Strengthening Emergency Care in Sierra Leone

Emergency medicine is not a speciality in Sierra Leone. Emergency care is provided by doctors, community health officers and nurses trained as generalists, and rarely in rooms specifically designed for resuscitation.

KGHP recruited a team of eight expert volunteers from Sierra Leone and the UK to develop course material and deliver the 7-day course in two major cities, Makeni and Bo, to a total of 75 multidisciplinary healthcare staff ranging from a newly qualified nurse to medical superintendents and senior matrons. Attendees were selected by MoHS from 16 hospitals across all districts of the country who, on return to their places of work, delivered a 5-day cascade training course.

The course covered a formal triage system, a standardised handover process between ambulance and hospital staff, recognition and immediate treatment of life-threatening emergency presentations including trauma, and a review of patient flow to identify and address delays in care delivery.

After presenting the proposed training package to the MoHS, the Chief Medical Officer and senior clinicians to obtain approval, we packed up two Land Cruisers with eight volunteers, simulation training equipment and reams of resources and headed to Makeni in the north to start the first course.

Delivering the course for 7 days was physically and mentally demanding for all our trainers! We collected anonymous feedback daily and constantly adapted to meet the learning needs of the group. By the end of the first day there was a real enthusiasm for ER training, in part fostered by attendees mapping the patient journey for emergency patients and highlighting the delays and risks to patient safety. On the last day attendees (now new ER Trainers) came back to this exercise and discussed low-cost, practical strategies to address delays in their settings. No solutions were offered by KGHP volunteers – a nationwide multidisciplinary team working together in a room for a week proved an incredible environment for sharing innovations!

Following delivery of the courses, the team split into pairs of one Sierra Leonean and one UK volunteer to visit each hospital facility. A devastating explosion in Freetown on 5th November meant Sierra Leonean members of the team were needed in the capital, so some of the visits were postponed for a week. Once started it was another fast-paced period – it was lovely to meet the ER trainers working in their own environments, enthused to show how plans were going to implement changes following the course.

In one hospital the KGHP team were shown a new ER formed from existing equipment and staffed by a team recently trained on an ER cascade course delivered on site. This was a real highlight of the project for the whole team as our WhatsApp group kicked off with photos and celebratory emojis! Here was our evidence that we had achieved impact.

The visits were valuable for putting the challenges described to us in context. There is no piped oxygen and electricity is unreliable, so there is often no light or oxygen from concentrators. Water is sometimes plumbed but is usually carried inside in buckets for handwashing. In small hospitals there is often only one doctor, supported by a large number of ancillary staff who volunteer without pay whilst waiting years for a paid position to become available. Drugs are often out of stock or too expensive for patients to buy, and diagnostics such as labs and imaging are limited by stock-outs of equipment and consumables, lack of training, and unreliable electricity. Traumas are frequent and deadly, as roads are dangerous, and patients lack the funds to pay for lifesaving treatment. Staff often make themselves available 24 hours a day, 7 days a week - an exhausting work environment.

For some of the Sierra Leonean team members this was also new information. The majority of professional training takes place in Freetown or internationally, so those who had not worked outside of the capital were surprised to find how challenging the environments in which their colleagues were working could be.

KGHP’s principle of partnership working was evident in this project, where training materials were developed and delivered together. All members of the team have built on existing experiences in training, health system evaluation and strengthening, and cross-cultural working. The predominantly Sierra Leonean team taught new clinical and training skills to 75 healthcare workers, who have gone on to cascade clinical skills to a further 238. ER trainers have soft and hard copies of resources should further funding become available for additional courses.

There is a nationwide enthusiasm for further developing emergency care capacity and we hope this baseline of ER trainers will provide a launchpad for future partnership work.

With thanks to the team of Emergency Room trainers: Dr Lucy Jackson, Dr Zosia Bredow, Dr Tejan Mansaray, Moses Tarawally, Dr Fatu Amie Kalokoh, Matron Martha Kailondo, Sorie Samura and Zoe Corbett