Each week, over the Nyaya Health team list, we send out an update from the happenings of Bayalpata Hospital. Our Executive Director Dan Schwarz gave me the distinct honor of producing the report this week. We do not often publish our weekly updates on the blog, but we like to occasionally give our readers a more detailed and unpolished glimpse at our team reflections and operations. Please find below my update to the team:
Clinical updates:
Staffing:
- Dr. Amir Bista is away on leave CAC training. I did have the honor of working with him clinically a bit and found him to be highly skilled, from everything from HIV management to bear bite lacerations to large stone-in-small-ear extractions. He will be missed for now and will return.
- Taraman Kunwar (Health Assistant) is away on family leave. Among many many things, he manages the TB program; given that he is away, Dr. Bikash is now managing our newly diagnosed tuberculosis patient.
- Dhansara dhungana (ANM) was away in Mangalsen for CMAM training, but has returned now.
- Hospital Nandramji has now finished his second week on the job. I have been thoroughly impressed by his grasp of all logistics/management/maintenance/utilities issues (you have to be a generalist to manage this kind of hospital) as well as his calm but firm demeanor with government officials and in staff meetings. He also has a beautiful blue scarf that, together with his very proper dress, makes for an authoritative presence. He promises to be a tremendous asset in leading Bayalpata Hospital forward.
Patient flow:
- Registration: Huijalji has masterfully run OPD registration while Dhan Bahadurji has been receiving his on-site X-Ray training.
- Outpatient: Challenging with only two clinicians. The daily outpatient flow has been 80-100s. This Sunday with the leadership of Dr. Bikash, we have implemented the new ICD code for data recording, which will save so much time since we can do all reporting electronically instead of by hand.
- Emergency: This month, we had 150 emergency visits.
- Inpatient:
This month, we had 82 inpatients. We provided food for 182 patient-days.
A snapshot of patients: elderly woman with a septic elbow jointàantibiotics, improved, home on antibiotics after 4 days. 50 year-old woman with a burn and likely acute stroke, transferred to DHG. COPD exacerbation. Medical abortion. Pyelonephritis. Conservative medical management of non-perforated appendicitisà did well on IV antibiotics. Nine month old with PNA did well on antibiotics, went home. Pregnant woman at 28 weeks with eclampsia/seizures broken by diazepam, BP controlled with atenolol and nifedipine. Bear bite extensive laceration of the anterior shin, doing well, working on finding an orthotic. Septic at-home abortion, retained POCs with endometritisàMVA, antibiotics, referral to OB 6 hours away (see shortly story as well as M&M about this).
Lab issues:
- Dronaji was away on leave this last week. This severely limited our services. The lab has been at much scaled back capacity late, only providing QBC, blood typing, HIV, urine dip, urine pregnancy. No AFB, no microscopy. Colorometric tests have not been working owing to lack of standards, and the i-Stat is not working owing to an error. He has now returned and we hope to return to better capacity.
Pharmacy issues:
- I was stunned by the shelves in the lab. Really nicely organized. There are many many boxes however that need to be properly stored. We need more shelves to better manage our pharmacy stocks. Good high-quality shelves however are very expensive since they are hand-welded in DHG. One of the many many improvements that we will make over time.
Radiology:
- X-Ray: I have already seen this being put to great use, particularly in orthopedics and in pulmonary processes. I will be sending a story about orthopedics shortly. The dark room is impressive, complete with old tires as door stoppers to keep out the light. Our X-Ray technician Dhan bahadurji is a genius, and he has just become even smarter with his new on-site training. Dr. Bikash has been very happy with the improved techniques and results. We have performed 213 X-Rays in the first two months, including 113 this month.
- Ultrasound: The machine remains operational and great to see clinicians using it. I have seen it used nicely in a case of pyelonephritis in a 15 yr old boy. Our ability to use it effectively remains limited, far less than its potential impact. I am skeptical, for example, of its utility in most routine pregnancies and its use in evaluation of kidney stones, and these are our two largest uses. But the foundation is there, in that it is incorporated into clinician work flow and patients and clinicians really value it. It occasionally has a red background color owing to a faulty VGA card that is a nuisance, but, perhaps owing to the lower ambient temperature (an excellent hypothesis proposed by Dan), it has been black this whole week.
CHW update:
- We currently cover 3 VDCs with 35 FCHVs. Ranjuji coordinates this program.
- I went to see the Siddeswor FCHV meeting last week w/ Ranju, Dan, Greg, and Nandramji. CHW Satya didi ran the meeting. It was amazing to see attendance at 13/14 at this meeting, 1 didn’t make it owing to death of family member. Per Ranjuji, this is the norm; the expectation is 100% attendance. Nandramji continued to impress me with his professionalism and seriousness that he approaches the job. He conducted a bit of an ad-hoc Q&A/meet&greet the new Hospital Admininstrator. This FCHV program is an amazing foundation on which to build an impactful program. Much respect to the govt for providing the mortar of this foundation, and I am glad that we have the opportunity now to put that foundation to work at healthcare. Not too much “deliverables” yet but a real deal foundation. Awesome to see Ranju’s excitement in the project as well.
- Two powerful snapshots: Spiritually: FCHVs introducing themselves with pride as FCHVs, their ward numbers, their time in service. I felt like a stupid white guy when my eyes welled up a little. Logistically: Satya didi giving the women their weekly “incentive”. She had an envelope that Ranjuji had given her the day before. Simple, but not trivial nor straightforward logistically. That took an incredible amount of logistical/govt/organizational strife to make that simple act happen. The FCHV logistical analogy of good water pressure.
- Next steps: our primary focus will be on follow-up from the hospital. There is a clear outcome for this (%followed-up at hospital), and this is the foundational base for a good adherence system. OPD providers have had forms to fill out but they are cumbersome and not integrated into the work-flow. With our data simplification overhaul, they now will check off a box on their redesigned (simplified) registries as an “FCHV referral”, and Deepakji will print out an Access query to give to the CHW coordinator.
Antenatal Care and PMTCT program updates:
- Recruiting women into antenatal care remains a challenge given the logistics of travel and outreach
- Antenatal HIV testing: this month, 0/45 women tested positive for HIV. 2 women unfortunately were not able to be test owing to lack of time
- Of the 16 deliveries this month, 12/16 had been tested prior to presenting for delivery services, and the other four all received an HIV test prior to delivery at the hospital. Over the last nine months (Nepali year 2067), we have tested 204 women, one of whom have tested positive. That woman, who delivered six weeks ago, was already on HAART. She delivered at home, though her baby has been followed by Dr. Amir and was seen three weeks ago. We have not tested 5 ANC patients for logistical reasons, for a testing rate of 199/204 (98%).
Safe Motherhood program update:
- Bayalpata Hospital welcomed 13 new babies into this world. Sadly, we had one still birth. I discussed with Urmila sister issues surrounding the need for an additional delivery bed. She said that our bed is the very best she has ever used in our career, but we need another one. Problem is space. We don’t have a room to put it in right now. Nandramji is redesigning patient flow, and will be thinking about this issue carefully.
Family Planning and Comprensive Abortion Care program update:
- Government held a mini-lap and vasectomy camp this week over three days at the Hospital. We appreciate their efforts and collaboration.
- This month was the start of providing medical abortion services (misoprostol+mifepristone). 33 women received abortion services, 6 of which were medical abortions and 27 were manual vacuum aspirations. Of these, one received oral contraception and one was referred to mini-lap. All the others have received condoms. Historically, we have provided 553 abortions since the start of services, but only 26 of these women have received an IUD and only 9 have received depo (injection). Counseling is happening but our providers need to more time. Also, according to Urmila sister, most woman come in with concerns about the side effects of depo and IUD, and the time course of their husband’s extensive trips to India do not make for much interest in the pill. This will need to be a priority for our community education and outreach work, to achieve the goal of truly making abortion “safe, legal, and rare”. Having seen a devastating case of septic abortion this month after an at-home traditional bamboo stick abortion, I am convinced we are saving lives with our services, but we can and must do better.
- As per below, we will be procuring additional IUDs given the delays in the government supply.
CMAM program update:
- I have awaited the arrival of incoming Executive Director Mark Arnoldy to do this. He, Ranju, and I will be discussing with Dhansara sister the program and provide an update soon.
HIV program update:
- To date, we have enrolled 81 patients. There is one patient in the registry that we have not seen for 3 months. Concerned, I asked Ranjuji about this patient. As it turns out, he is followed by Gangotri and receives his care in Nepalgunj. All the others, we have seen in the months of mangsir/pus.
- With Dr. Amir, I met a middle-aged gentleman from sideswor VDC with TB/HIV transferred after being initiated on ATT/ART. He was quite weak but doing well. No SGOT/SGPT available at our hospital or at Mangalsen, so following bilis. He had mild bilirubinemia a few weeks ago that has largely resolved, so Dr. Amir will forge onward with Rif/INH consolidation+AZT/3TC/EFZ.
TB program update:
- We initiated one new patient on ATT this month. He is nearby so Dr. Bikash will do DOT with him. See my story about this patient. Since the start of TB program 2.5 years ago (including sanfe), we have initiated 33 patients on ATT.
- 2065/66: 25 total patients, 18 sputum positive, 5 sputum negative, 2 unknown, 9 extrapulmonary
- 4 deaths
- 9 transferred out (ie managed by other health post)
- 11 completed/cured
- 4 lost to follow up/defaulted
- 2067: 6 total patients, 4 sputum positive, 1 sputum negative, 1 unknown (the new patient), none extrapulmonary
- 1 cured
- Others treatment ongoing: 2 for four months, 2 for two months, 1 from this week
I have provided the names of these patients from the registry to Ranjuji and she will work with the FCHVs to follow the two from the wards that our FCHVs currently cover. We will be instituting routine follow-up of all TB patients by FCHVs. The patients without FCHVs we need to think more about.
Logistics:
Energy:
- The grid has been working relatively well, only several hours of load-shedding a day. That’s a good thing because our inverter/battery system remains non-functional (as it has for over a year), and will remain so until the army engineers get out here to check it out. We decided not to have Lotus come out here because
Water:
- I walked along the Bhageswor pipeline with Bharat Raul ji, Greg, and Nandramji. It is an impressive feat to get water to the hospital. This week, the pressure has been impressively good, with occasional outages. Unfortunately, the water pump got burnt out so we will need to get a new one if that can not be fixed in Dhangadi (DHG; 12 hours away). With it out, folks had to re-rig the system and the capacity is less. But it is functioning well; something within the several km-long system will of course break again, and our team will fix it.
Communications:
- The VSAT and CDMA and GSM signals have been working well for internet and mobile use, respectively.
- The landline poles have reached the hospital. We anticipate the land lines reaching the hospital over the next several months. As with many such things dependent upon outside parties, it is unclear when this may occur, but it will.
Data management
- A good chunk of my time here has been spent working with the team to overhaul the data system. The key word is SIMPLIFY. Our data problems have stemmed from a fundamental SIGNAL:NOISE problem where we have been collecting too much noise. I walked around and watched how folks were recording data and took notes. Our data guru Deepakji is a very smart man and his time will be much better utilized by this system. Our clinical staff have beautiful handwriting and their excellent registry-keeping is the foundational culture for a sound data system. The data overhaul represents simply a better management strategy to maximize our staff productivity and data quality. The new system is based on the following data:
- Data Streams
- Core clinical operations: OPD, inpatient, emergency, ANC, Deliveries
- Ancillary services: pharmacy, X-ray, Ultrasound, Lab, procedures
- Programs: HIV, TB, CMAM, CAC, FCHV, Family Planning
- Principles
Database Design:
Only data that will be analyzed should be input into the database.
All data fields in the database are either checkboxes, numbers, or dropdowns (no free text aside from first names).
Registry Design:
Data entry is either a number or a checkbox. Exception is when we use the free text programmatically, such as for giving FCHVs time to return to Bayalpata.
For the most part, only data that are input into the database should be collected on the registries. There are a few exceptions to this, such as collecting the date in the registry when we only care about the month/year in the database, and collecting a few data points that serve as prompts to the clinician.
Supply chain management:
- We couldn’t find tweezers, crocodile forceps for minor procedures; need to procure some.
- Our plaster quality is very poor. We are procuring new, higher-quality plaster.
- The government supply for Intrauterine Copper Devices is out. We will procure 5 from DHG as back-up so that we never turn away a woman in need of this life-saving device.
- Dr. Amir is looking for additional materials in KTM:
ankle foot orthosis [for patient with foot drop s/p bear bite]
emergency/procedure trolley (2)
spinal needles (10) [for spinal anesthesia; in speaking with Dr. Bikash he had one-year anesthesia training in which he had performed over 500]
crocodile forceps (2) [for foreign body extractions]
cautery machine (1) [for minor surgical procedures]
silver nitrate (5 cartons or however they come in)
14-panel urine dipstick (100)
Facilities maintenance:
- Patient toilets are much much cleaner than they once were but they remain quite dirty. Old light fixtures remain and need to be removed at some point. The hospital beds are rusted and dirty. There is still mud and grime on the floors and walls. We need to clean this place up. But I will maintain this: Bayalpata Hospital is a beautiful place. And we are making progress, slowly. The health aides are washing the floors more regularly. There are new garbage bins outside the hospital. There is a checklist in the patient bathroom. I have to admit my first impression of Bayalpata was that this place was disgusting and undignified. Yes, cleanliness is next to godliness but we are not Gods my brothers and sisters but rather a bunch of folks trying to make healthcare work in a very imperfect world where our hospital represents 10% of the entire health budget for a district of 266,000 people for whom the per-capita health expenditure is $5 a year.
Grounds maintenance:
- There is trash and old fire pits all over the place. The grass is uncut. Again, we are working on these matters even as we expand needed services with the financial resources available to us.
Renovations
- As I was walking into the emergency room for the first time, a man was hacking away at the side-wall with a sledge hammer. Within a day, he had installed the new door in the emergency department. This will make it much warmer during the winter, a critical patient issue as far as their own experience at the hospital.
- Great to see continued progress going on with the staff quarter renovations
- Surgical building is nicely renovated, structurally. It is currently used as a storage house for staff quarters renovations materials but is ready for when we, over the next months, outfit the operating theater.
Waste Processing:
- The incinerator + sharps pits are awesome. Loved seeing dan’s enthusiasm for entombing sharps. Expletives and all, a very poetic tutorial. That’s why hes the right man for the job. I do miss Ana Serralhierro, one of our very first volunteers who designed the system, but her spirit lives on here via the waste management system.
——————
Duncan Maru, MD, PhD is one of the co-founder’s of Nyaya Health. He is currently a resident in the Internal Medicine – Pediatrics program at Brigham and Women’s Hospital and Children’s Hospital of Boston.
