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  • 1

    End of Mission Report

    Foya Borma Hospital

    Agnes Gullestrup, Ditte Marie Hansen

    & Marianne Brehm Christensen

    September 1st to November 27

    th 2010

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    Table of Contents

    End of Mission Report ...................................................................................................... 4

    The Mission ........................................................................................................................... 4

    PUMUI ............................................................................................................................... 4

    Economy ............................................................................................................................. 4

    Contacts in Liberia.............................................................................................................. 5

    The stay in Foya ................................................................................................................. 5

    Projects at Foya Borma Hospital ........................................................................................ 5

    Improving the usage of the buildings at Foya Borma Hospital: ......................................... 5

    Interior ................................................................................................................................ 7

    Training .............................................................................................................................. 8

    ER ....................................................................................................................................... 8

    IPD ...................................................................................................................................... 9

    OR ..................................................................................................................................... 10

    OB ..................................................................................................................................... 10

    OPD .................................................................................................................................. 11

    Recommendations for Foya Borma Hospital .................................................................. 11

    The usage of the buildings at Foya Borma Hospital ........................................................ 11

    Interior .............................................................................................................................. 12

    Training ............................................................................................................................ 13

    Routines ............................................................................................................................ 13

    ER and IPD ....................................................................................................................... 13

    OR ..................................................................................................................................... 15

    OB ..................................................................................................................................... 16

    OPD .................................................................................................................................. 16

    Future projects ................................................................................................................... 17

    The usage of the buildings at Foya Borma Hospital ........................................................ 17

    Interior .............................................................................................................................. 17

    Training ............................................................................................................................ 17

    Routines ............................................................................................................................ 17

    ER ..................................................................................................................................... 17

    IPD .................................................................................................................................... 18

    OR ..................................................................................................................................... 18

    OB ..................................................................................................................................... 18

    OPD .................................................................................................................................. 18

    Suggestions for costly improvements................................................................................ 18

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    Conclusion ........................................................................................................................... 19

    Appendix 1: Donation Budget ........................................................................................ 20

    Appendix 2: Emergency Room Budget ....................................................................... 21

    Appendix 3: Donated Equipment .................................................................................. 22

    Appendix 4: Map of Foya Borma Hospital ................................................................. 23

    Appendix 5: Usage of Buildings at Foya Borma Hospital ...................................... 24

    Appendix 6: In-Service Training ................................................................................... 26

    Appendix 7: The Whiteboard System .......................................................................... 27

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    End of Mission Report Expats Agnes Gullestrup, Ditte Marie Hansen & Marianne Brehm Christensen

    Medical students from the University of Copenhagen, Denmark

    Foya Borma Hospital, Lofa County, Liberia

    September 1st to November 27

    th 2010

    The Mission

    We are three medical students who have all finished our bachelors in medicine. The time

    spend in Liberia is not a part of the study, it is time taken out of the university schedule, and

    it is on a completely voluntary basis.

    PUMUI

    In Foya, Liberia, we are representing PUMUI, an organization constituted by doctors and

    medical students from the University of Copenhagen. The organization was funded in the fall

    of 2009, based on a pilot project made by Jesper Kjærgaard and Torsten Roed during the

    summer of 2009. They concluded that the Foya Borma Hospital, at that time Foya Health

    Centre, would benefit from receiving Danish medical students to help in the day-to-day

    running of the hospital, organization, and staff training.

    As the organization is fairly young, we are the first expats travelling from Denmark to Foya

    Borma Hospital on behalf of PUMUI.

    The members of PUMUI in Denmark are campaigning regularly at the university to get more

    students involved and to find future expats. Campaigning and fundraising is one of the main

    assignments for the members in Denmark.

    Economy

    PUMUI’s economy is completely based on Danish donations and fundraising made by the

    members. The money that the organization collects is going strictly to the Foya Borma

    Hospital.

    The three of us have received a Danish donation of DKR 20,000 (USD 3,333) that has

    exclusively funded medical equipment for the hospital (Appendix 1). We also had DKR

    10,000 (USD 1,667) with us from PUMUI for building a new emergency room at Foya

    Borma Hospital (Appendix 2). Furthermore we have graciously received medical equipment

    donated from hospitals in Copenhagen that we were able to bring to Foya Borma Hospital

    (Appendix 3).

    As the mission is on voluntary basis all expenses covering travelling to and from Liberia are

    financed by ourselves.

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    Contacts in Liberia

    PUMUI has provided us with the contacts in Liberia. Before leaving Denmark we had contact

    with Dorbor M. Akoi, executive director of PMU Liberia, Oscar Börjesson from PMU

    Interlife and Phillip Azumah, P.A. and assistant medical director at Foya Borma Hospital.

    PMU has provided the transport and accommodation in Liberia, as well as all the practical

    arrangements regarding our stay in Foya.

    The stay in Foya

    We arrived to Foya September 2nd

    2010. The first two weeks of our stay were spent on

    getting to know the hospital and staff, as well as preparing and setting our goals for the

    mission. During our stay we have also been visiting different local health clinics, a spiritual

    healer, and a traditional healer, to gather a more complete image of the health system in Foya

    District. The last week in Foya was spent on creating this End of Mission Report as well as

    concluding and completing further recommendations. The mission was finished November

    27th

    2010.

    Projects at Foya Borma Hospital

    When we arrived at the hospital we had no exact schedule for how our time should be spend

    the best and most optimal way. In Denmark we had a meeting with Jesper Kjærgaard and

    Torsten Roed who gave us some advice and recommendations regarding the hospital.

    Furthermore, by reading their End of Mission Report and Recommendations regarding Foya

    Health Center, we got a lot of ideas on how we wanted to improve the quality of the hospital.

    In the first two weeks we held meetings with the administrative director of the hospital,

    Francis Fondia, and the assistant medical director, Philip Azumah, about their

    recommendations regarding our stay. Besides this, we observed the staff and routines on all

    wards of the hospital.

    In the following we state the achievements of our mission.

    Improving the usage of the buildings at Foya Borma Hospital:

    Creating a new emergency room (ER)

    Moving women’s in-patient department (IPD) and pediatrics into an empty reconstructed building

    Creating an intensive care unit (ICU) and a post-operative ward

    Making space for isolation of IPD patients

    Creating two new and well-equipped nurse stations in IPD

    Creating a room for antenatal screening in the obstetric ward (OB)

    Creating a proper room for counseling in OB

    Organizing medical and non-medical stocks

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    Comments and evaluation:

    One year ago Jesper Kjærgaard and Torsten Roed made a very detailed recommendation

    document about the best usage of the buildings at Foya Borma Hospital together with a map

    over the hospital (Appendix 4). When we arrived to the hospital a big part of all the buildings

    were empty or simply used for stock. Most of the empty buildings were already renovated

    and ready to take in use; they just needed to be emptied and cleaned up.

    From the recommendations, from discussions and from meetings with the staff and the

    administrative director, and after having observed the routines of the staff for two weeks, we

    made our final recommendations regarding the usage of the buildings at Foya Borma

    Hospital (Appendix 5).

    The ER was placed in E1 because of the easy access for the ambulance, the stretcher, and for

    patients arriving directly from the road. The room is situated so that no other persons than the

    ER staff has to pass through it. Furthermore, the fundament, piles, and roof existed already,

    and it was possible to create the walls, windows, and the entrance in the most optimal way for

    an ER.

    Earlier women’s IPD and pediatrics were placed together in building F. This building was

    very dark with small rooms and it was unacceptably crowded. Pediatrics has been moved to

    B1 and B2 and women’s IPD to B3 and B4. These rooms were already renovated, had

    windows, and were all attractive and appropriate rooms for patients. We moved the beds from

    building F to B, and clean mosquito nets were placed above each bed.

    When we arrived the staff had no routines for placing critically ill patients and the post-

    operated patients separately. These patients require much more attention and monitoring than

    other admitted patients, and there is a big risk of losing patients by not identifying them and

    instead keeping them scattered in the IPD wards. The ICU and the post-operative ward are

    now placed in B5 and B6. Our recommendation is to place ICU in B8 with a window from

    the nurse station in B7. This makes it possible for the staff to observe the critically ill patients

    more frequently. The post-operative ward is placed in B6 due to a short and easy access from

    the OR.

    The annexes, G1, G2, H1, and H2, are used for men’s IPD, but if a demand of isolating

    patients arises, these buildings can be used for that purpose.

    We have created two nurse stations in E2 and B7 according to the movement of pediatrics,

    women’s IPD, ICU and post-operative ward. The staff has to be close to their patients and not

    spend time on running back and forth between buildings.

    The room for antenatal screening has been moved from A3 in the out-patient department

    (OPD) to C1 in OB. This makes it possible to use A3 for HIV counseling just next to the

    laboratory. Moving the antenatal screening room to the OB has meant that everything

    concerning pregnancy, mother and child health, and family planning is gathered at the same

    location. The OB staff will be more attentive to patients needing immediate care at the OB.

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    We have created a counseling room in C2 for counseling the obstetric patients concerning

    HIV, family planning, and pregnancy in general.

    Interior

    Buying a generator for the surgical ward (OR), ER, and OB with selective circuits

    Buying an air-conditioner in the OR

    Creating a library with books available for all members of the staff

    Creating an overview of equipment and drugs in every stock

    Comments and evaluation:

    During our time at the hospital, current and fuel for the generator was a big financial

    problem, and current was only running from 6-11 am and again from 7-11 pm. Deliveries

    during the night take place without any electricity, and the ER is also without current during

    the night, even though it is a very busy working area. If surgery is necessary during the

    afternoon or night - which happens quite often - the hospital has to put on the big generator

    providing the whole hospital with current. We found that there was a big need for a small

    generator with three separate circuits to run the ER, OR, and OB whenever necessary during

    the afternoon or night. The generator has been bought in Monrovia, but the installation is not

    completed. The facility manager, John Falkornia, is responsible for finishing the installation.

    The OR is a very busy place and often more than one surgery takes place each day. The

    hygienic level of the operation room is unacceptably low; there are no full-glass windows and

    no entrance door. It gets unbearably hot during the afternoon, and the surgical staff suffers a

    lot from the heat during operations. In regards to both the hygiene and the heat problem we

    bought an air-conditioner in Monrovia, but did not have the possibility to install the machine.

    Before installation the operation room needs a proper door and full-glass windows.

    The staff members at the hospital are all very eager to learn. As we brought some books from

    Denmark and have also found medical books in the administrative director’s office, we found

    it obvious to create a library. The library is placed in the big nurse station in E2, where most

    of the IPD staff is gathered during the day. The library is now functioning successfully and

    the books are available for all staff members from 8 am to 8 pm. The cupboard with books

    should always be locked, and the staff working in the dispensary just next to the library is

    responsible for the key. Every time a book is borrowed it should be noticed in the library

    ledger in the dispensary. No books are allowed to be taken away from the hospital grounds.

    All stocks have been well organized and the maintenance is now up to the different selected

    supervisors at each stock.

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    Training

    Having 45 minutes of training at the weekly Monday meeting in important medical topics (Appendix 6)

    Having 90 minutes of in-service training in important medical topics every Wednesday for the staff (Appendix 6)

    Training the staff in the different wards in ward-specific topics

    Comments and evaluation:

    All training sessions have been completed successfully as the staff members were all very

    motivated and eager to learn. The level of knowledge varies a lot between for example the

    laboratory technician and the P.A., which can make it difficult to teach at a level where

    everybody understands and gains knowledge. In comparison to the level we had expected to

    teach at, we soon realized that it had to become more basic. We found that training in small

    groups and in the wards seemed to be the best way for the staff to profit from the training.

    ER

    Having meetings with the administrative director and the assistant medical director on building a new ER

    Guiding the building project of the new ER

    Putting up direction signs guiding patients to the ER

    Making a clear entrance sign for the ER

    Moving all interior from the old ER to the new ER, including cleaning and organizing of all equipment

    Providing the ER with proper equipment and guidelines for emergency management

    Providing the ER with current

    Building a scale for infants

    Having a reception for the official opening of the ER

    Comments and evaluation:

    After spending just a short time at Foya Borma Hospital it was clear that the hospital needed

    a new ER. The former ER was too small and crowded, and the working area was not

    appropriate for dealing with emergencies. To get into the ER the patients had to be carried

    through one section of men’s IPD. The windows in the room made it possible for caretakers

    and patients to observe procedures and emergency treatments taking place in the ER. We

    decided that creating a new ER should be our major project. We had several meetings with

    the administrative director, medical director and assistant medical director. We received a

    budget for the building expenses, and on behalf of PUMUI we began the building project. We

    were engineers on the building project and decided to place the windows in a position where

    it is impossible to look in from the outside, and to place the entrance with easy access for the

    ambulance. Signs were placed outside the hospital to direct the patients to the ER, and the

    entrance was marked with big red letters.

    The new ER is now private and spacious. There are three patient beds, appropriate working

    space for the staff, and a corner for office.

    After the ER was finished and ready for use, we had an opening reception. At the reception

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    38 staff members of Foya Borma Hospital were present. We presented the emergency room

    and emphasized the importance of keeping the doors closed and only having ER staff and

    patients in the room. This has been respected by the ER staff.

    The ER has been of great use to patients and staff since the opening. It is clear to us, that this

    improved working area has given the staff better opportunities of providing good emergency

    care.

    IPD

    Creating two nurse stations

    Implementing the use of a whiteboard system

    Creating an ICU and a post-operative ward

    Improving the hygiene

    Placing curtains by exposed beds to ensure patient integrity

    Organizing all charts, chart boxes, and bed numbers

    Training the ward staff in intensive care: Triage, CPR, detecting and correct placement of critically ill patients, admission criteria for the ICU, and monitoring

    Meetings with the ward staff on: Communication, compliance, confidentiality, pre-operative care, palliative care, and the role of caretakers

    Comments and evaluation:

    Since the IPD is severely understaffed, a lot of changes were needed. The work routines in

    the IPD were unorganized and there was a lack of documentation. This resulted in critically

    ill patients being neglected, laboratory notes forgotten, and medicine not given. Besides this,

    the hygiene was of poor standard, and patients seemed very exposed in the wards.

    We saw a need for organizing the IPD ward and finding a way to help the staff deal with the

    big working load. While changing the usage of buildings we therefore created two nurse

    stations, one next to the ICU and the other one next to the new ER. In these nurse stations we

    provided the staff with an office area, a bed, and necessary guidelines and equipment such as

    blood pressure cuffs, pulse oximetres, thermometers, stethoscopes, and clinical handbooks.

    At the same time, we implemented the whiteboard system (Appendix 7), putting a whiteboard

    up in each station. The whiteboard system will give the nurses a quick overview of all

    patients in the wards, and most importantly it will help them to divide the nursing tasks and

    responsibilities. We have held training sessions about the use of the whiteboards, and

    therefore the staff is familiar with the routines. The whiteboard in the nurse station next to ER

    contains space for ER notes. As a result from meetings with the nursing director, Thomas

    Tamba, he has taken responsibility of the implementation. It is essential that everyone uses

    the whiteboards correctly for the system to be successful.

    Next to one of the nurse stations the rooms for post-operated patients and those needing

    intensive care were placed. To implement the use of ICU we had meetings with the IPD staff,

    discussing triage and care of critically ill patients. We also stressed the importance of

    transferring patients between wards. Even though we spend many hours training the staff in

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    using the ICU and post-operative ward correctly, it was never fully implemented.

    To improve hygiene we put up dispensers in each nurse station and provided clean water

    containers and soap found hidden away in stocks. We also had a Monday meeting about

    hygiene, and the importance of proper hygiene has been mentioned to the staff at many

    occasions.

    OR

    Organizing the medical stock and the equipment stock

    Fixing the OR oxygen concentrator

    Training the ward staff in: Ketamine, hygiene, and adequate surgery monitoring

    Comments and evaluation:

    Organizing in the OR was badly needed, and it turned out that the OR had resources that no

    one knew of. The OR staff has been included in the organizing and should now know all the

    equipment at stock.

    The oxygen concentrator was said to be broken, but all it needed was for someone to find the

    oxygen filters located at the OR stock and exchange it with the old one. This was all we did

    to “fix” the oxygen concentrator.

    The training of staff has improved the work routines at the OR, and relevant books have been

    shown to them in order for them to gain more surgical knowledge. Hygiene training was

    necessary to improve the hygiene standard, since the hygiene was at a terrible state.

    OB

    Fixing the OB ward oxygen concentrator

    Organizing working areas, stock, and medicine closets

    Creating a baby chart paper

    Making a suitable placement for newborns in the delivery room by putting borders on a table

    Putting legs on an “incubator” and introducing the staff to the correct usage of it

    Providing the nurse station with equipment

    Training the ward staff in: HIV and pregnancy, kangaroo mother care, and handling critically ill patients

    Comments and evaluation:

    An OB ward should have the possibility to administer oxygen to both mothers and newborns

    in need, which is why we focused on the oxygen concentrator there at hand, but not ready for

    use. We fixed the humidifier and have found filters in stock. If used properly it will safe

    many lives at the OB ward, and the staff has been instructed on the usage of the machine.

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    In collaboration with the staff we created a baby chart paper for monitoring babies with

    complications or special needs. This seemed necessary, since the newborns of the ward were

    not considered patients.

    Besides organizing in general, we improved the working space by hanging up a clock and a

    whiteboard for special notice cases in the nurse station, and found a head torch in the stock

    for use when the current is off.

    The OB staff members were very poorly educated on the subject of HIV and pregnancy. A

    newly educated staff member has begun to handle HIV screening and counselling for the

    female patients of the ward, but even her knowledge was limited and in many cases wrong.

    We therefore made it a high priority to train the staff in HIV and pregnancy, besides training

    them in more general skills suitable for an OB ward.

    OPD

    Providing the screening rooms with equipment and books

    Creating a weight-for-height board in real-person size

    Training ward staff in: Nutrition, screening techniques, and drug resistance

    Comments and evaluation:

    The OPD ward functioned fairly well before our arrival, why we concluded that the staff

    would benefit mostly from training.

    We discussed many ideas and possible changes for the laboratory, which is a part of the OPD,

    but since we know of coming structural changes in a near future, we decided to direct our

    focus elsewhere.

    Recommendations for Foya Borma Hospital

    The usage of the buildings at Foya Borma Hospital

    Our recommendations for the usage of buildings and rooms at the hospital are partly based on

    our suggestions for the building plan (Appendix 5).

    The present location of the ICU and the nurse station in building B are not in line with our

    recommendations for the hospital. We wished to use the biggest room for ICU, but this room

    was destined to become the nursing director’s office. Our recommendations are still to use

    this office as the ICU, and furthermore to create a window in the wall between the nurse

    station and the ICU to make it easier for the staff to observe the critically ill patients. The

    room now in use for ICU can remain ICU still according to these recommendations, since our

    experiences from the hospital are that there are many patients who would benefit from

    intensive care and a higher degree of monitoring. We know that a plan of the administration

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    for the future is to create a building for all offices, where we propose to locate the nursing

    director’s office as well.

    The annexes should always be available for isolation of for example patients with

    tuberculosis. As it is presently, the annexes are used for men’s IPD, mainly housing patients

    who all have a relatively long stay at the hospital for treatment purposes. We recommend that

    this system is maintained, because it offers space for isolation patients if needed, at the same

    time as providing the IPD patients a higher degree of privacy during their long stay if the

    rooms are not occupied.

    In the OR we recommend that the room presently used for surgery should be made into a pre-

    operation room, and that the empty room next door is taken in use as the operation room. We

    offer these recommendations because of structural advantages. It is optimal for the operation

    room to be the furthest away from the entrance to the OR, because of hygienic problems of

    holding a sterile environment next to an entrance facing the open area of the hospital. Also,

    when a patient leaves the OR after surgery, the stretcher bed is only able to fit through the

    doors of the presently empty room, which make this room even more obvious for surgery.

    The pre-operation room should be used for getting washed and dressed before entering the

    operation room.

    We recommend that the empty room between the pre-natal and post-partum wards in OB is

    used for office.

    The two screening rooms in OPD are too small to house the screener, patients, table, and bed,

    and we therefore recommend that the screening rooms are made bigger. The room wherein

    the two screening rooms and the archive are located is a perfect size for two screening rooms,

    if a wall is created in the middle. The archive naturally has to move, and we have made a

    suggestion for the new archive location (Appendix 5).

    The laboratory is not big enough to handle the patient load. Building a bigger laboratory will

    improve the working conditions for the staff members as well as creating more room for

    laboratory equipment. We encourage the administration to follow through on their plans on

    creating an entry from the laboratory’s blood bank to the new counseling room in order for

    HIV testing and counseling to happen unknown to the people outside the rooms.

    Our recommendation regarding building F is to use it for offices, to create a room for

    laundry, and to create a conference room.

    Interior

    The new generator has been installed, and the recommendation is to use it whenever it is

    profitable. Three different circuits should be connected to the generator, namely an OR

    circuit, an ER circuit, and an OB circuit. If any one of these wards is in need of current

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    outside the current hours, the small generator should be the generator of choice instead of

    turning on the big generator that provides the whole hospital with current.

    We strongly recommend that the administration of Foya Borma Hospital makes it a high

    priority to install the newly bought air-conditioner in the OR. The OR will never live up to

    any normal hygiene standard without this air-conditioner. It is important to note that the room

    in where the air-conditioner is installed cannot have open divided windows. The windows

    must be full-glass or replaced by a wall in order to keep the OR from being contaminated

    from the outside in, and in order for the air-conditioner to run efficiently. It should also be

    possible to completely close the OR, which means that doors are needed in every door

    opening.

    The hospital should have dispensers with disinfection available in each room with patients.

    This implies that staff should disinfect their hands before and after interaction with patients.

    If this routine is implemented, it will improve the hygiene and prevent transmission of

    disease.

    Many of the scales at the hospital are incorrect in weighing, and weight can be important for

    evaluation of patients and treatment planning. We recommend that scales are fixed or

    replaced.

    Training

    We recommend that the nursing director maintains the CPR skills of relevant staff. Our

    training in CPR was successful, but skills that are rarely used needs to be refreshed, why CPR

    training could be held twice annually under supervision of or by the nursing director.

    Routines

    For every important piece of equipment at the Foya Borma Hospital, there should be a

    supervisor responsible for maintenance and availability. This responsibility also includes

    informing the administration if equipment breaks down or runs out of disposable parts (such

    as oxygen filters for the oxygen concentrator)!

    ER and IPD

    To improve patient care it is first of all necessary that all staff members working at ER and

    IPD, including the ICU and post-operative ward, take on the responsibility it inevitably is to

    work with patients. Responsibility should be a key principle at these wards which is presently

    not the case.

    Whenever there is a shift of work, a report meeting should be held. This meeting should

    evolve around the patients in the wards. By giving report to the next staff members, the status

    of patients is evaluated, which means that the staff is always updated on their patients.

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    A lot of our attention has been evolving around the new whiteboard system. We emphasize

    the need to start using the whiteboards and using them correctly (Appendix 7). The nursing

    director is instructed on the proper use of the whiteboards, and therefore the hospital and its

    relevant staff has every opportunity to implement the whiteboard system. The nursing

    director is responsible for making sure that whiteboard makers are always available.

    We have created the possibility to gather the patients in need of intensive care. More

    precisely, we have created 4 dedicated ICU beds and 3 flexible beds for ICU patients or post-

    operated patients. Sadly the staff has not begun to work together on getting these units

    running according to guidelines. On behalf of all patients ever to be admitted at Foya Borma

    Hospital we recommend and plead the staff to start placing the admitted patients in the

    correct ward, give proper intensive care to the patients in the ICU and post-operative ward,

    evaluating the patients over time, and transferring them between wards whenever necessary.

    By gathering the critically ill patients instead of keeping them scattered in the wards, the

    workload will also decrease, as staff will not have to run between these patients.

    We acknowledge the fact that the IPD and ER are severely understaffed. But this fact is

    hardly an excuse for lack of skills in dealing with patients. Improving patient contact and

    increasing the level of informing patients will make a big difference for the admitted patients

    in the wards.

    Every staff member should consider the hygienic level and work hard to improve it, even

    though stress and lack of staff and therefore time makes hygiene seem like a low priority. If

    the wards are dirty, or if handling of equipment is not according to guidelines, the hospital

    will become a dangerous place for patients to be.

    It is the responsibility of each staff member to keep themselves updated on specific

    treatments. We therefore recommend that the staff frequently read the guidelines visible in

    the nurse stations and in the ER, and encourage them to use the library in the big nurse station

    to gain more knowledge and refresh old knowledge in order for them to perform their best as

    nurses.

    The working spaces should be kept tidy. This also implies that materials are refilled daily to

    always be ready for emergency situations and everyday use. A supervisor should be made

    responsible for keeping an overview over stocked materials. If nothing hides in the stock, the

    hospital can use its resources to the fullest.

    We recommend that a staircase is built outside the IPD dispensary. Patients and caretakers

    should not have any reason to enter the nurse station, but they have as long as the dispensary

    counter is located within this room. By building a staircase on the outside, the dispenser can

    perform his or her job just the same, managing patients and caretakers through the window.

    This will improve the working space and the working conditions for the staff.

  • 15

    OR

    We highly recommend that oxygen is administered to every patient undergoing surgery, or at

    the very least administered if the saturation drops.

    During surgery, only personal needed for the surgery procedure should be present in the OR.

    If someone has a proper reason for entering in the middle of an operation, this person must be

    wearing an outfit suitable for entering, meaning that the hair and mouth must be covered,

    hands are washed and kept in gloves, shoes are borrowed from the OR shoe shelf, and that

    clothes from the OR is worn above the normal clothes. This person has to enter the operation

    room through the pre-operation room. Besides this, all doors should be closed during surgery

    and preferably never be opened as long as surgery is taking place. This means that all needed

    members of the staff should be present from the beginning to the end of each operation.

    The OR should be the tidiest ward at the hospital. Keeping all work spaces clear and clean

    and refilling used materials after each surgery will increase the chance of having successful

    operations.

    It is up to the staff of the OR to know exactly what is at stock. When we went through their

    stocks, we threw away materials that expired in 1987! We were forced to burn a huge pile of

    sponsored materials because it had either expired or had simply been spoiled as result of poor

    stocking conditions or poor maintenance. This is completely and utterly unacceptable. No

    organization or private donor is willing to donate materials and equipment, if the donated

    goods are not handled properly and respectfully – this includes PUMUI.

    We recommend that the OR gets a more suitable table to place newborns after caesarian

    sections. The main criterion is that there should be borders on the table in order to keep the

    baby from falling down on the floor. If the new high table for placing newborns in the OB is

    used as a model, the borders should higher and the table preferable bigger for cases of twins.

    The condition of electricity in the OR is not functioning. As it is, staff has to touch a plug

    collector located on the floor, which is everything but optimal in an OR. Each machine

    should have its own plug in the wall, and all electricity connections should be stabile.

    Every week all equipment should be checked in function. If this is implemented, the

    machines such as the vital sign monitor will be more likely to function properly and the

    lifespan of each machine will be prolonged.

    We have given the staff of the OR the WHO Surgical Safety Checklist. After we all discussed

    the questions of the checklist, we hung it up in the OR. We recommend that it becomes a part

    of the surgery routine.

    Improvement of most routines in the OR would help the staff to be more organized. Before

    surgery begins, the equipment table should therefore be ready for use with all possibly

  • 16

    needed equipment and materials, and it should be kept tidy during the operation. It is the

    responsibility of the staff member in charge of the equipment table to make sure that these

    protocols are followed.

    OB

    The OB ward would benefit greatly if the usage of the “incubator” increased. Newborns with

    jaundice, which means all the premature babies, need phototherapy to activate liver enzymes,

    and this light is already installed in the “incubator”. We recommend that the Foya Borma

    Hospital makes it protocol to treat every premature newborn with phototherapy. The

    “incubator” should also be used for heating newborns, and especially the premature babies.

    We therefore also recommend that a heating lamp is bought and installed in the “incubator”

    in order for it to be used for both purposes. If for some reason this does not happen, the

    “incubator” can still be used with hot enwrapped water containers to keep newborns warm.

    Whenever there is a shift of work, a report meeting should be held. This meeting should

    evolve around the patients in the wards who have special needs such as ongoing deliveries,

    newborns with difficulties, and post-operated women.

    With the new whiteboard placed in the nurse station at OB, it has been made easy to keep an

    eye on the status of patients who need special attention. Still strongly needed is the

    monitoring of these patients. The staff of the OB prefers to keep all OB patients at the ward,

    but with this wish follows great responsibility. The mothers and newborns with special needs

    or complications should be monitored as often as those admitted in the ICU, and treatments

    should be quickly accessible. If the staff is not able to meet these demands, the patients of the

    OB ward should be transferred to the ICU or the post-operative ward. The wishes of the staff

    must never be above the interest of the patients, so the staff at the OB ward must improve the

    monitoring of critical patients and patients with special needs.

    We recommend that the staff will keep using the baby chart that we have created together. It

    will make it easier to follow the progress of the newborn’s condition if documentation is

    available.

    The OB staff members would benefit from educating themselves. A whole bookshelf in the

    library is dedicated for books on the subjects of obstetrics, neonatology and pediatrics, so it

    has been made very easy for the OB ward to generally uplift the level of knowledge about

    their patients and their patients’ needs.

    OPD

    The OPD ward is functioning well in many aspects. In the children under 5 section the

    children are being screened according to guidelines. The vaccination section and the

    registration also seem well-functioning.

  • 17

    The screening rooms, however, do not meet the hygienic expectations. Improvement of

    hygiene in the screening rooms, implemented by each screener, is necessary in order to

    minimize the risk of passing microorganisms and diseases between patients.

    Future projects

    The usage of the buildings at Foya Borma Hospital

    Create an ICU in B7 with a window to the nurse station in B6

    Create a pre-operation room in A11 and an operation room in A12

    Make bigger screening rooms in OPD

    Make a proper and private HIV counseling room next to the laboratory

    Create a bigger laboratory

    Improve the delivery room

    Interior

    Install air-conditioner in A12

    Make sure disinfection dispensers are available in every room with patients

    Training

    Train in usage of and routines regarding the whiteboards

    Train in relevant topics

    Improve hygiene

    Routines

    Implement report meetings at shifts in both IPD and OB

    Make sure that vital signs are taken on all patients before the doctor does the morning round, and make sure that at least one nurse is available to assist

    Make sure that every patient is checked several times during the day

    Improve and ensure the usage of the oxygen concentrators, including changing water in the humidifiers daily

    Implement a system where patients are identified by admission number and not by bed number or name. Bed number changes when patients are referred, and different

    patients may have the same name. The patients should have the admission number on

    a badge or a bracelet

    ER

    Work as a doctor

    Train in: Emergency care and triage

  • 18

    IPD

    Do rounds in the evening

    Train in: Responsibility, identifying critically ill patients, correct transfer of patients, intensive care, important diseases, history taking, physical examination, differential

    diagnostics, blood transfusion routines, catheter and IV line management, drug

    administration, and physiotherapy

    OR

    Improve the interior in the pre-operation room and the operation room

    Make a suitable placement for newborns after caesarian sections

    Train in: Saturation, hygiene, use of surgical suction, surgical hand wash, correct position of patients on the operating table, use of the oxygen concentrator, spinal

    anesthesia and monitoring

    OB

    Improve the delivery room facilities

    Create an office

    Install a heating lamp in the “incubator”

    Do health education of women in the community

    Train in: Critically ill patients, resuscitation, pre-eclampsia and eclampsia, use of baby charts, vacuum extraction, HIV/AIDS, and how and why to cut the umbilical

    cord close to the abdomen

    OPD

    Work as a doctor in the screening

    Improve the laboratory facilities by for instance supplying equipment for culturing bacteria and fungus

    Do health education in the community and detecting malnourished children

    Train in: Screening techniques, nutrition and malnutrition

    Suggestions for costly improvements

    Resources at the hospital are limited.

    Following items would improve the hospital quality:

    Air-conditioner for the pharmacy

    Incubator

    Oxygen concentrator

    Blood sugar measuring equipment

    Measuring equipment for hematology

    Centrifuge with sealers

    Handbooks on nutrition

  • 19

    Blood pressure measures

    Chart folders

    Lumbar puncture equipment

    Scales for infants and adults

    Travelling bags for community health work

    Tablet cutter

    Caesarian section surgical kits

    Surgical instruments

    Sutures (2.0 vicryl, 1.0 vicryl, 1.0 non-absorbable)

    Cuvettes

    Urine stix

    Conclusion

    We have found the administration and staff of the hospital very cooperative. We have made

    many improvements and successfully trained every staff group at the hospital. The people of

    Foya Borma Hospital have shown large engagement and believe in our changes; without this

    our work would not have been as successful as it was. We hope to continue the relationship

    between Foya Borma Hospital, PMU and PUMUI in order for future expats to gain

    knowledge from Liberia while improving the level of staff education and health facilities at

    Foya Borma Hospital.

  • 20

    Appendix 1 Donation Budget

    Expats Agnes Gullestrup, Ditte Marie Hansen & Marianne Brehm Christensen

    Medical students from the University of Copenhagen, Denmark

    Foya Borma Hospital, Lofa County, Liberia

    September 1st to November 27

    th 2010

    We have received DKR 20.000 = USD 3.333 donated by Medarbejdernes Honorarfond i

    Novogruppen.

    Purchased in Denmark:

    Medical books 167 USD

    Gloves 83 USD

    Equipment for the hospital 2.083 USD

    6 blood pressure measures

    6 blood pressure cuffs for children

    6 pulse oximetres

    10 nurse stethoscopes

    4 doctor stethoscopes

    4 reflex hammers

    Purchased in Liberia:

    Air-conditioner 550 USD

    Generator 340 USD

    Whiteboard 65 USD

    Whiteboard markers 6 USD

    Wooden boards for creating a crib, two beds and a document box 30 USD

    Lock and hinges for the library cupboard 9 USD

    Total: 3.333 USD

  • 21

    Appendix 2 Emergency Room Budget

    Expats Agnes Gullestrup, Ditte Marie Hansen & Marianne Brehm Christensen

    Medical students from the University of Copenhagen, Denmark

    Foya Borma Hospital, Lofa County, Liberia

    September 1st to November 27

    th 2010

    The budget for the emergency room was funded by PUMUI.

    32 bags of cement 560 USD

    Transporting sand 60 USD

    2 piles of sand 90 USD

    11 yards of mesh wires, 11 yards of screen wires 38 USD

    Steel rods, wedding for slide 50 USD

    Window frames, planks, nails, carpenter fees 75 USD

    Fixing one double door 80 USD

    Constructing, plastering, feeding, masons fees 300 USD

    Sewing 2 USD

    Gasoline 12 USD

    Printing and signs 15 USD

    Hinges and lock 46 USD

    Glass 100 USD

    Painting and painters fees 170 USD

    Whiteboard 65 USD

    Total: 1.663 USD

  • 22

    Appendix 3 Donated Equipment

    Expats Agnes Gullestrup, Ditte Marie Hansen & Marianne Brehm Christensen

    Medical students from the University of Copenhagen, Denmark

    Foya Borma Hospital, Lofa County, Liberia

    September 1st to November 27th 2010

    We have received donated equipment from Bispebjerg Hospital, Rigshospitalet, and Herlev

    Hospital:

    6 blood pressure cuffs for children

    2 extra blood pressure cuffs for adults

    8 ventilation masks

    1 ambu bag

    16 pieces of surgical instruments

    35 scrub suits

    250 pairs of sterile gloves

    26 boxes of suture

    2 boxes of big wound band-aids

    8 boxes of single-use scalps

    4 boxes of single-use blades

    4 boxes of canula

    1 bag of syringes

    We have also received books from medical students at the University of Copenhagen:

    10 books on anatomy and physiology

    1 atlas of the human body

  • 23

    Appendix 4 Map of Foya Borma Hospital

    Expats Agnes Gullestrup, Ditte Marie Hansen & Marianne Brehm Christensen

    Medical students from the University of Copenhagen, Denmark

    Foya Borma Hospital, Lofa County, Liberia

    September 1st to November 27

    th 2010

  • 24

    Appendix 5 Usage of the Buildings at Foya Borma Hospital

    Expats Agnes Gullestrup, Ditte Marie Hansen & Marianne Brehm Christensen

    Medical students from the University of Copenhagen, Denmark

    Foya Borma Hospital, Lofa County, Liberia

    September 1st to November 27

    th 2010

    Building Usage Remarks

    A01 Community Health Department + EPI

    A02 Registration and patient line

    A1 Screening room 1 and 2 Split room in two with wall

    A2 Entrance to counselling room Close entrance to A1

    A3 Counselling room Put in door to A4

    A4 Blood bank + entrance to counseling room

    A5 Laboratory Tear down wall to A6

    A6 Laboratory

    A7 Archive

    A8 Dispensary

    A9 Injection and dressing room

    A10 Medical director’s office

    A11 Pre-operation room Build a door to A12

    A12 Operation room Install air-conditioner

    A13 Medical equipment stock

    A14 Staff room

    A15 Wardrobe and stock

    B1 Pediatric ward

    B2 Pediatric ward

    B3 Women’s IPD

    B4 Women’s IPD

    B5 ICU/post-operative ward Build toilet

    B6 ICU

    B7 Nurse station Create a window to B8

    B8 ICU

    C1 Antenatal screening room

    C2 Counseling room

    C3 Labour room

    C4 Sitting area

    C5 Delivery room

    C6 Nurse station + stock

    C7 Post-partum ward

    C8 OB office

    C9 Pre-natal ward

    D1 Pharmacy + vaccine stock

    D2 Warehouse + logistic’s office

    D3 Administrative director’s office

    D4 Waiting room

  • 25

    D5 Drug storage room Put in air-conditioner

    D6 Stock

    D7 Finance office

    E1 Emergency room

    E2 Nurse station + library

    E3 Men’s IPD

    E4 Men’s IPD

    E5 Dispensary Build staircase in front of window

    E6 Men’s IPD

    E7 Men’s IPD

    E8 Men’s IPD

    F1 Office

    F2 Office

    F3 Office

    F4 Office stock, printer room

    F5 Laundry room

    F6 Hall + waiting area Build toilet

    F7 Conference room

    G1 IPD isolation/long-term patients

    G2 Tuberculosis office

    H1 IPD isolation/long-term patients

    H2 IPD isolation/long-term patients

    Estimate of beds:

    Bed # Amount

    IPD

    Pediatric ward 1 – 14 14

    Women’s IPD 15 – 26 12

    ICU 27 – 29 3

    Post-operative ward 30 – 33 4

    Men’s IPD 34 – 47 14

    Annexes 48 – 53 6

    Total IPD beds 53

    OB

    Pre-natal ward 7 – 21 15

    Post-partum ward 22 – 35 14

    Total OB beds 29

  • 26

    Appendix 6 In-Service Training

    Expats Agnes Gullestrup, Ditte Marie Hansen & Marianne Brehm Christensen

    Medical students from the University of Copenhagen, Denmark

    Foya Borma Hospital, Lofa County, Liberia

    September 1st to November 27

    th 2010

    Monday meeting:

    Nutrition

    Hygiene

    Wound Management and Burns

    Communication and Compliance

    Nosocomiel Infections and Surgery

    Diabetes

    Wednesday workshop:

    Key Values and Laboratory Values

    Pneumonia and Tuberculosis

    Oxygen Administration

    Blood Pressure – Hypertension and Hypotension

    Triage

    Diarrhoea

    HIV/AIDS and Stigma

    Anaemia and Blood Transfusion

    Neurology and Mental Health

  • 27

    Appendix 7 The Whiteboard System

    Expats Agnes Gullestrup, Ditte Marie Hansen & Marianne Brehm Christensen

    Medical students from the University of Copenhagen, Denmark

    Foya Borma Hospital, Lofa County, Liberia

    September 1st to November 27

    th 2010

    If the whiteboard is used correctly, it will decrease the staff work load, make the work more

    accessible, create a good overview of the patients, and thereby minimize the risk of patients

    being forgotten or not treated. This will decrease the patient mortality.

    For the whiteboard system to be working all staff members must be engaged in using it and

    all squares must be correctly filled in at all times. It is the staff’s responsibility to update the

    whiteboard when any patient changes occur on the wards.

    It is important that no patient or caretaker have access to the whiteboard to secure that

    patient-sensitive information never leaves the ward.

    Bed #:

    All bed numbers should be listed here with a permanent marker.

    If the wards are overcrowded and extra beds or mattresses are taken in use, the empty rows in the bottom of the whiteboard should be taken in use to keep track of these

    patients.

    Patient name:

    When a patient is admitted to a specific ward, the patient name should be written on the whiteboard next to the number of the bed that the patient is placed in. If the name

    of the patient is long, only use the first letter of the first name (for example Finda

    Saah = F. Saah).

    If the patient is transferred between wards, the name should be moved according to the bed that the patient is transferred to.

    Once the patient is discharged, the patient name should be erased from the whiteboard.

    Admission criteria:

    To get a quick overview of the patients it is important that the admission criteria for all admitted patients are written on the whiteboard.

    The admission criteria should be the diagnose or impression of the patient. All diseases should be written and only the very stigmatized diseases such as HIV and

    tuberculosis should be replaced by codes.

    Caretakers and patients should not have access to the information on the whiteboard.

  • 28

    Special notice:

    The special notice should only be filled in if there is a need for specific attention to the patient. This could be a change in patient condition, a proceeding blood

    transfusion, a need for extra monitoring, or alarming vital signs.

    Vital sign (V.S.) time:

    The nurse and nurse aid should write the time for when the vital signs have been measured on the patient. This square should only be filled in with the time of when

    the vital signs were taken, and not with the actual vital sign values.

    Nurse:

    For the whiteboard system to work sufficiently, this square is the most important to fill in!

    At shifts, all leaving and arriving staff members should be attending the handover of patients. This is a very important procedure, and during this the staff leaving should

    give a quick evaluation of all patients by using the patient overview on the whiteboard

    to the arriving staff.

    Once all patients have been evaluated they should be divided between the arriving staff members, so that each nurse or nurse aid takes responsibility for a certain

    amount of patients.

    The number of patients for each staff member should be divided according to work load. For example should the nurse or nurse aid responsible of the ER only have a few

    IPD beds to care for. And the nurse or nurse aid responsible for the ICU and post-

    operative ward should only have responsibility for these units, unless if there are only

    a few patients needing intensive care, in which situation the nurse or nurse aid should

    also take responsibility for beds in the other IPD wards.

    All patients should be divided between the staff at work. The nurse or nurse aid is responsible for the patients that have been signed for and only these patients.

    The Nurse square is to be filled in when the shift is handed over, and the nurse writing the initials in the square is responsible for this specific patient throughout the shift.

    The initials should stay in the square during the entire shift. This means that the nurse or nurse aid can be held responsible for any forgotten patient care and is responsible

    for giving a good report when handing the patients over to next staff member at shift.


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