Guyana Nurse Training Program: It's not Pinterest, It's Guyana!

Walk into Nationwide Children's Hospital and you will be wowed by the design. There is a two story tall coo-coo clock, an indoor play space, 6 foot tall wood sculptures of animals and color everywhere. It's like disneyland for hospitals. The hospital has been awarded many design awards and was even featured on "tanked" to receive a large colorful fish tank in the outpatient lobby. While the care provided to patients is excellent, many parents and visitors remember us for the attention to details in order to make kids feel comfortable. This is the Pinterest hospital. It's beautiful, but ask any nurse and they will tell you many ways that it's not functional for workflow. Georgetown Public hospital is by no means a Pinterest hospital. It's not fancy or colorful. The equipment is old and consumable supplies are always in constant demand. Medications are not always available. Heck, we can't even get soap in the staff bathroom! But it's functional (or at least we're helping them get there). At one point today, Priscilla was commenting about how something needed to be done and Randy exclaimed, "It's not Pinterest, it's Guyana!". In other words, stop worrying if it will be pretty and fashionable and concentrate on it's functionality. These words have rang true over the last few days as our team hustles to get all our projects finalized before having to leave on Friday.

Sunday Priscilla and I spent 6 hours cleaning, organizing, and labeling the central supply room for the NICU. Over the last 2 days we have been able to find homes for pediatric and adult equipment, fixed a couple pieces of equipment, and brought life to others through new batteries. Everyone who passes by comments on how amazing it looks and they all say, "I hope we can keep it this way". Yeah, me too. A few even said they had no clue there were white shelves in the room-there was always too much stuff piled everywhere. It was an exhausting day but well worth the time for the staff to have easy access to their equipment and supplies.

Monday was our last class day with the nursing students. While I'm sure there are many other topics that could have been covered, none was more important or urgent than having a discussion with them about infant mortality. An article published in Kaieteur News on Sunday brought a story about the infant mortality rate in Guyana in 2014, which was way above the goal the nation set for itself. There is a link to the article below. In short, the ministry was upset with the previous government for not doing enough to improve mortality. The goal for 2014 was to reduce infant mortality to 14 out of 1,000 live births (The U.S. hovers around 6 out of 1,000, Canada and most of Western Europe are around 4 out of 1,000. Barbados, who has the lowest rate in the Caribbean was at 14 out of 1,000 in 2013). At the end of 2014, Guyana was at 23.1. While this may seem high to most people reading this blog or the article published in the paper, I would like to state that the rate in Guyana in 2012 when we started the training program was around 30 per 1,000. My optimism did a crazy happy dance when I learned that they were down to 23.1! Regardless, I had an hour and a half discussion with the nurses about what they feel is the main contributors. They suggested the lack of knowledge surrounding having a healthy pregnancy and maintaining check ups (even though care is free, not everyone sees the importance of going). They also suggested the actual process of maternal care (which is also mentioned in the paper) and the failure to recognize warning signs in mom and baby during pre-natal and delivery. They even suggested lack of adequate staffing of both physicians and nurses. All great suggestions for future programs/advocacy, but as change always starts at home, I wanted to hear what they had to say about improving NICU care. Infection control was number one. If only I could get people to spend as much money on soap and hand gel as they do on purchasing more fancy equipment, I would be ecstatic. [shameless marketing plug...If anyone wants to make a donation, an autoclave machine would be greatly appreciated and WELL used for sterilizing equipment in the NICU]. If only the ministry would listen to nurses...

Tuesday (today) brought a trip to West Demarara Hospital to revisit the NICU that was dedicated and opened in August of 2014. While it has basically never been used because there is no physician or nursing leadership to staff it, it looks like it's over 20 years old. The fancy wood paneling was peeling away from the mold growing underneath due to keeping an air conditioner running a full blast while the surrounding non-used post-natal ward is not air conditioned at all. There was a leak in the ceiling and the floor and all the equipment was covered in a layer of dust. A year ago I was present for the dedication, and it was sparkly and pretty....definitely a Pinterest NICU by Guyana standards. Now it was a dumping ground and a health hazard. All because there was no focus on functionality. You can't run a unit without staff. So we go back to basics. I suggested the peel off all the paneling and wash the walls with a hydrogen peroxide/water mixture (kills mold better than bleach), let it dry, then paint the walls with a sealer and paint. Then turn back the air conditioning to a higher temperature and clean all of the equipment inside and out. We also made lots of suggestions like adding soap dispensers and a phone for better communication with labor/delivery. Matron Dolphin, the head nurse of the hospital, was very appreciative and said while it will be some work, they are very dedicated to getting the unit fixed and are excited to have their 3 nurses return in December after their training in our program. By May they will have a permanent attending physician who will be a graduate of the pediatric residency program. We are scheduling our nurse educator and nurse outreach coordinator to lead resuscitation courses and mini training/lecture sessions with the midwives and other staff to boost their knowledge of baby care in labor/delivery and post-natal. I'm hoping by this time next year I will be able to see a completely different unit. Start with the basics. Start with functionality before finesse.

My last two days have also been spent being an architect. During a meeting with the hospital CEO, Mr. Kahn, on friday, I learned that the expanding Maternity block will also house a new NICU. Delighted at the opportunity to start in a new space, I asked if I could give some input into the new layout. He forwarded me the blueprint on Monday. It's very obvious that NICU nurses and physicians were given absolutely no input into the plans. The entire block will be a beautiful home for obstetrics and gynecology. New birthing suite, recovery room, and operating theatre. A remodeled first and second floor will be used for new triage rooms, a critical care recovery for mothers, and a large post-natal ward. Oh, and there's a NICU in thrown on as an afterthought. We get a measly 35 foot by 42 foot space that features a choppy layout, no storage space, a large wasted space in the middle, and no washroom or room for the nursing staff (physicians get a new "doctor's quarters" on the third floor, and OB nurses get a break room, but NICU nurses were not thought of at all). So I spent the better part of Tuesday afternoon creating a layout that will have all the components needed to have a functional NICU with thoughts of workflow and staffing levels and a need for an inclosed isolation room. I'm just glad I was in country when I was- the lead physicians didn't even know they were getting a new unit! The key to functionality is including the staff who will be working in the unit...duh. So we're gathering input from physicians and nurses to do what we can with our new little space.

Of course, there can be some prettiness too...we took the nurses out for dinner on Monday night and had a great time. I love how they all get dressed up! I guess there is room for a little Pinterest in Guyana :)

http://www.kaieteurnewsonline.com/2015/08/23/infant-mortality-perhaps-at-its-worst-over-160-infants-died-at-georgetown-public-hospital-in-five-months-last-year-health-minister/