Hospitals in shambles - WRHA clinicians take great risk to be creative in caring for patients
Below are excerpts from the audit done on the Western Regional Health Authority (WRHA), whose chairman is Calvin G. Brown. The audit team examined the Cornwall Regional Hospital (CRH), Savanna-la-Mar Public General Hospital (SPGH) and the parish health centres.
The WRHA, through its network of four hospitals and 80 health centres, provides public-health services to 17.6 per cent of the Jamaican population, serving 478,016 residents in Hanover, St James, Westmoreland, and Trelawny.
The Type A Cornwall Regional Hospital, located in St James, is the specialist and largest hospital, with 417 beds. The Type B Savanna-la-Mar Hospital, with 164 beds located in Westmoreland, is the second-largest hospital, offering services in the four major disciplines of medicine, and orthopaedics as a specialist service.
There are four parish health centres in the region: the comprehensive Montego Bay Type V and three type IV facilities - Savanna-la-Mar, Falmouth, and Lucea health centres.
There is an average of 33,265 admissions per year to the hospitals with 173,545 visits annually for the last five years to the Accident and Emergency Department. There has been a general decline in visits to accident and emergency, but an increase in visits to the health centres, with an average of 512,052 visits per year to the primary care facilities.
The operating theatre audit was conducted in April 2015 and the audit of all other areas from May to June 2015.
- Maternity wards at CRH and SPGH generally clean; adequate access to laboratory services, complementary services and pharmaceuticals.
- Lack of some key equipment and supplies, including sphygmomanometers, stethoscopes, wheelchairs, and stretchers at SPGH. At CRH, inadequate amounts of resuscitation equipment; more laryngoscopes, infant warmers and resuscitators needed; additional pulse oximeters required and no ultrasound machine on the ward.
- General layout did not fully allow for patients' privacy and at CRH, delivery beds needed. Lighting poor in the delivery room at SPGH.
- Availability of linen inadequate at both facilities.
- Lack of adequate supplies to carry out basic functions, especially disposable supplies such as laryngeal masks, anaesthetic/ventilator circuits, suction tips and filters which the staff reuse after cleaning and sterilisation. In the case where items are reusable, they are often utilised in breach of the guidelines from the manufacturers; for example, reused above the number of times recommended. While not a good practice, these measures have to be employed in order to save lives and assist in cost efficiency.
- Clinicians place themselves at high risk in trying to be creative in order to ensure that care is offered to the patients. It also raised red flags in relation to the inherent risk of this practice to the patients and possible litigation risk to the institutions.
- Documentation of the supplies and issues of inventory control is inadequate or non-existent. There is no formal inventory management system instituted in high-risk areas. All inventory issues are handled by the Ward/Departmental Sisters in charge. This does not allow for the recording and systematic accounting of stock, stock levels, and appropriate reorder quantities or levels.
- Stock out of drugs and general supplies. It was further noted that the stock out of drugs in the OT was as a result of stock outs at the CRH pharmacy of various drug items.
- Inadequate equipment in place and most in need of replacement and/ or repairs.
- No evidence of maintenance schedules for equipment in order to ensure the optimality of their operations. This suggests that patients may be placed at risk while undergoing treatment with the use of equipment that is not adequately serviced.
- Routine microbiological swabbing was not conducted as prescribed. It was last completed at CRH in May 2014 and at SPGH in June 2014. Concerns were raised that in the past when tests were done, stipulated recommendations were not adhered to, hence the same conditions that predisposed to the growth of microbes in the first place still existed.
- Findings for infection-control practices at CRH and SPGH operating theatres are generally good; training and supervision of cleaning staff should be strengthened. SPGH requires improvements in general layout of the operating theatre. Restrictions needed in the number of staff that traffic through department at CRH. Health status of staff at both institutions requires improved monitoring.
- CRH has a designated Special Care Nursery (SCN) independent of the paediatric ward, equipped with three ventilators. Renovations were done in 2014 to improve layout to facilitate infection control. The SCN at SPGH is within the paediatric ward and there are no ventilators in the nursery. SPGH layout is inadequate and requires renovation to improve infrastructure. This includes piped compressed air, ventilators and necessary supplies.
- Inadequate equipment and supplies, including pulse oximeters, phototherapy lights, radiant warmers and infusion pumps at CRH. There is a list of all critical equipment and a log is kept of preventive and unscheduled maintenance at SPGH. Monthly list not made of inoperable pieces; usually a maintenance order is written but no active follow up is done at both sites
Unit - CRH
- ICU is a seven-bed unit, but is currently operating four, and on occasions, five beds because of equipment and staffing challenges.
- Human resource: not at optimal levels with inadequate medical officers and critical-care nurses. A consultant anaesthetist is always on call and accessible.
- Access to microbiology laboratory services are not at substantial levels and portable echocardiography services are minimal. MRI services are not available at the hospital.
- Structural concerns exist as the ICU is not in close proximity to the Accident and Emergency Services. ICU is air-conditioned but there are issues with optimal functioning. No battery-powered sources for lighting although back-up generator is available. Inadequate storage space for large equipment.
- Deficiencies in the tools, equipments, supplies and services for the monitoring and support of vital organs, including assessing cardiac output with pulmonary artery/transthoracic catheters and availability of intracranial pressure monitors. Pharmaceutical supplies not available 100 per cent of the time.
- Absence of a microbiologist employed to the Western Region results in inadequate infection-control surveillance and the expert would be required in the routine care of the patients admitted to the ICU.
Accident and Emergency
- Accident and Emergency department found to have a generally safe and clean environment at SPGH and CRH.
- Inventory listing of critical equipment updated within 12 months prior to the audit at CRH and SPGH; however, maintenance schedule was not in place, with no records of the last preventative maintenance and minimal recordings of corrective maintenance. Follow-up on items sent for repair was also a gap identified at SPGH
- Reception of patients of CRH and SPGH hindered by inadequate stretchers and wheelchairs at SPGH. No portering services manual in the departments to guide acceptable management of the sick and injured patients. This was included in the training for new staff but not done on a routine basis.
- The triaging system utilised at CRH and SPGH did not strictly adhere to the policy manual; however, the time to see critically ill patients was adhered to. Log book to capture critical and non-critical patients was in use but not adequately updated. No system in place to record the time of arrival of the patient to the emergency room. Difficulty assessing the time spent to triage patients as the start time is usually not documented.
- Laboratory results not available in the Emergency Room at SPGH; results are available to the emergency room physician at CRH but not within the standard one hour, and may take up to five hours. Radiology services available within the standard time once the unit in the department at CRH is operable.
- Drug supply management system in place and there were reports of difficulty obtaining essential drugs over the last 15 months at CRH and SPGH.
PARISH HEALTH CENTRES
- Inadequate space in the parish health centres, especially in the waiting areas. Space not adequate to facilitate additional examination rooms, medical records storage and office spaces.
- Emergency trolleys required equipment for resuscitation, especially laryngoscopes. Equipment lists indicated the need for items such as industrial nebulisers, ECG machines, speculae, sphygmomanometers, foetoscopes and dental equipment. Need for furnishings, public address systems, wheelchairs and computers.
- Inadequate supplies management system.
- Laundry department at SPGH has been closed for refurbishing since March 2015 and laundering services were being provided three days per week at CRH. CRH's laundry is only functioning at one third of its capacity for washing and drying.
- Prior to the audit, planning meetings to address shortage of linen were held at CRH between the operating theatre staff and the administrators to establish usage patterns and generate a needs list to include a buffer stock. There was progress in meeting the needs list; however, the entire request had not yet been filled.
- Linen-management system was inadequate at both CRH and SPGH and requires restructuring to ensure there is a count by type of the linen in circulation, attrition rate (losses), replacement of losses, buffer stock management, and overall monitoring.