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The Fortress in the Forest: Efforts at New Edubiase Government Hospital in the fight against COVID-19

By Frederick C. Agamah (with support from Isaac Asante Somuah)

New Edubiase Goverment Hospital Signage

The New Edubiase government hospital is a small hospital at New Edubiase, the capital of the Adansi South district in the Ashanti region of Ghana. The district shares boundaries with the Adansi North district and Obuasi municipality to the north, the Central region to the South, and the Eastern region to the East. Adansi South falls within the forest belt of the country and is mostly rural with a lot of villages scattered in the forest. It is in this environment that the team of professionals at the hospital is rigorously implementing safety measures to protect the staff, the clients and every visitor to the hospital from the novel coronavirus. The planning, implementation and regular review of activities, with so little resources, has a striking resemblance to a military operation and an account of it is vital in the fight against the COVID-19.

In the wake of the novel coronavirus, several guidelines were issued by the management of the hospital in line with the directives of the World Health Organization (WHO) and the Ministry of Health in Ghana. There was a general awareness and effort at the personal level to keep safe. Of course, the standard protocols for keeping patients and staff safe were in place within the limits of the scarce resources the hospital operates with. However, things took a drastic turn upon the declaration of the disease as a pandemic by the World Health Organization (WHO). A series of measures were put in place at a remarkably fast pace.

 

 

Formation of the District Covid-19 Management and Response Team

Dr Allan Tiertoore, Medical Superintendent, New Edubiase Government Hospital

The multidisciplinary group of professionals, which was formed on 28th March 2020, is headed by the Medical Superintendent of the hospital. It is composed of all the professional groupings in the hospital and other persons from the community. The members and stakeholders represented are the District Director of Health Services, Health Service Administrator, Infection Prevention and Control Unit, Disease Control Unit, Physicians, General Nurses, Critical Care Nurses, Community Health Nurses, Mental Health Nurses, the Pharmacy unit, Biomedical Scientists, Orderlies, General Stores, Procurement unit, Reverend Ministers/Imams, Mortuary Assistants, Security Officers. Other groups would be added as and when it became necessary.

 

 

The first meeting of the team also marked its launch. The stated objectives of the committee were to:

  • Promptly detect suspected cases of COVID-19 among our out-patients or patients already on admission.
  • Systematically report suspected COVID-19 cases to higher levels of the Service.
  • Safely hold suspected cases until laboratory confirmation can be done.
  • Collect adequate demographic and other information from cases to allow for speedy contact tracing.
  • Tracing of contacts of probable and confirmed cases within the New Edubiase Sub-district.
  • Initiate community isolation and monitoring of contacts for up to 14 days after last known contact with an index case in New Edubiase Sub-district.
  • Provide adequate monitoring of cases that may be managed by isolation within communities.
  • Provide adequate supportive clinical treatment to confirmed cases, if required.
  • Provide psychological, psychosocial, and spiritual support to cases and their relatives.
  • Undertake continuous facility-wide monitoring and supervision to ensure all units and staff are practicing appropriate IPC measures routinely during this outbreak.
  • Facilitate safe removal and disposal of corpses of persons who die from COVID-19.

There was a long discussion about the measures that the hospital needed to put in place to be able to achieve these objectives and position it well in the fight against the menace. Several important points were raised and deliberated upon, some for immediate implementation and others to come with time. The Medical Superintendent led the meeting and did a thorough job of conveying the seriousness of the pandemic to the gathering. He fervently appealed for individuals to take good care of themselves and stated rather somberly that the disease would spread far and impact virtually everybody in the world. People would die, possibly in large numbers. But his overarching goal was that no member of his staff would lose his or her life to the virus. He reiterated the need to wear personal protective equipment within the hospital, wash hands frequently and observe social distancing. This meeting set the pace for a series of swift actions taken at the hospital to boost preparation for the fight. A COVID-19 Coordinator was appointed to spearhead all activities related to the pandemic.

 

Logistics

Immediately after the formation of the team, management mobilized resources to procure new items and increase the stock of the existing ones in anticipation of a possible outbreak of the disease in the district. These items included tents for screening all staff and clients, veronica buckets, more Personal Protection Equipment (PPEs), some locally manufactured and several non-drug consumables. Every department  now has the veronica bucket set for handwashing for all staff and visitors. They also gets a weekly supply of cleaning materials to disinfect surfaces regularly.

 

Awareness Creation

Flyers and posters were printed for display at vantage points within the hospital,  the New Edubiase town and the surrounding villages. Hotels, Guest Houses, offices and other public spaces within the district were provided with copies to display. A public relations group from the hospital and District Health Administration is allocated airtime at the local radio station to educate the inhabitants of the district on the safety protocols and respond to questions from listeners.

 

Restructuring of Security

Among the measures for immediate implementation was the restructuring of security in the hospital. It was observed at the meeting that the security staff had relaxed in the execution of their duties over the years. People came in and out of the hospital at will without proper scrutiny. The hospital was frequently used as a thoroughfare by members of the public. With immediate effect, all access routes to the hospital except the main entrance were blocked. This was challenging as there is no boundary wall around the hospital. But all vehicular access was limited to the main entrance of the hospital. Everyone visiting the hospital is thoroughly questioned at the security checkpoint at the gate. Care providers and visitors of patients on admission are now limited to one per in-patient; no pastors or to caregivers are allowed on the premises. As the global and national impact of the disease worsened, it became mandatory for all people entering the hospital, especially staff, to have a face mask on.

 

The Triage Area

Triage area

A pre-triage area has been created close to the entrance of the hospital to screen all visitors. It has been nicknamed among the staff as the COVID-19 Tent. Here, everyone entering the hospital, especially staff, is required to wash their hands at one of the two Veronica buckets mounted by the tent. Their temperature is then taken by the team manning the tent. Throughout that period, they are closely observed by the team. If there is any suspicion from the temperature check or observation, they are offered a seat and probed for travel history and other symptoms. The staff here are always nurses and at least one Physician Assistant. The Tent is manned every day from morning to evening and during the night shift. The first three cases in the district were first identified at the tent for further testing which led to Covid-19  confirmations.

 

 

COVID-19 Sample Collection and documentation

The COVID-19 Coordinator, together with the Head of the laboratory, trained twenty (20) staff including non-clinical staff on how to take COVID-19 samples for suspected cases and their contacts. As of 22nd June 2020, a total of 240 samples have been collected for testing, 199 results received, with 184 testing negative to the virus. The facility has recorded 15 positive cases with 14 recoveries.

 

Provision of Personal Protective Equipment to the Staff of the Hospital

Before the creation of the COVID-19 management and response team, and as part of general preparations for the pandemic, every member of the staff of the hospital was provided with the N-95 mask and disposable masks. The disposable masks were to be worn over the N-95. The disposable mask is changed very often. This way, the N-95, which is more expensive, lasts longer. In the week after the launch of the management and response team, the hospital ordered cotton fabric and a local tailor was contracted to make enough cloth masks for the hospital staff. Suspected cases are made to wear the cloth masks before any form of handling by the staff of the hospital to prevent infection.  The cloth masks are now worn over the N-95 and washed regularly. Coveralls and face shields were also made locally, for the staff of the laboratory and other staff who take samples from suspected cases to enhance their protection. The wearing of masks became mandatory, after a week of the formation of the COVID-19 management and response team. This is because it became apparent a few people would not wear the mask willingly. Given the high level of interaction among the staff in the day and the likelihood of spread of possible infection, this directive came with sanctions as severe as the possible withholding of salaries if flouted. At a regional COVID-19 workshop, a few weeks after the formation of the response team, it was reported that only the representatives of the New Edubiase Government Hospital had N-95 masks on.

 

The COVID-19 Holding Ward (CHW)

Immediately after the creation of the COVID-19 management and response team, the Male Ward of the hospital was designated as the COVID-19 Holding Ward. This ward now holds suspected cases until test results are negative. They are moved to regular wards if there are persistent symptoms after a negative result. If test results are positive, the patients will remain there to be managed. The Female Ward is now known as the Adult Ward and holds male and female patients on admission. Fortunately, there are three rooms in the ward, so the males and females are still separated. The CHW has staff on duty around the clock in three shifts. The team is made up of nurses and at least a Physician Assistant. The ward has been cordoned off and is out of bounds to all unauthorized persons. As of May 2020, the New Edubiase Government Hospital was the only hospital in the Ashanti region with a whole ward dedicated to COVID-19. Additionally, in collaboration with the District Assembly, the District Assembly Guest House and dormitories of New Edubiase Secondary School were secured for use as a treatment center and isolation center respectively for confirmed cases and their contacts.

 

Skeletal Staffing of Special Clinics

Specialized clinics such as the Ear, Nose and Throat (ENT), Eye Clinic, Dental Health, Physiotherapy, Mental Health Department and Hypertensive (HPT) unit have been stripped of most of their staff, leaving them at skeletal strength to operate where necessary or total shutdown of the units, to be opened only on days they have clinics. The freed staff have been assigned to the COVID-19 screening Tent and the Holding Ward to beef up their strength to staff all the shifts.

 

Infection Prevention and Control (IPC)

Following a workshop organized by the IPC unit for the staff of the hospital, with practical components, the IPC coordinator selected independent assessors to pay weekly visits to all departments/offices in the facility to assess the level of compliance with IPC protocols on hand hygiene, decontamination, social distancing and the use of face masks/goggles/lab coats and scrubs.

On hand hygiene, they ask questions on the proper procedure for handwashing and hand sanitizing and take note of the handwashing equipment: The Veronica bucket, rubber bowl, soap dish with soap and towels or tissue paper in the unit. They often request for practical demonstration and pay attention to how well it is done to keep the palms, fingernails, the back of the palms, knuckles and wrists clean. They also take note of the duration of the washing.

On decontamination, the team verifies the availability of the essential cleaning reagents in the office: Dettol, chlorine, methylated spirit, savlon and liquid soap, the integrity of their containers and how well they are stored. They find out the knowledge of the staff on the dilution factor for the reagents and the frequency of decontamination of all surfaces: tables, doorknobs and handles, keyboards, drawer handles, fridge doors and others.

On social distancing, the team assesses the level of awareness and the practice of reasonable distancing among the staff of each unit and how well the staff enforces it among clients or visitors to their department. The number of staff per shift is also noted.

Finally, on the wearing of face masks, goggles, and Lab coats and scrubs the team assesses whether these are worn and how properly they are worn. The Medical Superintendent has shown great leadership in this regard as he has almost always been cited as an example by the team for religiously wearing his mask, goggles and coat.

Marks are awarded for the level of compliance with each protocol for each unit/office in the hospital and compiled. The results are presented publicly on a league table and staff are invited to comment on the results. The more successful units share what they do differently, and the less successful ones indicate their challenges. This has improved the level of awareness and practice of basic hygiene among the staff of the hospital as part of the fight against COVID-19.

 

Raising Funds

The hospital is fortunate to have some influential members of some religious and social organizations on staff. Management took advantage of this to encourage them to solicit donations from their organizations for the hospital to support the meager resources of the hospital. The response was immediate. Within April, donations were received from the Afrikania Mission, the Pentecost Church, the Seventh Day Adventist Church and the Roman Catholic Church. Other individuals, political groups and businesses in the district donated generously to the hospital. Close to the end of May, the Chief of New Edubiase and the traditional authority also gave to the hospital. The brief ceremony provided the opportunity for the chiefs and people to be updated on the activities going on in the hospital and to request for more assistance with the other pressing needs of the hospital.

 

Auxiliary Measures

The conference room of the hospital has been rearranged to have fewer well-spaced seats. The hospital also obtained health data on all staff, and those with underlying conditions have been either reassigned to roles that lessen their exposure or asked to proceed on leave. Pregnant staff and those who commute daily to work from communities outside of the district have been asked to proceed on leave. Following a directive from the government for all nurses on study leave to return to the hospitals they worked in to boost the numbers, the nurses that returned were all assigned. The hospital also received a new set of nurses on National Service (Rotational nurses). They have also been put to good use in the various wards and units.

 

Impact of these measures on organizational culture

The impact of these measures on the staff of the hospital is quite pronounced. There is a heightened awareness of the protocols and staff often prompt visitors to wash their hands or apply the hand sanitizer upon entering a unit. It’s rare to see staff without masks on and virtually no one has seen the full faces of anyone else in a very long time. Members of staff are quick to remind colleagues to either put on their masks or put them on properly.

It is now common to see staff strain themselves to open and close doors with elbows wherever possible, to avoid touching entry handles with fingers. There are no longer any handshakes. There is hardly any meeting at any level in the hospital where COVID-19 is not on the agenda and the vocabulary of the staff has also been affected. The Holding Ward and Tent are now a permanent part of it. ‘Social distancing,’ ‘sanitizer,’ ‘COVID’ and many more have come to stay for some time.

 

Conclusion

The discussions and commencement of these activities took place very early, when there were still less than ten confirmed cases nationwide (Ghana), at a time when the national health and political authorities had not mounted a unified and coherent approach to combat the pandemic. But these efforts at the hospital are not random. The hospital has been on the path of excellence for some time. It won third place among forty-eight hospitals in the 2019 peer review of hospitals in the Ashanti region. In that same review, the hospital came second in clinical practice and since 2019, there has not been a single case of maternal mortality in the hospital. In early May 2020, when the Regional team led by Dr. Rita Larsen-Reindorf, Deputy Director for Clinical Care, visited hospitals in the region to assess preparedness for the COVID-19, the New Edubiase Government Hospital was adjudged to have put up the best response in the fight.

While the deliberate activities going on in the hospital can be rightly described as the reflection of one man’s immediate and deep appreciation of the enormity of what is unfolding and his willingness to marshal resources and exert the force of his character to drive the hospital in a direction it must take to protect the staff and visitors of the hospital, it is also the story of a supportive and dedicated management team and the commitment of a hardworking staff which must be told for many years to come. It is still hard to predict what will happen in the coming weeks and months as far as the novel coronavirus is concerned. But sandbags are piling in this part of the forest, the logs are being arranged strategically and the battle is on.

 

CONFLICT OF INTEREST:

The views and opinions expressed in this article are those of the author, and they do not purport to reflect the policies, opinions, or views of the AfroScience Network platform.

ABOUT THE AUTHOR:

Frederick C. Agamah, MBA, is the Operations  Manager for AfroScience Network and a Supply Chain Management professional with the Ghana Health Service.

DISCLAIMER:

This article has not been submitted, published or featured in any formal publications including books, journals, newspapers, magazines or websites.