The Gambia – Swansea Vision 2020 Eye Link

A team of 8 professionals from Swansea visited The Gambia from the 11th to 18th November. The team consists of David Laws, Consultant Ophthalmologist, Stella Elliott, Link Co-ordinator, Suzanne Martin, Orthoptist, Susan Williams, Theatre Sister, Jatinder Singh, Pharmacist, Constantin Magurean, Medical Engineer, Martin Wasik, Ophthalmologist and Elinor Laws.

Here is Jatinder’s report:

2011 ‘Swansea-Gambia Vision 2020 link’ Pharmacist Report 

Visit to Sheikh Zayed Regional Eye Care Centre (SZRECC), Serrekunda, The Gambia, November 11^th-18^th 2011

 

 

Objectives of Visit

 

• Develop a production management system in order to meet eye drop demand of the hospital. It was observed on previous visits that stock for certain forms of pharmaceutical powders were available in the hospital, however there was inadequate production management which meant demand for eye drops was not being met. Also provide worksheets for eye drop manufacture of other essential eye drops in order to further develop the role of the Local Production of Eye Drop (LPED) lab.

 

• Promote effective use of eye drops through introduction/improvement of patient counselling. Safe, effective use of any drug is important and a patient needs to be informed in order to achieve this. I will aim to assess current practice and improve where necessary.

 

• Understand the supply chain and the challenges the hospital faces to meet demand for medication. One of the main contributions a pharmacy can have to patient care is through its core service, a timely, high quality and safe supply of medication. There are many factors that need to come together to achieve this and it would be prudent to understand the systems in SZRECC and The Gambian Health Service. It would be useful to identify the issues around maintaining/achieving this service and consider possible solutions.

 

• Present on the subject area of sterile manufacture of eye drops. I will be presenting to a lecture room of refractionist students and healthcare professionals. This subject area has been chosen as it is one of the main functions of SZRECC pharmacy.

 

 

Observations During Visit

 

My time at the hospital was spent in the pharmacy dispensary with Marie Mendy (Nurse Attendant who dispenses the prescriptions) and in the triage room with Eliman Samba (LPED Technician). I visited the chief pharmacist at the Royal Victoria Teaching Hospital (RVTH) and at Central Stores and I also viewed the anaesthetising of a patient prior to cataract surgery.

Picture 1: Production Unit at SZRECC. Pictured left to right: Eliman Samba (LPED Technician), Marie Mendy (Nurse Attendant), Jatinder Parmar (Clinical Pharmacist)

Eye Drop Production and Ordering

Currently, production in the LPED lab is on hold due to unavailability of plastic pipettes for the eye drop bottles and difficulty in getting hold of raw ingredients. The lab contains pharmaceutical powders (such as sodium cromoglycate, chloramphenicol and benzalkonium chloride) which have been wasted as they have all expired. Eliman is also lacking equipment such as a water bath for sterilisation and a filtration device.

 

The main stock of drug is held by Kato (matron) and the dispensary obtains stock as required. The eye drops available for patients in the dispensary were timolol, Betnesol-N and chloramphenicol. The current stock of eye drops had been obtained by Kato as a donation from a charity (?who). The hospital was struggling to buy stock itself.

 

The hospital is required to submit a yearly order of medication to Central Stores, who then look to bulk buy the medication in order to get the best price. Central stores do this for the entire Gambian Health Service. The amount of medication ordered for SZRECC is not solely determined by their order but by their drug budget as well. If the hospital requires stock of eye drops that cannot be filled by Central stores they are to obtain further supplies themselves, through ‘supplementary ordering’. The main suppliers the hospital deals with is ‘AutoLab’ inIndiaand ‘Unimed’ in theUK. They also obtain stock throughEgypt, but the current crisis has currently stopped this route. The cost of eye drops from their suppliers is “high”. One option the hospital uses is ordering through the charity Sight Savers, as they charge a fraction of the price. However orders through Sight Savers can take a while and usually the hospital is depleted of drops during this time.

 

Pharmacy

Every Monday Eliman stocks the clinical areas in the clinic with the required eye drops for examination (i.e. dilating drops). Eliman obtains the stock to do this from the person in charge of the clinic. Eliman spends most of his time in the triage room, he carries out the tonometry, measures blood pressure and dilates patient’s eyes as requested. Eliman also examines minor eye conditions himself and also prescribes medication for patients.

 

Picture 2:SZRECC Pharmacy Dispensary

The pharmacy dispensary is a small room with a hatch that patients approach to present a prescription. Medication is then supplied accordingly and each item is ticked to show it has been dispensed. A record book is filled in to document what eye drop is handed out. The particulars recorded in the book are patient name, prescriber name and drug dispensed. If an item is out of stock the letters NA (not available) is endorsed on the prescription and the patient is expected to purchase this from a community pharmacy. Medication is labelled using a pen and the directions simply consist of lines representing the frequency of use of the drops (e.g. four lines for four times a day). The nurse attendant is aware she should counsel patients regarding their eye drops, but patient counselling was not occurring. Patients in The Gambia are in need of counselling, I have been shown photographs of patient eye drop bottles containing sand on the dropper, also the packs being handed out are in a foreign language and the labelling provides little info.

 

The main eye drops being prescribed while I was in the dispensary were chloramphenicol, Betnesol-N, sodium cromoglycate and timolol. To some extent the prescribing was being influenced by the stock the hospital was holding. The doctor had informed me that he is seeing patients who have eye infections that are resistant to chloramphenicol, gentamicin and sensitive to ciprofloxacin, which is unavailable in the hospital. The unavailability of sodium cromoglycate presents a problem for the many patients with vernal keratoconjuctivitis (VKC). For patients, the supply problem is further compounded by community pharmacies that increase the price of their drops when they are aware the hospital is out of stock of an eye drop, sodium cromoglycate can cost as much as 300 dalasis (£6.60), whereas in theUKit will cost £2.15 on a private prescription. The hospital has even seen cases where the pharmacy has sold patients the wrong eye drops, as they have not got stock of the prescribed item, and this has resulted in the loss of an eye. The need for a fully stocked pharmacy in SZRECC is clearly high.

 

 

 

 

 

 

 

 

Theatre visit

Picture 3: Lidocaine vial in Use at SZRECC

I attended theatre and I observed a patient receive anaesthesia via a retro-bulbar injection prior to cataract surgery. The lidocaine vial being used was on a trolley and had a needle through the rubber bung, this is bad practice as it allows air entry into the vial as well as potential pathogens. The nurse administered the injection and we waited for the anaesthesia to take effect. After about 15 minutes we realised that the anaesthetic was not going to work. The nurse should have given a cocktail of lidocaine, adrenaline and hyaluronidase. The nurse had assumed that somebody had ready mixed the preparation in the lidocaine vial, which had no additional labelling (I believe the needle protruding out of the vial indicated somebody had mixed something into it). The nurse suspected nobody had added the hyaluronidase, so the nurse used the needle that was present in the lidocaine vial to draw up the hyaluronidase and add it to the lidocaine vial. I was hoping to observe the surgery, but I had to leave in order to go to the RVTH and Central Stores. While I was in theatre I noticed their drug/stock cupboard has a stock list (a result from Sue’s efforts) to ensure it is stocked. Also we noted a vial of fluorouracil (a cytotoxic drug) which had been re-taped back together in order to reuse it.

 

 

Changes Implemented

The staff in SZRECC are keen and enthusiastic about improving their hospital. I was able to get the nurse attendant, in the dispensary, counselling all patients she dispensed eye drops to. Nurse attendants rotate around the hospital, so eventually a different person will be handing out medication. It is important that each person dispensing eye drops is trained to counsel patients. In order to ensure this occurs, myself and Eliman created a poster for pharmacy stating what information each patient should be told. The poster was placed in pharmacy and it received a positive reception from the staff. The nurse attendant mentioned she had not been counselling on everything the poster stated, so she changed her practice accordingly. Eliman does not rotate from pharmacy and he will train new members of staff to the dispensary on how to counsel patients.

 

As SZRECC has to send a yearly order for stock to Central Stores it is important this report is accurate. The only reports going back to Kato from the dispensary is the record book of items handed out. Unfortunately this does not give a complete picture of the eye drops required by SZRECC pharmacy, as it does not contain a list of things not dispensed. Therefore an extra column has been added to the record book for the drugs not dispensed. This will help management identify eye drops they should concentrate their ordering efforts on and aid in the production of an accurate order each year. With the intent of promoting regular communication with SZRECC pharmacy and the Link, Eliman will fill in a monthly report for me which I will receive over the phone.

 

The management of pharmacy and medicines is currently carried out by individuals with nursing and optometry backgrounds. My teaching session concentrated on the production of eye drops and a summary of how Singleton Hospital Pharmacy operates. This was extremely useful in order to raise awareness of the functioning of the pharmacy as well as the specialist nature of the department. The presentation raised an interesting comment from Mr Sillah (Director of Eye care Program, Gambian Ministry), who stated that The Gambia is looking to setup a centralised pharmaceutical production unit that will manufacture pharmaceuticals for West Africa and reduce the need for import.

 

I was unable to observe production practice at SZRECC. This is unfortunate, as this is a viable option for easing the eye drop shortage in SZRECC and would provide good value for money. I was able to provide Eliman a WHO document containing formulations that are designed to be used in a resource limited environment such as those found at SZRECC. This will expand the range of formulations that can be produced at SZRECC and it also made Eliman smile.

Picture 4: Eliman Samba

Future Work

• Medicines management (i.e. storage, ordering, maintaining of adequate stock levels, supply to clinical areas and patients) systems within SZRECC are in urgent need of development. As the drug usage of SZRECC increases so does the need for effective medicines management systems. I believe the employment of a dedicated pharmacy technician to take on medicines management at SZRECC is necessary. Obtaining stock of eye drops in The Gambia is a difficult task and a person focused on medicines management might be able to find solutions to the ordering challenges (e.g. negotiate the best price, take advantage of charitable donations etc). It would be useful to centralise medicines management within the pharmacy, but with the current staffing levels and skill mix this is not possible. If SZRECC cannot employ a pharmacy technician they could train Eliman. In order for us to improve medicines management within SZRECC our future visits should not just concentrate on pharmacy as most of the core medicines management issues are not controlled by pharmacy.

 

• SZRECC have begun to use cytotoxic medication and the practice witnessed is disturbing. It is important that staff at SZRECC are trained in the safe use and handling of cytotoxics.

 

• A wide range of healthcare providers are prescribing within SZRECC (LPED Technician, Cataract Surgeons, Doctors etc.). However not all prescribers have had training in prescribing. During my visit I only viewed one prescription for oral medication and this was an incorrect dose. We have donated BNFs to SZRECC, however I do not believe they will be used to their full potential. Therefore on our next visit a prescribing teaching session will be necessary.

 

• SZRECC order medication from around the globe. It may be of use for us to speak to our suppliers in the UK and discuss the possibility of supplying to The Gambia.

 

• The equipment (water bath and filtration machine) Eliman requires maybe easily sourced in the UK for a low price. Also it maybe possible to come up with low maintenance low cost alternatives, for instance an alternative to the filtration machine might be to use a filtration system that requires manual pumping.

 

Conclusion

In my week at SZRECC I was able to achieve most of my objectives. However one week was not enough time to introduce an organised medicines management system to improve supply of medication to patient’s and clinical areas within the hospital. I have learnt this objective is the ultimate goal for SZRECC pharmacy and it will require a stepwise approach to its achievement. I am pleased the dispensary is now recording the drugs they are not dispensing as well as those dispensed, as this is one of the early steps to achieve this aim. SZRECC is a great place and this is in the main down to the positive, enthusiastic behaviour of the staff. Their willingness to change will see them improve leaps and bounds in a relatively short space of time. Despite all the difficulties faced by the staff of SZRECC and the people of The Gambia they are still smiling and the phrase ‘hakuna matata’ sums up their attitude perfectly.