Mass casualty incident training in a resource-limited environment.

BACKGROUND: A mass casualty incident (MCI) occurs when a disaster involves a large number of injured people, overwhelming the capacity of local emergency medical services. This article describes the planning and execution of a MCI workshop created for use in Sierra Leone, a low-income country. METHODS: Surgeons OverSeas (SOS), an international non-governmental organization, partnered with the Sierra Leone Office of National Security and Connaught Hospital to develop a 2-day MCI workshop designed to meet needs specific to their resource-limited environment. Pre- and post-course questionnaires were completed. Day 1 consisted of didactic teaching focused on triage principles, resource deployment, communication/operations and tabletop drills. On day 2 a mock MCI with performance assessments by independent observers was staged, followed by post-event debriefing. RESULTS: Pre-course questionnaires identified the following deficits: lack of triage training (29 per cent), and transportation (19 per cent) and communication (17 per cent) shortfalls. Only 11 per cent could define MCI. During the drill, on-scene and hospital triage was accurate in 28 (93 per cent) and 23 (77 per cent) of 30 casualties respectively. Systematic deficiencies identified included: transport issues, no accurate system for tracking victims, and undersized triage areas. Participants identified interagency coordination (63 of 136 responses; 46·3 per cent) and triage (32 of 136; 23·5 per cent) as the most valuable lessons learned. CONCLUSION: Pre-existing MCI programmes based on first-world logistics do not account for challenges encountered when caring for casualties in resource-constrained settings. Logistical training, rather than medical skills or knowledge, was identified as the educational priority.

Improving nursing documentation for surgical patients in a referral hospital in Freetown, Sierra Leone: protocol for assessing feasibility of a pilot multifaceted quality improvement hybrid type project.

BACKGROUND: There is an urgent need to improve quality of care to reduce avoidable mortality and morbidity from surgical diseases in low- and middle-income countries. Currently, there is a lack of knowledge about how evidence-based health system strengthening interventions can be implemented effectively to improve quality of care in these settings. To address this gap, we have developed a multifaceted quality improvement intervention to improve nursing documentation in a low-income country hospital setting. The aim of this pilot project is to test the intervention within the surgical department of a national referral hospital in Freetown, Sierra Leone. METHODS: This project was co-developed and co-designed by in-country stakeholders and UK-based researchers, after a multiple-methodology assessment of needs (qualitative, quantitative), guided by a participatory 'Theory of Change' process. It has a mixed-method, quasi-experimental evaluation design underpinned by implementation and improvement science theoretical approaches. It consists of three distinct phases-(1) pre-implementation(project set up and review of hospital relevant policies and forms), (2) intervention implementation (awareness drive, training package, audit and feedback), and (3) evaluation of (a) the feasibility of delivering the intervention and capturing implementation and process outcomes, (b) the impact of implementation strategies on the adoption, integration, and uptake of the intervention using implementation outcomes, (c) the intervention's effectiveness For improving nursing in this pilot setting. DISCUSSION: We seek to test whether it is possible to deliver and assess a set of theory-driven interventions to improve the quality of nursing documentation using quality improvement and implementation science methods and frameworks in a single facility in Sierra Leone. The results of this study will inform the design of a large-scale effectiveness-implementation study for improving nursing documentation practices for patients throughout hospitals in Sierra Leone. TRIAL REGISTRATION: Protocol version number 6, date: 24.12.2020, recruitment is planned to begin: January 2021, recruitment will be completed: December 2021.

Universal precautions and surgery in Sierra Leone: the unprotected workforce.

BACKGROUND: Surgical patients and healthcare workers in sub-Saharan Africa are at an increased risk of contracting HIV. Sierra Leone is one of the poorest countries in the world and has a documented HIV prevalence rate of 2%. Because surgeons and other healthcare staff in sub-Saharan Africa are at risk for HIV exposure from their patients, an assessment of protective supplies and equipment was considered essential. METHODS: A Society of International Humanitarian Surgeons team in cooperation with the Sierra Leonean Ministry of Health and Sanitation undertook a survey of HIV-protective supplies and equipment at government hospitals in Sierra Leone. The presence of eye protection, sterile gloves, aprons, functioning suction machines, and sharps containers was recorded and compared with a local mission hospital and a local private hospital. RESULTS: Only 20% of government hospitals in Sierra Leone have adequate stores of sterile gloves or eye protection. Suction pumps and aprons are available in only 30-40% of facilities, respectively, and only half have functioning sterilizers and sharps containers. The mission and private hospitals were fully stocked. CONCLUSIONS: Although surgical healthcare workers are at risk for exposure to HIV, resources for their protection at government hospitals in Sierra Leone are severely lacking. The Society of International Humanitarian Surgeons is developing a program to provide protective supplies and equipment to hospitals in Sierra Leone, but additional efforts by other organizations working to decrease the spread of HIV are essential.

Improving emergency obstetric care at a district hospital, Makeni, Sierra Leone. The Freetown/Makeni PMM Team.

PRELIMINARY STUDIES: A facility review and focus group discussions revealed poor capacity to manage obstetric complications. INTERVENTIONS: In response, a physician with obstetric skills was posted, and a second physician was trained. Courses in life-saving obstetric skills were held for nurses and midwives. An unused operating theater was made functional with simple modifications. A generator and blood bank were installed. Drugs and supplies were made available through a revolving fund. Subsequently, community interventions focused on improving utilization. RESULTS: The number of women seeking treatment for major obstetric complications at the district hospital increased from 31 in 1990 to 98 in 1995, while the case fatality rate (CFR) among these women dropped from 32% to 5%. Cesarean sections increased from two in 1990 to 38 in 1995. In 1995, 444 abortion-related procedures were performed--almost all of them for unwanted pregnancy--compared with only 22 in 1990. COSTS: The cost of material improvements and training was approximately US$39,000, of which 46% was from project funds, 41% from non-governmental organizations and 13% from government. CONCLUSIONS: Women with obstetric complications will seek hospital care if services are available. Government hospital services can be improved by building on existing resources. Obstetric CFR can be dramatically reduced. The need for safe abortion services, which are currently illegal in Sierra Leone, is demonstrated.