Rockefeller Oteng

Optimizing Clinical Operations as Part of a Global Emergency Medicine Initiative in Kumasi, Ghana: Application of Lean Manufacturing Principals to Low‐resource Health Systems

BACKGROUND Although many global health programs focus on providing clinical care or medical education, improving clinical operations can have a significant effect on patient care delivery, especially in developing health systems without high-level operations management. Lean manufacturing techniques have been effective in decreasing emergency department (ED) length of stay, patient waiting times, numbers of patients leaving without being seen, and door-to-balloon times for ST-elevation myocardial infarction in developed health systems, but use of Lean in low to middle income countries with developing emergency medicine (EM) systems has not been well characterized. OBJECTIVES To describe the application of Lean manufacturing techniques to improve clinical operations at Komfo Anokye Teaching Hospital (KATH) in Ghana and to identify key lessons learned to aid future global EM initiatives. METHODS A 3-week Lean improvement program focused on the hospital admissions process at KATH was completed by a 14-person team in six stages: problem definition, scope of project planning, value stream mapping, root cause analysis, future state planning, and implementation planning. RESULTS The authors identified eight lessons learned during our use of Lean to optimize the operations of an ED in a global health setting: 1) the Lean process aided in building a partnership with Ghanaian colleagues; 2) obtaining and maintaining senior institutional support is necessary and challenging; 3) addressing power differences among the team to obtain feedback from all team members is critical to successful Lean analysis; 4) choosing a manageable initial project is critical to influence long-term Lean use in a new environment; 5) data intensive Lean tools can be adapted and are effective in a less resourced health system; 6) several Lean tools focused on team problem-solving techniques worked well in a low-resource system without modification; 7) using Lean highlighted that important changes do not require an influx of resources; and 8) despite different levels of resources, root causes of system inefficiencies are often similar across health care systems, but require unique solutions appropriate to the clinical setting. CONCLUSIONS Lean manufacturing techniques can be successfully adapted for use in developing health systems. Lessons learned from this Lean project will aid future introduction of advanced operations management techniques in low- to middle-income countries.

Skills and educational needs of accident and emergency nurses in Ghana: An initial needs analysis

Background The specialty of emergency medicine is highly reliant on a well-trained team of providers. Ghana has recently begun a specialist training program for physicians and the need to train specialist emergency nurses has been recognized. The first step to developing this training is to conduct a needs assessment. This study was conducted to elucidate current nursing functioning and gain knowledge of the educational desires and needs for nurses in the Accident and Emergency Center (A&E) at Komfo Anokye Teaching Hospital (KATH). Methods Three nurses from the University of Michigan (UM) worked collaboratively with the nursing leadership at KATH to conduct a needs assessment of currently practising nurses in the A&E. The UM nurses observed nursing practice in the department and KATH nurses participated in a multiple choice exam, a self-assessment questionnaire of educational desires, answered written open-ended questions and participated in focus groups. Results KATH nurses scored relatively low on a general knowledge multiple choice exam, and indicated through the self-assessment that they would like to learn more about many topics. Open-ended questions gave further insight into areas of knowledge gaps. Several themes including Cohesion, Carrying out Orders/Decision Making and Overwhelming Volume, emerged from observations in the emergency department. Discussion Current nurse knowledge and function as well as areas to focus on for future specialty training in emergency nursing have been identified by this needs assessment. The emergency department nurses shared an overwhelming interest in increasing their skill level, learning new methods of patient care and implementing new technologies into their clinical practice.

The implementation of the South African Triage Score (SATS) in an urban teaching hospital, Ghana

INTRODUCTION Triage is the process of sorting patients based on the level of acuity to ensure the most severely injured and ill patients receive timely care before their condition worsens. The South African Triage Scale (SATS) was developed out of a need for an accurate and objective measure of urgency based on physiological parameters and clinical discriminators that is easily implemented in low resource settings. SATS was introduced in the emergency center (EC) of Komfo Anokye Teaching Hospital (KATH) in January 2010. This study seeks to evaluate the accurate use of the SATS by nurses at KATH. METHODS This cross-sectional study was conducted in the EC at KATH in Kumasi, Ghana. Patients 12 years and over with complete triage information were included in this study. Each component of SATS was calculated (i.e. for heart rate of 41-50, a score of 1 was given) and summed. This score was compared to the original triage score. When scores did not equate, the entire triage record was reviewed by an emergency physician and an advanced practice emergency nurse separately to determine if the triage was appropriate. These reviews were compared and consensus reached. RESULTS 52 of 903 adult patients (5.8%) were judged to have been mis-triaged by expert review; 49 under-triaged (sent to a zone that corresponded to a lower acuity level than they should have been, based on their vital signs) and 3 over-triaged. Of the 49 patients who were under-triaged, 34 were under-triaged by one category and 7 by two categories. CONCLUSION Under-triage is a concern to patient care and safety, and while the under-triage rate of 5.7% in this sample falls within the 5-10% range considered unavoidable by the American College of Surgeons Committee on Trauma, concentrated efforts to regularly train triage nurses to ensure no patients are under-triaged have been undertaken. Overall though, SATS has been implemented successfully in the EC at KATH by triage nurses.

The Development of Sustainable Emergency Care in Ghana: Physician, Nursing and Prehospital Care Training Initiatives

BACKGROUND Ghanas first Emergency Medicine residency and nursing training programs were initiated in 2009 and 2010, respectively, at Komfo Anokye Teaching Hospital in the city of Kumasi in association with Kwame Nkrumah University of Science and Technology and the Universities of Michigan and Utah. In addition, the National Ambulance Service was commissioned initially in 2004 and has developed to include both prehospital transport services in all regions of the country and Emergency Medical Technician training. Over a decade of domestic and international partnership has focused on making improvements in emergency care at a variety of institutional levels, culminating in the establishment of comprehensive emergency care training programs. OBJECTIVE We describe the history and status of novel postgraduate emergency physician, nurse, and prehospital provider training programs as well as the prospect of creating a board certification process and formal continuing education program for practicing emergency physicians. DISCUSSION Significant strides have been made in the development of emergency care and training in Ghana over the last decade, resulting in the first group of Specialist-level emergency physicians as of late 2012, as well as development of accredited emergency nursing curricula and continued expansion of a national Emergency Medical Service. CONCLUSION This work represents a significant move toward in-country development of sustainable, interdisciplinary, team-based emergency provider training programs designed to retain skilled health care workers in Ghana and may serve as a model for similar developing nations.

Bypassing proximal health care facilities for acute care: A survey of patients in a Ghanaian Accident and Emergency Centre

Objective  To characterise the population that presents to the Accident and Emergency Centre (AEC) at Komfo Anokye Teaching Hospital (KATH) and to identify risk factors associated with bypassing proximal care facilities.

Development of an emergency nursing training curriculum in Ghana

The formal provision of emergency health care is a developing specialty in many sub-Saharan African countries, including Ghana. While emergency medicine training programs for physicians are on the rise, there are few established training programs for emergency nurses. The results of a unique collaboration are described between a university in the United States, a Ghanaian university and a Ghanaian teaching hospital that has developed an emergency nursing diploma program. The expected outcomes of this training program include: (a) an innovative, interdisciplinary, team-based clinical training model, (b) a unique and low-resource emergency nursing curriculum and (c) a comprehensive and sustainable training program to increase in-country retention of nurses.

The Ghana Emergency Medicine Collaborative.

Current emergency care in Ghana is sub-optimal with significant delays to definitive care and high morbidity and mortality. The Ghanaian government has recently invested in physical infrastructure for emergency care at major teaching hospitals, but the human resources to provide care are inadequate. To address this need, the Ghana Emergency Medicine Collaborative has proposed an innovative training program focused on medical students, nurses, and residents with the formation of a new faculty for sustainable training. This program will train emergency medicine personnel in injury and acute medical illness management, expose trainees to research methodology, administrative and leadership aspects of emergency medicine. This program receives funding from the Medical Education Partnership Initiative (MEPI).

Triage capabilities of medical trainees in Ghana using the South African triage scale: An opportunity to improve emergency care

Introduction The incidence of emergency conditions is increasing worldwide, particularly in low- and middle-income countries (LMICs). However, triage and emergency care training has not been prioritized in LMICs. We aimed to assess the reliability and validity of the South African Triage Scale (SATS) when used by providers not specifically trained in SATS, as well as to compare triage capabilities between senior medical students and senior house officers to examine the effectiveness of our curriculum for house officer training with regards to triage. Methods Sixty each of senior medical students and senior house officers who had not undergone specific triage or SATS training were asked to triage 25 previously validated emergency vignettes using the SATS. Estimates of reliability and validity were calculated. Additionally, over- and under-triage, as well as triage performance between the medical students and house officers was assessed against a reference standard. Results Fifty-nine senior medical students (98% response rate) and 43 senior house officers (72% response rate) completed the survey (84% response rate overall). A total of 2,550 triage assignments were included in the analysis (59 medical student and 43 house officer triage assignments for 25 vignettes each; 1,475 and 1,075 triage assignments, respectively). Inter-rater reliability was moderate (quadratically weighted κ 0.59 and 0.60 for medical students and house officers, respectively). Triage using SATS performed by these groups had low sensitivity (medical students: 54%, 95% CI 49–59; house officers: 55%, 95% CI 48–60) and moderate specificity (medical students: 84%, 95% CI 82 - 89; house officers: 84%, 95% CI 82 - 97). Both groups under-triaged most ‘emergency’ level vignette patients (i.e. SATS Red; 80 and 82% for medical students and house officers, respectively). There was no difference between the groups for any metric. Conclusion Although the SATS has proven utility in a number of different settings in LMICs, its success relies on its use by trained providers. Given the large and growing burden of emergency conditions, training current and future emergency care providers in triage is imperative.

Sharps injuries among emergency department nurses in one tertiary care hospital in Ghana.

Exposure to bloodborne pathogens is the most serious occupational health risk encountered within the healthcare profession worldwide. The World Health Organization estimates that 3 million healthcare workers experience percutaneous injuries each year. The objectives of this study were to: (1) examine the frequency of sharps injuries, and (2) assess the adequacy, understanding, and use of post-exposure protocols within a sample of the nursing staff at a busy tertiary care emergency department in the Ashanti Region of Ghana. A mixed-methods descriptive study design was used including key informant interviews to develop the survey, a structured survey of emergency department nursing staff, and document review. Overall, the emergency department staff was well informed regarding the risks of sharps injury and the immediate steps to take in the event of a sharps injury. However, few staff could list essential post-exposure follow-up steps. Over one-quarter (28.9%) of emergency nurses reported a sharps injury during a one-year period according to hospital records. The high incidence of sharps injuries indicates an urgent and pressing need for policy and educational interventions to address the infectious disease risk to this group of emergency department staff.

The role of short-term volunteers in a global health capacity building effort: the Project HOPE-GEMC experience

BackgroundIncreasingly, medical students and practicing clinicians are showing interest in traveling to low-income settings to conduct research and engage in clinical rotations. While global health activities have the potential to benefit both the individual and the host, there can be challenges. We describe one way to harmonize the desire of volunteers to have a meaningful impact on the health care delivery system in a developing country with the needs of that country.MethodsThe Project Health Opportunities for People Everywhere (HOPE)-Ghana Emergency Medicine Collaborative (GEMC) Partnership has successfully integrated short-term volunteer physicians and nurses to facilitate the training of emergency medicine (EM) residents and specialist nurses in Kumasi, Ghana.ResultsSince the launching of this partnership in 2011, eight physicians and 10 nurses have rotated at Komfo Anokye Teaching Hospital (KATH). The impact of these volunteers goes beyond the clinical service and supervision they provide while on the ground. They act as mentors to the trainees and assist the program leadership with teaching and assessments.ConclusionsAlthough generally smooth, there have been challenges, all of which have been met and are being resolved. This partnership is an example of how collaborations can harness the expertise and energy of short-term volunteers to achieve the goals of capacity building and self-sustainability.