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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.
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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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