Chapter 6 - Support services

Introduction

The hospital activity is supported by a series of services. They can be categorised as clinical support, general support and training.

6.1. Clinical Support Services

The five main clinical support services are the theatre, the laboratory and blood bank, the diagnostic imaging department, the pharmacy, the physiotherapy unit, the Chaplaincy. Other clinical support services are the fluid production unit, non-sterile production unit and the central sterile supply department. Only brief information will be given here. For more detailed information refer to the tables in appendix.

Surgical Theatre, FPU, CSSD, NSPU (table 6.1.)

The theatre is well staffed and equipped. It can operate at any given time for emergency requirements. Only major operations are carried out in the theatre; biopsies and surgical débridements are performed in most cases in the Wards. Since May 98 the theatre has a solar power supply that makes it independent from the Hospital generator. Surgery is extremely expensive and all attempts are made to reduce it to the strict necessary interventions, although the proportion of emergency surgery in rather high. The sterilisation services (centralised since the beginning of the AIDS epidemic to ensure quality), the IV fluid production unit and the non-sterile production unit (Oral Salt, disinfectants) are attached to the theatre. One unit (standard 500 ml bottle) of fluid produced in Matany has a cost of about 1,200 Ush (including depreciation costs of equipment) and of about 800 Ush without such costs, with a production of about 22,000 500ml unit/equivalent. The Hospital does not normally need IV fluids from outside, but during the Cholera Epidemic of Apr-Aug 98, IV fluids were purchased from JMS and received from District Health Office. In the following table the data concerning the financial year 98/99is different, because a new classification system was introduced in 1998 (see table 6.2).

Year	1993	1994	1995	1996	1997	FY98/99
Nervous System	1	-	-	1	3
Endocrine System	-	-	-	-	-
Eyes	(100*)10	12	10	13	(82*) 6	(89*)
Ears	-	1	-	2	1
Nose,Mouth,Pharynx	-	3	7	7	2
Respiratory System	10	12	4	1	9
Cardiovascular System	-	1	-	-	-
Blood and lymphatics	2	-	-	-	-
Digestive System	159	153	132	116	128	112
Obstetric	57	79	78	84	73	83
Urinary tract	6	9	3	8	6
Male Genital System	55	56	42	34	27	23
Female Genital System	66	28	44	69	47	39
Muscoloskeletal	79	60	77	70	58
Skin and Subcutaneous	28	37	16	17	3
Tissue disruption	51	26	41	23	38
Breast	1	10	7	-	4
TOTAL	525	487	461	435	403	432
Emergencies	28%	27%	29.9%	29%	36.4%	37%
Traumatology	2.5%	0.4%	n.a.	n.a	n.a.	13%
Table 6.1: Major Surgical operations *operations performed by the visiting ophthalmic surgeons team

The new way of presenting the surgery activity is presented in the following table 6.2. It will be a more type of surgery oriented than system oriented.

Type of operation	Elective	Emergency
Caesarean section	5	78
Pelvic surgery	33	6
Laparotomy:
- for peritonitis	3	29
- for intestinal obstruction	3	9
- for hemoperitoneum		12
- expl. Laparotomy	28	1
Hernia repairs	23	5
Hydrocelectomy	22
Operations on the limbs:
- amputation	9	2
- external and internal fixation	23
- ostheomielitis	16
- others	8	2
Craniotomy		10
Cleft lips	6
Thyroid resection	6
3^rd degree tears, VVF	8
Others	79	7
Total	272	160 (37%)
Table 6.2: major surgery performed FY 98/99

Laboratory - Blood Bank (table 6.3)

At the beginning or the financial year (on 2^nd July 1998), a VSO (Volunteer Service Overseas) qualified laboratory technologist from U.K. arrived to managed the laboratory. His presence had an immediate effect on improving the quality of the laboratory results.

New methodologies, techniques and improved quality control measures were introduced and accepted by existing laboratory staff.

The staff comprised of one manager, two male and one female unqualified laboratory assistants. In October 1998, a qualified laboratory assistant was recruited. Unfortunately, the two male assistant’s contract were terminated in November 1998 and April 1999 for disciplinary reasons (alcohol abuse).

However, with rescheduling the routine work, the staff coped with increased workload, especially in blood transfusions and maintained a 24 hours callout service throughout the year.

In table 6.3 the laboratory tests performed are compare over the years.

	1993	1994	1995	1996	1997	1998
Blood smear for Malaria parasites	11524	11536	12541	13482	12641	12560
Blood smear for other purposes	112	28	n.r.	1758	1613	n.r.
WBC count (total and differential)	2964	3117	2687	1680	1405	1885
Sputum smears (specific MT/aspecific)	2208	2180	2446	1990	1607	2101
Urethra and vaginal smears	445	306	170	401	359	394
Haemoglobin estimations	1756	3030	2483	4735	4341	7181
PCV	314	19	25	9	36	10
Sickling Test	67	54	71	88	54	47
ESR	2305	1748	1379	1050	514	542
Blood grouping and X- Matching	1160	1739	1252	741	2069	3990
Urine examination	2530	2372	2587	2370	1769	1050
CSF examination	361	251	270	561	451	538
Other body fluid examinations	113	6	n.r.	n.r.	60	104
Stool examinations	5189	4100	2934	2698	2480	1655
Widal test	32	20	56	69	28	29
VDRL	277	85	214	212	71	316
BUN	143	28	2	91	8	n.r.
Serum Creatinine	103	17	60	88	54	21
Serum Bilirubine	132	17	n.r.	46	5	n.r.
Blood Glucose	144	100	19	119	88	51
Pregnancy test	82	75	73	58	59	97
HIV test	489	435	477	329	412	487
B Hepatitis	--	--	--	--	--	144
SGOT						33
SGPT						33
TOTAL	32540	31302	29741	32575	30125	33269
Table 6.3: laboratory tests

Graphic A

Nakasero continued to supply blood every 2-3 weeks by MAF plane and also by road when Matany vehicles went to Kampala but holding sufficient levels of blood proved difficult at periods throughout the year. A total of 210 Blood transfusion (mostly children with severe malaria related anaemia) were administered in 1995, 732 in 1996, 781 in 1997, 1726 in 1998 and 975 to June 1999 (graphic A, previous page).

At year-end June 1999, there are three laboratory staff being trained externally. One should return in August 1999, one in December 1999 and the third in June/July 2000.

In the following table the HIV and hepatis B seroprevalence on replacement Blood Donors sent to Nakasero is shown:

	1995	1996	1997	1998
HIV seroprevalence	4.4%	2%	2%	4.2%
Hbs Ag +	n.r.	14.2%	6.6%	19.7%

Diagnostic Imaging (table 6.4)

The diagnostic imaging service of the Hospital is equipped with X Ray apparatuses and an Ultrasound scanner. It is manned by a qualified radiographer and his assistant (trained on the job) for the X-ray and by the Medical Officers for the ultrasound investigations. The service is available on a 24-hr basis, though its utilisation outside duty hours is tentatively minimised.

Year	1993	1994	1995	96/97	97/98	98/99
Radiology
Chest	1785	1394	816	1840	1493	2304
Plain abdomen	60	59	64	135	84	70
Barium Enema	2	-	7	2	9	2
Barium meal	32	16	83	28	20	15
Traumatology	507	441	621	721	829	995
Skeletal	446	319	298	774	624	691
Urogenital	20	21	4	24	17	3
TOTAL	2839	2073	1641	3524	3076	4080
N. of patients	2839	2073	1641	3272	1310	3594
Chest Screening	275	234	359	245	35	377
Ultrasound Scanning
Obstetric	294	224	307	505	468	709
Gynaecologic	384	225	293	357	312	420
Liver, Pancreas, Spleen	676	576	576	992	679	917
Abdomen	311	244	150	161	236	317
Urogenital organs	120	102	62	83	106	164
Heart	188	102	114	71	180	231
Tissue	48	43	30	44	52	110
TOTAL	2021	1553	1532	2213	2033	2868
N. of patients	1676	1414	1507	2005	1833	2458
Table 6.4: Activity of diagnostic imaging department

Pharmacy

There is a Pharmaceutical Assistant who runs the Dispensing store. There is a regular monitoring of drug consumption and stock levels. Shortages of drugs are an exception. The pharmacy is also supplied with a refrigerator for the preservation of heat perishable drugs.

Physiotherapy Unit

Once manned by two staff trained on the job by a qualified physiotherapist, the unit has since 1996 become very weak. Interventions are rarely requested by the medical officers, though the high number of Traumatology patients would require a better follow-up. Table 6.5 documents the decline of the unit. In December 1998 a Physiotherapist was interviewed and appointed, but he failed to appear. No records are available for 1997 and 1998.

PHYSIOTHERAPY
	1992	1993	1994	1995	1996
Patients treated	83	58	48	40	15
Number of sessions	436	243	161	218	-
Table 6.5: Physiotherapy unit activity data

Chaplaincy

The spiritual support of the patient is of paramount importance. For this reason the management has tried to secure to the hospital a permanent chaplain (obtained in 1995) and to erect a centre of prayer and worship easily accessible to patients. The Chapel was started in 1995 and completed in 1996 thanks to the Italian organisation ‘Cuore Amico’. Regular services for the RCC take place in the Chapel. The premises of the Hospital are made available to other Christian denominations for their worship. Unfortunately the Chaplain was transferred in December 1997 to another Parish and has not been replaced.

Points for Action for 1999/00

· The laboratory unit needs to improve further the quality and type of investigations.

· The X-Ray department needs a new qualified radiographer to replace the one who left at the end of the financial year, having completed his bonding agreement with the Hospital.

· The diagnostic imaging needs to be improved with a gastroscopy service.

· Revive physiotherapy unit.

6.2. General Support Services

Other services supporting the Hospital operations are: the ambulance service, the mortuary and burial service, the domestic service, the administration, the medical record and archive, the technical department. Baseline information are given on all these in 1994 edition of this report. Here follows some update.

Domestic Service

The domestic service comprises catering and domestic store keeping, food preparation and supply, laundry, tailor, compound and ward cleaning, waste disposal and wastewater treatment.

Since the opening of the School, the GuestHouse and the Teaching Centre, the domestic service has become quite burdensome; but at the same time it generates additional income. For this reason the employment of a full time domestic officer has become necessary and one has been identified to be trained in catering services. During the financial year a large project co-funded by DKA and the Austrian government was implemented:

· the laundry has been completely renovated and now works with a heating solar system and a new washing machine that saves half the amount of water previously used.

· The sewage of the Hospital has been connected to a biological wastewater treatment plant and the purified water produced is used for a reforestation project.

· All of the hospital compound is now connected to main sewage line.

· A high temperature incinerator has been installed and it burns all the solid waste of the Hospital but metal.

· The theatre, the administration block, the laboratory and maternity ward are now supplied by a PV plant and therefore are no longer dependent on generator.

· An additional water tank has been installed but not yet link with the local Catholic Mission.

The water supply remains adequate: it is provided by two bore-holes (one at some 1500 Mt westward distance from the hospital, with one submersible pump linked to the hospital mains by underground cable, another within the hospital compound, with a solar panel operated submersible pump, donated in 1995 by Grundfos and installed by LWF. With the introduction of new sewage system it has been realised that the main water supply system of the Hospital (30years old) is leaking and a considerable amount of safe water is wasted along the pipes underground. The pipes will need to be completely renovated and it will a point of action for this FY.

Administration, Medical Records and Archive

The Administration is strong of a full-time administrator (a Comboni Brother), 1 officer supervisor (a VSO-UK volunteer), a secretary, 2 cashiers, 2 accountant, but towards end of the financial year lost one of the accountant because of ill health. The secretary was trained to handle some of the most basic data processing and is able to computerise the routine hospital data. The analysis of the financial data is done by the Administrator while the analysis of the epidemiological data by the Medical Superintendent.

The strengthening of the administration is still a priority for the next financial year.

Technical Department

The hospital workshops (carpentry, mechanic, electric workshop end building unit) provide most of the current maintenance, renovation and rehabilitation. Besides the ordinary routine maintenance and repair of equipment and buildings, the work carried out in 1998/99 were: construction of the Staff Houses and all the above mentioned constructions financed by DKA and Austrian Government; a new office for the SNO, a building with 3 offices for the public health department and the renovation of one part of the NTS’ hostel.

Two new vehicles have been acquired, one Suzuki 4WD from UNICEF and one Toyota Prado from DKA and a second hand small lorry with a crane for the DKA project.

Points for action for 1999/00

· Strenghetening the Administration with more personnel.

· Complete the renovation of the NTS (roofing, ceiling , toilets and shower ).

· Provide the NTS with a student’s vehicle.

· Complete the teaching centre with a facilitator’s house.

· Establishment of connection of the water tank with Mission.

· Underground pipes renovating.

6.3. Training

Training has always been given a priority by the Management, since the beginning, when training for aide nurses and field health workers was taking place in an informal yet effective way. As time went by the need of a more formal training for nurses emerged and therefore a School was founded for the purpose. Recently a teaching centre was opened to facilitate the ongoing training for the region, as no easily accessible and well-equipped structure existed. Though this centre has been better utilised over this FY, it should be used even more to stress the great potential of activity development in the District.

St. Kizito Nurses’ Training School (table 6.6)

The School, established in 1984 has since then qualified 220 nurse, EN (191) and RN (29). In the course of 1998 classes have been held smoothly. The teaching personnel has been stable for years and has managed to keep teaching standards high. In 1993 the vertical extension course for Enrolled to become Registered Nurse occurred. To adapt the school to the new standards required a complete restructuring of the premises had to take place. A new kitchen, dining hall and new classrooms had to be built; a larger library was created from the former refectory. During 1998 5 DMO (Danida) sponsored candidates were accepted for training as UEN.

	‘86	‘87	‘88	‘89	‘90	‘91	‘92	‘93	‘94	‘95	‘96	‘97	‘98
Admitted to Enrolment Course	12	20	24	38	24	26	29	20	25	26	25	26	26
Admitted to Registration Course								6	-	11	-	14	-
Reported for E.C.	11	19	21	27	24	26	29	20	22	26	25	26	26
Reported for R.C.								6	-	11	-	14	-
Qualified as EN	-	16	8	7	14	18	13	20	17	22	14	22	20
Qualified as RN									5	-	11	-	13
Dropped out E.C.