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ACTIVITIES OF EMERGENCY DEPARTMENT QUALITY IMPROVEMENT

(QI) PROJECT

Ababa University, College of Health Sciences, School of Medicine.

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 October,2015

CONTENTS
The Summary of Emergency Department Quality Improvement (QI) Projects

Addis Ababa University, College of Health Sciences, School of Medicine

Aklilu Azazh, Sisay Teklu, Muluwork Tefera,Tigist Bacha,Haymanot Geremew, Assefu W/Tsadik

Improving Infection Prevention Practices at Tikur Anbessa Specialized Hospital’s Emergency

Department

Aklilu Azazh, MD

Improving Adherence to Hand Hygiene Practice at Tikur Anbessa Specialized Hospital’s Pediatric
Emergency Unit

Muluwork Tefera , MD

Improving Infection Prevention Practices at Tikur Anbessa Specialized Hospital’s Emergency

Department

Aklilu Azazh, MD

Improving the Emergency Training Center (EMTC) activities by increasing the number of trainees
by 50% within a one year period through active coordinating and managing the training calendar
Haimanot Geremew, MSC.N

Improving the availability and accessibility of emergency drugs and equipment in the ER.

LemlemBeza (RN, EMCCN)

Improving patient satisfaction at Tikur Anbessa Specialized Hospital’s Emergency

Department

Haimanot Geremew,MSC.N, Dr Aklilu Azazh,MD

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Acknowledgement

Our local stakeholders

Addis Ababa University School of Medicine+

Tikur Anbassa specialized Hospital

Fedral Ministry of Health Bureau

Addis Ababa City Fire and Emergency Authority

Ethiopian and Addis Ababa City Red Cross Society

Ethiopian Road Safety Authority

Our International partners

US President’s Emergency plan for AIDS Relief

US Centers for Disease Control and Prevention in Ethiopia

American International Health Alliance,HIV/AIDS Twining Center

University of Wisconsin, Madison

University of Toronto

University of Cape Town and Stellenbosch University

People to People(P2P)

Ethiopian North American Health Professionals Association

African Federation of Emergency Medicine (AFEM)

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The Summary of Emergency Department Quality Improvement (QI) Projects

Addis Ababa University,Colledge of Health Sciences, School of Medicine

Aklilu Azazh, ,Sisay Teklu, ,Muluwork Tefera,Tigist Bacha,Haymanot Geremew, Assefu W/Tsadik

Introduction:
Quality improvement refers to a continuous and ongoing effort to achieve measurable improvements in
the efficiency, effectiveness, performance, accountability, outcomes, and other indicators of quality
services or processes which achieve equity and improve the health of the community .
In Ethiopia during the past decade, efforts to develop emergency medicine capacity and programs have
been underway at TASH and the AAU Medical School and at other sites . Toward this end the Emergency
Rooms at TASH were converted into Emergency Department(ED). In addition to these organizational
and structural changes, academic programs were launched, including an EM Residency and a Masters in
EM and Critical Care Nursing. These changes led to a large increase in the volume of critical patients
seeking care in the ED. As a new department, the ED faced many challenges and it was felt that
collaboration with a university partner that had an established emergency medical program would help
the program to advance and meet its objectives. With the support of the AIHA/Twining center
&CDC/PEPFAR support, a twinning collaboration in EM between AAU and UW was established in 2009.
During the first year of the collaboration the twining focused on adult emergency medicine support.
Pediatric emergency medicine was added to the partnership in 2010.Through this collaboration nurses
and physicians participated in academic fellowships at the University of Wisconsin to develop core staff
for the TASH ED.
The EM partnership between AAU and UW, with academic fellowships and exchanges in place and a
Twinning philosophy that emphasizes collaboration and joint learning, was an ideal program in which QI
program was incorporated. It was hoped that the QI effort would maximize success, promote
sustainability, and reinforce basic principles for effective healthcare service delivery organizations such
as patient focus, rigorous and deep understanding of processes, teamwork, and use of data to assess
progress.

Methodology

QI inception phase: From the outset QI training was included in the fellowship, based on the intention
that trainees could use QI tools and approaches to introduce, monitor and sustain changes, as well as to
motivate staff and develop an organizational culture conducive to delivery of quality care 13.
Since the inception of the project in 2009, 16 clinical fellows ( 8 doctors and 8 nurses) have participated
in academic fellowships at the University of Wisconsin-Madison. During these 4-8 week exchanges,
each of the fellows participated in a QI training program that enabled them to design a quality
improvement effort to implement upon return.
Identification of priority problems: Priority problems were identified by fellows both during QI
trainings and follow up brainstorming session with departmental staff. Some of the challenges included:

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1) poor knowledge and practice of triage protocols, 2) low compliance with infection prevention
standards, 3) long waiting time for care in trauma and other emergencies, 4) bottlenecks in relation to
access to operating rooms and inpatient beds, 5) crowding and lengthy ED stays, 6) irregular availability
of essential ED drugs and supplies, and 7) poor communication, both in terms of systems and
interpersonal dynamics and teamwork skills.
In order to address these and other challenges, the following QI implementation process was employed.
Project Development Phase: After outlining a QI project during the QI course, the fellows returned to
TASH and reviewed their projects with other staff involved in the problem areas to more deeply
understand root cause analysis and possible strategies for improvement. Further, a preliminary
implementation and action plan was developed at this stage. ( Table 1 and 2 lists the QI projects initiated
in the initial QI training. )

Baseline and sensitization phase. Baseline measures, in the form of ad hoc surveys or compilation of
routinely collected data, were taken in order that pre and post intervention comparisons could be made.
Then the project proposal and the baseline results were presented to stakeholders who included ED staff,
hospital QI team, hospital administration other relevant hospital staff and AIHA/Twining staff.

Quality Improvement Projects cycles: A standard QI process was developed and codified in a QI
charter that was established for presentation and documentation of projects. This process is, by design,
very similar to plan-do-study-act cycle, and the FOCUS-PDCA cycles that are commonly used in
healthcare QI programs. It is also informed by QI approaches developed for low income countries

QI charter includes:
1) an aim statement (or problem statement),
2) identification of a team leader and team members,
3) the option of including cause and effect analysis and/or process flow analysis,
4) the definition of indicators that will be used to measure change,
5) a summary of the action for improvement,
6) articulation of the expected outcome,
7) a timeline, and
8) a sustainability plan that anticipates how the change will be sustained beyond a “special project” cycle.

Standards that define quality. Ministry of Health standards provided guidance for this program. While
some QI projects worked to define how given standards might be applied in a specific setting, and others
explored standard ways of dealing with challenges for which there is not standard, projects which
compare the clinical effectiveness of clinical protocols with the aim of revising Ministry standards were
considered outside of the scope of the QI effort.
Monitoring tools: indicators
Given the relatively recent introduction of 36 key performance indicators(KPI) for hospital and there
was not a need to develop a TASH specific quality monitoring system. The KPI indicators were deemed
highly appropriate and the system allowed for adding indicators as needed. Rather, it was determined that
a concerted effort would be made to reinforce these indicators and make the KPI system more effective
and relevant by linking QI projects to KPI indicators where possible. As both programs mature this well
be more and more feasible.

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RESULT
Over the years Since quality improvement initiatives started in Tikur Anbessa Hospital EM
different achievements have been registered. The main developments were training with
capacity building, sensitization and feedback workshops and QI implementation.

1.Capacity Development :The QI training was delivered to 16 EM fellows through a 12-hour program
Upon return to Ethiopia fellows received follow up support from the training team to implement their
projects. Over time the nature of the collaboration shifted from training, to advisory support on program
development, to joint scholarship. Currently , the Ethiopia team has the capacity to deliver the QI
training course, which has been reviewed for alignment with Ministry of Health guidance on QI training
and has been modified to include case examples from Ethiopia.

2. Sensitization and feedback workshops: The ED staff held its own QI training sessions for
sensitization and delivery of feed back at different times for 200 professionals.
3. QI scaling up trainings:

In addition about 110 staff and leaders from Tikur Anbessa Hospital and college of Health
sciences had got basic training in QI in February 2011 and May 2013. Besides 86 MSC
students in EM and critical Masters and 25 EM residents have got similar training in QI and
they have been engaged in ED QI projects at different levels.
4. QI implementation results : both in adult and pediatric sections of the emergency
department there are 16 QI projects among them few are completed in the planned project
time while the rest are under implementation.

5. QI Organizational structural for culture development and sustainability:

The importance of having an internal structure to ensure ongoing planning, implementation, and
sustainability of QI activities was emphasized from the outset and currently the department operating with
standing QI comittee..
In the past four years Since QI initiatives started in TASH EM department different
achievements have been registered. The main developments were capacity building with QI
training of EM fellows, EM residents and EM and critical care nurses.QI Training was also
conducted to Tikur Anbessa Hospital and college of health sciences leadership. In addition,
various QI projects have been designed and started ,while some are finalized and the rest are on
implementation phase. sensitization and feedback workshops and QI implementation.

Conclusion:
The QI experience in the department suggests that a QI program can effectively support, complement, and
enhance health system strengthening partnerships, and that establishment of a QI program at the

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department level is feasible and beneficial, enhancing the adoption and sustainability of health care
improvements such as marked improvements in triage, improved infection control and other critical
improvements. Therefore, program leaders have determined that scale-up to a hospital-wide QI program
is needed to fully realize the potential for increased quality, efficiency and system strengthening.

challenges
While these successes are heartening and promising, it was also important to review projects that were not
successful, or that lagged behind schedule, both to provide needed stimulus and support, and to determine
if changes in the approach are needed. Among projects that did not succeed, the most common problem
was that the indicators were not appropriate or well-defined, or that the monitoring plans were vague. The
team realized that this is an area where supervision and support from a highly skilled leader (perhaps the
QI leader for the department) is needed so that there is precision and clarity in the original designed.
Based on this finding, the ED leadership worked with teams to redesign failing QI projects, ensuring that
topics, strategies and indicators were clear.
Conclusions
Quality improvement precepts and tools can play an important and synergizing role in health systems
strengthening partnerships. The experience of the emergency medicine partnership between AAU and
UW demonstrates that establishment of ongoing QI programs is feasible and beneficial in low-resource
settings, and that specific measurable improvements can be achieved and maintained. This experience
suggestions that implementation of a QI strategy that is well-aligned with national initiatives can improve
emergency care in low-resource settings, and has promising potential for scale-up both within Ethiopia
and throughout Africa.

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Improving Infection Prevention Practices at Tikur Anbessa Specialized Hospital’s Emergency
Department

Aklilu Azazh, MD

Objective: To improve infection prevention standard compliance from baseline 33% to 70% within 6
months period at Tikur Anbessa Specialized hospital’s emergency department.

Methods:The hospital’s infection prevention checklist (IPC) that uses a score system to measure hand
hygiene set up, ED environment setup, waste disposal systems, sharps care systems, equipment
decontamination and linen care, was used for measuring improvements quantitatively.

A root cause analysis was performed using a fish bone diagram to identify the multiple issues for poor
infection prevention. Hospital infection prevention team did the surveillance and the technique is
observation of the setup using the checklist. All the points from the checklist are weighed in line with
federal ministry of health reporting standard. Specific strategies implemented to improve this low
compliance rate of infection prevention practices included:

Stakeholder Meetings and Awareness Creation: Stakeholders were recruited to communicate and
discuss the low compliance rate of infection prevention practices in the ED. These included the hospital
infection prevention committee, hospital leadership, emergency department nurses and physicians, the
hospital quality assurance staff, hospital finance and property department, custodians and guards who
regulate crowding around the ED waiting area. Possible solutions and root causes of non-compliance
were discussed.

Training and Supervision: All department staff comprising 33 nurses,8 guards,7 cleaners and one
infection prevention assistant were trained in infection prevention principles and practice. The training
consisted of theoretical discussion and demonstration on universal precaution, methods for proper
cleaning of hazardous body fluid, disposal of medical waste and sharps, sterilization of equipment, and
post exposure prophylaxis. The hospital’s infection prevention policy was also introduced and the
standards in the checklist were explained.

Leadership and Commitment: The head nurse in the ED is appointed as responsible body for infection
prevention in the ED. Motivated custodians were also assigned to undertake leadership on double-
checking some crucial activities such as decontamination of equipment, sharps safety box allocation, and
distribution of hand antiseptics to healthcare workers. The lead custodian and the rest of the team were
committed to conducting daily morning surveillance of ED environment and take the necessary action for
improved safe environment.

Resource Utilization and Environment Change: Materials such as hand washing sinks, additional
windows for ventilation, liquid soaps and antiseptic hand rubs, and waste management needs separating
biologic and non-biologic waste were secured for the ED through stakeholder collaborations.

Periodic Surveillance of the ED: Periodic surveillance was conducted by the hospital infection
prevention team and feedback was given to ED staff and head–nurse for follow up.

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Results: After QI implementation started in August 2010, IPP compliance rate increased significantly.
Results from several different IPP surveillance results can be seen on Figure 1. Due to this QI project,
system to measure hand hygiene set up, ED environment setup, waste disposal systems, sharps care
systems, equipment decontamination and linen care increased. This assigning of ED workers as
individual leads in different teams created accountability and responsibility to improve IPP compliance
results.

Fig 1: the standard waste segregation on the right and the practice on the left side (Pictures taken to
show the gaps to show to the staff)

Figure 2 Overall Infection Prevention Quality Improvement

Conclusion:

Results from this project brought the much-needed attention to the hospital’s ED where infection
prevention materials and resources are limited and crowding is apparent. The project has achieved its
goals and created an improved environment for patients and providers. This small checklist step has
created a big change.

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Improving Adherence to Hand Hygiene Practice at Tikur Anbessa Specialized Hospital’s Pediatric
Emergency Unit

Muluwork Tefera , MD

Introduction: Hand hygiene is a fundamental measure for the control of nosocomial infection. However,
sustained compliance with hand hygiene in health care workers is poor.

Objective: To assess the knowledge and develop successful implementation of hand hygiene
improvement programs in Pediatrics Emergency Unit.

Methods: The structured questioner was prepared to assess the knowledge and practice of hand hygiene
in pediatrics emergency unit. The questioners were filled by health worker who were working in the unit.
According to the response which was given by health workers the following problems were identified:
The hand hygiene in pediatrics emergency unit were poor due to lack of knowledge and availability of
water .Depending on the identified problems training was given to all health worker , the water less
alcohol base hand rub was put in every corner . The training consisted of theoretical discussion and
demonstration on proper hand hygiene and different ways of proper hand hygiene and special emphasis
was given on easy available waterless alcohol base hand rub.

Result: After QI implementation started in 2012 the hand hygiene knowledge, attitude and adherence has
increased. The same number of pre assessment participant was filled the questioners and what was
observed among 31 participant half of them the age range 25 to 30 years .25/31 has worked in health unit
from 0 to 5 years. 20/31 of the participant has respond they are using hand rub before and after evaluating
the patient. The importance of drier of the hand after washing was appreciated by 26/31 participants.

Comparative improvement what was observed 9/31 know the importance of hand rub in earlier
observation but now it became 27/31 .The importance of drying the hand after washing knows 5/31 but
now 26/31.

Challenge: The QI project was implemented by support of AIHA which was external supporter after 2
years of support the project was takeover by the hospital then after the problem identified to implement
the project the supply was not adequate .The turnover of nurses affect also the knowledge and attitude .
Lack of water in the pediatric emergency unit is the big challenge.

Way forward: Discussing with the hospital administration make avail water less hand rub in acceptable
amount , the frequent turnover of nurses has to be decrease and frequent training on proper hand hygiene
to health worker in emergency unit has to be given .

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Conclusion This project has achieved its goals by increasing the knowledge, improve the attitude of
health worker toward the hand hygiene with this decreased the rate of infection in pediatrics emergency
unit. The hospital has to give attention to remain the quality of hand hygiene.

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Improving crowding of Emergency Department by reducing patients’ length of stay(LOS) at Tikur
Anbessa Specialized Hospital’s Emergency Department among patients kept for treatment and
observation.

Aklilu Azazh, MD

Introduction

During the past decade, efforts to develop emergency medicine capacity and programs have been
underway at Tikur Anbessa Specialized Hospital(TASH) and the Addis Ababa University (AAU)
Medical School and at other sites in Ethiopia. Toward this end the Emergency Rooms (ERs) at TASH
were converted into Emergency Departments, located at what was previously a surgery out-patient
department site, a prefab structure was added to the physical plant to house the program. In addition to
these organizational and structural changes, academic programs were launched, including an EM
Residency and a Masters in EM and Critical Care Nursing. These changes led to a large increase in the
volume of critical patients seeking care in the ED. After Emergency service started in organized form it
appears overcrowding and prolonged length of stay is a problem.Studies conducted previously have
showed Increased LOS at EDs may contribute to systematic problems in the delivery of efficient and high
quality medical care. If there is Increased LOS patients wait longer to see ED physicians and to obtain
critical treatments and test results . The moral problems posed by ED boarding and resultant crowding
have a variety of undesirable consequences such as increased patient waiting times, decreased ability to
protect patient privacy and confidentiality, impaired evaluation and treatment, and difficulties in
delivering person-centered care .

Overcrowded emergency departments (EDs), prolonged waiting times, patient care delays and scarce
resources are common themes in emergency medicine departiment. Patient length of stay (LOS) is a key
measure of ED throughput and is a marker of overcrowding. In TASH QI project was designed in May
2011 to identify the existing situation of LOS in the department, identiy the causes and design an
intervetion activity.

Objective: Improve Adult ED crowding through reduction of length of stay in the treatment and
observation and resuscitation area from baseline 3.8 days to 2.0 within 6 months.

Methods:

A check list was developed in the department to follow length of stay for patients in the ED at observation/
treatment area and resuscitation.

It included patients demographics, diagnoses, category (which unit or department will be responsible in
the continuum of care) and length of stay in terms of hours or days. A root cause analysis was performed
using a fish bone diagram to identify the multiple issues for lengthy stay in the department. Subsequently
data collectors were hired and recorded the length of stay at baseline month and ongoing base. The data
is collected in crossectional base once with in 24 hrs ,every morning from 6-7 AM. From the data 24
hour LOS, length of stay for different categories, total number of patients in the department at the survey

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time and the range of stays in the department was analyzed.

Stakeholder Meetings and Awareness Creation: The stakeholders were recruited to communicate and
discuss the abnormally lengthy stay in the ED. These included the ED faculty, representatives from
clinical departiment,the ED nurses, graduate program physicians(residents) practicing in the ED,the
hospital leadership and the nurses data clarcs .In addition in significantly long patients stay in the ED
departments heads and chief residents were periodically communicated on individual patients decision.

Training and Supervision:

The nurse data Clarks were trained to use the format and after pilot tests were done implimentation was
started.The department secretary was also trained to record the data daily on excel sheet fro analyses.
Feedback was being given to these workers whenever there is incomplite information and follwup made
until quality data was collected.

Leadership commitment and periodic surveillance:

The lead owner of the project and the rest of the team were committed to follow daily morning
surveillance of the LOS ,analyze the results and act accordingly.

The interventions to reduce ED LOS:

After results are obtained it became a signal to detect isolated cases who satyed long and the avaerage
length of stay.The cases for specific individuals is analyzed and decisions made. The department has
recognized the reasons for abnormal LOS were shortage of inpatient beds, patients waiting in the ED to
compete investigations, social problems ,shortage or absence of resources like orthopedic or spine
implants and Operation Room(OR) dysfunctional for long time on intermittent base ,etc. When resources
were absent in the hospital side like the OR patients were obliges to stay oin the ED.After the causes
were identified for each patient active communication was done with other clinical departments and either
discharge or admission was decided on many patients.

Results: After QI implementation started in June 2011 the LOS started to decline and the results can be
seen on table 1 and Figure 1. In addition to the total LOS there was also improvement in specific
categories and the total number of patients staying in the Emergency floor.

Table 1: Length of stay records in May 2011(the baseline) and June 2011 after QI project implementation
was started

Variable May(Baseline) June(month 01)

Average length of stay 3.8 days 1.66days

Range 1day-25 days 1-5days

LOS among medical patients 3.7 days 1.5days

NOS among Surgery/trauma 6days 1.87days

Range of stay among medical 1-12days 1-4days

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 Range of stay among Surgery /trauma 1-25daysg 1-5days

%of PTs staying >48hrs 16/31(51.6%) 4/16( 25%)

<48hrs(%)-Med.patients 7/18 (38.8%) 2/12(16.6)

<48hrs(%)-surgery/trauma 6/13(46.1 %) 2/8(25 %)

Figure 1 Length of stay records from May-December 2011

Subsequent Activities and sustainability plans:

1. There is continuous monitoring of length of stay in the ED.

2. Abnormally lengthy stays in the ED is being reported to respective deprtiment and the
hospital administration on several occasions inorder to reduce ED overcrowding and
improve the continuum of care. was reported to Federal Ministry of Health and our
hospital.
3. There is ongoing Internal discussion i in TASH to develop capacity and improve flow
through prompt evaluation and admitting critical patients.
4. furthermore this data is also shared to Federal Ministry of Health (FMOH) leadership.
Based on these reports a concept note was written by our department to establish
emergency coordination team in Addis Ababa to coordinate Emergency care activity and
use resources evenly including ward beds in all public hospitals. The idea has been
accepted by the FMOH and Addis Ababa City Emergency coordination team has been
established which is working in facilitation of emergency patients among facilities and
sharing information on various resources .

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 5. The LOS periodic reports had shown that injury burden is a critical problem in the
country and is overburdening TASH. Hence it was decided by the FMOH to expand ICUs
and trauma centers in hospitals in Addis Ababa and the regions. In Addis Ababa in
ALERT hospital and saint Paul Hospital have expanded their emergency and trauma care
centers.
6. In the ED the staff nurses have replaced the data Clarks work and this documentation
has been the routine of the department.
7. Currently Scaling up of this documentation is planned and the format is distributed by
the medical director to all departments

Challenges

Emergency department has to work with all clinical departments and other hospitals and these have
made communication complex and difficult.Departiments and units heads are also changing and these
concept has to be explained to new people. Therefore commitment level is varies when change occurs.

Name of Organization: Tikur Anbessa Specialized Hospital (TASH) Emergency Departiment(ED)

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Improving the Emergency Training Center (EMTC) activities by increasing the number of trainees
by 50% within a one year period through active coordinating and managing the training calendar

Haimanot Geremew, RN,MSC.N

Back ground: Sudden death in Trauma, Medical Emergencies, Obstetrical and Gynecological
emergencies are becoming common and increasing in Ethiopia. This printable death and disability has
became a public health problem. Every year, approximately 5 million people worldwide die from injuries.
In 2002, road traffic-related injuries, self-inflicted injuries, interpersonal violence, burns and drowning
were among the 15 leading causes of death occurring among people aged between 5 years and 44
years.

The Government, FMOH, and various partners have showed interest to develop strategies to tackle this
growing problem. Addis Ababa University in collaboration with FMOH and AIHA/Twining Center
opened Emergency Training Center .AAU School of Medicine provide the space American International
Health Alliance (AIHA) Prepared a standard Emergency Training Center with full training materials.

Objectives: To train health professionals and first respondents to develop knowledge and skill who
are competent to provide an immediate life saving actions to those in need of urgent Emergency care
and to get AAU ETC accredited

Methods: As a strategy to attain the objectives, the first priority was to send abroad Doctors and
Nurses for Emergency training (BLS ACLS, PALS,ATLS ,for EMT basics) and a bench mark visiting of
different Emergency Training Centers in collaboration with AAU & AIHA.

Developing Training Manuals: Training Manuals of American Heart Association ( BLS, PALS,ACLS )
ATLS,ALSO,ALSID, Pri- Hospital Care in line with pre and post tests, Evaluation papers were developed
and converted in the contexts of Ethiopian culture. This manual was prepared integrated with Federal
Ministry of Health.

Advocacy works and advertizing: Advertizing the Emergency activities and type of Emergency Trainings
which are given for professionals and for the community through Ethiopian Television programs ,
Ethiopian Radio &Radio Fana, in different professional society and national conferences were done.
Posters , booklets and leaflets which emphasize about emergency training were distributed to
different stake holders .

Training and Evaluation: Based on Annual training calendar trainings on prepared Training modules for
professionals and non professionals were given .Before starting the training pre test and after
completion the coarse post test is administered. EMTS and pre hospital care activities were evaluated by
preparing simulations .refresher courses and practical sessions were prepared for those who showed
gaps.

Materials and training mannequins’: To keep the training Center up-to-date and competent ,CDs,
AED ,CPR mannequins ,Rhythm simulators, Defibrillators and sparpartes for spoiled mannequins’ were
secured for EMTC.

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Results:

Table 1: Total number of trainees per year per Module , Oct,2015,Addis Ababa,EMTC

Module 2010/1 2011/1 2012/1 2013/1 2014/1 TOTAL

1 2 3 4 5
BLS 240 475 585 210 113 1633
ACLS 25 83 198 34 72 442
PALS 25 32 164 80 343334 335
ETAT 65 60 44 91 71 331
Pre-Pals/ECGre-Ppals/ECG 46 56 80 72 55 309
ALS-ID/REDS 57 38 27 122
ATLS 25 32 164 91 26 338
QI 185 104 65 40 50 444
EMT (TOT) 26 - 27 44 - 97
Adult & Peds Emergency Nursing - - 70 74 53 197
EMT 24 90 309 25 - 448
PREHOSPITAL CARE 64 234 270 130 98 796
Clinical research and mentoring - 40 - 84 75 199
Also/blso 117 10 62 47 37 273
Adult Emergency for Medical   150 331 350 106 937
students
Peds Emergency fo Medical     150 165 80 395
students
Sedation     7 21 33 61
E/ALTRASOUND 20 24 12 58 60 106
BLSO(Orthopedics) - 15 11 26 - 26
Other first aid Emergency 298 270 114 682 281 936
trainings
Total 919 1703 2846 1683 1271 8425

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 Fig 1: Number of trainees by profession from 2010-2014, Addis Ababa, EMTC.

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 Table:2 Number of trainees by Module and training year,October,2013,Addis Ababa

Conclusion: Results were above planed this is due to strong advertizing works and strong
leadership. Even if the training Center is still busy on giving different trainings should work hard
to be accredited to sustain the business plan.

Challenges:

 Getting accreditations and business administration

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Improving the availability and accessibility of emergency drugs and
equipment in the ER.
LemlemBeza (RN, EMCCN)

The ability to react immediately to the emergency at hand, including telephoning for help and having the
equipment and drugs needed to respond to an emergency, can mean the difference between successful
management and failure.

Objective-to improve the availability and accessibility of drugs and resuscitation equipment from
baseline 45% to 90 % within six month period at TikurAnbessa Specialized hospital’s emergency
department.

Methods -Before this project was implemented base line assessments had been done and the root cause
of the problem was analyzed using fish bone diagram to identify different factors for reduced availability
and accessibility of drugs and resuscitation equipment’s in the ED. Strategies recommended to improve
the shortages were collaborate with the different stakeholder (hospital leadership and pharmacy
directorate) to increase the supply of emergency drugs and equipment’s ; prepare standard lists of
emergency drugs and equipment’s;offer ongoing training for staff nurses on proper utilization ; storage
and restock of emergency drugs and equipment; system for notification of newly arrived or finished
emergency drugs and equipment; preparing consumption rate of emergency drugs and equipment to make
the availability sustainable; Preparing basic needs of emergency drugs and equipment of each station ;
Preparing a check list that help to assess the presences of the drugs/ equipment as per the
standard;Establish committee that work on sustainable supply, availability and accessibility of emergency
drugs, equipment and supplies in collaboration with responsible stakeholders .

Results

After the initiation of this improvement project three years back in 2012 significant improvement on
availability and accessibility of emergency drugs and resuscitation equipment were observed. The result
measured from monitoring and evaluation on improvement presented below on sample items.Fig.1 and 2

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 Challenges

 Purchase- process of the drugs and equipment in the hospital is taking too long and makes
sustainable supply of items in the ED difficult . The Budget also appears limited to
purchase relevant supplies.
 Quality – emergency equipment usually have poor quality so that it will be out of use easily
and that make the demand very high.
 Adaptation- since staff turnover and number of health professional working in the ER is too
frequent it became challenge to execute the quality improvement strategies and sustain it.
 Infrastructure- the setup and space in the ER is inconvenient to store and use emergency
drugs and equipment’s properly.
 Leadership- there is a limited support from hospital leadership

Way forward

The way forward to strength the strategies established improving the availability and
accessibility of emergency drugs and equipment to acceptable level.

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Improving patient satisfaction at Tikur Anbessa Specialized Hospital’s Emergency
Department

Haimanot Geremew,MSC.N, Dr Aklilu Azazh, Associate professor

Back ground: Tikur Anbassa specialized Hospital is the central public hospital in Ethiopia. Emergency
department is the get where every referred and un referred patients are triaged and multiple
investigative and emergency treatment services before transferring to various disciplines of medicine.
Despite shortage of emergency bed, and space constraints , it renders quality services to meet public
demand.
To accomplish such a holistic purpose ,Emergency department patient satisfaction Quality Improvement
team ,identified the root causes of the adult Emergency poor quality health care, were; Poor team
work sprit, luck adequate manpower, training and trained instructor, Overcrowding, lack of medical
equipments, drugs and items and Poor referral policy that need urgent intervention.

Objective:To improve patient satisfaction system quality from base line 50% to75% within 6 months
period at Tikur Anbassa Hospital’s Adult Emergency Department by developing strong team work &
good communication among all Er staffs and administer patient satisfaction survey every 3 months and
monitor and evaluate patient care activities based on results .

Methodology:

Team meeting and awareness creation: After a Quality improvement training was given to All
emergency, Residents, Nurses, security, cleaners, porters and then after the team was divided
into a small groups. to discuss on possible problems of poor quality patient care and identify
solutions to improve the problems.

Training and supervision: Training on Emergency Triaging,

team resuscitation and team building, Recording and documenting,
keeping patient findings, Emergency Equipments ,drug &
Patient hand over during shifting for all emergency reside3nts,
Nurses and other professionals were given.
Resource utilization and environment change : Equipments and materials like bed mattress
were covered with easily washable plastics, straitchairs,cap boards, Oxygen flow metres, patient
scream, EKG machine with papers, Blood Pressure apparatus, Lockers etc were bought with
partners collaboration
Administration of instruments and Evaluation Methods: All Emergency patents from
Medical, Surgical and orthopedics (stretcher) who stayed more than 24 hours were asked to fill
the Amharic Questionnaires which was developed by the ministry of health and was administered for 35
patients as a base line prior to the administration of the questioner. The questioner was administered
every 3 months. In addition to demographic information, the questioner covered Nurse Communication,
Physicians communication, patient safety & infection prevention, patient assessment of personal privacy
during health facility stay, patient assessment of pain control ,patient assessment of medication

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communication and over all scoring of the ER/TASH. Each item was score using two item (yes & no) and
four point- likert scale: Strongly disagree, disagree, strongly agree, and agree. Submission of score was
carried out for each individual to get the total very satisfaction and satisfaction and very dissatisfaction
and dissatisfaction. Oral informed consent was signed by all respondents.

Results

nursing rounds

Tab 1: Patient satisfaction rate before and after QI project

before After
Nursing communication skill 70.36% 76.36%
Doctors communication skill 51.69% 78.86%
Physical environment safety 49.66% 53.60%
Pain management rating 60.90% 71.65%
Medication communication 25% 51%
patient rating of facility 25% 63%
Total 47.10% 65.73%

Fig. 1 Patient satisfaction rate before base line and after base line of QI project AAU TASH Emergency

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Fig 2: patient satsfaction graph line before and after QI Project AAU, TASH/Emergency, Oct,2015

Challenges: Patient satisfaction is a cumulative challenge of all QI Project activities

Conclusion; Overall results showed an improvement in patient satisfaction rate .This was due to
continues by monthly introduction of the quality improvement activities to newly assigned nurses
,residents and other professionals, daily nursing rounds and monitoring and evaluations based on
Emergency protocols and by quarterly administering questioners and by presenting & discussing on
gaps.

Way forward

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The way forward to strength the strategies established improving the quality of health care and
by quarterly data collection and analyzing results we will fill gaps to improve through continues
monitoring and evaluation

Improving Triage Practices at Tikur Anbessa Specialized Hospital’s Emergency

Department

Asefu W/Tsadik,MD, Anesthesiologist

Objective:

To improve the triage service coverage from baseline 10-20% to 75% and quality of triage
format use from less than 50% to 75% within 6-12months, at Tikur Anbessa Specialized
Hospital’s Emergency Department

Methods: The goal of this QI was to evaluate a newly implemented emergency department
triage system in Tikur Anbessa Specialized Hospital of Addis Ababa, Ethiopia through a record
review of triage forms and check lists. A root cause analysis was performed using a fish bone
diagram to identify the multiple issues for poor triage system. For the evaluation of the number
of patients assessed or triaged using triage format verses those patients not having the triage
format in their chart three phase evaluation using checklist was done. For the evaluation of the
completeness of the triage format triage forms were collected from the record room pre and post
QI implementation period. Random samples of 592 triage forms were obtained, 296 pre and 296
post triage QI project implementation. The randomization was administered by nursing students
who were not aware of the evaluation project. They were instructed to pick every 5 th triage form
from a year ago, before the QI project started. Another group of nursing students were instructed
to collect every 5th triage forms post QI project implementation. Neither group of nursing
students was aware of the evaluation process or what the reviewer was looking for in the forms.
After the selection of triage forms, excel was used to record and list out the 22 contents of each

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triage form.

Stakeholder Meetings and Awareness Creation: having the chart review results and analysis
of the root causes of the low compliance on the use of triage form and completeness of the triage
forms two days workshop was organized. Participants were: emergency nurses, hospital quality
office members and people from the leadership. On the first day of the workshop training on
triaging of emergency patients and its importance was given. On the second day of the workshop
group work on the triage format evaluation done and format was revised according the workshop
participants recommendations.

QI implementation and supervision: the Principal Investigator was responsible for monitoring
and evaluation of the QI process. Pre prepared check list format was used to evaluate the number
of patients assessed or triaged using triage format verses those patients not having the triage
format in their chart. Feedback of the accomplishment was given to the nurses and discussion
was made on the gaps identified.

Results: Results showed that the proportion of patients assessed using triage format increased
from less than 20% to 96% and quality of triage format completeness improved from less than
50% to more than 75%.

Conclusion: Simple quality improvement tools, such as plan-study-act-do cycle, can be used to
implement projects that yield greater improvements in low-income hospital settings such as that
of TASH. This triage improvement project is a testament to the value of attainable small-scale
improvement projects and its impact in changing the culture with the “we can do it” attitude.
Quality improvement projects are possible in developing countries without spending much to
implement them.

Appendix 1
QI Project Charter
The Aim Statement: What do you want to change?
Team/leader:Who should be involved?
Cause and Effect Analysis
 What are the root causes?:Fishbone diagram-
optional
The Process
 What is really happening now?:Flow Chart-
optional
Indicators
 How will you measure change?

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Action for improvement
 What is the plan for change?
Expected Outcomes
 What is the new process and what changes will
occur?
Timeline: What will happen and when?
Sustainability Plan:Who will sustain the change and
how?

Appendix 2: a charter for reducing crowding through improving length of Stay

in the ED –the implementation is filled for reporting

The Team/leader Dr. Aklilu Azazh (M.D.)

 Who should be
involved?
Cause and Effect Analysis -Shortage of beds

 What are the root -Poor communication with departments and other hospitals
causes? (Describe
-Delayed and incomplete bed reporting system
causes in the
process, -Poor internal facility like the Intensive care Unit( ICU), wards, etc
materials, human
power, clients, -Delayed decisions for inpatient admission
environment and
-Delays of investigation
leadership)
 [Fishbone -Lack of ED protocol of admission and discharge
diagram-optional]
+ -Social problem

The Process Average length of stay (Total) = 3.8 days and after a month of implementation

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  What is really Variable May 2012 (baseline) June 2012 (01month)
happening now?
Average length of stay 3.8 days 1.66days
[Flow Chart-
optional] Range 1day-25 days 1-5days

LOS of Medical patients 3.7 days 1.5days

LOS for Surgery/trauma 6days 1.87days

Range for Medical patinets 1-12days 1-4days

Range for Surgery /trauma 1-25daysg 1-5days

%of patients staying< 48hrs 48%(15/31) 80%(16/20)

%o Medical staying <48hrs 11/18(61%) 83%(10/12)

%o surgery/traum <48hrs 5/13(38%) 75%(6/8)

Indicators  Percentage improvement in daily average length of stay,

 %improvement in LOS in medicine, surgery,orthopedics and neurosurgery patients
 How will you  %improvement of patients staying over 48hours
measure change?  Number of patients staying less than 24 hours
Action for improvement  Obtaining frequent inpatient bed information
 Create smooth communication between ED and ward teams
 What is the plan  Schedule inpatient team visit to the ED and facilitate decision making
for change?  Closely working with liaison officers to facilitate disposition of patients
 How will you  Periodic monitoring/evaluation and feedback.
implement it?
Expected Outcomes Overcrowding will be reduced; length of stay will be reduced.

 What is the new

process?
 What changes will
occur?
Timeline June 2012: Baseline assessment

 What will happen July – December 2012: Implementation

and when?

Sustainability Plan Development of protocols and procedures for the ED will sustain the project.

 Who will sustain

the change and

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 how?

ACTIVITIES OF EMERGENCY DEPARTMENT QUALITY IMPROVEMENT

(QI) PROJECT

28
Ababa University, College of Health Sciences, School of Medicine.

October,2015

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