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New Year Greetings

December 31, 2011 Leave a comment

Ahmed Afaal, Managing Director

I extend my heartiest greetings and well wishes to all of you and your families on the New Year. May the year 2012 bring happiness, peace and prosperity to you and your family.

As we look back at the past year, year 2011, the ADK Hospital marked a number of achievements. The most significant of them is the full operationalization of the new extension of the Hospital. A brand new facility with increased and improved inpatient and outpatient facilities have brought a number positive acceptance from our clients.

In addition, delivery services were improved with the establishment of a more spacious, sophisticated and modern delivery suits with extra capacity has given a major boost to a much-needed area of service.

Year 2011 has also marked a significant increase in the number of service seekers. With the expanded facilities, more people have been able seek services from the Hospital and hence again brought a positive boost to the institution.

Apart from this, year 2011 has also been a year where more training opportunities were available for staff. In this regard, the most significant improvement is in the area of in-service trainings.

Furthermore, initiatives to reach and communicate with the clients were also initiated. In this regard, operator phone answering system came about with changes and a live SMS service to ADK was also initiated. More needs to be done on this though.

Significantly, the economic recession was a major challenge to the organization. Despite this, staff salary schemes across the board have been assessed and improvements made in most areas and are still on going. All staff was enrolled in the national Pensions Scheme and Medical Insurance and/or coverage.

The year ahead faces us with more challenges and more goals to reach. Firstly, the change in the Maldivian Health System financing from January 1st 2012 will bring about a major challenge to the internal operations of the Hospital. How it works, how feasible it is and of course the benefits to the clients are yet to be seen.

The Hospital now gears to initiate Blood Banking and Renal Dialysis services early in the year 2012. In addition, a major expansion project worth over USD13 million is now being planned for initiation in the first quarter of 2012. This initiative will bring about a major boost to the Maldivian Health System as a whole. New state of the art tertiary care services, old age care, critical care and emergency care are all included for upgrading in this project.

So as we say good-bye to 2011 and look forward to year 2012, I deeply appreciate and thank all of you for the hard work that you have put in to the institution. Your sincerity and commitment to ADK is immeasurable. I personally and the Management as a whole appreciate your valuable contribution without it we will not be able to reach the height that we have.

Once again, I wish you and your families a very Happy Near Year with a lot of fortune and fulfilment. I have the confidence that you will continue to serve the people of Maldives through the Hospital.

Categories: Issue 22: Jan 12

How Doctors Die. It’s Not Like the Rest of Us, But it Should Be

December 31, 2011 Leave a comment

By Dr. Ken Murry, Clinical Assistant Professor of Family Medicine, University of South Carolina, USA

Contributed by Dr. Ken Murry, This piece was originally published in Zocalo Public Square, an online magazine of ideas.

It’s not a frequent topic of discussion, but doctors die, too. And they don’t die like the rest of us. What’s unusual about them is not how much treatment they get compared to most Americans, but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently.Years ago, Charlie, a highly respected orthopedist and a mentor of mine, found a lump in his stomach. He had a surgeon explore the area, and the diagnosis was pancreatic cancer. This surgeon was one of the best in the country. He had even invented a new procedure for this exact cancer that could triple a patient’s five-year-survival odds—from 5 percent to 15 percent—albeit with a poor quality of life. Charlie was uninterested. He went home the next day, closed his practice, and never set foot in a hospital again. He focused on spending time with family and feeling as good as possible. Several months later, he died at home. He got no chemotherapy, radiation, or surgical treatment. Medicare didn’t spend much on him.

Of course, doctors don’t want to die; they want to live. But they know enough about modern medicine to know its limits. And they know enough about death to know what all people fear most: dying in pain, and dying alone. They’ve talked about this with their families. They want to be sure, when the time comes, that no heroic measures will happen—that they will never experience, during their last moments on earth, someone breaking their ribs in an attempt to resuscitate them with CPR (that’s what happens if CPR is done right).

Almost all medical professionals have seen what we call “futile care” being performed on people. That’s when doctors bring the cutting edge of technology to bear on a grievously ill person near the end of life. The patient will get cut open, perforated with tubes, hooked up to machines, and assaulted with drugs. All of this occurs in the Intensive Care Unit at a cost of tens of thousands of dollars a day. What it buys is misery we would not inflict on a terrorist. I cannot count the number of times fellow physicians have told me, in words that vary only slightly, “Promise me if you find me like this that you’ll kill me.” They mean it. Some medical personnel wear medallions stamped “NO CODE” to tell physicians not to perform CPR on them. I have even seen it as a tattoo.

To administer medical care that makes people suffer is anguishing. Physicians are trained to gather information without revealing any of their own feelings, but in private, among fellow doctors, they’ll vent. “How can anyone do that to their family members?” they’ll ask. I suspect it’s one reason physicians have higher rates of alcohol abuse and depression than professionals in most other fields. I know it’s one reason I stopped participating in hospital care for the last 10 years of my practice.

How has it come to this—that doctors administer so much care that they wouldn’t want for themselves? The simple, or not-so-simple, answer is this: patients, doctors, and the system.

To see how patients play a role, imagine a scenario in which someone has lost consciousness and been admitted to an emergency room. As is so often the case, no one has made a plan for this situation, and shocked and scared family members find themselves caught up in a maze of choices. They’re overwhelmed. When doctors ask if they want “everything” done, they answer yes. Then the nightmare begins. Sometimes, a family really means “do everything,” but often they just mean “do everything that’s reasonable.” The problem is that they may not know what’s reasonable, nor, in their confusion and sorrow, will they ask about it or hear what a physician may be telling them. For their part, doctors told to do “everything” will do it, whether it is reasonable or not.

The above scenario is a common one. Feeding into the problem are unrealistic expectations of what doctors can accomplish. Many people think of CPR as a reliable lifesaver when, in fact, the results are usually poor. I’ve had hundreds of people brought to me in the emergency room after getting CPR. Exactly one, a healthy man who’d had no heart troubles (for those who want specifics, he had a “tension pneumothorax”), walked out of the hospital. If a patient suffers from severe illness, old age, or a terminal disease, the odds of a good outcome from CPR are infinitesimal, while the odds of suffering are overwhelming. Poor knowledge and misguided expectations lead to a lot of bad decisions.

But of course it’s not just patients making these things happen. Doctors play an enabling role, too. The trouble is that even doctors who hate to administer futile care must find a way to address the wishes of patients and families. Imagine, once again, the emergency room with those grieving, possibly hysterical, family members. They do not know the doctor. Establishing trust and confidence under such circumstances is a very delicate thing. People are prepared to think the doctor is acting out of base motives, trying to save time, or money, or effort, especially if the doctor is advising against further treatment.

Some doctors are stronger communicators than others, and some doctors are more adamant, but the pressures they all face are similar. When I faced circumstances involving end-of-life choices, I adopted the approach of laying out only the options that I thought were reasonable (as I would in any situation) as early in the process as possible. When patients or families brought up unreasonable choices, I would discuss the issue in layman’s terms that portrayed the downsides clearly. If patients or families still insisted on treatments I considered pointless or harmful, I would offer to transfer their care to another doctor or hospital.

Should I have been more forceful at times? I know that some of those transfers still haunt me. One of the patients of whom I was most fond was an attorney from a famous political family. She had severe diabetes and terrible circulation, and, at one point, she developed a painful sore on her foot. Knowing the hazards of hospitals, I did everything I could to keep her from resorting to surgery. Still, she sought out outside experts with whom I had no relationship. Not knowing as much about her as I did, they decided to perform bypass surgery on her chronically clogged blood vessels in both legs. This didn’t restore her circulation, and the surgical wounds wouldn’t heal. Her feet became gangrenous, and she endured bilateral leg amputations. Two weeks later, in the famous medical center in which all this had occurred, she died.

It’s easy to find fault with both doctors and patients in such stories, but in many ways all the parties are simply victims of a larger system that encourages excessive treatment. In some unfortunate cases, doctors use the fee-for-service model to do everything they can, no matter how pointless, to make money. More commonly, though, doctors are fearful of litigation and do whatever they’re asked, with little feedback, to avoid getting in trouble.

Even when the right preparations have been made, the system can still swallow people up. One of my patients was a man named Jack, a 78-year-old who had been ill for years and undergone about 15 major surgical procedures. He explained to me that he never, under any circumstances, wanted to be placed on life support machines again. One Saturday, however, Jack suffered a massive stroke and got admitted to the emergency room unconscious, without his wife. Doctors did everything possible to resuscitate him and put him on life support in the ICU. This was Jack’s worst nightmare. When I arrived at the hospital and took over Jack’s care, I spoke to his wife and to hospital staff, bringing in my office notes with his care preferences. Then I turned off the life support machines and sat with him. He died two hours later.

Even with all his wishes documented, Jack hadn’t died as he’d hoped. The system had intervened. One of the nurses, I later found out, even reported my unplugging of Jack to the authorities as a possible homicide. Nothing came of it, of course; Jack’s wishes had been spelled out explicitly, and he’d left the paperwork to prove it. But the prospect of a police investigation is terrifying for any physician. I could far more easily have left Jack on life support against his stated wishes, prolonging his life, and his suffering, a few more weeks. I would even have made a little more money, and Medicare would have ended up with an additional $500,000 bill. It’s no wonder many doctors err on the side of overtreatment.

But doctors still don’t over-treat themselves. They see the consequences of this constantly. Almost anyone can find a way to die in peace at home, and pain can be managed better than ever. Hospice care, which focuses on providing terminally ill patients with comfort and dignity rather than on futile cures, provides most people with much better final days. Amazingly, studies have found that people placed in hospice care often live longer than people with the same disease who are seeking active cures. I was struck to hear on the radio recently that the famous reporter Tom Wicker had “died peacefully at home, surrounded by his family.” Such stories are, thankfully, increasingly common.

Several years ago, my older cousin Torch (born at home by the light of a flashlight—or torch) had a seizure that turned out to be the result of lung cancer that had gone to his brain. I arranged for him to see various specialists, and we learned that with aggressive treatment of his condition, including three to five hospital visits a week for chemotherapy, he would live perhaps four months. Ultimately, Torch decided against any treatment and simply took pills for brain swelling. He moved in with me.

We spent the next eight months doing a bunch of things that he enjoyed, having fun together like we hadn’t had in decades. We went to Disneyland, his first time. We’d hang out at home. Torch was a sports nut, and he was very happy to watch sports and eat my cooking. He even gained a bit of weight, eating his favorite foods rather than hospital foods. He had no serious pain, and he remained high-spirited. One day, he didn’t wake up. He spent the next three days in a coma-like sleep and then died. The cost of his medical care for those eight months, for the one drug he was taking, was about $20.

Torch was no doctor, but he knew he wanted a life of quality, not just quantity. Don’t most of us? If there is a state of the art of end-of-life care, it is this: death with dignity. As for me, my physician has my choices. They were easy to make, as they are for most physicians. There will be no heroics, and I will go gentle into that good night. Like my mentor Charlie. Like my cousin Torch. Like my fellow doctors.

Categories: Issue 22: Jan 12

SMS ADK

December 31, 2011 Leave a comment

ADK SMS service launched

The Hospital has introduced a brand new service to bring Clients closer to the hospital. The SMS service, launched in collaboration with the main telecom provider DHIRAAGU, allows patients to check needed information related to their appointments and doctors availability right at their fingertips.

In this, patients will be able to check their waiting, last token consulting, doctor’s duty timing as well. They can also get specific information on a particular too.

The SMS short number for the service is 235, which corresponds to the letter ADK on the conventional mobile phone keyboard.

It is envisaged that with this new intervention, patients will enjoy a more user-friendly service and it will help to reduce the time patients have to wait physically in the hospital.

Firstly, the service help the patient to reduce time waiting for operator call answers. The feedback message, since electronic will reach the SMS sender, on average, within 10 to 15 seconds. This has an additional benefit of reducing the number of calls to the hospital for this service, hence reducing the operator load. Thus, it is felt that there will be an efficiency gain by implementing this service.

Secondly, the patient can now drop into the hospital just in time for the appointment. Since they can check the live queue of the doctor’s consultation, the patient can continue their daily chores instead of waiting in the Hospital lobby. Again this brings a welcome convenience for the patients who are pressed for time.

On December 28, 2011 the Hospital signed a one-year agreement with the largest telecom provider in the country DHIRAAGU, to provide this service. Although this service is initiated with DHIRAAGU, the Hospital will work to bring the same service to patients who use other networks for their communication needs.

Further more, at present new technological initiatives are taken and in being worked out to bring even better and timelier information to the service seekers. Hence, in future, the Hospital will introduce email appointment and feedback services to those who wish to be in contact with us on a more accessible manner.

We have to accept that our telephone system load is so heavy at present that we have to struggle to keep up with the required demand. Especially, those important calls that are missed for many patients is a concern. The aims of these new interventions are to minimise these

instances and provide as many avenues for customers to reach and communicate with the hospital.

In order to do so, it is imperative that the users provide constructive feedback to these initiatives. New ideas, innovation and even simple comments to the adequacy of the service are welcome to all staff and readers. The easiest way to leave a comment or idea is to simply use our e-suggestion services. Just send an email to suggestions@adkenterprises.com and we will be there to provide feedback and attend to matters.

It is our hope that as many customers will use this new service and the full benefit of the service is seen. It is envisaged that as customers get to know more about the service, they will accept this service as a routine. One customer tweeted to ADK Hospital

“this is helpful and time saving …”

The Hospital will continue to make advancements and use technology wisely to ensure that both service seekers and the Hospital.

Categories: Issue 22: Jan 12

Training Nurses for Improving Patient Safety

December 31, 2011 Leave a comment

By Department of Nursing

Nurses at work

Today there is growing awareness and recognition of patient safety as a vital factor in health care. It is one of the most pressing health care challenges. Any point in health care delivery process contains a certain degree of inherent safety issues. Unsafe or adverse events may result from problems in practice, products, procedures or systems. Patient safety improvements demand a complex system-wide effort, involving a wide range of actions in performance improvement, environmental safety and risk management, including infection control, safe use of medicines, equipment safety, safe clinical practice and safe environment of care. Since, nurses have a major role to play in improving patient safety; a training program was conducted by Department of Nursing, for 25 nurses from 23rd October to 8th November 2011 with the following objectives:

  • To enhance knowledge related to principles of chain of infection.
  • To improve knowledge about elements of standard precautions and transmission based precautions.
  • To be able to apply and implement strategies for preventing health care associated infections: UTI, pneumonia, surgical site infection and bloodstream infection.
  • To improve knowledge related to hospital waste management and hospital laundry management.
  • To enhance knowledge related to patient safety: risk management, deteriorating patients, falls, medication safety, surgery and invasive procedures, patient identification errors.

Most of the sessions were conducted by Patient Safety Focal Point nurses from ADK Hospital who had undergone trainings at both national and international level. Upon completion of this training, participants were evaluated for their knowledge level and their feedback had shown that all the participants were satisfied with the training and recommended to conduct such trainings in future too. Participants work related to patient safety were also monitored after completing the training and it is showing that nurses are committed for improving patient safety practices in their units.

Categories: Issue 22: Jan 12

Police Post

December 31, 2011 Leave a comment

Maldives Police Service and ADK Hospital has agreed to establish a 24 hour police post at the Hospital premise effective from January 2012.

The purpose of this Post is dual. One, it is establish to facilitate Police personnel and their families to access ADK Hospital services on a more organized and routine basis. And secondly, it will assist in keeping and attending to Hospital security matters as well.

It has been some time that the two organizations have been negotiating to establish such a mechanism and now, it is finally underway.

This is welcome news both for the Police families and also the Hospital Staff as well as the patients.

In recent times, the increased security issues for the service provider and also the patients have been a major concern. Violence, unacceptable behaviour towards professionals and staff, theft has again increased after a dip in the recent past.

This, partnership will help mitigate such incidences more quickly with the direct presence and link with the Police and the Hospital.

The Management is also taking steps further improve the security measures at the Hospital so that the Hospital environment is safe for all.

Categories: Issue 22: Jan 12