Angkor Hospital for Children

Siem Reap, Cambodia

TREATMENT EDUCATION PREVENTION

SATELLITE CLINIC January 2013

Abbreviations

• AFH- Action for Health

• AHC- Angkor Hospital for Children

• APLS- Advanced pediatric life support

• CB- Capacity Building Project

• CME- Continuing Medical Education

• CoC: Children of Cambodia Singapore

• CP- Cerebral Palsy

• CQI- Continuous quality improvement

• ETT- Endotracheal tube

• GE- Gastroenteritis diarrhea

• HC- Health Center

• HEF- Health Equity Fund

• IC- Infection Control

• KBH- Kanta Bopha hospital: Siem Reap

• MOH- Ministry of Health

• NG- Nasogastric feeding

• OD- Operational District

• PP- Phnom Penh (Capital City of

Cambodia)

• PHD- Provincial Health Department

• Pro-TWGH- Provincial technical working

group for health

• SRH- Sotnikum Referral Hospital

• UTI- Urinary tract infection

• VHSG- Village health support group

Contents

• Monthly highlights

• Outpatients + nutrition support

• Outpatient and HEF

• Health center referral

• Inpatients

• Inpatient diagnosis

• Emergency care

• Shot in the heart

• Emergency room diagnosis

• Referral and transfer to AHC

• Neonatal care

• Education

• Neonatal training in Satellite

• APLS course in AHC

• Clinical developments

• Medical forum

• Nursing workshop in Satellite

• Non-medical training sessions

• Health center in-service training

• Community coordinator

• Social Work training

• Satellite staff achievement

• Conclusion

• Thank you

Monthly highlights • January has been a momentous start to the year with some very dramatic trauma cases which

clearly demonstrated the skill and knowledge of the clinical team, as well as the fantastic team work between Satellite and AHC resulting in amazing outcomes despite all the odds

• Education and training has included the APLS course in AHC, neonatal training in Satellite and health center in-service training provided by our team in two health centers

• Medical and nursing forums held in Siem Reap were an opportunity for the Satellite seniors to share their departmental goals for 2013 with the wider AHC team

• Other highlights include:

• Visit by our donors John and Nina Cassils and friends

• OD annual meeting and presentation on Dengue fever and HFMD by Dr Samol

• Non-clinical course on the 5 dysfunctions of a team and conflict resolution

• Social work training for Sambath with Friends International in Siem Reap

• Medical CME and lunch talks by visiting volunteers including Dr Marvin and Dr Myron psychiatrist

• Clinical developments and innovations applied as a result of the neonatal training in Bangkok and Singapore

• Annual nursing workshop and goal setting for 2013 in Satellite

• Neonatal training from Singapore including case presentation by Dr Sophal

• Ministry of Health hospital assessment by URC

• Action for health (Health Equity Fund provider) steering committee meeting

• Meeting with PHD regarding Sotnikum Referral hospital management collaboration

Outpatients

• Outpatient numbers were higher than in 2012

• The first few months of the year are always our quietest period with most of the rural community busy in the field

• We use this time as an opportunity to build staff capacity through education and training and train government healthcare staff too

• Annual volunteer Dr Marvin (photo) joined OPD work and supported the juniors with advice on consultations, history taking etc. In addition to teaching nurses and providing ideas for improvement of the department generally. We very much value his input and experience

• Among OPD patients this month 35% were new patients 54% returning patients (follow-up and chronic cases) and 10% were referred

Outpatients

Month HEF Other %HEF HC refer letter

%HC referral Total

Jan 99 1150 8% 120 10% 1249

Health center referral

• We had over 120 health center referrals this month

• We see a much more evenly balanced number of referrals from health centers in Sotnikum district

• We aim for the same even distribution of referrals across health centers in Chikreng district too

• In January Kok Thlokrom HC referred by far the highest number of patients and is partly due to having a strong health center manager and also because Satellite and CB have been working closely with this health center and have provided training this month

Inpatients

Month HEF Other %HEF HC letter

Total

Jan 42 86 33% 6 128

• Gastroenteritis/dysentery + pneumonia were the most common diagnoses this month among IPD patients

• Average length of stay is 5 days, a little longer than in AHC as patients are discharged directly from Satellite IPD. In AHC there is a low acuity unit where IPD patients transition to before discharge

• Safe discharge helps prevent the need for re-admission

Inpatient diagnosis

Asthma, 6, 5% Bronchiolitis, 2, 1%

CP, 2, 2% Dengue , 8, 6%

Poisoning, 3, 2%

GE/Dysentery, 32, 25%

Meningitis, 4, 3%

Febrile Convulsion, 3, 2%

Neonatal Infec, 10, 8%

Pneumonia, 38, 30%

Septicemia, 4, 3%

Typhoid, 3, 2%

Virus, 2, 2%

Other, 11, 9%

Emergency care

• Newborns and neonates were the largest single group of patients in the ER this month representing 34% of all emergency cases

• Trauma patients represented nearly a quarter of all patients and included an amazing case of a boy shot with an arrow in the heart, and another who had fallen over 15 m from a palm tree and then travelled over 20 km to reach Satellite

• We had a slightly higher number of transfers out of the ER to AHC ICU this month reflecting the severity and specialist need of the patients There were several occasions this month of

transferring 2 patients at the same time, and one day with 3 trauma patient transfers

Shot in the heart • Phal Pheap is a 14 year old boy from Bakong

who was out shooting field rats when he was himself shot, quite literally, in the heart (directly into the left ventricle to be precise)

• Fortunately, he knew it would be a mistake to try and remove the arrow in the field and so his fellow hunters just cut it down and brought him the to Satellite

• The team at Satellite responded quickly and appropriately and stabilized Pheap and transferred him to AHC, where the heart surgery team were called in at 1.30am and operated until 6am to remove the arrow

• This was an exceptional and very high risk case and yet with staff skill, knowledge and tremendous team work Phal Pheap’s life was saved

Emergency diagnosis

Burn, 2, 4% Meningitis, 1, 2%

CP/epilepsy, 2, 4%

Dysentery/GE, 3, 7%

Neonate, 16, 34%

Sepsis, 3, 6%

Asthma, 2, 4%

Pneumonia, 5, 11%

Trauma, 11, 24%

Poisoning, 1, 2% DSS, 1, 2%

Referral and transfer to AHC

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We transferred a total of 42 patients from OPD, IPD and ER 6 patients were transferred intubated (photo)

Neonatal Care • We had a total of 16 newborns presenting as

emergency cases either immediately after birth or within the first week of life

• 8 cases were directly from SRH delivery room and 6 from health centers. We sent 9 neonates to AHC for ICU care

• This month SRH has seen a record number of deliveries. The chief obstetrician believes this is due to the community’s knowledge about the emergency call bell to Satellite

• The community now know deliveries are safer and the outcomes for newborns much improved due to the Satellite service. Thus the number of deliveries in SRH has increased as a result

• 4 of the newborns were either premature or of very low birth weight: the lowest weight being a mere 750g and another at 800g

• Following the critical care nursing neonate course in Bangkok and the Singapore observational study tour, some improvements in our neonatal care have been made (slide: Clinical developments)

Education • We have held lunch talks by volunteers Dr

Marvin and Dr Myron, as well as Dr Pises presenting a medical protocol update

• Dr Samol presented to the OD annual meeting on Dengue fever and Hand, foot and mouth disease

• Sambath joined the OD to Lveng Rusey health center to provide health education

• Nursing groups are working on developing strategies for improving the quality of nursing care overall

• The education group taught in-service training in two health centers in the district

Neonatal training in Satellite

• The NUHS team visit this month was well attended by staff

• Dr Krishnamoorthy generously gave his time to teach on neonatal infections and sepsis

• Morning lectures were given followed by a case presentation given by Dr Sophal on a neonate who was affected by the mother drinking traditional medicine (photo below)

• This was particularly interesting for the NUHS team who seldom see such cases

• The afternoon teaching was ward based bed-side teaching where neonate cases were presented by the medical team led by Dr Samol

APLS course in AHC

• The bi-annual AHC APLS course was held in January in AHC. Dr Samol was part of the instructor team (photo below)

• Nurse Chamnabb and Dr Bolyly both joined the intensive 3-day course and passed

• It is a great opportunity for doctors and nurses to learn together and to strengthen both theory and practical skills in advanced pediatric life support

• Practical sessions include the use of mannequins and also the side of a pig (photo below) to practice chest drain insertion and thoracocentesis

Clinical developments • A patient satisfaction survey was initiated to

collect feedback from patients on quality of care

• Clinical developments this month have included many innovations to improve neonatal care following the nursing course in Bangkok and the Singapore study visit:

• Umbilical catheterization

• Use of an oxygen hood to provide oxygen as less damaging than nasal prongs (photo)

• Eye mask is used for neonate during phototherapy and music is played to create a soothing environment (photo)

• Plastic wrap is used as an effective technique for keeping neonates warm especially during transfer or when they arrive at Satellite hypothermic

Medical forum

• The AHC annual medical forum was a chance for our medical team to present the Satellite medical department activities and goals for 2013

• Dr Samol, Dr Sophal and our pharmacist Chiva all took their part in the presentation

• Questions were generated and answered and hopefully a better understanding has been gained of the work of the medical department in Satellite

• Going forwards this year we encourage more AHC senior medical staff involvement on-site at Satellite in order to share learning and experience

Nursing workshop

• AHC also held a nursing forum for the first time this year, which Bunchhouen joined and presented Satellite activities and goals for 2013

• Following this a nursing workshop was held in Satellite for the nursing team to set goals and priorities for 2013

• It was a very productive day with goals set and delegation of tasks among four teams who will take the lead in quality improvements

• In summary, quality care, infection control and education and training are the key areas of focus

Non-clinical training

• Aside from clinical courses our staff were also able to build valuable non-clinical skills and knowledge through one-day workshops in Siem Reap, Possibilities World school. These included:

• 5 Dysfunctions of a team

• Communication and conflict resolution

• Staff from all 3 departments were able to join and found the sessions valuable. The teaching is interactive and many key points illustrated through games which facilitates understanding

• Our head housekeeper Sreya was particularly inspired as it is the first of such a training course she had attended and she now has plans to share the learning with her whole team

Health center in-service training

• The Education group provided in-service training for two health centers Rusey Lok and Khok Thlokrom, in conjunction with the OD and CBHEP

• They observed the health center staff seeing patients and presented teaching sessions on two commonly presenting complaints among patients at the health center level, namely:

• Upper respiratory tract infections

• Impetigo (skin infection)

• The health center staff completed a feedback form after the training which was quite positive

• Points made in the feedback will contribute to changes and improvements for the next training

Community coordinator • He has joined VHV meetings in Knorng Pnom

with the OD, Popel, Song Veuy and Lveng Rusey again with the OD and this visit also included providing health education to the community (photos right)

• Sambath also joined the OD monthly, annual and Pro-Twg-H meetings and chaired and facilitated the AFH HEF steering committee meeting which was held in Satellite

Social work training

• Sambath joined the 3 day in-house training at Friends International in Siem Reap. The comprehensive training covered child protection issues and working with marginalized and abused children, and was very valuable

• Going forwards Sambath is going to work much more closely with the AHC social work team and is very enthusiastic about developing his role in this sphere

• Sambath already spends a considerable amount of his time solving social issues among patients, and this new development will ensure he has the training and support necessary to do it even more effectively

Satellite staff achievement • The AHC anniversary saw many staff

celebrated for special awards and for educational achievements

• We were very proud that five of our Satellite staff were awarded

• Team leader housekeeper Sreya won the Kamachi award for infection control (photo) which was an amazing achievement being selected among all AHC staff

• Dr Samol: Faculty development certification

• Nurse Chanlong: Pediatric nurse certification

• Dr Sophal: Post graduate certificate 3 year AHC pediatric residency

• Nurse Lork Loeurn: 10 years of service to AHC

• Congratulations to all!

Conclusion

• It has been an outstanding start to the year exemplified perfectly with the case of Phal Pheap who was shot in the heart

• No clearer example can be given of the highly skilled, quality care of the entire Satellite/AHC team and the importance of the service we, as an organization, provide

• Not only saving children’s lives but having critical impact on a whole family, and the community in which that family belongs

• To reach that level of service requires continuous education and training which AHC has an unwavering commitment to

Phal Pheap in AHC ICU post emergency heart surgery

Thank you

With sincere thanks to The

Planet Wheeler

Foundation and

The Cassils-Wettstein Asia

Fund for their support

Thanks to the PHD, OD , AHC staff and volunteers who generously give their time, knowledge and expertise here on the ground

And of course thanks to Satellite and SRH staff for their hard work to make all of these achievements possible

Phal Pheap shortly before discharge home