Quality Assurance

I somehow ended up at a quality assurance seminar for hospital workers today. At first I thought it had the potential to be interesting. But then, about 70% was in Tagrinya (the common language) and only 30% was in English... And you thought your staff meeting today sucked!?!?!

I was surprised to note the introduction of several terms I am familiar with. For example, the "5 rights of medication administration" is a poster familiar to almost anyone who works in an American hospital setting. However, at the same time that the hospital is trying to combat medication errors, several more basic problems also need to be addressed - cleaning beds between patients, making restrooms and sinks available to patients and staff - a few minor things like that.

It is interesting to me this idea of western standards in a hospital in a developing country. How are we supposed to give the patients privacy and confidentiality when there's 6 families in one room? Does patient satisfaction really matter when they have no where else to go, literally? I guess I am being a little cynical. But I have become frustrated with the way we practice medicine here - if that's what you call it.

I mean, the WHO guidelines diagnose any child with tachypnea with pneumonia and recommend antibiotics for illness that are known to be most commonly viral in origin, because of the possibility of bacterial super-infection. Maybe it's not the guidelines themselves that bother me the most, but the strict adherence to them as protocol? It seems like every child with diarrhea gets an antibiotic - even if the child is already improving. And there is no faith in blood cultures. So a child who has a history consistent with a viral illness, has a negative blood culture, and is clinically improved after a day or two will still get a full course of antibiotics - "just in case." I figured there would be less antibiotic use here compared to the United States on the theory that one would want to conserve limited resources. But it's the other way around. If you only have one tool - use it on everyone.

I have certainly become more familiar with the diagnosis of rickets and the treatment for malnutrition. But I don't know that I've improved my clinical diagnosis skills.

Anyhow, that's enough griping for now. I've decided to talk to the medical director about a few "suggestions". Maybe being proactive and feeling like I have something to add will help my mood?

In case you're wondering, the suggestions I have include
1. Take a complete history and physical... How about asking about sick contacts? relevant family history? Specifics of the symptoms? And what about a complete physical exam? Isn't there anything important on exam besides listening the heart and lungs, checking the skin turgor and looking for palmar pallor? A neuro exam perhaps? Development anyone?
2. Is it really too hard to record more vital signs that just the child's temperature? They are called "vital" for a reason...
3. How about documentation? If you're going to add steroids and a bronchodilator several days into an infant's hospital stay can you put a note in the chart please? There may not be lawyers breathing down your neck here, but maybe the next doc to come along might be interested in the thought process???

Oh, my list goes on. But seriously, I can't change the WHO guidelines. And I can't make expensive equipment materialize out of thin air. But maybe I can remind these guys of stuff even Osler would have considered important...