Funding etc.

We have been approached by a charity, Spreading Health, who fund nurse training in Cameroon.  In essence, they identify a student from the village then send them off for training and they then have to come back to their village and run a health centre.  There needs to be a suitable health centre and support throughout their training and I spoke with Professor Jasper who is keen in principle.  The list of questions and answers is Appendix 2.  I see two options, either someone from South Sudan or we work with a charity Love Mercy, who have a health centre about 1 hour out of Lira, and would be able to provide the necessary back up at a local level.

 

  1. Introduce a new Prescription chart at University Hospital

We prepared a drug chart and lecture to support its introduction.  I was able to present the lecture to the new Medical Staff at their CPD meeting, to each year group of midwives and to the pharmacists.  It was well received and I am hopeful that it has been introduced.  The lectures gave a good opportunity for staff to feed back some very relevant questions and I have no doubt there will be changes for our next visit.

 

  1. Further training on safety/infection control.

We gave training on these topics to several of the year groups as well as the University doctors.

 

15 Get some more film footage on new developments.

Not enough had changed at this stage so we will take some footage in October.

 

16 Start to arrange Primary Trauma Course for October.

I discussed this with the Hospital Director and Professor Jasper.  We have identified several faculty and I have been advised on who should be invited from outside Lira. I have the details of the current interns at the Referral Hospital and will get details of the new Interns from the Hospital Director nearer the time. I agreed with Professor Jasper that this should be held at the University Campus.  Hotels for visiting faculty would be Kanberra.  I discussed with Sean Puleh, Research Tutor, from Public Health, whether he would like to help with the planning.

 

Sarah Clark.

 

Initial impressions:

The importance of the first day orientation must be emphasised for new team members who have not visited Lira before. In order to be able to teach the students effectively it is important to understand the structure and facilities they will ultimately be working in. In future visits it would be useful to try and organise as many meetings as possible on this first day to ensure that the 2 week visit is well timetabled and productive and all the necessary personnel are met.

 

Lira Referral Hospital:

The Emergency department was extremely busy and staffed by one intern, 2 senior sisters and multiple students. There is a high incidence of trauma cases and little space to assess them properly. The staff performed admirably and managed some extremely unwell patients very competently. Some patients are kept overnight and the morning ward round takes quite some  time, which led to delays in seeing new patients. However, the ward round was stopped appropriately for an acutely unwell patient. The main problem facing the emergency department was the lack of space, with nowhere to easily assess seriously unwell patients. A slight re-organisation of the department could improve the through flow of patients and in turn efficiency.

I also spent time on the male general surgical ward. Approximately 2/3rds of the patients were orthopaedic cases. I was extremely impressed with their wound care protocols. I introduced the drug chart but was told that at the Government Hospital all paperwork has to be printed centrally. It was obvious that a prescription chart is needed as patients did not receive antibiotics or pain relief in a timely fashion. The ward is well run and I saw some examples of excellent nursing care including a patient who had burns to 30% of his body that were virtually fully healed.

I spent a short time in main theatres. It was good to see regular elective lists running. Surgical technique was very good and it was lovely to see the interns being trained properly. Improvements could be made in safety procedures, including swab and instrument counts, and safe handling of sharps. There was not a formal recovery bay and pre- and post-op patients seemed to be kept together with little monitoring of post-op patients. This would be an area where simple changes could be made with good result. The WHO surgical safety checklist was not in use and at future visits it would be useful to try again at introducing this as standard practice.

I gave informal teaching sessions to the students and interns on a variety of topics during my time at the referral hospital. I had planned a formal teaching session on general surgery topics for the interns, unfortunately the day I planned it was the same day as they changed specialty so no-one attended. In future better thought is needed for timetabling such sessions.

The hospital has a lot of equipment that isn’t being used. There is an excellent biomedical technician, Obia Daniel, who is well trained and keen to get everything in use. They asked for help with a decontamination protocol for the endoscopy machine as they do not have a manual disinfector. I will discuss with Poole Hospital endoscopy department and aim to produce a simple decontamination protocol so that endoscopy cases can be undertaken

 

Lira University Hospital:

I was impressed with the theatre set-up and it was great to see the surgical check list in use. The surgeons were extremely proficient but again there were issues with safety including swab and instrument counts and safe handling of sharps. I met with Dr Wilfred Inzama (Consultant Obs & Gynae) and fed this back formally.

There are plans to set up a women’s clinic which will include cervical and breast screening. I met with Edward Kumakech (Dean) to discuss this and have promised to write a simple breast protocol for the planned clinic.

I also had discussions with the IT manager, Usama, and the medical Records Manager, Mugisha Dennis, and will continue to work with them to try and produce a way of scanning the prescription charts to allow formal audit of the new system to take place.

 

Teaching at the University:

The students are keen to learn and have a very good background knowledge. It was useful to have seen the curriculum pre-visit and be able to plan teaching appropriately. There are issues with time keeping, with late starts and sessions cancelled for tests etc. Also, problems with an intermittent power supply means it is not always possible to use prepared power point presentations so some flexibility is required.

It was useful to have one year for a whole day. The best format seemed to be a formal teaching session first thing, followed by group work mid-morning and scenario based teaching in the afternoons. This allows a topic to be thoroughly explored and keeps the students interested. The heat makes it difficult for both staff and students to concentrate on didactic teaching for long periods which is why interactive sessions work better later on.

 

 

Alison Ahvee and Sophie Boot –   Paediatric Report

 

Education

  • Students have excellent knowledge, need to grasp theory to practice link. To do this they need to be doing more hands on care, rather than the technical skills. For example students should be proficient at doing initial assessment and ongoing care of patients.
  • Practice environment – lots of opportunities in the Referral Hospital to develop paediatric nursing skills. Trained staff need more guidance and support to mentor students.
  • Lack of trained nurses on the ward to facilitate student learning and do patient care.
  • We only saw Lira students who were on a Field day; however they were keen to do observations and interact with patients under our guidance.
  • We had a meeting with Edward Kumakech to discuss the new BSC curriculum; this gave us the opportunity to raise some points to address.
  • Lack of leadership on the ward. It was not clear who was in charge and staff grade.
  • Lecturers asked for teaching on malnutrition and HIV, we did not feel that this would give the students enough insight and knowledge due to our lack of experience and knowledge. Therefore we arranged for Moses Odokodit, a nutritionist from the Referral Hospital to come and give the students a lecture, which was very well received by the students and Moses is keen to be part of this teaching in the future.

Recommendations

  • Students could spend 50% of time in the practice environment which will give greater exposure to clinical situations, therefore making students more confident in their practice.
  • Discussion with Edward led to him suggesting the possibility of more clinical supervision of students by the lecturers in the practice environment.
  • Possibility of a mentorship programme.
  • On discussion with trained staff at the Referral Hospital, the staff want to improve the student experience but staff resources do not allow for this.
  • Unsure of the university’s expectations of the students when on Field Day. I.e. what are they supposed to achieve on this day.
  • University could make use of clinical expertise from practice environment to lecture students on some specialist subjects as they can give clinical insight. This would develop links between the hospital and university.

 

 

 

 

Referral Hospital Environment/ resources

  • Paediatric ward lacked space for patient capacity and was not closely located to other paediatric specialities – eg NICU and TFC.
  • Cots were rarely used by patients, instead parents slept under and behind cots with their child. Cots that were on the ward were broken.
  • Difficult access to common medications i.e. – no paracetamol on ward or in pharmacy.
  • Documentation we saw was very good, but was not replenished. There was no process to restock paperwork. There were no drug charts or observation charts and no continuation sheets. Medications were often missed as it was difficult for the nurses to visibly see what treatment had been given and what was required.

 

Recommendations

  • Staff suggested that by closely locating paediatric area closer together it would enable them to share staff and other resources. To consider relocating paediatric ward closer to NICU and TFC. This would enable medical staff to do more timely assessments of patients.
  • Consider swapping some cots for bed which would allow parents to sleep with child under the mosquito nets provided.
  • Unclear how drugs are restocked and how the pharmacy drugs are budgeted
  • Staff reported difficulty in replenishing documentation paperwork (drug charts and observation chart) to ensure safe timely care is delivered. This is not a nurse’s role, this is an administrative duty.

 

 

Sally Loven, Amy Tucker – Midwifery Report

 

This trip has seen the two of us joining forces very successfully, teaching midwifery practice in Lira University. The trip has provided the opportunity for personal growth and profession-al development for both of us. We have really enjoyed it.

We both have very different experience in midwifery practice which we feel facilitated the needs of our teaching brief.

 

The team has been extremely cohesive and worked well together; we have enjoyed each other’s company which benefitted the working environment.

 

Highlights

 

Travelling to two outlying health facilities created exciting teaching experiences for us and for the students, in a different setting to the university and Referral Hospital. We feel this can be developed further as these facilities are very basic and less chaotic than the referral hospital so teaching opportunities were really fruitful.

 

We also spent a lot of our time using the wonderful skills lab facility at Lira University. We feel this is an under-utilised facility and could benefit from more a practical-based skill set from the next midwifery team.

 

Team working has been a highlight of this trip. Mentorship of clinicians visiting for the first time has proved to be very successful, increasing their confidence and teaching expertise. It also promotes a positive environment, encouraging future clinicians to dedicate time to the charity.

 

Future developments

 

  • Increased midwifery teaching allocation, if possible, as very few hours were allocated for this speciality in the university

 

  • Specific development of mentorship and the importance of leadership within a hospital culture to be pursued as a subject for future teams

 

  • Teaching allocation if not pre-determined should be decided within each speciality. This will enable a reduction in time wasted

 

  • Skills lab is invaluable for skills teaching. However the amount of unused equipment that could be distributed to other areas needs to be looked at

 

We brought a wealth of midwifery experience and knowledge to this trip which we both feel we could have utilised more effectively given a higher allocation of class room teaching. However, spending time in the field, especially at outlying health facilities, could have a positive effect on the learning culture as historical practices remain strong in these areas.

 

 

Appendix 1 Teaching Hours

 

Formal University Teaching

 

We prepared a drug chart and lecture to support its introduction.  I was able to present the lecture to the new Medical Staff at their CPD meeting, to each year group of midwives and to the pharmacists.  It was well received and I am hopeful that it has been introduced.  The lectures gave a good opportunity for staff to feed back some very relevant questions and I have no doubt there will be changes for our next visit.

 

We covered topics from their curriculum and taught for 8 days from 8.00am till 4.30 pm, with lunch break and a morning break. (Total 6-7 hrs each day.)

Each year group has between 40 and 60 students attending for lectures.

 

PROGRAM FOR POOLE AFRICA LINK TEAM

Week 1 25th to 29th March

Class Day Subject to be covered Tutors
Year two  Tuesday 26th ·         Breast Cancer Exam/management

·         Fluid Management

·         Handwashing/Infection control

·         Basic Communication

Sarah

Ali

Sophie

Year three  Wednesday 27th ·         Pediatrics

·         Respiratory disease, asthma, diarrhea &vomiting

·         Malnutrition

·         Triage and treatment.

·         Child development

Ali

Sophie

 

Year four Thursday 28th ·         Importance of accurate prescribing

·         Medication charts

·         Abnormal midwifery topics and scenarios

·         Sepsis/Post-partum Haemorrhage.

 

 

Frankie

Amy and Sally

 

Year One Friday 29th ·         Importance of accurate prescribing

·         Medication charts

·         Observations

·         Communication

·         History taking

·         Physical exam

Sarah

Frankie

Saturday 30th   9.00 am Registration.  9.15 film.  

ETAT Course.  Emergency Treatment and Triage of Children.

Max 60 people.  Year 4, doctors and tutors priority.

 

Week 2 April 1st to 5th

 

Class Day Subject to be covered  
Year two Monday 1st ·         Importance of accurate prescription

·         Medication charts

·         Community engagement in preventing spread of HIV

·         Reflective practice

Frankie, Ally,

Sarah. Sophie

Year three Monday 1st ·         Clinical practice for normal Midwifery (in the practical area)

·         The partogram

·         Scenarios/mamma Natalie,

Sally

Amy

Year four Thursday 4th ·          ETAT Scenarios

·         Theatre techniques

·         Scenario – The patient journey. Pre and post op care.

Sarah,

Frankie

Sally/Amy

Year one Friday 5th ·         Drug calculations

·         Clinical Decision Making

·         Taking observations (practical)

Sarah, Frankie, Sophie, Amy

CPD day Wednesday .  University Hospital Staff.

Week 1.  Drug Prescribing  8-9 Frankie

Week 2.  Sepsis/Infection control.  8-9 Sarah Frankie

 

 

We gave the CPD lecture both Wednesday mornings to the University Staff

We taught ETAT on Saturday morning to the 10 students who came.

 

Other teaching.

 

There was informal teaching at the referral hospital and midwifery teaching at the clinics and the hospital.  See individual reports.

 

Appendix 2.  Potential link with Spreading Health charity.

 

We discussed a project suggested to me by Glynis Hearn.  They have a charity which has been supporting students in Cameroon.  For political reasons this is coming to an end and she was wondering whether there might be an opportunity to do the same thing in Uganda.  There are huge benefits of training at Lira University, especially the lower costs of accommodation and food than Kampala. Also the standard is high and the course offered is much more than midwifery.  The 4 year course equips these students to work very closely with doctors in partnership.  In addition the skills are less transferable as they would never be able to work abroad with the same degree of autonomy.

 

The charity Spreading Health approached us at Poole Africa Link with a view to exploring a partnership in Uganda. We have been speaking with Glynis Hearn and her husband, Peter.  They had a number of questions.  I have reproduced the questions and put the answers in italics.  If you wish to add anything please let me know and we can send a reply.

 

1 Is there a need in the area for nurses for rural and isolated communities?

The training at Lira University is a 4 year BSc, in Nursing and Midwifery.  In essence the graduates are virtually doctors as their training is very comprehensive, including detailed anatomy, physiology and biochemistry.  They don’t even start midwifery till Year 3!  Their skills are totally comprehensive and they would be able ultimately to run a Level 4 unit with a doctor as a team with additional experience. There are many Level 4 units without adequate nursing or medical cover.

 

2 Do we know whether nurses that we support through training will be employed by the government in the end or not?

This might need further exploration, at the moment the students have to find a job, but the majority do so with good salary scales. If there are posts available in their district this would be likely to occur.

 

3 If so, will we have any control or input into whether they will work in the community from which they came?

Again, this can happen.  Students with good reasons to work in specific areas are given a degree of priority.

 

  1. What other options are there for employment in rural healthcare clinics?

There is a mixture of NGO run clinics, private clinics and government clinics, in addition to the referral hospitals, level 4 health centres etc.

 

  1. Where do most of the students get their money from?

Most are self-funding, about 10% receive funding from local government.

 

  1. How much is the course?

About $500 per semester, with 2 semesters per year and 4 years for the course. (Total $4,000)

In addition food and accommodation, but this is relatively cheap in Lira and there are a number of new hostels building up around the University.

 

Where do you see the 4 year course graduates practising?

Uganda, level 4 units, and above.  Their skills are such that they are not transferable to UK, they would not be recognised to practice with the autonomy that they will enjoy in Uganda.  We have often asked on our feedback forms where they see themselves, some wish to become doctors but the majority want to work in the Level 4 unit or above. Very few want to go abroad (about 5%).

 

What is the Salary of a BSc nurse graduate?

About $100 per month

 

Is there a 3 year SRN or equivalent course at the university?

No, there are several such schools in town, the nurses do not have the depth of knowledge that the university students gain, although they receive more practical training at this time.

 

Is there a local NGO experienced in working with rural communities who could administer the scheme?

I have been in discussion with an Australian charity, Love Mercy, who run their own clinic, the Katerina Clinic, out in the rural area.  It is doing well and about to increase midwifery services. They also run schemes for microfinancing seed cultivation, delivering/selling the seed and then buying the crop after harvest.  They also help with cultivation advice and irrigation. They have a team permanently in Lira as well as the CEO etc. visiting regularly. In addition they have links with the local political scene.

 

Are all rural and isolated clinics set up by the Government or are some set up by the community and later taken over and paid by government.?

There is a mixture of the two types of development.

 

Is there an official professional regulatory body that nurses are responsible to and have to be registered with? Will this course be eligible for registration?

The Nurses and Midwifery Board of Uganda has been in place for many years.  All the students are ultimately registered.

 

 



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