Gastro intestinal Endoscopy Unit

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
There was no endoscopy service in Mauritius. The ministry of health had several health issues to deal with and led to delay in setting up an organized endoscopy service. There was no appropriate infrastructure. There was inadequate endoscopy equipment. Prior to our project in 2007 patients had difficulty to undergo endoscopy as the service was erratic. There were no qualified staff and a high rate of equipment breakdown. There was no protocol for endoscopy, no reporting system, no proper disinfection procedures. Thus there was no guaranty for an acceptable standard for endoscopy. Mauritian patients were deprived of these important gastro intestinal investigations. Only diagnostic gastroscopies and colonoscopies were minimally being performed. There was a need to provide the public with a fully comprehensive set of endoscopic procedures of high standard to be performed by qualified, competent, and independently certified endoscopists and specialist’s endoscopy nurses. Patients with obstructive jaundice were either not treated or some underwent surgery or went abroad for expensive treatments. Many of these patients could have been treated by advanced Endoscopic Procedures i.e. Endoscopic Retrograde Cholangio-Pancreatography (ERCP). There was no ERCP service in Mauritius. In addition to introducing several new endoscopic therapeutic procedures there was an urgent need to start an ERCP service Mauritians. Issues to be addressed 1- We had to identify and upgrade the infrastructure to contain the Endoscopy Centre. 2- We had to prepare a list of equipment and accessories with proper specifications for endoscopy. 3- Ministry of health to purchase all endoscopy equipment. 4- Seek support and training from qualified gastroenterologist from the UK. 5- Set up training programs in Mauritius for doctors and nurses. 6- A team of doctors and nurses to be trained in the UK in Gastro Intestinal Endoscopy Centre with hands on training, working alongside consultant Gastroenterologists and specialists Endoscopy nurses. 7- Had to obtain clearance from MOH&QL. 8- UK immigration clearance. Certificate of character. General medical council registration for doctors to practice in the UK. Nursing and Midwifery Council registration for nurses for hands on training. Signing of honorary contracts with Bradford Hospitals NHS Trusts, York District Hospitals and St James Hospital Leeds. 9- In addition to advanced gastroscopy and colonoscopy procedures we had to plan ahead to obtain adequate training to start for the first time an ERCP Service in Mauritius such a training would require a minimum of three month to spent abroad. This would have an expensive program and also cause disruption in the service in Mauritius. 10- The ERCP training program thus had to be condensed and tailor made to a highly compact, intensive shorter period. 11- X-ray equipment and a new lead lined room had to be made available for ERCP procedures.

B. Strategic Approach

 2. What was the solution?
We at hospital level initiated the project and worked along with the hospital director, the hospital administrator and the staff of various grades at the headquarter of the MOH. We also discussed and worked with the heads of the nursing division, the charge nurses of theatre and medical wards. Our project was ambitious and undertaking but we were committed to make it a success. The driving force for the project was at our level. However we had the blessing of the various staff mentioned above and in particular the minister of health who was convinced of our project. He showed a particular interest and had a vision for the future of endoscopy in Mauritius. We convinced him of the improvement in the delivery of health care in Mauritius in gastroenterology. The Prime Minister of Mauritius Dr. NavinRamgoolam also became involved with the project and made personal contact with Dr S Moreea consultant Gastroenterologist in the UK. This added further momentum to the project. Dr Moreea met me and we discussed all the issues mentioned above. Dr. S.Moreea was prepared to assist us and made an unconditional offer to get engaged with the project. 1- A department in the hospital had been unused for some years due to a defective lithotripsy machine. We identified this area to setup the endoscopy unit. We wrote several letters to the hospital administrator to obtain authorization. After much persuasion this was achieved. The building was modified to contain a waiting area, a reception area, the endoscopy theatre and a recovery room. This was the most important step to initiate the project and it took us several months to find a solution. Though the space was not being used and we encountered strong opposition. We took the matter to the minister of health in person and got the green light. 2- We prepared all the specifications for the equipment and forwarded it to the purchasing division of the MOH&QL. Following several bids from various companies we identified the appropriate equipment which were duly purchased 3- We organized in collaboration with Dr. S Moreea and his team from UK several endoscopy training workshops over the years. This has provided training for doctors and nurses interested in endoscopy. Several new endoscopic procedures were introduced in Mauritius. 4- We had several meetings with parties concerned at the ministry and organized an intensive training in ERCP in the UK. Funds had to be made available to cover our travel expenses, accommodations and living expenses. 5- Registration with the General Medical Council UK was obtained. 6- Dr. S. Moreea made special arrangements with several consultant gastroenterologists in the UK for our training program. 7- The 3 main hospitals in the UK namely Bradford, Leeds and York showed a lot of enthusiasm to extend their help to Mauritius and without any hesitation and enroll us on a honorary contract. 8- The knowledge acquired was quickly translated into action and patient started benefitting. 9- The number of patient treated at the Centre increased rapidly and we increased our weekly list. 10- We have been able to solve all the issues by showing our determination, by continuous explanation to the authorities and when necessary seek support with higher authorities including the Minister of Health.

 3. How did the initiative solve the problem and improve people’s lives?
This was an innovative project propelled by the doctors and nurses at hospital level. Normally decisions are taken at headquarters and subsequently translated to hospital level. We were behind in this specialty and much more time would have been wasted waiting for an eventual future development. Hence we took the initiative, arranged for a series of meetings and convinced the hospital Director of our project. A small GI endoscopy unit was then quickly set up in a medical ward. We informed all the specialists in all the main hospitals of the service being offered. The number of referrals increased over the following months. There was a big demand for endoscopy and we made use of the statistics to promote the unit further and this led to the development of a bigger unit. The staffing of the unit was of utmost importance for its success. Only doctors and nurses interested in endoscopy and were willing to work long and odd hours were selected. Besides our basic salary most of the additional work is on a voluntary basis. We developed a good team spirit and worked as a strong united team. We have succeeded in our mission.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
We have dedicated sessions to perform endoscopic procedure – currently on Mondays, Tuesdays, Wednesdays and Thursdays for ERCP. We ensure that nurses and doctors have dedicated times so that there are no delays during sessions. Nurses are allocated to the endoscopy unit through their off-duty and we no longer are in a position where nurses have to be scrambled on the day of the endoscopy sessions (which has been the case in the past). We ensure that patients are contacted by phone to confirm their attendance to keep the ‘DNA’ (Did Not Attend) rates low. We stagger the appointment times to ensure the flow of patients with minimum waiting times for patients. We ensure that the patients receive all the necessary information on fasting and bowel preparation so that no procedure is cancelled on the day. We ensure that our equipment is in functioning order by regular inspection (for example, leak testing). We also ensure we have all the disposables in stock – this includes endotherapy equipment and disinfection fluids. We perform the procedures in a timely and internationally recognized standard way by highly trained staff such that failure rates are kept low and patients do not have to attend again. We have dedicated waiting, changing and recovery rooms to ensure a laminar flow of patients but more importantly to ensure patient dignity and confidentiality. We endeavour to provide an inpatient service (patients who are already in hospital as opposed to patients who come on an outpatient basis) within 2 days of any request to keep the length of stay in hospital to a minimum. Our endoscopists have been highly trained to perform procedures which up to 2010 would have required an open operation leading to a long length of stay in hospital. For example, ERCP’s allow the removal of gallstones from the bile duct, which would otherwise require an operation with a high morbidity and mortality and would require a hospital stay of at least 7-10 days. In contrast, following an ERCP the patient can be discharged either the same or the next day. Furthermore, whereas in the past some of these patients would have to be sent abroad with the associated monetary and social costs, now we can provide these services locally with the associated savings and patient wellbeing.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
The Ministry of Health and Quality Of Life has been fully committed for the approval of the Unit to be opened in the Medical Ward. After the set in the Medical Ward the unit has been opened with more space and fully equipped new technology to perform ERCP endoscopy procedure Dr. Moreea is the key stakeholders that help Dr. F. Bholah for the implementation of the unit by given in house training and training in England (Leeds, Bradford and York Hospitals) The Ward Manager of Female has given her approval for the Unit to be in the medical Ward The Ministry and the Regional Health Director has given a bigger place for running of the unit The Store has involved for the purchase of equipment and consumables respecting the green policy of the environment The Infrastructure has involved several stakeholders for supplier the set of the Medical equipment such as C-arm has involved the X-ray dept and Physicists for control and ensuring the amount of X-rays emitted in the unit is within the control limits in accordance to the Radiological Act and regularly measured by providing the dosimeter The Ministry of Public Infrastructure has given a helpful hand in the design and installation of the electrical supplies in accordance to electricity at work regulations for providing good source of light using during endoscopy procedures The Head of Nursing Unit, Regional Health Director and the Regional Hospital Administrator has totally involved in this process by providing skilled and the required staff including Medical Specialist, Nursing Officers, Health Care Assistant and Health Care Attendant However, infection control set up was performed by the Infection Control Committee The Biomedical Unit has set up the equipment as per the user manual and has been calibrated to provide good results.
 6. How was the strategy implemented and what resources were mobilized?
Equipment were purchased through the procurement section of the ministry of health . Total cost 30 million Mauritian rupees. Infrastructure development funding was made through the Ministry of Public Infrastructure (MPI) approximate cost 10 million Mauritian Rupees. Running cost including medical disposables, repairs and maintenance, funding through central supply department ministry of health and at hospital level.Rs 500000 monthly Staffing salary as per contract with the ministry of health. All financing was funded by the ministry of health and the ministry if public infrastructure. Applications for the above funding were made by the head of the unit through the hospital director following established procedures to ensure full transparency.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
1 The creation of the first dedicated and up to date endoscopy unit for Mauritius. 2 In addition to diagnostic endoscopy this unit is able to provide a full range of therapeutic endoscopic treatment. 3 The unit provides a full ERCP service and Mauritian patients for the first time are benefitting such treatment. 4 There is now no need for Mauritian patients to go abroad for endoscopic treatment in gastroenterology.

 8. What were the most successful outputs and why was the initiative effective?
 We evaluate services by auditing every aspect of ‘endoscopy’ – from pre-procedure waiting times and patient experience to endoscopic outcomes.  We keep a central record of all procedures and outcomes performed in the unit.  We also keep a hard copy of every single procedure carried out on the unit for audit purposes and for ease of access of reports for the future.  We hope to develop an electronic reporting system which can be shared with future endoscopy units in other hospitals.  All endoscopists keep a log of their procedures and these are audited in terms of fixed international criteria on a yearly basis. For example, endoscopists need to reach the end of the colon in at least 90% of cases and if this is not achieved, remedial training is provided.  We record all cases of adverse effects and we analyse these at regular intervals for educational and remedial purposes. Patients Satisfaction Surveys are utilized to evaluate the level of services provided by the unit before discharge.  A suggestion box is fixed in the unit where the patients can suggest measures that can be implemented so as to bring improvement in the service.  Track records of the improvement of health of our patients are kept by giving them regular reviews. They are also given the liberty to call up at the unit in person or by phone and inform our team of any change in their health status so that corrective measures could be taken in time.  A visitor’s book is available for any person as a member of the hospital community to write his feedback on anything at the unit during his treatment. The book is reviewed at least every two weeks.

 9. What were the main obstacles encountered and how were they overcome?
1 Shortage of funds to develop and upgrade the infrastructure. – several problems were encountered in modernizing the infrastructure namely 2 Buying the best equipment for the unit encountered problems because of the open bidding exercise where the cheapest quotation is awarded the tender. 3 Overcoming objections from the adjacent gynaecology unit who wanted to make use of the existing premises. 4 Staffing the unit 5 Seeking expertise for advanced endoscopy. The above obstacles were overcome by us making a strong case to develop this prototype unit and made representations to higher officials at the ministry, several correspondences were also sent to the minister of health and even the prime minister of the island. The project convinced the authorities of the major contributions the unit will bring to the population of the country. Following this we obtain the green light to develop this unit.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
 Before 2009, the number of endoscopic procedures performed at the SSRN Hospital was small. Since the opening of the unit, we have had a number of innovations: first and foremost, we have a dedicated unit which now does more than 1500 procedures every year.  We do advanced procedures such as banding of varices, advanced colonoscopies and more importantly we have introduced ERCP in Mauritius (see above). We have introduced for the first time in Mauritius dedicated endoscopy reports which we have shared with other hospitals. We also have electronic reporting and recording system.  We also train doctors and nurses from our own and other hospitals. We use dedicated training proformas, again a first in Mauritius.  We can record all our procedures on DVD in real time and share difficult and rare procedures with other specialists in the field on You Tube ensuring full confidentiality. We have shown a novel way of placing the Sengstaken tube in patients with severe uncontrolled bleeding from oesophageal varices. We can provide patients of their procedures at their request, which is not the case in other hospitals.  In November 2012 we renewed all our equipment and now using endoscopes with the latest technology: • High definition imaging. • Narrow Band Imaging • Universal Positioning Device (UPD) for painless colonoscopy. • Laser Image Capture and Picture. We are the only Centre in Mauritius and in the Indian Ocean to benefit from such high tech equipment.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
In addition to its high sensitivity in diagnosing and treating gastro intestinal disease, this project has shown to be highly cost effective. The unit is extremely popular among Doctors, nurses, patients and public at large. There has been extensive media coverage demonstrating the immense contribution this unit has made to health care in Mauritius. Hence this unit is now well established and continues to function in the future. This unit has already assisted in training and transferring of knowhow to two new units recently set up in Mauritius namely the A.G. Jeetoo Hospital in Port-Louis and Jawaharlall Nehru Hospital in Rose Belle.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
We have learned that through perseverance the endoscopy unit set up at ssrnh has revolutionized the treatment of gastro intestinal diseases. In addition to providing high diagnostic precision endoscopy do not use polluting or chemical agents dangerous to the environment compared to previous techniques which were in place before. The previous techniques made use of barium solution which was either swallowed or introduced rectally. The patient then had to undergo several X-rays to trace the barium inside the body. X-rays make use of radioactive particles and they are potentially hazardous to health. They can cause damage to several organs and also increase the risk of cancer. Endoscopy is “clean” and eco-friendly and has considerably cut down the use of X-rays for the gastro intestinal investigations. Endoscopic disinfection is done by eco-friendly solutions which are biodegradable and do not pollute waste water. Introduction of our electronic system for recording patient’s data, and telephone booked appointments has led to considerable reduction in the use of paper. Participating for the award has been a major motivation for the unit to continuously improve and excelled itself. It has also been a major leverage for us to negotiate with the administration and the authorities to invest in.

Contact Information

Institution Name:   Gastro intestinal Endoscopy Unit
Institution Type:   Government Agency  
Contact Person:   Farouk Bholah
Title:   Doctor  
Telephone/ Fax:   52532182
Institution's / Project's Website:  
E-mail:   endoscopyssrnh@gmail.com  
Address:   SSRN Hospital, Pamplemousses
Postal Code:  
City:  
State/Province:  
Country:  

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