Neurosurgical Care in Uganda
Team profile by Stephan Beauge, Veronia Brtek, Taylor Horowitz, Suzanna Joseph, Amina Mohamed, Rifah Najiba, Oluwaseun Oguntunmibi, Sarah Perez, Priyanka Rao, Jein Seo, Annika Sharma, Jonah Sinclair and Bruno Valan
In 2015 The Lancet journal published Global Surgery 2030: Evidence and Solutions for Achieving Health, Welfare, and Economic Development. This landmark commission described the role of surgical care as an essential aspect of individual and community health, as well as economic productivity. With nearly 5 billion people lacking access to safe and affordable surgical services, worldwide gaps in surgical care account for roughly one-third of the global burden of disease.
Our Bass Connections team works to close these gaps through quality-improvement interventions and research at the Mulago National Referral Hospital (MNRH) in Uganda. In close collaboration with the local staff we build and test protocols that help strengthen the systems needed to support surgical patient outcomes. Our student-led teams focus on three vital aspects of peri-operative care:
- Patient-caretaker education
- Infection control
- Medication management
Earlier this spring our team was invited to present at Duke Global Health Institute’s “Think Global” seminar series. This presentation showcases our cumulative work over the past 5 years.
Think Global: Improving Neurosurgical Patient Outcomes in Uganda
Talk by Tony Fuller, Suzanna Joseph, Sarah Perez and Bruno Valan
Patient-Caretaker Education (PCE) Team Profile
Due to the lack of substantial health care resources in the low-income setting of Uganda, caretakers—typically family members of the patient—often play a vital role in taking care of patients. Their tasks include feeding, cleaning, and administering medication to their loved ones. However, these caretakers often have little to no formal training in patient-care practices. This lack of knowledge greatly affects neurosurgical patients who experience difficulty in conducting basic tasks, therefore requiring assistance from family members.
The Patient Caretaker Education team seeks to address these barriers to patient care by targeting the health education of caretakers. We do so by implementing various educational interventions, in addition to creating educational resources. Past projects have included using a periodic SMS-based intervention to remind caretakers to turn patients in order to prevent bedsores. Other interventions have included creating educational posters outlining proper feeding techniques to both increase caretakers' understanding of feeding techniques and prevent aspiration. These interventions have made a beneficial impact on the ward with SMS reminders increasing patient turning rates 1.78-fold, and over 70% of the staff reporting that they found the posters helpful in educating themselves on proper feeding techniques.
This past summer, the team collaborated with nurses and doctors to create a culturally competent educational video showcasing proper feeding and care techniques. The video was made in two different languages—English and Luganda—and it detailed the proper methods used to feed patients using different feeding practices (NG tube and normal feeding). It also highlighted proper hand sanitation practices and general ward policies. A television was placed on the walls with the video playing on loop in order to ensure that the information reached everyone in the ward.
Our current project focuses on implementing an aspiration risk training program for nurses in the neurosurgery ward. We plan to conduct a pre and post study in order to track knowledge gain among the nurses. Our goal is to implement an aspiration risk screening tool to help increase health providers' ability to recognize high-risk patients. Through this program, we aim to increase nurses’ knowledge in identifying aspiration risk factors and reduce aspiration related deaths in the neurosurgery ward. The nurses will also be able to obtain a certificate after completion of the training program. We hope that by focusing on nursing education and introducing a screening tool, nurses will feel more empowered and be able to educate caretakers on the necessary practices in order to reduce aspiration risk in the ward.
PCE Team Poster: Evaluating a Routine Education Program to Improve Patient Aspiration Rates in Mulago Hospital Neurosurgical Ward, Uganda
Poster by Sherry Yang, Chinemerem Nwosu, Priyanka Roa, Amina Mohamed, Michael Haglund and Anthony Fuller
Infection Control (IC) Team Profile
The Infection Control team aims to reduce infection in the neurosurgery ward by addressing some of the main factors that lead to a preventable infection. To do this, the team works jointly with a local infection control team composed of several staff members that work in the neurosurgery ward full-time throughout the year. This enables constant communication and feedback from the ward to determine if implementations are necessary, successful, and maintained.
In previous years, the infection control team has mainly focused on hand sanitization to combat infections. To do this, several implementations were put in place that involved hand sanitization such as installing bed pups, wall-mounted pumps, and personal clip-on sanitizing units. Data was also collected to determine which wall-mounted pumps were used mostly to create a map of pump usage. A consistent problem that was faced, however, was maintaining these implementations after the team left Uganda. Every time the team would return the following year, most of the installed pumps were broken or removed. To combat this, the team worked with the local infection control team to conduct monthly check-ins on the status of the pumps that were installed. This allowed the team to monitor if the pumps had been removed or broken so that their maintenance could be ensured.
The team’s main focus shifted this year to catheter-associated urinary tract infections. The team developed an all-encompassing implementation that would ideally improve aseptic technique and catheter monitoring to minimize the risk of patients contracting UTIs. Parts of this implementation included educating nurses on proper aseptic technique and nurse-initiated checks during rounds to determine if a catheter could be removed. The team also developed a system that would allow for better monitoring of how long catheters had been inserted. From this, the team hoped to see the overall prevalence of catheter-associated UTIs drop.
IC Team Poster: Improving Hand Hygiene through Accessibility in an LMIC Neurosurgical Ward
Poster by Samantha Sadler, Bruno Valan, Praruj Pant, Akash D. Patel, Kelsey Graywill, Margaret Lund, Joao Ricardo Nickenig Vissoci, Michael Muhumuza, Hussein Ssenyonjo, John Mukasa, Joel Kiryabwire, Michael Haglund and Anthony Fuller
Medication Management (MM) Team Profile
Medication nonadherence is a global problem that can lead to infections, complications, and preventable death. It is often exacerbated in low-resource settings in which patients are reliant upon their caretakers to interpret their complicated regimens and administer their medications. The Medication Management team seeks to increase medication adherence in the neurosurgery ward of the Mulago National Referral Hospital by implementing various interventions aimed at simplifying the medication administration process.
Past interventions implemented by the team include information sheets used to promote medication understanding and pillboxes to help patients organize their medications. While there was some improvement in patient understanding due to the information sheets, its overall effectiveness was limited by the high rate of illiteracy on the ward. The pillboxes were well-received by patients and increased the percentage of patients taking the correct dose, both the amount and times per day. However, despite the immediate increase in medication adherence seen after this intervention, our team noticed several problems with sustainability. Nurses were required to ensure that each patient’s pill box was regularly filled to reflect their constantly evolving medication regimen. This high level of demand placed on an already strained resource (i.e., the nursing staff) prevented the pillbox intervention from continuing past the summer.
Learning from our past work, the intervention from this summer (2019) aimed to better communicate pertinent information to caretakers in a sustainable way. We worked with the hospital’s medical illustrations department to revise the old information sheet into visual color-coded posters, allowing it to be more useful to a greater population of the patients/caretakers. The posters worked in tandem with an in-person education session held by local pharmacy students studying at the university that is affiliated with the hospital. Pharmacy students color-coded patients’ medications to correspond with the posters, wrote down the exact dosages and time of day each medication should be administered, and answered any questions the caretakers had. By partnering with the pharmacy students, we avoided further straining the nurses and improved the sustainability of this intervention.
Our current project aims to expand upon this by measuring the impact of our education-based intervention. We plan to analyze patient medication adherence rates and understanding of medication purposes in the Neurosurgery Ward against that of the Gastrointestinal Ward to determine the efficacy of this intervention.
MM Team Poster: Interventions to Improve Medication Adherence Among Neurosurgical Patients at Mulago National Referral Hospital
Poster by Suzanna Joseph, Jonah Sinclair, Sarah Rapaport, Garrett Holmes, Hyun Keun Ahn, Raahina Malik, Winnie Nambatya, M. Pharm, Michael Muhumuza, Michael Haglund and Anthony Fuller