Two Public Health Issues (plus one)

Two days ago, I was driving my daughters to school when they spotted a lady on a motorbike. She was smartly dressed in a white shirt on a beige colored skirt. Her shirt had epaulets on them signifying she was a ranked member of a uniformed organization. Ruby, the older of my two daughters asked “Daddy, which organization does this lady work for?” Tara replied “she is a special mobile police woman”.

I couldn't help laughing as I told them that she was a Sanitary Officer/Inspector. Nowadays, they are also referred to as Environmental Health Officers (EHOs). I went further to explain the functions of EHOs to include monitoring and inspection of restaurants, eateries and other establishments to ensure that they adhere to the prescribed standards of public hygiene. My daughters were surprised that such an organization existed because in their combined 17 years on earth, they had never seen anyone performing such functions.

The next question from Ruby was: “why don’t these people inspect our school canteen? It is always so filthy and has flies all over the place.” “I guess that is why children who eat there are always going to the toilet.” Tara contributed.

How true! We do have EHOs but they don’t really do much to earn their pay. When they do inspect and monitor public establishments, many of the EHOs end up collecting money from offenders without actually penalizing such offenders. This is a danger to our collective health because an epidemic can break out from such unhygienic facilities.

That incidence reminded me of another public health disaster noticed in our neighborhood about a year ago. We woke up one morning to find that a newly constructed house had a drainage pipe which was emptying waste water directly into the street! The water consisted of bath water and kitchen waste. Guess who owned the house: a (dis)honorable member of the State House of Assembly. The health hazard posed by this impudence was immeasurable. Several hundreds of school children and others walked across that puddle of water daily. Imagine if a child had fallen right into that watery bacterial mess. For those of us who drove past it daily, it was quite an eyesore. Several months and multiple visits later, the legislator finally constructed a proper drainage system to handle the waste water.

The above scenario plays out in so many cities across Africa and the developing world every day. Little wonder that we still have people dying from cholera and other diarrheal diseases.

After dropping Ruby and Tara in school, I decided to see my Auto Mechanic to fix a minor fault in my car. At the workshop, I saw a well dressed and apparently enlightened middle-aged man having a pedicure. I wasn't fascinated that he was having his toenails trimmed and cleaned in such a public place. Rather, I was shocked at the manicurist/pedicurist who was doing the job. The chap was barely literate and knew nothing about infection control nor the proper use of sharp objects. He had a rusty scissors that was razor sharp and a few other sharp things. (These traditional manicurists/pedicurists are ubiquitous in Northern Nigeria). I tried unsuccessfully to educate both the manicurist and the ‘manicuree’ on the dangers of using sharp unsterilized instruments. When I wasn't making any headway and it looked obvious that I was a busy body, I shut my trap, did my business and left the scene.

As I drove to the office that day, I realized that we still had a long way to go to ensure public health and safety. While the developed countries have progressed to producing cutting-edge medical technologies, the developing world is still struggling with basic public health issues like personal hygiene, clean school canteens and unregulated practitioners.

Though the future may appear bleak, healthcare professionals should not despair. We must continue to partner with both the government and the public. Our role remains to educate the public in our consulting rooms, at the market, in our homes, neighborhood and yes, even in the auto mechanic workshops. We must also hold the government accountable to ensure that relevant agencies inspect and monitor public facilities, enforce the laws, eliminate (?) corruption, punish offenders and reward exceptional compliers.

The journey to a safer public health seems far, but each determined step taken will lead us closer to our destination.

See you soon….

Using Checklist to Improve Hospital Services

I must really apologize that I did not write this post as I had earlier promised. I have been on the road and it has really being hectic. 

However, here is my take on using checklists in healthcare settings.

A checklist is a list of items or points for consideration and action. Like its name, a checklist may be a list of things to check before you do something. A common example of a checklist is the aviation pre-flight checklist used by pilots. Before taking off, there is a list of things that every pilot must do regardless of his/her level of experience. This is done all the time. The purpose is to ensure that the plane is functioning properly before take-off and to prevent any future air mishap.

There are different types of checklists used in medicine. These include:

• ·        Procedure Checklist e.g. Surgical Checklist

• ·        Diagnostic Checklist e.g. Algorithms

• ·        Equipment Checklist e.g. Medical Equipment Checklist

• ·        Iterative Checklist e.g. Protocol for Monitoring Post-Op Patients

It is sad to note that a lot of errors take place in the healthcare industry on a daily basis; wrong surgeries are performed, wrong medication given e.t.c. Majority of these errors arise from lapses in concentration, distractions, or fatigue. Some are quite preventable.

In a recent discussion with a female physician, she said something like “we are doing quite well without checklists. Checklists will just add to the current paperwork burden that we have”.

 Before you nod your head in agreement, please consider the following:

• ·         Firstly, human beings are not infallible. Distractions, fatigue and concentration lapses lead to variability in service delivery. Variability leads to mistakes and mistakes can lead to severe disability or death (What physicians like to call iatrogenic). With the use of checklists, the hospital system is strengthened, peer review and assessment enhanced and variability reduced.

• ·        Secondly, you cannot remember everything or commit everything to memory. I am sure you can recall several instances that you forgot a critical step or item in a procedure. Using a checklist will make sure you don’t forget a thing. You become almost infallible.

• ·        Thirdly, different people follow different steps to perform the same procedure. Some steps may be necessary and correct; others may be unnecessary and incorrect. This results in a waste of time, resources, efforts or skills. This also causes variability which is an enemy of quality service. A checklist will thus help to standardize procedures, reduce waste, eliminate variability and improve quality.

I will illustrate with the case study below:

Dr. Wright is in the OR performing an elective C-section on Mrs. Gabo, a 42 year old primigravida. He has already extracted a 4.5kg male neonate. In the process, there is a deep tear extending from the anterior part of the lower uterine segment towards the posterior surface of the urinary bladder. In an attempt to close the uterus beginning at this “angle of sorrow”, the suture snaps. The scrub nurse is so jittery that he drops the replacement on the floor. That happens to be the last Chromic 2 suture available in the hospital. The only other available chromic suture is a Chromic 2/0. Dr Wright struggles and fumbles to use this to repair the tear. Unfortunately, Mrs. Gabo continues bleeding and eventually dies from severe hemorrhage.

A simple procedure checklist used at the beginning of the surgery could have prevented this death. An equipment checklist used before the commencement of the surgery could also have revealed the inadequate quantity of relevant sutures.  

The World Health Organization (WHO) developed a simple surgical safety checklist some years ago. This can be adapted and modified to suit local conditions. You can see it here.

Before developing any kind of checklist for your hospital, it is important you determine first and foremost the purpose of the checklist. What is the checklist meant to do specifically? 

Next, decide on the type of checklist that is needed to fulfill the given objective i.e. a procedure checklist, equipment checklist e.t.c.

Another important step in developing checklists is to involve the group of people to use the checklist in a brainstorming session. This group should also include experts/specialists in the area of need. Several different ideas may be considered during development. A checklist that is acceptable to all concerned should be the product of this session.

Of course, you also need to set benchmarks to help you determine the effectiveness of the checklist. This will enable you review the checklist periodically to ensure it remains relevant to your practice.

Please note that a checklist is as important in a private hospital as it is in a public hospital.

They should be a necessary part of any hospital. 

Thanks for reading. See you soon….

My Apologies

Dear Readers,

I will like to apologize for the long silence on this blog. I have been on the road handling several family issues. I will certainly write something fresh soon.
Thanks for your constant readership.

Cheers.

Ohi