Clinical Services Plan TTM Samoa

SAMOA HEALTH SECTOR MANAGEMENT PROJECT CLINICAL SERVICES PLAN FOR TTM HOSPITAL
DEPARTMENT OF HEALTH March 2001
TABLE OF CONTENTS Page No.
1. 2. 3. 4. 5. 6. 7. 8. 9. 10
BACKGROUND ISSUES & ASSUMPTIONS PRINCIPLES HEALTH SERVICE PROFILE SAMOA DEMAND FOR HEALTH SERVICES TTM HOSPITAL SERVICE UTILISATION & FLOWS PROJECTED DEMAND FOR SERVICE SERVICE PLANNING ISSUES CORE CLINICAL SERVICES 10.1 10.2 10.3 10.4 10.5 10.6 10.7 10.8 Outpatients & Emergency Internal Medicine Surgery & Orthopaedics Obstetrics & Gynaecology Paediatrics Anaesthetics & Critical Care Dental Services Mental Health Services
1 1 3 4 5 9 13 15 17 18 18 22 26 29 34 37 39 42 45 45 48 50 53 55 57 59 61 63
11.
CLINICAL SUPPORT SERVICES 11.1 11.2 11.3 11.4 11.5 11.6 11.7 11.8 11.9 Laboratories Pharmacy Radiology Rehabilitation Nutrition & Dietetics Medical records CSSD Biomedical engineering Prosthetics & Orthotics
Services Plan for TTM 27/04/01
SUMMARY
SERVICE PROFILE TTM is currently a hospital of about 200 beds, providing a mix of general and specialist referral services. Core Clinical Services Emergency (includes retrieval) Internal Medicine Surgery (includes orthopaedics & specialist surgical services, theatres) Anaesthetics & Critical Care Obstetrics & Gynaecology (include neonatal services) Paediatrics Dental services Mental health
Clinical Support Services Laboratories, Radiology, Pharmacy, Rehabilitation Nutrition & Dietetics Medical Records, CSSD, Biomedical Engineering Prosthetics & Orthotics
General support services include administration, hotel services, maintenance, etc PROJECTED DEMAND It is estimated that existing bed numbers beds, efficiently used, will be adequate for the next 5 years. Indicative allocation is:
Clinical specialty Medical Surgical/orthopaedic O&G Neonatal Paediatrics HDU Mental Health Total
Bed equiv. 45 45-50* 40 10 35 6 6** 187 - 192
* **
includes 10 short stay or day surgery beds. includes 4 rehab beds
Main issues Increasing demand on TTM as more people move to Apia or travel from rural areas. Staffing shortages and inefficiencies of dispersed layout, particularly in maternity. All areas are affected by shortages in clinical and support staff. Imbalance between demand and supply of services especially at inpatient level, with pressure on medical, obstetric and paediatric beds. OPED has large numbers of primary medical care patients but is not well set up for emergencies. Deficiencies in clinical support services especially pathology, radiology & theatres affect service efficiency and quality. Biomedical engineering workshops also need upgrading. Deficiencies in general support services (eg maintenance, wardsmen, laundry) also have an impact on clinical staff. Basic infrastructure maintenance problems. Workshops and basic services such as power supply, gases, sewerage and waste disposal need upgrading. Water supply
Key elements of the service planning strategy: Reconfigure OPED to separate emergency from GOPD & special clinic functions, with better triaging of patients so that waiting times reflect clinical needs. Shift some outpatient services to other sites. Increase efficiency in use of inpatient beds so that hospital has average occupancy of at least 80% by means such as day surgery, early discharge planning, outpatient follow-up and more post-acute care by community nurses. Organise inpatient bed allocations to match patterns of demand. Use inpatient beds more flexibly eg surgical/orthopaedic; medical/surgical; antenatal/postnatal. Upgrade facilities strategically, to take account of service planning priorities. Strengthen rehabilitation programs at TTM to get patients back on their feet sooner and reduce complications and disability among patients discharged. Increase efficiency, flexibility and mobility of community nursing resources strengthen linkages with clinical services Develop integrated programs in health priority areas such as diabetes, reproductive health, hypertension and injury with outreach to district hospitals. Adequate staffing levels: this implies substantial increases. Improved management systems in key areas. IT infrastructure development Effective provision of general support services eg wardsmen, maintenance, laundry.
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TTM CLINICAL DEPARTMENTS SPECIFIC PROPOSALS General requirements Adequate staffing levels: this implies substantial increases. Improved management systems in key areas. IT infrastructure development Effective provision of general support services eg maintenance, laundry, cleaning Refurbishing beds, paint, floors, curtains etc widely needed. Family accommodation.
Outpatients & Emergency Space & location adequate current organisation problematic. Separate emergency , GOPD and special clinic functions with separate treatment areas for each Reconfigure traffic flow, with registration & triage desk first point of contact and patients being sent to relevant waiting area Within GOPD, an area for clinics doing dressings/injections/routine checks. Additional ECG machine for inpatients
Medicine Allow for increased activity 40-45 beds. Some medical/surgical beds suggested. Develop intermediate or step-down care service for selected long-stay patients Develop integrated multi-disciplinary programs for diabetes & hypertension, including regular outreach clinics to district hospitals/health centres Adequate provision for infectious disease patients (4 beds) & improved sterilising facilities Therapy/treatment area within ward. ECG may be done here. Endoscopy room within theatre area (with proper sterilising system)
Surgery 45-50 inpatient beds in 2 wards. * Shorten average stays - intermediate care protocols for selected long-stay patients Redevelop theatres as 3 room suite, one theatre associated with 8-10 place short stay/day surgery unit. Recovery area of 6-8 beds. Theatre management systems need upgrading.
Anaesthetics Introduction of anaesthetic technicians New anaesthetic machines
Obstetrics & Gynaecology Birthing area to be redeveloped as 6 birthing suites, 2 assessment/prep rooms, theatre and first stage lounge. Outpatient clinic area in new building for gynae & high risk clinics. Combined postnatal/antenatal ward - 40 beds Neonatal nursery upgraded as functioning 10-12 place facility, with gas, suction etc. with provision for acute, step down and infectious zones.
Paediatrics Increase bed allocation to 35 possible observation/short stay unit. Outreach clinics at MT2
* Includes ENT and Dental
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HDU No change necessary in facilities
Rehabilitation Outreach/community service with community nurses. Therapy area needs provision for OT.
Mental health Strengthen community nursing skills + provide access to consultancy advice Redevelop special care suite (secure) and rehabilitation unit at TTM Possible telepsychiatry link
Dental Training area may need upgrading in longer term. Replacement of dental units and X-ray equipment.
Laboratories Existing space is adequate for present functions but could be better used. Main issues relate to equipment maintenance and replacement. Needs review of current work practices and flows by experienced clinical pathologist.
Pharmacy Inventory control issues. Bulk store problematic crowded, needs reorganisation, airconditioning & should have loading dock access. Relocation to be considered.
Radiology Equipment issues special studies unit and image intensifier need immediate replacement and ultrasound will also need replacement within next few years.
Biomedical engineering Training and specialist support required Equipment issues tools and test facilities need replacement
Prosthetics & Orthotics Increase service Training and management support needed Lack of materials and equipment
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1. BACKGROUND The Government of Samoa is undertaking a three-component program of reform of health services and is developing strategies to achieve its goals together with the World Bank and other donors. The three components are: Institutional Strengthening Primary Health Care/Health Promotion Services Quality Improvement
The project is advanced in preparation, and it is expected that implementation will commence in the second half of 2000 and continue for five years. The earliest stage will include refurbishment and/or construction at TTM Hospital and the potential development of an Apia health center facility. Planning for these is being brought into the project preparation phase to accelerate implementation. The purpose of this service planning exercise was to determine hospital and health centre roles in urban Apia, to develop clinical service plans for the TTM Hospital and for a potential health centre in Apia, and contribute to the preparation of functional and design briefs for priority construction activities. This required an overview of health service delivery more broadly in order to determine the nature and scope of the role of TTM, its clinical service levels and its relationship with other health care providers. Separate discussion papers have been prepared on the broad health service strategy and on options for primary health care delivery in Apia. Planning for rural health services will be undertaken later in the project. 2. ISSUES AND ASSUMPTIONS 2.1 Policy Context The Health Sector Strategic Plan 1998-2003 provides the strategic directions, goals and planning objectives for this exercise. Briefly summarised, policy guidelines are: Continued emphasis on primary health care to promote health, prevent disease, support self-care and promote responsibility for health within the community Universal access to affordable health services, including health promotion, first level care, essential drugs, emergency care, a range of secondary level care and overseas treatment for specific conditions Provision of health services which are needs-based, affordable and sustainable Government as the main funding body, giving high priority given to health funding Charges for health care to reflect both costs and capacity to pay Community consultation in planning, implementation and evaluation of health services Provision for the development of health insurance Support for partnerships between government, non-government and private sector organisations in the provision of some services.
[Source: Health Sector Strategic Plan, 1998-2003]
2.2
Health financing and private sector role Changes in the role of the private sector have considerable potential influence on future patterns of demand and service response. However, at this stage, policy relating to the financing of health services (eg insurance, co-payments) and the role of the private sector is relatively undeveloped. In the absence of clear direction, this plan assumes no changes in public sector charging policies in short term but recognises that these may be necessary to support longer term service development. It is also assumed that, in the short term at least, the level of private health care will remain constant. At the same time, it is understood that options for contracting out of selected services (eg hotel, transport, clinical support) are to be pursued where appropriate and costefficient. It is assumed that this will not have major impact on the overall functioning of clinical health services, although it may yield some efficiencies.
2.3
Health Workforce Workforce issues predominate in any examination of current service delivery, with nursing workforce attrition being of particular concern. This exercise has concluded that workforce shortages may in fact be artificially suppressing demand for health care, resulting in significant unmet need and morbidity. The 1998 Workforce Plan identified problems with high turnover and attrition rates, recruitment difficulties, staff shortages, poor remuneration and working conditions, ageing workforce and geographic distribution. Since that time, the situation has deteriorated, with medical staffing falling from 47 to 42 positions and RN staffing falling from 271 to 175 positions. Similar problems were identified in other disciplines. The workforce plan provided workforce targets and identified strategies to be implemented. It is assumed that ongoing workforce planning will be undertaken by DOH in parallel with service planning and that over the next 5-10 years, significant improvements in workforce will be achieved. At the same time, it is recognised that in the short term, staffing constraints will limit the extent of service delivery, so that strategies which make the most efficient use of skilled personnel will be essential for service planning.
2.4
Integration of health services An integrated model for clinical and preventive health services has been developed in rural areas. It is assumed that the principle of continuity of care and the value of integrated models of service delivery apply equally in the urban area.
2.5
Role of TTM and MT2 Currently, TTM provides for around 40% of patient days for Savaii residents, yet Savaii residents have a much lower rate of hospital use than Samoans nationally. This suggests the need to strengthen medical services at MT2 and to provide more effective cover to Savaii as a whole.
DOH is committed to enhancing equitable access to health services and it is assumed that 2.6 while TTM will remain the major specialist referral hospital for Samoa, MT2 will be developed to increase inpatient self-sufficiency on Savaii to at least 70%. MT2 will be developed as the main inpatient service on Savaii, providing general inpatient and outpatient care and through a networking arrangement with TTM, a range of specialist clinics. service networking & staffing links between TTM & MT2 will be strengthened.
Partnership approach Partnership approaches are seen as an important means of building cooperation between Health Department and NGOs, principally in relation to rural communities and specific services (eg family planning, youth health)
2.7
Family focus policy This policy is in place in both hospital; and community settings, with emphasis on personal responsibility for health. This will have both service and facility implications. While overall inpatient bed provision may be reduced as more patients are cared for at home, greater family involvement in the care of inpatients will mean providing amenities for family carers. At community level, more carer training and support will be required.
2.8
Coordination of Aid Projects Coordination with other international donor projects is seen as essential given the inter-relationships which apply. Shared assumptions and planning baselines will be needed. Service planning assumes the continuing development of appropriate organisational structures and management practices/capacity. Previous bilateral agreements regarding the need for upgrading of maternity, theatres and laboratories are recognised, but there is a need to clarify actual and projected activity, determine optimum location and functional requirements in the context of broader clinical service delivery.
3. PRINCIPLES The following principles for service planning were drawn from the 1998 Health Sector Strategic Plan, other policy documents and the consultation process. The principles were endorsed by the Health Aid Coordinating Committee (HACC). Emphasis will continue to be placed on primary health care to promote health, prevent disease, support self care and promote responsibility for health within the community Health services should be planned on the basis of ensuring fair and equitable access to appropriate health care for all Samoans. Health service planning should be guided by the health priorities determined on the basis of epidemiological data and evidence of effectiveness. Health services will be provided in a way that makes efficient use of available resources to achieve health gain.
Health services will be of a quality acceptable to consumers, providers and independent arbiters. Health care providers will work in partnership with other sectors of government and community organisations to meet the health needs of communities. Health care providers will work in partnership with families to ensure that the needs of individual patients are met. Public sector health services should complement and work in conjunction with those provided by the private sector. Workforce planning should ensure an adequate, appropriately trained health workforce. Primary health care will be provided through an integrated network of hospitals, health centres, mobile community outreach services and home visiting. The community health nurse is the key provider of these services. General outpatient consultations and inpatient admission will be provided at strategically located district health centres. A CNC will be responsible for clinical assessment and triaging at these sites and medical consultation will be provided from TTM or MT2. Specialist outpatient services and admission will be provided at TTM and through outreach clinics to MT2 and selected district health centres, as appropriate. Specialist consultation and support will be provided to district health centres by TTM clinicians medical, nursing and allied health. An emergency response system should support the network of primary and secondary referral services. It is recognised that a critical mass of medical staff is required to sustain a service: staffing and organisational arrangements should reflect this. Physical and technological infrastructure should be appropriate and properly maintained.
4. HEALTH SERVICE PROFILE SAMOA Samoa is divided into a number of health districts, each serviced by several health facilities. The maps on the following pages show the district boundaries and services. 4.1 Hospitals
Outside of the major referral hospital in Apia, there are four district hospitals ranging in size from 10 to 24 beds and providing a mix of inpatient and outpatient care to defined health districts. At March 2001, only two of these hospitals MT2 and Leulumoega had permanent medical staffing, with the others being supervised by a clinical nurse consultant, trained in first line emergency care, midwifery a well as general nursing.
Name Tupua Tamasese Meaole (TTM) Hospital
Location Apia
Beds 200
Role Secondary referral hospital, providing specialist services in emergency medicine and critical care, internal medicine, general, orthopaedic and specialty surgery, obstetrics, gynaecology and paediatrics. Main district hospital for Savaii, providing general medical, obstetric and limited surgical services. District Hospital, primarily outpatient role District Hospital, primarily outpatient role District Hospital, primarily outpatient role
Malietoa Tanumafili II Hospital Leulumoega District Hospital Aleipata District Hospital Sataua District Hospital
Tausivi, Savaii Upolu Lalomanu, Upolu Savaii
24
23 10 10
Table 1: Hospitals, Samoa, 2000
4.2
Health Centres As well as the five hospitals, most rural areas are serviced by a network of health centres (see table below), each of which supports one or two sub-centres. Most health centres are staffed by RNs (CNCs at Safotu and Foalalo) and in spite of the apparently large number of inpatient beds they provide, inpatient use in most cases is very limited. The role is principally to provide primary health and outpatient services to the local population. In rural areas, an integrated model of health care applies, with nursing staff being responsible for centre-based, community and home health activities.
Name Fagamalo Health Centre Foalalo Health Centre Safotu Health Centre Satupataitea Health Centre Afega Health Centre Fagaloa Health Centre Falelatai Health Centre Fusi Health Centre Lefaga Health Centre Lufilufi Health Centre Poutasi Health Centre Location Savaii Savaii Savaii Savaii Upolu Upolu Upolu Upolu Upolu Upolu Upolu
Table 2: Health Centres, Samoa, 2000
5.
DEMAND FOR HEALTH SERVICES
Health service demand is shaped by a range of factors including: population size, distribution, growth and demographic characteristics health status and patterns of disease the supply of health services and the way these are used. 5
5.1
Population profile The population of Samoa is growing only slowly about 0.6% per year - because although the fertility rate is high, this natural growth is off-set by a high level of outmigration. Assuming this trend continues, the population is expected to increase by just under 4% to around 176,500 by 2006. The age structure is young, with almost 40% of the population aged <15 years. Only slight ageing is expected by 2006, although the change in New Zealand pension arrangements may lead to a more noticeable increase in the elderly population.
Year 1996 2001 2006 Estimated population 165315 171044 176597 3.47 3.25 % change
Table 3: Projected population growth 1996-2006, Samoa Source: Samoa Dept Statistics
The distribution of population shown below is based on the 1991 census, projected to 1998. (Distribution to be confirmed!) There is a reported trend for families to move away from rural areas to Apia when children attend school and to remain there for employment and further education. Land releases in areas close to Apia also contribute to this trend.
Urban Upolu Rural Upolu Savaii TOTAL 1991 49383 66865 45050 161298 % 30.6% 41.5% 27.9% 100.0% 1998 51024 69198 46522 166744
Table 4: Population distribution by Health Region Source: DOH Annual Report
5.2
Health status The health status of Samoan people has greatly improved over past decade with major reductions in infectious diseases, improved infant mortality and increased life expectancy. However, disease patterns are changing with more people suffering noncommunicable lifestyle related diseases such as hypertension, diabetes and cancer. Poor nutrition is an issue, with protein malnutrition affecting significant numbers of young children and over half of all adults being overweight or obese. Motor accidents are an increasing cause of death and injury and suicide rates remain high. Leading causes of inpatient death diseases of the circulatory system perinatal conditions respiratory conditions infectious and parasitic diseases
Given the relatively small numbers of deaths occurring in hospital, it is uncertain how reliable these figures are as a health indicator. Information on causes of death outside hospital are not readily available.
Leading causes of inpatient morbidity respiratory conditions notably asthma and pneumonia (14% of admissions) pregnancy and childbirth excluding single spontaneous deliveries (10%), injury and poisoning (7%) infectious and parasitic diseases (7%).
A more detailed health profile is provided in the 1998 World Bank paper Meeting the challenges of development. At TTM, the impact of non-communicable diseases notably diabetes and hypertension is of growing significance. In particular, the complications of these diseases diabetic sepsis, blindness, stroke, disability are having an impact on both inpatient and outpatient care needs. Clinicians have expressed concern about non-compliance with treatment regimes and delayed presentation of complications, particularly in the case of patients from the rural areas. 5.3 Health service utilisation Inpatients The total demand for inpatient services at all sites in Samoa in 1999 was about 12,000 admissions and 50,000 patient days (equivalent to 170 beds at 80% occupancy or 195 at 70% occupancy). Over 80% of inpatient demand was met at TTM and 11.5% at MT2. District hospitals and health centres played a relatively minor role, with the busiest ones admitting only 3-4 patients per week.
Facility TTM MT2 Safotu HC Aleipata DH Sataua DH Foalalo HC Fusi HC Lefaga HC Falelatai HC Poutasi HC Falealupo SC Grand Total Admissions 9517 1642 159 168 191 176 84 37 27 18 1 12020 % of total 79.2% 13.7% 1.3% 1.4% 1.6% 1.5% 0.7% 0.3% 0.2% 0.1% 0.0% 100.0% Beddays 41806 5732 654 612 436 364 154 95 45 37 1 49936 % of total 83.7% 11.5% 1.3% 1.2% 0.9% 0.7% 0.3% 0.2% 0.1% 0.1% 0.0% 100.0% ALOS (days) 4.4 3.5 2.3 2.1 4.1 1.0 3.6 1.8 2.6 1.7 2.1 4.2
Table 5: Health service utilisation, Samoa 1999 Source: HIS
The average length of hospital stay (ALOS) has fallen from 5 days in 1995 to 4.2 days in 1999, reflecting increased community management of patients with chronic illnesses, TB and leprosy and reduced inpatient bed numbers. TTM continues to absorb an increasing share of inpatient demand. Over the same time, admissions to district hospitals and health centres fell by 40% and the share of inpatient demand at TTM increased from 73% to 83.7%. Residents of urban Upolu appear to use inpatient health services at over twice the rate of people in rural Upolu and Savaii. The reasons for this uneven pattern of use include: Services Plan for TTM 7
27/04/01
Easier access (proximity, transport, cost) to health services Doctor-related activity more admissions where doctors are present Less healthy lifestyles, overcrowding & more reliance on drugs in urban areas More reliance on traditional healers in rural areas.
It is also possible that the population figures do not adequately reflect the drift to Apia, so that the urban population is under-estimated and the rural population over-estimated. However, these figures do raise the issue of equitable access and suggest that there is a need to improve health service access for Savaii residents.
Region Urban Upolu Rural Upolu Savaii TOTAL Region Urban Upolu Rural Upolu Savaii TOTAL 1998 popln 51024 69198 46522 166744 1998 popln 51024 69198 46522 166744 adms 1999 6225 3173 2594 11992 b'days 1999 24890 13941 11009 49840 adms per 1000 122.00 45.85 55.76 71.92 b'days per 1000 487.81 201.47 236.64 298.90
Table 6: Utilisation rates x Health Region of residence all facilities
The largest numbers of admissions to Samoan hospitals in 1998 were for pregnancy and childbirth, respiratory illnesses (particularly among children), injury and poisoning, infectious and parasitic diseases (notably diarrhoeal disease) and cardiovascular illness. Outpatients There were 221,056 outpatient visits to hospitals, health centres and sub-centres in 1998 a rate of 1.3 per head of population.
Facility location Urban Upolu (TTM) Rural Upolu Savaii TOTAL No. visits 83536 41947 47336 172819 1991 % total No. visits 101121 27846 1998 % total
Table 7: Outpatient presentations, 1991 and 1998 (Source: DOH Annual Reports)
The pattern of patients by-passing smaller, nurse managed facilities to attend TTM outpatient clinics observed in the 1994 World Bank report persists and the balance has shifted in favour of TTM. Reasons for this change have been identified as: Improved roads & transport, making access to Apia easier Changes in service delivery in rural centres - notably reduced medical staffing levels 8
Attendance fees charged by Womens Committees to non-committee members Urban drift many people from rural areas either move to Apia, have relatives in Apia, or travel to Apia for shopping etc so are more likely to seek health care there. 6. TTM HOSPITAL 6.1 Service profile TTM is Samoas major referral hospital with around 200 inpatient beds. It provides a mix of specialist referral and general acute care services, as outlined below. Core clinical services Emergency and outpatients Medicine Surgery (includes Orthopaedics & sub-specialties) Obstetrics and Gynaecology Paediatrics Anaesthetics & Critical Care Mental Health Dental
Clinical Support services Laboratories Radiology Pharmacy Allied health services nutrition, rehabilitation, prosthetics Operating theatres Medical records CSSD
General support services hotel services (food, cleaning, linen, laundry etc) maintenance & engineering waste management
The current bed allocation by specialty is shown in table 8 below. A 40 bed TB and Leprosy ward and a six bed infectious diseases ward were closed in 1998.
AdmissionSpecialty Medical Surgical Orthopaedic Antenatal Postnatal Neonatal Paediatric High Dependency Unit Mental Health Total 1999 30 30 42 11 33 10 30 6 4 196
Table 8: Inpatient bed distribution, TTM 1999
6.2
Role & relationship with other services Referral Hospital Role TTM plays a referral role at both secondary and tertiary levels. Community nurses, district hospitals and health centres refer patients to the general outpatient department for medical consultation. Referrals for specialist medical consultation and/or management are received from doctors in general outpatients, peripheral hospitals and health centres and also from private medical practitioners. Patients requiring more specialised treatment or medical care are transferred from district hospitals and health centres at the rate of about 2-3 per week, with most of these transfers coming from MT2. Transfers increased by 20% between 1998 and 1999, hightlighting the importance of this role. TTM also plays a role in the Medical Screening Committee, assessing patients needing to travel overseas for tertiary referral services. 83 patients were sent to NZ for treatment in 1998, a slight decrease from the 97 sent in 1997. Emergency Response Ambulance transport is arranged from TTM to retrieve seriously patients being transferred from other hospitals. There are currently 2 ambulances and nurse escorts are required to accompany ambulance drivers. The ambulance service coordinates with the ambulance based at MT2, with patients from Savaii being transferred to the TTM ambulance at the Mulifanua ferry terminal. In very urgent cases, patients from Savaii are transferred by plane or a flying squad of specialist and anaesthetist may fly to MT2. Outreach and Consultancy Support As well as the referral role, TTM clinicians provide consultancy support and advice to staff in peripheral hospitals and health centres. Regular outreach clinic visits are made to hospitals on Savaii by surgical and obstetric specialists, with an anaesthetist for operating sessions. As well, telephone advice is provided to staff in peripheral hospitals regarding patients who are seriously ill. Clinical Nurse Consultants (CNCs) in Emergency Medicine, Acute Clinical Care, Midwifery and Mental Health, based at TTM, provide consultancy support and training to nurses in community health services and district hospitals. Clinical Support Services Pathology, radiology and pharmacy services based at TTM are responsible for the provision of clinical support, drugs and medical supplies to all health facilities, although the only clinical support staff outside TTM are those at MT2. Other clinical support services provided to a broader catchment from TTM include medical records, CSSD, biomedical engineering, prosthetics and orthotics. Infection control is the responsibility of the CNC PDRS supported by a committee. Primary Health Care While TTM provides primary medical care via the GOPD, the bulk of primary health care is provided by community nurses who work out of health centres, villages and homes.
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Increasing numbers of patients with prolonged and chronic illnesses are now managed at home rather than in hospital. For this reason, linkages between TTM and PHC are vitally important for the efficient use of health resources. Clinical Nurse Consultants based in each health district provide a clear point of contact for acute care clinicians seeking to arrange intermediate care or follow-up of patients discharged home or to peripheral health facilities. There are also regular consultations between CNCs based at TTM and those in rural services. A range of other primary health care services is provided through the Preventive Health division from the TTM site and share referral linkages with TTM eg health promotion, antenatal care, nutrition, sexual health. However, there are relatively few collaborative programs linking preventive and clinical health services. General Support Services These include all hotel services (catering, cleaning, linen, laundry), stores, transport, security, maintenance and engineering (including power supply) and waste management. Currently, these are provided through corporate services. Administrative and clerical support is also provided through corporate services. At hospital level, a senior administrative officer is responsible for managing the supply of corporate services to TTM. There is no general manager responsible for ensuring the delivery of clinical and non-clinical services at TTM. Private sector At a clinical level, traditional referral relationships exist between TTM and the private medical practitioners (mainly GPs) who refer patients to TTM for specialist care and for diagnostic services. The laboratories at TTM provide some pathology testing services to the private hospital, and there is limited contracting of private providers to provide clinical services to TTM or other health facilities. 6.3 Human resources TTM accounts for some 90% of medical staff employed in clinical services in Samoa. The level and distribution of medical staffing is shown in table 9 below.
Clinical dept OPED Medicine Surgery+ orthopaedics Obstetrics & gynae. Paediatrics Anaesthetics ENT Ophthalmology Radiology Pathology Total @ TTM Total - all clinical services
Consultant/ specialist 1 1 2 1 2 1 0.2 2 1 12.2 12.2
Registrar/ senior registrar 4 3 1 1 1 2 1
House surgeon 1 1 1 1 2 1
Overseas doctors
Total 6 5 5 4 5 4 1.2 1 1 1 35.2 39.2
1 1
15 16
7 8
3 4
Table 9: Medical staffing, TTM and other, March 2001
By comparison, less than half of the nursing workforce is based at TTM.

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Service Area TTM MT2 Savaii Upolu Cty Health - Apia PDRS TOTAL
Principal Nurse 1 Vacant 1 1 3 + 1v
Nurse Manager 6 + 2v 1 3 5 1 16+2v
Nurse Consultant 4 1 2 2
RNs 91 11 16 21 17 156
ENs 37 10 14 26 15 102
Total 118 23 35 55 33 1 265
Table 10: Nurse staffing, TTM and other, March 2001
6.4
Physical facilities The major construction of the TTM hospital buildings was completed in the early 1970s with the assistance of the New Zealand Government. These buildings, of solid masonry construction, incorporate all wards except the 2-storey orthopaedic ward block, designed and constructed with assistance from the French government in the early 1990s. In general the buildings are physically sound and the areas adequate. The main facility issues relate to facility and equipment maintenance and the functionality of certain areas, such as maternity. Some buildings within the hospital site date from the early 1900s: most of these are of light-weight construction. They are used mainly for preventive health services and DOH administrative functions, but still house some support services (eg orthotics, biomedical workshops, dental training).
7. SERVICE UTILISATION AND FLOWS 7.1 Inpatient Services Over the three years to December 1999, TTM has experienced an increase of over 18% in inpatient admissions, while bed utilisation has fallen by over 8%. Average length of stay (ALOS) fell by over 20%, largely due to the closure of two long stay wards during 1998. Closure of TB/Leprosy and infectious disease wards resulted in a fall in inpatient activity equivalent to about 40 beds from 1996 to 1999.
Adms 7993 8373 9512 Beddays 45560 41661 41797 ALOS 5.7 5.0 4.4
1997 1998 1999
Table 10: Inpatient activity, TTM 1997-99
The pattern of inpatient activity at TTM is consistent with the national pattern, which it influences heavily. In 1999, over 37% of all admissions at TTM related to pregnancy and childbirth and a further 7% to perinatal conditions. However, the pattern of bed use at TTM reflects the impact of relatively short stays for maternity patients, the large number of paediatric patients and longer stays for surgical and orthopaedic patients. Table 11 below shows the 1999 pattern of inpatient demand by clinical specialty.
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Admission Specialty Paediatrics Surgery + orthopaedics Obstetrics & Gynaecology Internal Medicine Mental Health Others* Total
Adms 2298 1508 4081 1431 2 192 9512
Beddays 10994 12952 8641 8042 101 1067 41797
ALOS 4.8 8.6 2.1 5.6 50.5 17 4.4
Bed equiv. 38 44 34 28 0 4 147
Table 11: Distribution of inpatient activity by specialty, TTM 1999

* includes episodes attributed in error (eg: TB/Leprosy, OPED). Most expected to be medical admissions
There is some evidence to suggest that the current pattern of use is influenced by supply factors. Internal medical admissions fell by 11% and bed use by 24% between 1998 and 1999, with ALOS falling from 6.6 to 5.6 days, possibly reflecting the closure of infectious disease beds in 1998. At the same time, surgical activity increased slightly and ALOS remained quite long. In part this reflects the impact of the long hospital stays (6 weeks) of patients with diabetic sepsis, as well as those with spinal injuries and chronic osteomyelitis which require extended treatment. The catchment served by TTM extends across the whole of Samoa, although almost two thirds of admissions are from the Apia area. Only 6.2% of patients are from Savaii, but these patients account for over 10% of bed utilisation, as they are generally referred from MT2 due to the seriousness of their condition.
Area of residence Urban Upolu Rural Upolu Savaii Overseas Unknown Total Admissions 6089 2825 589 7 7 9517 % of total 64.0% 29.7% 6.2% 0.1% 0.1% 100.0% Bed days 24488 12971 4292 28 27 41806 % of total 58.6% 31.0% 10.3% 0.1% 0.1% 100.0%
Table 12: Distribution of inpatient activity by specialty, TTM 1999
7.2
Outpatient activity On average, over 300 patients per day are registered at TTM outpatient clinics, with more than half of these being at general outpatient (48.5%) and dressing (6.5%) clinics. 15.3% of all attendances are at paediatric clinics. Approximately 10% of GOPD patients leave before being seen and there is a failure to attend rate at of around 15% at specialist clinics. Thus the number of patients actually seen is 130-140 per day in GOPD and 115 per day in specialist clinics.
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ClinicType
Clinic sessions Attendances 1999 (half day) per week 24 hr cover 10 10 3 5 7 8 2 4 10 2 2 51 (excl GOPD) 55119 7331 17396 4909 3809 6947 5082 3658 3037 2331 1899 1576 115093
GOPD + Emergency GOPD - Dressing Paediatric Orthopaedics Ante-Natal - Booking Medical Eye Surgical General Diabetes ENT Cardiac Obstetrics & Gynaecology Total
Average attendance per session 150+ per day 14 34 33 15 20 13 37 15 5 19 16 221
Table 13: Distribution of outpatient activity by specialty, TTM 1999
The catchment served by outpatient clinics in 1999 was predominantly urban Upolu, which accounted for three quarters of all patients. Only 4% came from Savaii. Special clinics had a slightly broader population base than GOPD, but still drew patients mainly from urban Upolu.
Outpatient's Region of Residence Clinic Apia No. % 42744 78% 5953 81% Upolu No. % 10655 19% 1146 16% Savaii No. % 1647 3% 224 3% Total 55119 7331
General OPD Emergency Dressing clinic
Table 14: Distribution of outpatient activity GOPD, TTM 1999
8.
PROJECTED DEMAND FOR SERVICES On 1999 utilisation figures, total inpatient bed demand at TTM was just under 150 beds (refer table 11 above). Available data do not provide sufficient information on trends in utilisation to form a reliable basis for projecting demand. While inpatient admissions have increased and bed demand has been reduced, the extent to which these trends will be maintained is unclear. Clinical staff report that the level of inpatient activity has been limited in recent years by nursing staff shortages and that current activity figures may mask a degree of unmet need. Per capita utilisation rates remain low, particularly in comparison to those observed in developed countries and it seems almost inevitable that there will be increases in demand with the increasing prevalence of conditions such as cardiovascular illness, renal failure and chronic airways disease. Policy decisions regarding the provision of interventions such as coronary artery bypass grafts, haemodialysis and chemotherapy will have some influence on developments in this respect. It seems likely that with growing population exposure to
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the more sophisticated range of services provided in New Zealand and Australia, community expectations of treatment and demand for admission will rise. With improvements in screening and early detection (eg diabetes, hypertension, mammography, pap smears) more patients may be treated at an earlier stage, reducing the long stays associated with late presentation, diabetic sepsis, stroke etc. However, it is likely to take some time to turn around the increases in demand now occurring in these areas. Changes in clinical practice such as day surgery, community rehabilitation, use of district hospitals and community nursing for intermediate care may effect further reductions in ALOS, although these may not be great as the ALOS is already very short particularly in areas such as obstetrics. There appears to be scope to reduce ALOS for surgical, orthopaedic and paediatric specialties. In the short term (5 years), reductions in ALOS are likely to be off-set by increasing numbers of admissions. Changes in utilisation rates could have a major impact on inpatient service demand. If residents of Savaii used hospital beds at the average rate for Samoa (ie 298.9 bed days per 1000 population), demand from Savaii would increase by the equivalent of 10 beds. If residents of rural areas used inpatient services at the same rate as Apia residents, they would occupy more than 100 extra beds. Developing health services to be more responsive to the needs of rural populations could increase demand. It may be possible for much of this demand to be met in peripheral health facilities, through networking arrangements with TTM. If the population of Samoa increases by 4% over the next 5 years, it is fair to assume that most of this growth will be in Apia urban area. On population figures alone, then, we would expect demand for admission to increase by some 4-5%. Other factors which could result in changes in demand at TTM are: Changes in medical and nurse staffing with more staff, more patients can be seen and more may be admitted Further reductions in district health services is it viable to maintain medical services at places like Lalomanu and Leulumoega Unexpected increases in HIV/AIDS
If current patterns of morbidity and service use are maintained, these factors are likely to balance out, so that around 180-195 beds, efficiently organised, would be adequate to meet demand at TTM for the next 5-10 years. If utilisation rates of rural residents increase, then more use will need to be made of district hospitals but even so, it is likely that TTM will be expected to provide for some additional demand. (Thus provision should be made to allow some flexibility and possible expansion to at least 180 beds.) A suggested distribution of beds to reflect patterns of demand is shown in Table 15 below.
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Clinical specialty Medical/ Surgical/Orthopaedic O&G Neonatal Paediatrics HDU Mental Health Total
Bed equiv. 45 45-50* 35-40 10 35 - 40 6 6** 180-195
Table 15: Suggested distribution of inpatient beds * ** includes short stay or day surgery beds includes 4 rehab beds
Outpatient demand could also be expected to increase, but again strategies such as strengthening primary care services, developing outreach clinics, reviewing service charges and forming service partnerships with other non-government providers could reduce the impact of growth in demand on outpatient clinics at TTM. 9. ISSUES IN SERVICE PLANNING Current utilisation data and projected demand estimates suggest that while the current inpatient bed supply may be adequate, the current distribution of beds by specialty does not fit well with the pattern of demand. This means that either beds will need to be redistributed or more flexible use made of existing inpatient units to accommodate projected growth in demand. Future planning for outpatient and emergency services may be influenced by other developments such as charging policies and development of a primary care centre on the TTM site. A significant reduction in presentations may be effected. The likely impact of such developments on demand at the TTM outpatients and emergency department is difficult to gauge without having a clearer understanding of the nature of existing ED demand. There is considerable scope for the provision of outreach services from TTM. This could have the effect of increasing demand for admission in both peripheral health facilities and at TTM due to expanded case finding. At the same time, earlier intervention may reduce the long stays now associated with late presentation of some conditions. Workforce capacity will be a critical issue in determining the level of service which is provided at TTM. In particular, nurse staffing influences the number of beds and procedural services which can be supported. The ability of medical staffing to support an extended role outside TTM will influence patterns of use in district hospitals. Adequate allied health, technical and clerical staffing is required to enable clinical staff to be used most effectively and to improve service performance. Clinical staff development is required within TTM and the extended health service setting. As well as sending selected staff away for postgraduate and specialist training, there is a need for specialist consultants to work with staff in Samoan health services to provide specialist clinical training, supervision and to build skills among local clinicians. Telemedicine links can also be used for both education and consultation.
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Management capacity building among clinicians has also been identified as a key direction for future service planning. This should incorporate the development and use of management information and reporting systems and links with HPIRD. CORE CLINICAL SERVICES Outpatients and Emergency
10. 10.1
Description Emergency services are currently integrated with the general outpatient department (OPED) of TTM and located adjacent to the special clinics, radiology and medical records departments. Services currently provided include: Resuscitation and initial management of all accidents and medical emergencies Ambulance retrieval of patients requiring transfer from other hospitals General outpatient consultation and referral Minor procedures (eg suturing, lancing boils) Specialist consultation Short term observation/holding beds and access to admission beds Referral to specialist clinical services Medical phone consultation to rural health centre staff Dressing clinic.
The service is staffed by a full time Director + 4.0 FTE medical officers and 21 nurses. The CNC for A&E is based here and is responsible for training community nurses in resuscitation and basic life support. Activity and catchment served General outpatient and emergency attendances (including dressing clinics) at TTM totalled around 57,200 in 1999 an average of >150 patients per day. Attendances peak between 7 and 11 am and are generally highest on Mondays. The bulk of this activity is general practice (ie primary medical care) type cases. Clinicians estimate that the number of cases warranting emergency care is under 10% and the admission rate from GOPD is only 2%. Some patients also attend OPED for routine checks and minor complaints, rather than seeing a community nurse. Some 80% of GOPD patients were from Apia urban area, and only 3% from Savaii. (see table in section 7 above). Projected Demand Growth in demand for outpatient and emergency services at TTM has outstripped population growth by a factor of 10. Outpatient attendances increased by 36% between 1991 and 1999 an average annual growth rate of 4.5% - but appear to have fluctuated significantly over the past five years, as shown in Table 16.
Date 1995 1996 1997
Attendance 118753 104854 97157
17
1998 1999
101121 104485
Table 16: TTM outpatient attendances, 1995-1999

[Source: 1995-98 DOH Annual Reports, 1999 HIS, adjusted for non-inclusion of DNAs]
There is some evidence that this is now plateauing or declining slightly possibly reflecting developments in the private sector or just saturation. To a degree, outpatient activity is supply-driven: as more clinics and more staff are provided, it can be expected that more patients will attend. However, other factors are expected to maintain or increase demand for both general outpatient and emergency medicine services: the increasing prominence of lifestyle related non-communicable diseases (diabetes, asthma, pneumonia, chronic airways disease, hypertension) among the population of urban Apia in particular an expectation that with increasing urbanisation, per capita ambulatory care utilisation rates will move closer to those observed in more developed countries rising rates of road trauma.
Projected demand is:

Service Emergency General outpatients Special clinics (OPED) TOTAL Visits 1999 2,500 55,000 27,000 84,500 Projected visits 2006 5,000 55,000 25,000* 84,500
Table 17: Projected demand for emergency and outpatient care * assumes some clinics (eg gynaecology) will be relocated to other areas
Issues in Service Delivery As a result of the changes in patterns of demand, activity levels at TTM GOPD remain very high an average of around 120 patients per day. About half arrive between 7 and 9 am. This has a number of negative effects: Long waiting times up to 6 or 7 hours Overcrowding in waiting area Pressure on medical staff to process patients and limited time for dealing with more complex health issues or providing targeted health education work is stressful and potential for burnout considerable. Patient dissatisfaction 10% of patients leave without being seen and GPs report seeing many patients who are unable to wait at GOPD or are dissatisfied with the service/treatment they have received there. Concern that patients may be discouraged from presenting early enough for potentially serious conditions to be treated delays in presentation leading to worse outcomes.
Currently, it is difficult for the GOPD to function efficiently due to shortfalls in the organisational system and support services. Specific problems relate to: Effective triaging of patients on the basis of clinical need and service required Retrieval of medical records and test results to reflect clinical priorities more closely 18
Nursing shortages which have resulted in reduced nursing support/activity in OPD. Protocols to ensure consistent responses to common presenting problems/conditions No appointments or scheduled sessions for routine follow-ups, BP checks etc hence these cases increase demand at peak periods. Problems in clinical support services, such as delays and inaccuracies in pathology results and inadequate sterilising facilities Equipment deficits (eg ECG, sphygmanometers, pulse oximeters, monitoring equipment, wheelchairs) and shortages in supplies (bandages, syringes, plasters) which slow patient processing.
GOPD has a number of holding beds, which are commonly occupied by patients awaiting transfer to the wards. Transfer of patients to medical wards is often difficult to limited bed availability and this places additional pressure on OPED staff. Specific outpatient clinic areas are currently allocated to each special clinic, although some of these clinics operate only 2 sessions per week. At times three clinics run concurrently: at other times areas lie unused. There is a need to rationalise the use of clinic areas, with generic consultation rooms/cubicles being shared across several special clinics and clinics being scheduled to improve efficiency of use. Proposed Service The current location and space available for outpatient clinics are appropriate, but reconfiguration of the outpatients area is required to separate Emergency, GOPD and specialist clinics and rationalise facilities for each, allocating space on the basis of activity and functional requirements control access, improve patient flow and processing introduce high profile, effective triaging to direct traffic facilitate timely retrieval and filing of medical records, radiology and laboratory test results centralise the staff station to improve supervision of treatment areas improve handwashing facilities and other infection control measures (eg waste disposal) include provision for nurse-led primary health clinics if these are not provided elsewhere on the hospital site (ie community health centre).
Strengthening of emergency response capability is required, including ambulance retrieval, establishment of a trauma team involving emergency, anaesthetics and surgery staff, and provision of appropriate first line emergency, CPR and trauma training and resources for staff at all hospitals providing acute care. Consideration may be given to linking special clinics organisationally with relevant inpatient services rather than including these with general outpatients. Staffing requirements:
Staffing FTE Medical (excl. house surgeon) RN EN Ward assistants 2000 5.0 15.0 6.0 1.0 Required 2006 6-7 19.5 8.0 3.0
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Functional requirements Emergency department : trauma room with 2 resuscitation bays, immediately adjacent to ambulance entry Stretcher waiting area Acute treatment area Consultation/treatment rooms, including one for psychiatric patients Clean and dirty procedure rooms Quiet room Staff station centrally located to provide supervision
General outpatients department Triage desk at entry Adjacent registration desk 3 treatment bays/cubicles and 2 consultation rooms (including one suitable for psychiatric patients) a separate patient assessment area adjacent to triage to allow for more accurate triaging observation/short stay/holding area (4 beds) separate waiting area (up to 60 people).
Treatment and interview areas should allow adequate visual and acoustic privacy for patients and clinical staff. Other requirements include: offices (director, transport, security others) storage area, with secure storage for medical supplies improved lighting and ventilation staff room and amenities
Locational Requirements: . Good public and ambulance access, clearly signposted Easy access to X-ray, operating theatres, HDU, pathology covered access to pharmacy
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10.2
Medicine
Description The Department of Medicine provides specialist inpatient and outpatient consultation and care to patients with a wide range of medical conditions including respiratory illness, cardiovascular disease, diabetes and its complications, gastrointestinal illness and infectious diseases. The department provides 7 specialist outpatient clinics per week at TTM and also provided weekly outreach clinics to district hospitals. Referrals are made from GOPD, private GPs, and district hospitals. The medical ward (Acute 8) currently has 30 beds. Although there is space for up to 35 patients, nurse staffing limits the number of patients that can be managed at any one time. As well, medical staff admit and manage patients in the high dependency unit (HDU). There are 3.0 FTE medical staff: 1 consultant physician, 1 senior registrar, 1 registrar plus 1 house surgeon (4 month rotation). Support services are provided through other departments/divisions and include: diabetic clinic TB & Leprosy team physiotherapy nutrition and dietetics
Activity Currently, medical patients account for around 31 beds (at 80% occupancy) but clinicians believe that actual demand is higher than this, with utilisation contained by nursing staff availability. Table 18 shows 1998 99 inpatient activity for the department of medicine. As well, most of the patients classified as other appear likely to be medical patients, so these have been included.
Activity measure Admissions Patient days ALOS Beds @ 80% occupancy 1998 1688 11259 6.7 39 1999 1623 9109 5.6 32 change -4% -19% -16% -19%
Table 18: TTM medical activity 1998-99

[Source: HIS]
Inpatient activity fell significantly between 1998 and 1999 with the closure of Ward 10 (infectious diseases) and the TB and Leprosy ward. Patients with infectious diseases are now managed at home with community nursing support or in the medical ward. Average length of stay fell late in 1999 as bed pressure intensified. Clinicians report that some patients are discharged prematurely or not admitted although clinically this is warranted, suggesting a level of unmet need. Medical outpatient clinics see an average of 20 patients per clinic a total of around 7000 per year. Other specialist medical clinics see a further 5,000. Demand for services such as diabetes and hypertension management has increased as a result of outreach clinics generating new patients.
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Clinic Medical Diabetes Cardiac Others (incl visiting) Total
attendance 6947 3037 1899 365 12248
Av/wk 135 60 38 7 240
Av/clinic 20 15 19 N/a
Table 19: TTM medical outpatient activity 1999
Projected Demand Demand for medical services can be expected to increase over the next 5-10 years due to the increased impact of non-communicable diseases and their complications, increases in the aged and disabled population and increased community expectations. Improved case finding could increase outpatient activity. The impact of these changes on demand at TTM may be contained if more use can be made of district hospitals, health centres and community nursing services for step-down care or management of chronic illness conditions. Nonetheless, an anticipated increase in the order of 10% appears likely by 2006, even assuming no significant change in the current pattern of disease. Issues in Service Delivery Nurse staffing shortages have resulted in current under-provision of medical beds relative to demand evidence of unmet need Pressure on TTM due to lack of medical staffing in other hospitals pressure on outpatient clinic due to excessive numbers of patients requiring general rather than specialist medical consultation (eg those with stable hypertension, uncomplicated diabetes) Diabetic sepsis patients admitted through Surgical Dept occupy some 6-8 medical beds, reducing access for other patients Management of some infectious patients in general wards is unsatisfactory the risk of cross-infection is increased by lack of sterilising facilities Equipment deficits constrain service able to be provided notably, sphygmanometers, ECG and exercise ECG machines. Endoscopy is limited by the lack of suitable sterilising system. Deficits in pathology service (eg blood gas analysis) and slow response times prolong LOS of some patients and mean that treatment may need to commence without confirmation of diagnosis Lack of feedback regarding TB patients discharged from medical ward complicates ongoing management of these patients Pharmaceutical supplies are problematic high frequency, low dose drugs and unreliable supply in villages aggravate problems of non-compliance and associated complications There is an increasing need for rehabilitation OT as well as physiotherapy with community-based service to assist recovery of stroke patients. The need for outreach clinics to Savaii is recognised, but the ability to provide this service with existing medical staff is limited: there are only 2 senior staff who are responsible for all specialist services and programs (eg rheumatic fever, TB) as well as departmental management, clinical supervision etc Collaboration between medical dept and relevant support services such as nutrition, diabetes education, community nursing and health promotion could be improved the service currently fragmented. 22
Proposed Service Development Increase in medical ward capacity to at least 35 fully staffed beds potential for expansion of bed spaces in existing ward or flexibility in use of some medical/surgical beds Development of multidisciplinary diabetes program with clinics providing screening, medical consultation, diabetic education, nutrition and podiatry services and eye checks. Clinics could be provided at both TTM and on outreach basis. Possible development of multidisciplinary diabetes centre, providing clinics and educational programs and staffed by diabetes educator, dietitian, doctor, podiatrist etc Designated infectious disease area (2 beds) for management of highly infectious patients + sterilising equipment on ward development of protocols for transfer of long stay patients requiring principally nursing care to district hospitals or to community nurse management strengthen links with rehabilitation services - therapy area in close proximity to ward to facilitate early access to rehabilitation at least one additional senior medical post is required to enable outreach clinics and special programs to be provided and to support/supervise staff at district hospitals Provision of scope facilities and adequate sterilising system in theatre area Amenities for relatives
Staffing Requirements
Staffing FTE Medical (excl. house surgeon) RN EN Diabetes educator/consulltant Ward assistants * includes cover to Savaii 2000 4.0 9.0 5.0 1.0 1.0 Required 2006 7.0* 17.5 9.0 2.0 3.0
Functional requirements Medical inpatient unit: 1 x 35 beds + access to flexible use (swing) beds shared with surgery. Designated infectious disease area (2 beds) for management of highly infectious patients with improved sterilising equipment on ward Beds for high dependency patients should be readily observable from the staff station. Crash trolley readily accessible to staff station and high dependency area. Toilet and shower facilities en suite for isolation rooms and shared for multi-bed rooms. Outpatient facilities for 7 specialist medical clinic per wk Endoscopy unit may be located with theatres (or scopes could be performed in a theatre) A diabetes centre should be an integrated, multidisciplinary unit containing clinic facilities, education areas and office space. It should be easily accessible from both inpatient and outpatient areas.
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The centre may be integrated within the GOPD, enabling some sharing of facilities. Office area for use by doctor, diabetes educator & dietitian 3 clinic rooms Clerical/reception area Waiting room Group room (50m2) Blood room Store
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10.3
Surgery
Description The Department of Surgery includes general surgery, orthopaedic surgery and some subspecialist services including ophthalmology and ENT surgery. As well as services provided by staff surgeons, some sub-specialty surgical services are provided by teams visiting from Australia and New Zealand for 2 week periods. On this basis, the range of surgical services is extended to include plastics, urology and specialised orthopaedic surgery. The department has 30 beds in Acute 7 ward and 42 beds in the orthopaedic block. Three operating theatres are in use, with 15 full day surgical scheduled sessions per week. Two surgical outpatient clinics are conducted each week in the special clinics area and orthopaedic clinics are held in the orthopaedic outpatients area, within the orthopaedics building. The physiotherapy service is also located in the orthopaedics building. Patients are mostly referred from emergency and general outpatients. A surgical team visits MT2 twice monthly to provide an outpatient clinic and minor surgical procedures. Patients with comorbid conditions and those requiring more complex care are referred to TTM. Surgeons also provide consultancy advice to doctors at MT2 as required. The unit is staffed by 2 specialists, one registrar, 2 overseas doctors and a house surgeon. Activity Surgeons perform an average of 45-50 operations/procedures each week around 2,200 2,400 per annum, although more recently elective surgical activity has been reduced due to anaesthetic and theatre staffing shortages. Clinicians report an increasing percentage of emergency surgery as a result of cancellation of elective lists. Surgical procedures performed July-December 1999 (excluding O&G) were as follows:
Specialty General Orthopaedics ENT Ophthalmology TOTAL No. procedures 740 189 19 183 1131 Table 20: TTM surgical procedures Jul-Dec 1999
[Source: Performance Review March 2000,]
Patients having minor procedures under local anaesthetic are not admitted and most children are admitted to the paediatric ward so that numbers of admissions to the surgical/orthopaedic wards are lower than the number of operations, averaging around 1500 per annum.
Activity measure Admissions Patient days ALOS Beds @ 80% occupancy 1998 1441 11359 7.9 39 1999 1508 12952 8.6 45 change +4.6% +14% +8.9%
Table 21: TTM surgical activity 1998-99

[Source: HIS,]
25
Average length of stay is relatively long, reflecting the impact of high levels of comorbidity, patients who present late with advanced conditions, patients with diabetic sepsis who stay for prolonged periods and clinician concerns about discharging patients without adequate community nursing follow-up and to environments where the risk of infection is high. Even so, ward occupancy is relatively low around 50% in 1999 and ALOS increased slightly from 1998 to 1999. Even in 1997 when activity levels were higher, surgical and orthopaedic patients occupied only the equivalent of 50 beds. Outpatient attendances for 1999 were as follows:
Clinic Surgical Orthopaedic ENT Eye Visiting teams attendance 3658 4909 2331 5082 221 Av/wk 70 95 45 98 N/A
Table 22: TTM surgical outpatient activity 1999
Projected Demand Current levels of surgical activity are expected to be maintained or to increase slightly. However, inpatient bed demand could be maintained at current levels or reduced with changes in practice such as: Transfer of long stay patients to district hospitals Introduction of day surgery for minor procedures Developing protocols for community nurse follow-up of patients requiring wound care Early commencement of discharge planning
The combined surgical operating caseload (up to 3,500 procedures p.a. with significant emergency component) is sufficient to justify three operating theatres and a 6-8 bed recovery area. Combined surgical/orthopaedic bed demand is not expected to exceed 45-50 beds, particularly if the introduction of day surgery and other efficiency measures proves practical. Issues in Service Delivery See previous notes re shortages in nurse staffing for theatres currently about half strength, placing limitations on elective surgery. Anaesthetics service has also been restricted by workforce limitations. Very little surgery occurs outside TTM, hence surgical caseload for Samoa concentrated at TTM provision of a service at Savaii reduces demand at TTM, but this is difficult to support from current staffing. Need to provide for this in longer term. Lack of screening/early diagnosis (eg mammographic screening, BSE) results in late presentation of cancers and poor prognosis stronger preventive focus required. Current bed configuration underutilised hence inefficient. Theatres in urgent need of refurbishment including up to date anaesthetic equipment, adequate supply of instruments Instrument handling practices and sterilising/infection control provisions need review 26
Limited rehabilitation service an issue in management of patients with eg amputations, spinal injury, multiple trauma.
Proposed Service Expand medical and nursing staffing in line with workforce plan. Current bed allocation could be reduced 45-50 beds to cover surgery, orthopaedics, sub-specialties. Short stay ward of 10-12 beds to be included Crash trolley within ward. Develop intermediate care/follow up protocols for selected long-stay patients at district hospitals to improve efficient bed use. Upgrade anaesthetic equipment and instrument supply and sterilising/infection control provisions and review instrument handling practices. Maintain surgical service to MT2 and consider possibility of outreach eye clinics.
Staffing Medical (excl. house surgeon) RN theatres + ward EN Ward assistant * includes 2 Chinese volunteer doctors 2000 5.0* 19.0 5.0 1.0 Required 2006 6 25.5 12.0 3.0
Functional requirements Surgical Inpatients: 45-50 beds in 2 units, including combined 40 bed orthopaedic/surgical ward plus 10 short stay beds. Inpatient units should provide ready access to/from operating theatres, radiology and rehabilitation.
Operating Theatres Redevelop as 3 room suite, one theatre associated with day surgery unit. Theatres should be located close to the birthing suite, ICU/CCU, and the ED. The theatres should have reasonably easy access to the surgical wards, diagnostic services and the day surgery unit. Direct access should be provided to the CSSU. Each operating room should have direct access to the anaesthetic room, exit room and scrub area. The operating suite should have an adjacent 8 bed recovery area. In the longer term, a 6-8 day place day surgery unit with operating theatre access, pre and post operative lounges should be provided within or immediately adjacent to the main theatre complex. First stage recovery facilities would be shared with main theatre recovery area.
Other Office/consult room for head of department outpatient facilities for 6-8 clinics per week, including designated eye and ENT rooms plaster room asociated with orthopaedic outpatients.
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10.4
Obstetrics and Gynaecology
Description The Obstetrics and Gynaecology service provides antenatal care, birthing and postnatal care for around 2,800 women annually as well as outpatient consultation and inpatient gynaecology services. It is estimated that across Samoa, one third of all deliveries are performed by traditional birth attendants (TBAs). The figure is lower in the urban area and higher in rural areas, particularly Savaii, the figure is estimated to be up to 50%. There are two labour rooms (one is also used as an office) and two delivery rooms. As well as normal deliveries, NSTs and ultrasound scans for pregnant women are done in the labour ward. Some procedures (eg inductions, D&Cs) are also performed in the delivery area. Women requiring caesarean sections or other surgery are transferred to the main operating theatre suite. An 10 bed antenatal ward is used for both antenatal and gynaecology admissions: some 1520% of women are classified as high risk and may be admitted before going into labour to avoid risks associated with travelling long distances to hospital. The 10 bed special care nursery located within the postnatal ward, is supervised by the Paediatric Department but shares nursing staff with the antenatal ward. The postnatal ward of 33 beds is only partly occupied by women requiring postnatal care: an area of 12 beds is used as accommodation for gynaecology patients and breastfeeding mothers with babies in the special care nursery. The service is staffed by one specialist consultant, 2 registrars and one house surgeon (4 month rotation). Midwifery staffing provides for only one midwife and one EN in each of labour, antenatal/neonatal and postnatal ward areas. Antenatal clinics are held at the Family Welfare Centre and are formally the responsibility of Preventive Health Services. Women attend an initial booking clinic and are then seen at regular intervals throughout pregnancy. Community nurses also provide antenatal checks, referring women to the antenatal clinic for booking and assessment. Patients assessed as being at high obstetric risk are seen in High Risk Clinics by Obstetric staff. Women are referred from the FWC to the labour ward for NSTs or ultrasound scans. Each week, family planning clinics are conducted at the FWC and two Gynaecology outpatient clinics in the special clinics area. Twice monthly outreach clinics are provided to district hospitals on Savaii, with the focus on assessment and management of high risk pregnancy. Activity The maternity unit is one of the busiest units in the hospital, with almost 3,000 births annually, as well as over 700 antenatal and gynaecology admissions. The average length of stay is particularly short under 2 days for all patients including caesareans with many women going home within a few hours of delivery. The caesarean rate is low - between 5% and 7% and most are emergency caesareans. As well as gynaecology operations performed in the operating theatres about 300 p.a. clinical staff report performing some 8-10 non-anaesthetic procedures (mostly D&Cs) per week in the delivery ward procedure room.
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Activity measure Admissions antenatal/gynae* Patient days antenatal/gynae* ALOS - antenatal/gynae Admissions- postnatal Patient days - postnatal ALOS- postnatal Beds @ 70% occupancy Deliveries Caesareans
1998 615 2936 4.8 2778 5308 1.9 33 2761 188
1999 731 2271 3.1 3139 5543 1.8 31 2885 156
change 19% -22.6% -35% 13% 4.4% -8%
+4.5%
Table 23: Obstetrics & Gynaecology activity, 1998-99 (Source : HIS + Maternity Register)
It should be noted that there is some use of postnatal ward beds for gynaecology and antenatal patients, so that these figures may understate antenatal/gynaecology activity. Neonatal admissions averaged around 20-25% of births. average stay fell by 24% between 1998 and 1999.
Activity measure Admissions neonatal Patient days neonatal ALOS - neonatal Beds @ 70% occupancy 1998 594 3027 5.1 12
While admissions increased,
1999 698 2697 3.9 10.5
change +18% -11% -24%
Table 24: Neonatal unit activity, 1998-99 (Source : HIS)
Antenatal care coverage is estimated to be about 85% although late presentation for antenatal care remains an issue. Attendances average 3-4 visits per pregnancy. Activity data from antenatal clinics indicate an attrition of around 25% between bookings and births, reflecting both miscarriage rates and women electing to be delivered by traditional birth attendants (TBAs). About 33% of antenatal visits are to high risk antenatal clinics, which have a higher frequency schedule and cover up to 20% of pregnant women. The percentage of high risk pregnancies is reported to be increasing, due to growing numbers of teenage mothers and women with gestational diabetes or hypertension. Undiagnosed diabetes is believed to be an issue associated with stillbirth and mid-trimester abortions.
Outpatient activity Antenatal visits High risk visits Family planning visits Gynaecology clinic visits 1998 9946 N/a 2742 N/a 1999 11401 3778 3008 1085 Av. per clinic 50 ? ? 11
Table 25: Obstetrics & Gynaecology outpatient activity, 1998-99 (Source : HIS + preventive health)
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Projected Demand The number of deliveries at TTM has remained fairly constant at around 2700-2800 over the past five years, although the 1999 figure of 2855 suggests that some increase may be occurring. Factors driving this increase may include increasing urbanisation and improved screening and referral of high risk pregnancies. With continuing growth of the urban population, progressive development of Safe Motherhood practices and upgrading of current facilities, some growth in demand can be anticipated over the next 5-10 years. If current trends persist, deliveries are likely to reach 3,000 p.a. within the next 2-3 years. Further growth may occur subsequently, but this may also be off-set by continuing reductions in fertility rates and improvement of obstetric services outside TTM (eg MT2). It is proposed that the service be planned to accommodate some 3,000-3,200 deliveries p.a. with an average postnatal stay of 2-3 days. Assuming that a relatively high percentage of women will continue to present in second stage of labour, it is estimated that this will require 6 birthing suites (plus assessment/prep rooms and first stage lounge) and 30 postnatal beds (at 70% occupancy). If 15% of women are admitted antenatally with an average stay of 3.5 days, then about 7 antenatal beds will be required. Gynaecology demand is expected to remain relatively constant, given the age profile of the population. However changes in service provision, such as improved cervical cancer screening and treatment services, could see increases in some aspects of demand. If suitable treatment were available, more gynaecology demand could be managed on a day only basis, so that bed demand could be contained to around 3 inpatient beds. Neonatal admission rates are currently around 25% of all births. If this rate is maintained, then approximately 750-800 admissions p.a. would be expected. With ALOS of 3-4 days, then 10-12 cots would be required (70% occupancy). Issues in Service Delivery Current service spread and configuration difficult to manage with existing clinical staffing levels. Both medical and midwife staffing at minimal levels, given demand. Antenatal outpatient facilities and services do not facilitate efficient practice referral of women to labour ward for NSTs and ultrasound scans places pressure on staff and facilities lack of suitable waiting area and high volume of referrals which must be managed concurrently with labour ward activity. Need for NST room in antenatal clinic. Protocols for assessment and management of high risk pregnancies not systematically applied need for increased medical supervision of high risk clinics and closer linkages with community nurses to ensure early presentation and follow-up of non-attenders Need to strengthen training/advisory support to midwives and nurses in rural areas Lack of privacy in gynaecology outpatients clinic believed to deter attendance need for consultation rooms in O&G unit, rather than cubicles in shared outpatients clinic area. Separation of labour and delivery areas requires transfer of patient and strains staffing Birthing suites need room for supporting family Distance from operating theatres a major issue for staff transferring women for emergency caesareans. Unsatisfactory provision for minor procedures now performed without anaesthetic in delivery suites but more suited to day procedures unit or theatres. Sterilising facilities inadequate No hot water for client to use for pain relief or washing 30
Current neonatal unit facilities inadequate overcrowded, understaffed, no piped oxygen or suction, no procedure room, washing facilities inadequate and cross-infection an issue in current unit. Lack of amenities for relatives
Proposed Service Birthing area to be redeveloped as 6 birthing suites, 2 assessment/prep rooms, plus first stage lounge. Access to theatre needs to be improved to facilitate transfer if Maternity unit is not relocated closer to the theatre suite, then a theatre should be developed within the birthing area. Develop O&G outpatients area to better accommodate antenatal, family planning and gynaecology clinics. Area should be in close proximity to labour ward, and should include antenatal clinic facilities, 4 consulting/exam rooms, NST room and ultrasound scan room. Also consider provision for day only antenatal assessment area (couches/lounge) + waiting area, either adjacent to ward or in outpatient clinic. Strengthen links with preventive health services to ensure continuity and improved management of high risk pregnancies Antenatal inpatient unit of 6-8 beds flexible bed use with postnatal ward of 25 beds in total inpatient area of around 30-35 beds. Crash trolley easily accessible for resuscitation of mothers and babies Provision for group room for educational activities Increased use of day surgery unit for minor procedures Consider admitting some gynaecology surgical patients to female surgical ward. Maintain outreach clinics to Savaii consider expansion to Aleipata. In longer term, provide medical staffing for senior registrar at MT2.
Neonatal
Nursery upgraded as functioning 10-12 place facility, with gas, suction etc. Provision for acute, step down and infectious zones.
Additional task : review/monitor LBW, reasons for admission, utilisation patterns & outcomes Staffing Requirements
Staffing Medical (excl. house surgeon) RN EN Ward assistants Current 2.0* 16.0** 6.0 1.0 Required 2006 5-6 27.0 11.0 3.0
* includes Chinese volunteer doctor. Third appointment due 6/01.
** includes NZ volunteer midwife
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Functional requirements Birthing: 6 birthing suites Bathroom(s) First stage lounge 2 assessment/prep rooms, one with NST relatives waiting area centrally located staff station operating theatre (if birthing unit remains remote from main theatre suite) medical records storage
Antenatal/Gynaecology 10 inpatient beds in 40 bed shared ward with postnatal outpatient clinic area with 2 beds for antenatal day assessment, doctors office, clinic rooms, access to ultrasound, NST Staff station shared with postnatal
Postnatal 30 beds in shared ward of 40 beds with antenatal group activities/health education room staff station amenities for families, relatives.
Neonatal 10-12 place nursery with gas, suction etc. Provision for acute, step down and infectious zones Access to treatment room staff station Access to accommodation for boarder mothers with babies in nursery
Support medical & nursing offices tutorial/meeting room
Outpatients Outpatient clinic area (in FWC) with waiting for 60 people, 6 consult/exam rooms (one with NST equipment), group education room. Area should also house family planning clinics.
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10.5
Paediatrics
Description Children account for around 40% of the Samoan population and the paediatric service at TTM provides both general and specialist referral services to children up to the age of 12 years. Some younger teenagers may be admiitted to the paediatric unit, but more commonly, children between the ages of 12 and 14 years are admitted to general wards. The paediatric service includes daily outpatient clinics which see an average of 70 children per day. While some children are referred for specialist consultation, most are selfpresenting, with minor illnesses and conditions which could be adequately managed by general practitioners. 4 beds in an area adjacent to the clinic are used for short term observation, asthma management, rehydration etc after which patients are generally discharged, although some are admitted to the ward if they fail to stabilise or improve. After hours and on weekends, children are seen in the general outpatient department. There is one inpatient ward of 35 beds nominally 25 medical and 10 surgical. This is a reduction from two wards and 60 beds occurred when the downstairs ward was closed in 1997 and the area redeveloped for paediatric outpatient clinics. The inpatient unit includes a high dependency area of 3 beds and provision for management of infectious diseases in separate rooms. Sick high dependency patients needing ventilation are sent to HDU. The main reasons for admission relate to respiratory and gastrointestinal infections, malnutrition, abscesses and surgical procedures (hernia, appendectomy etc). Orthopaedic cases are admitted to a paediatric area within the orthopaedic ward. The paediatric service also provides medical staffing to the neonatal unit located within maternity. The unit is staffed by 2 paediatricians (including one neonatologist), a senior registrar and a house surgeon (4 month rotation). The medical staff provides a specialist consultancy service to general outpatients if children with serious illness present after hours or on weekends. Activity The Paediatric unit is one of the busiest areas within the hospital, with occupancy exceeding 100% not uncommon. HIS data show that paediatric specialty activity exceeds paediatric ward activity, (indicating an overflow of paediatric patients into other areas). Currently the paediatric ward is operating at around 90-100%+ occupancy, with epidemics posing particular problems in managing demand.
Activity measure Admissions Patient days ALOS Bed equivalents (80% occupancy) Paediatric outpatient visits Children seen in GOPD 1998 1679 9580 5.7 33 N/a N/a 1999 2298 10994 4.8 38 16810 2780 change 37% 15% -16%
Table 27: Paediatric activity, 1998-99 (Source : HIS)
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Average length of stay is quite long at just under 5 days: this is believed to reflect cautious clinical practice: prolonged inpatient admission of children with rheumatic fever and malnutrition and delays in surgical discharges. More active outpatient and community nursing follow-up could see reductions in ALOS, reducing pressure on inpatient beds. Projected Demand The percentage of children in the population is projected to fall slightly over the next 5-10 years, but demand for outpatient service at TTM is unlikely to reduce significantly, given its general nature, without some restructuring of services. Currently, the delivery of paediatric services encourages a pattern of use which may not necessarily reflect actual needs. Were the paediatric outpatient service to become a referral service only, outpatient demand would be expected to fall by as much as 60-80%. As with general outpatients, the nature of much of the demand suggests the need for a stronger primary health care presence in the paediatric outpatients. The potential role of primary health nurses could be considered further in this respect, to reduce inappropriate demand for specialist paediatric consultation. The provision of well baby or child health clinics at the proposed community health centre may relieve some pressure on the clinic, but the extent of any reduction is unclear. Inpatient demand, while excessive for the current service, might be reduced with changes in practice and a stronger focus on ambulatory care, day surgery and community-based followup. If ALOS could be reduced to 3.5 days, a 10% increase in admissions could be managed within the existing bed supply. The other issue in demand relates to the large numbers of children on Savaii who do not access the paediatric service. Only 2% of paediatric outpatients are from Savaii, which suggests under-utilisation. The provision of outreach clinics to Savaii may expose previously unmet demand, and make more effective use of specialist paediatric resources. While additional inpatient beds may be needed, it is suggested that in the short term, efforts should be made to reduce ALOS and strengthen networking with district and community health services. Issues in Service Delivery Appropriate use of paediatric resources see above re outpatient clinics and inpatient beds scope for efficiencies in practice to manage demand within existing infrastructure. Need for improved triage of outpatients presenting at clinics and an increased nursing role in the care of children requiring only primary care. Nurse staffing on wards remains an issue seriously ill patients needing high dependency care cannot be managed on the ward. Need to strengthen parent education in areas such as nutrition, hygiene, rehydration etc a possible link with the NZODA Child Health Project to be explored. Need to extend outreach clinic service to rural areas, particularly on Savaii, providing referral service for district medical officers and community nurses. Some problems with clinical support services - quality and response times of pathology service. X-ray films not returned to referring doctors. Facilities OK (refurbished 1997) but sterilising provisions inadequate and additional equipment (infusion pumps, humidicribs, monitors needed for care of high dependency patients Absence of relatives accommodation means walkways are used by families for waiting, sleeping, eating etc seen as unsafe and unhealthy.
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Proposed Service Consider increasing bed allocation to 35 or 40, pending review of inpatient management practices and increased use of day surgery. More flexibility in the use of medical and surgical beds possible transfer of paediatric surgical beds to surgical ward to be considered. Review demand in paediatric outpatient clinics, assess needs for specialist referral, primary care and parent education. Increase role of nurses in providing primary care in paediatric OPD. Establish outreach clinics at MT2 and other district hospitals. Consider development of parent education centre in outpatient area. Possible development of live-in nutrition program for malnourished children and parents: this could be a day program with hostel type accommodation provided.
Staffing Medical (excl. house surgeon) RN EN Ward assistant Current 3.0 9.0 6.0 1.0 Required 2006 5.0 18.0 9.0 3.5
Functional requirements Possible development of unused downstairs area for nutrition education program, with hostel accommodation.
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10.6
Anaesthetics and Critical Care
Description The anaesthetics service supports all operating theatre activity, both scheduled and emergency, at TTM and provides anaesthetic support for the surgical list at MT2 (twice a month). The anaesthetics service currently provides: general and/or regional anaesthesia and/or intravenous sedation for surgical procedures at TTM and MT2 some acute pain management, mainly post operative input into management of HDU patients participation in trauma and resuscitation activities.
Support, including 24 hour cover, is provided for general and paediatric surgery, gynaecology, obstetrics, orthopaedics, dental services, ophalmology, ENT and private surgeons. The high dependency unit (HDU) was redeveloped in 1996 with assistance from AusAid and now functions as a 6 place unit, providing more intensive care for patients with lifethreatening conditions (eg multiple trauma, head injury, cardiac failure etc). The anaesthetics service has recently assumed greater responsibility for patients in the high dependency unit, with the return of a senior anaesthetist from further training in intensive care in NZ. Currently, anaesthetists provide consultancy advice/support to other specialists such as physicians in the management of HDU patients. Provide total care of ventilated patients. The service is staffed by 1 consultant and two registrar and a private anaesthetist (Savaii patients). There is currently one vacancy. Activity Anaesthetic activity is strongly linked with surgical demand. In 1999, an average of 50-60 anaesthetics were administered each week. The HDU has had relatively low occupancy levels (around 30%) over the past two years.
Activity measure Admissions Patient days ALOS 1998 136 743 5.5 Table 28: HDU activity, 1998-99 (Source: HIS) 1999 150 622 4.1 change 10% -16.3% -6%
Projected Demand While demand for anaesthetic services at TTM can be met with existing staffing, an expanded role would be more difficult to support. Demand for anaesthetic services would be expected to increase with changes in service eg expansion of surgical and HDU services as nursing workforce is restored implementation of pre-GA/OT assessments, including outpatient high risk clinic 36
pain clinic provision of a service for Savaii based at MT2 development of specialist teams to address particular problems (eg a trauma team with rostered anaesthetist, surgery and emergency medicine staffing).
In turn, with improved emergency medicine, retrieval and and trauma management, demand for HDU care would also be expected to increase. However, the existing unit has considerable capacity to accept this. Issues in Service Delivery Current staffing barely adequate to cover present duties additional staffing required to ensure staff receive adequate CME, clinical supervision and to support any expansion of services. Anaesthetic caseload and activity recently reduced due to staff shortages Concern that risks associated with poor health status and comorbidity may compromise outcomes if patients are managed on day only basis or discharged earlier need for careful selection. Day surgery would require more expensive anaesthetic agents which promote quicker recovery economics would require evaluation. Existing anaesthetic machines outdated and all different need to replace with up to date machines, all the same and with guaranteed technical support. Scope to further develop role of anaesthetists in critical care and trauma management, staff training and development of clinical protocols, to strengthen retrieval and critical care management systems and improve outcomes HDU occupancy level of <30% in 1999 indicates inefficient functioning. Need to ensure consistent staffing with suitably trained and skilled nurses difficult given fluctuating needs and current nurse shortages. HDU currently experiences technical difficulties in maintaining monitoring and ventilation functions due to problems with power supply and equipment maintenance.
Proposed Service Additional anaesthetic staffing required to provide service on Savaii and assume expanded role in trauma and critical care management future management of HDU to be more strongly tied to Anaesthetics and Critical Care specialty possible development of trauma team and a cardiac arrest team. Responsible for ordering anaesthetic drugs use in operating theatre avoiding current problem of overstocking.
Staffing Medical (excl. house surgeon) RN - HDU Anaesthetic technician Ward assistant Current 2.5 10.0 0 0 Required 2006 5.0 10.0 3.0 1.0
Functional requirements Anaesthetists need office area within theatres. Larger store room for standby anaesthetic machine/equipment and fridge for drugs. HDU - nil change at this stage.
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10.7
Dental Services
Description The Division of Dental Services provides clinical treatment and preventive dental services to the population of Samoa by means of a clinical dentistry service based at TTM and including general dentistry, oral surgery, endodontic, periodontic and prosthodontic services a mobile community dental team working from district hospitals and health centres school dental services, provided by two teams with a focus on oral health training of dental nurses/therapists (2 year certificate program) research on dental decay evaluation of new technologies and products.
Due to concerns about increasing rates of decay, a stronger focus on oral health education has been adopted in recent years. The Division is also responsible for a new program for the training of Dental Hygienists who specialise in preventive dentistry. The service is staffed by 8 dentists and 27 dental therapists. Activity An average of around 60 people per day attend dental clinics at TTM. Of these, some 5-10% are referred for specialist dental care: the majority are seeking pain relief or attending followup appointments. Clinical dental services activity declined slightly between 1995 and 1998 and between 1997 and 1998 there were falls in many aspect of activity, notably oral surgery. However, rates of decay are increasing, as shown in dental surveys performed in 1986 and 1996. This has had an impact on the number of extractions and temporary dressings, which rose slightly.
Activity measure Examinations/consultations Extractions Surgical procedures 1997 16115 7293 404 1998 14956 7664 244 1999 ? ? ?
Table 28: Clinical dentistry activity, 1998-99 (Source : DOH Annual Report)
Similar trends were observed in the activities of preventive dental services (not reported here). Projected Demand Hard to predict current prevention programs may counteract the increase in decay reported by the surveys and there is apparently some consideration being given to fluoridation of water supplies which may have a longer term impact on decay.
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Meanwhile, it seems reasonable to assume that demand will continue to reflect population growth and the supply of dental services. An increase of around 1-2% p.a. is assumed for the purpose of this plan.1 Providing the Dental Service is able to increase its workforce, and replace ageing equipment as required, it is believed that demand will be able to be met. Issues in Service Delivery Key issues relate to Loss of dental nurse staffing has been an issue for some years but is now being addressed with the introduction of the three year diploma course for dental therapists as well as local one year dental hygienist training programs. Equipment and facility requirements include up to date dental chairs and air compressors, X-ray machines and safe X-ray room and adequate sterilising facilities including new autoclaves. Existing equipment needs to be adequately maintained: this is an issue because delays in repairs and maintenance of equipment reduce the productivity of the service. Training facilities are located in old timber buildings that will need replacement due to its physical deterioration and unsuitability for the current level of training activity. With more space in the waiting room, dental education programs could be conducted while patients wait their turn. Damage to dental equipment is occurring as a result of transport and use in rural clinics. The van used for the mobile clinic is unreliable. This raises the issue of service delivery to rural areas.
Proposed Service Service will need to recruit additional dentists and therapists to maintain capacity, given current and projected attrition/retirements Upgraded X-ray and sterilisation facilities required to maintain safe operating standards. 6 up to date dental units required with appropriate equipment. Redevelopment or relocation of dental training facility is required as a matter of priority. Maintenance requirements to be addressed Mobile dental service vehicle to serve the rural population
Staffing Dentists Dental therapists Dental assistants Other Current 8 27 3 4 Required 2006 13 40 5 12
The 1998 DOH workforce plan anticipated a 25% increase in demand from 1998 to 2008 but the basis for this projection is not clear.
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Functional requirements Current clinical areas are basically adequate, although waiting area becomes crowded. Training facilities to be relocated/redeveloped more detailed functional assessment will be required.
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10.8
Mental Health Services
Description Mental health services are oriented to community management of mental disorders, with a strong focus on the role of the family in supporting patients at home. The model of care involves a partnership between the DOH and the community, with some acute care and rehabilitation being provided at TTM, but with the majority of intervention provided in community settings by the mental health team working with community nurses and families. The Family Focus Mental Health service is unique in the urban area in that is operates an integrated service across both hospital and community settings. Services provided include: consultation, assessment and treatment counselling services to families acute intervention in psychiatric emergencies rehabilitation for patients discharged from the acute care community follow-up and supervision forensic psychiatric assessment and treatment.
The mental health facility has two secure rooms associated with a 4 place rehabilitation unit. The facility is located in a small, recently upgraded building at the rear of the TTM campus which also serves as a base and clinic area for the mental health team. A car enables a mobile clinic and home visiting service to be delivered in villages across Upolu. The Mental Health Mobile Clinic service, established with WHO support in 1990, improved access and service to people with mental health problems and their families by taking services out into the community or transporting clients to TTM for appointments. Mental health is closely integrated with community care. Senior community nurses have received training in mental health and are generally responsible for identification, initial assessment and on-going management of problems within the communities they serve. There is a strong focus on family education and support. The mental health team provides assessment and intervention in more complex cases and works with community nurses in continuing care of some patients. Crisis intervention is provided on a 24 hour basis to the hospital and community. The service has 3.0 FTE nursing staff with mental health training, with consultancy advice and clinical support provided on an informal basis by the Mental Health CNC formerly responsible for the service, but now lecturing at the National University. There is no medical psychiatric back-up where required, prescriptions are issued by the Director of Clinical Services on the advice of Mental Health staff. A forensic psychiatric service is provided for assessment and treatment of people with mental disorders who have committed criminal offences. Activity Currently, there are over 700 clients on the books of the MHS. Most activity occurs in community settings, but reliable figures are not available at short notice. Use of the inpatient facility at TTM is limited because of its general unsuitability and the absence of medical or consultant supervision.
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Activity measure Patients Patient Days Average Stay (days)
1998 6 164 27.3
1999 2 101 50.5
Table 29: Mental Health Inpatient activity, 1998-99 (Source: HIS)
Demand for mental health services is being influenced by factors which include: increased rates of substance abuse with psychiatric sequelae return of clients from overseas to traditional village settings the drift into Apia of some mentally ill people.
Some increase is expected in demand for mental health services due to these factors and the return to Samoa of mental health patients on NZ invalid pensions and young people with substance abuse problems. The need for adequate crisis intervention as well as for preventive and community-based care is expected to emerge more clearly. Issues in Service Delivery Workforce is a major issue, with no medical supervision of psychiatric patients. The one CNC in Samoa is currently employed by the University, not the Health Department, although she provides services to TTM and in the community. There are only four staff nurses with mental health qualifications and recruitment has proved difficult. Mental health nurses being required to work in other acute wards at times has a negative impact on their ability to maintain community-based services. Current facilities are inadequate and unsafe for both clients and staff. The 2 place secure unit is not secure and has been damaged by psychotic patients. The 4 place rehabilitation unit cannot house male and female patients at the same time and lacks therapy areas. It is also used for outpatient clinics and a drop in service, but does not have suitably private consulting areas. The capacity to provide crisis response in areas such as Emergency Department is limited by both staffing and facility problems. Supply of psychotropic medications is limited: newer medications are expensive and only available on special request. As more patients return from overseas on these medications, this becomes a greater problem. The Mobile Clinic van was not replaced when it wore out and the service now has access to only one car, which restricts the outreach clinic service. Operating as an integrated program with preventive, acute and continuing care activities, Mental Health does not fit neatly into existing divisional structures and this is seen to be problematic in terms of planning, management and reporting.
Proposed Service While maintaining the commitment to the community-based, Family Focus model of service delivery, the service needs to be strengthened in terms of level and expertise of staff capacity to provide crisis response & liaison psychiatry role access to appropriate facilities.
Consideration to be given to establishing a Mental Health Program with its own management and budget. Support for nursing workforce development Services Plan for TTM 42
27/04/01
Investigation of options for provision of medical support including - training for ED staff, other medical staff and general practitioners to improve crisis response and prescribing support - the possible establishment of a tele-psychiatry link with a mental health service overseas Inclusion of a secure room suitable for severely mentally disturbed patients within the redeveloped Emergency Department Redevelopment of a mental health facility incorporating - inpatient unit with 2 secure places and 4 rehabilitation places, with separate bed rooms enabling male and female patients to be accommodated at the same time - outpatient clinic with private consulting and group therapy areas - base for mental health team Replacement of mobile clinic van.
Staffing Medical (excl. house surgeon) RN EN CNC Ward assistant Current 0 3.0 0 0.5 0 Required 2006 1.0 7.0 3.5 1.5 1.0
Functional Requirements Mental health facility should incorporate Inpatient unit 2 secure places with enhanced security provisions, providing for containment of psychotic and violent patients, in a safe environment which also prevents self-harm. 4 rehabilitation places, with separate bed rooms enabling male and female patients to be accommodated at the same time, a therapy room, a counselling/consulting room, a kitchen/dining room, bathroom (+ access to secure rooms) and staff station. The unit should have access to an enclosed garden area with umu
The inpatient unit should have its own access and should be readily accessible from the Emergency Department. Outpatient clinic with private consulting room - may be located with inpatient unit or in general outpatient area. Group therapy area possibly shared with rehabilitation unit. Base for mental health team office with 3 desks and telephones. inpatient unit. Located with
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CLINICAL SUPPORT SERVICES 11.1 Laboratories
Description The National Health laboratory is an integral part of the Health Service and has a role in both preventive/environmental health and acute care services. The main laboratories are located on the TTM campus and include the following core functions: Biochemistry section Blood bank/ Immunology section Haematology section Microbiology unit/TB section Public health/ hygiene section Histology/cytology section Forensic pathology/ Mortuary Services School of Medical Laboratory Technology
The Laboratory services constitute a separate division of the DOH and are responsible for the provision of public sector pathology services across Samoa. The service provides both routine and emergency on-call services to TTM. Patients are referred by private sector doctors as well as by the hospital itself and some tests are also performed under a contractual arrangement for MedCen private hospital. In addition to the analytical areas, the laboratories include areas for blood donation and screening of donors, specimen collection, receipt of samples, processing of specimens for analysis overseas, secure storage of specimens pending public health investigations, staff training and development and research. A regional laboratory at MT2 does a limited range of tests chemistry, haematology, microbiology but the volume is about 10% of that at TTM. More complex tests are performed at TTM. There is no formal courier arrangement for transfer of specimens from MT2: these may be sent with a nurse, driver or by plane. The laboratory has an arrangement with Auckland Hospital for more sophisticated, low volume tests. The Director is the only qualified pathologist, and provides both clinical and forensic services. At TTM there is a staff of 28, including 17 technical staff, with a further 3 at MT2. Training is provided locally for laboratory technicians via a two year certificate program which has been effective in maintaining the technical workforce to date. At present there is negotiation with NUS for a combined program in ML Science. Activity The laboratories perform over 600 tests daily, with the largest number being haematology (about 220 per day in 1998).
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Activity measure Biochemistry Haematology Blood Bank Microbiology Public Health Histology/Cytology Total
1996 - tests 59571 90176 40910 45000 2430 662 230947
1998 tests* 53344 80584 36455 40079 2132 1897 219411
Table 29: Laboratories activity, 1996-98 (Source: DOH Annual Report) NB 1998 numbers are believed to understate actual activity by up to 10% due to problems with the introduction of computer-based recording.
Demand for certain tests (eg cardiac enzymes, thyroid function, liver function) has increased in recent years due to both the rise in non-communicable diseases, and the growing number of younger doctors returning to Samoa after working in larger hospitals overseas. Projected Demand Demand for laboratory services will inevitably increase, and the rate of increase is likely to outstrip growth in core clinical services due to the increasing impact of chronic, noncommunicable diseases. An increase of 15-20% over the next five years would not be surprising, providing that the current volume of tests does not reflect over-ordering or inappropriate patterns of use. This estimate needs further analysis and consideration, relative to peer services elsewhere. Issues in Service Delivery Currently, concerns among clinical service relate to both the timeliness and quality of pathology services. This has implications for both the quality and efficiency of core clinical services. If the laboratory can not function to the required standard, the quality of hospital care is at risk. Delays in turnaround are due to staff shortages, reliance on manual rather than automated equipment and problems arising from equipment failure. The urgent need to recruit a successor to the present Director, who is due to retire, was highlighted in the 1998 Workforce Plan and remains a major concern for the hospitals future functioning. Maintenance, replacement and use of equipment and instruments are a continuing concern. Erratic power supply compounds equipment issues. Lack of policies/procedures and quality assurance program to benchmark with other laboratory services. The inefficient layout and poor working environment in the laboratory has been raised as an issue of major concern by DOH and in several reviews. In particular, areas handling high volume tests (chemistry, haematology) are located to the rear of the building, increasing travel distances and reducing efficiency. Blood bank is to distant from wards, ED and theatres. Half-height/glass partitions rather than walls are needed to improve supervision. Security is an issue with public and analytical areas not effectively separated. Storage is a problem due to current inflexible layout and redundant equipment occupying floor and bench space. The need for HIS data entry to be done by technicians has slowed response times and some activity data are incomplete. Occupational health risk associated with installation/change of filters in safety cabinets need specially trained maintenance staff. 45
Proposed Service Support for workforce development/recruitment is considered essential to the future viability of the service. As well as the need for clinical and forensic pathology, the blood transfusion service requires clinical supervision. While the laboratories appear to have adequate space to support the present range of functions, there is no doubt that this could be better organised. The need for selective replacement or repair of equipment similarly needs expert review, in light of the current and projected workload. The potential capacity of the laboratories to perform some tests currently being sent to NZ in considerable numbers could be usefully examined. A review of ordering patterns and flows relative to work practices and available technology is needed to provide clear direction for future service planning. This review should be performed by a clinical pathologist familiar with accreditation standards and recent developments in laboratory service delivery. Staffing Requirements
Staffing Pathologists Chief technician Technicians Clerical Current 1 1 22 2 Required 2006 2
It is difficult to determine actual staffing requirements without knowing how far automated processes could substitute for current manual arrangements. Functional Requirements To be determined, subject to the above reviews. A few general observations can be made: Public areas should incorporate reception area with area for specimen reception/registration, specimen collection + phlebotomy (2 private cubicles) and a separate area for blood banking/collection. An area separate from but near reception and also accessible from the main laboratory, for packaging and storage of sendaways. Laboratory areas should be secure (P2) A more open plan, hub and spoke layout is suggested, with a central open laboratory area for common equipment (automated, high volume, multidisciplinary) shared by haematology, biochemistry and serology. Separate smaller areas for sections such as microbiology, haematology, biochemistry, TB/public health and anatomical pathology could accommodate tests requiring manual techniques. Improve refrigerated storage facilities including (shared) minus 70 degrees fridge and 4 degrees fridges these could be either shared walk-in or smaller separate facilities. Other storage also needs to be rationalised to improve efficiency and safety. A training area for technicians is needed but could be separately located. 46
11.2
Pharmacy
Description The Pharmaceutical Division, based at TTM, is responsible for the procurement, supply and management of drugs provided through all public health services and facilities in Samoa. Within TTM, the pharmacy provides drugs for inpatients and outpatients and is also responsible for procurement of theatre supplies. Daily deliveries are made in response to requisitions from wards and nurses also collect individual prescriptions from the pharmacy as required. A subsidiary pharmacy operates at MT2. Deliveries are made to other centres using cars accessed through the government car pool. The TTM pharmacy opens on weekdays from 8am to 4.30 pm and from 6pm to 10 pm and between 9am and 3pm on weekends. An on call service is provided out of these hours. While patients contribute to the cost of drugs, pensioners and patients with certain conditions are entitled to free drugs. Since drug charges were waived for some non-communicable diseases (eg diabetes, hypertension), drug subsidy costs have increased. The divisional budget rose from just over $2m in 1996-97 to more than $4m in 1997-98 with much of this increase reflecting changes in purchasing to improve drug quality. The Director of Pharmacy is the only registered pharmacist, although a second pharmacist is due for registration within the next year. Although there are five senior non-registered pharmacists, workforce remains a major concern. This has constrained the development of services such as clinical pharmacy, drug information and monitoring. There is an on-going training program for pharmacy technicians. A DOH Drug Policy has been prepared, to ensure that public sector pharmaceutical services are adequately staffed and equipped to supervise the implementation of the National Drug Policy. Implementation of this policy would see an expansion of the role of pharmacy services with a stronger focus on information, monitoring, quality and regulatory functions. The pharmacy is located at the top end of the TTM campus with bulk storage beneath. Activity The pharmacy at TTM dispenses an average of 600-700 scripts per day. Service Delivery Issues Workforce is the major concern for the Pharmacy service, given the broader role expected in future. In particular, the expansion of regulatory functions, clinical pharmacy, drug information, poisons information and therapeutic drug monitoring will require additional qualified pharmacy staff. Drugs at district hospitals are now dispensed by nurses: any change in this policy is likely to increase the need for trained pharmacy assistants (local certificate holders). Lack of control over the contents of aid containers being addressed in drug policy. Loss of delivery vehicle and need to rely on pool cars has meant delays in deliveries to other health facilities. Inventory management and storage are issues at present: the bulk store capacity is exceeded by the amount of stock held which results in some drugs and supplies being held in non-air conditioned areas. Changes in procurement practice and the move to a computerised inventory system may help. 47
The physical condition of the existing bulk store is unsatisfactory, given current ordering patterns. Only limited space is air-conditioned, there is no loading dock access and there is no secure storage for expired dangerous drugs. Consideration should be given to offsite storage. Stock management at district hospitals is a problem due to irregular deliveries and stock monitoring and uneven ordering practices. Current computer equipment is inadequate for needs of Pharmacy a PC or terminal is needed in each section (district supply, ward supply, internal, outpatients).
Proposed Service Maintenance of current role with improved procurement and inventory provisions Standard treatment guidelines needed to ensure optimal use of pharmacy. Electronic networking with wards and other health facilities to facilitate information, efficient ordering, drug use monitoring etc will require more computer equipment and training for staff. Review of current ordering patterns and storage arrangements with particular attention to temperature, security (notably for dangerous and expired drugs) and access for delivery vehicles. Expansion of activity in clinical pharmacy, drug information need for accessible area for drug education/information activities as well as health worker training. Pharmacy aims to train additional pharmacy assistants to rotate to about 6 district hospitals, to improve drug use and stock management. Development of Drug Inspectorate to implement quality assurance processes at all levels of the drug supply system.
Staffing Pharmacist - registered Other pharmacist Pharmacist Assistant Other Current 1 5 8 3 Required 2006 3 5 15 3
Functional Requirements To be determined, subject to the above review.
48
11.3
Radiology & Ultrasonography
Description The Radiology and Ultrasonography service provides a range of medical imaging services including general and special X-ray, ultrasound and mammography to support core clinical services. 24 hour, 7 day emergency service is provided at TTM and MT2 hospitals. The service is also responsible for the training of X-ray technicians and for overseeing radiation safety measures relating to both staff and patients. There are two qualified radiologists, supported at TTM by 8 radiographers (5 qualified, 3 locally trained) and a number of technicians and assistants. The service at MTII is staffed by one radiographer, one assistant and a technician. Facilities and equipment at MTII are relatively modern and are considered to be adequate for current and projected demand. The service has developed professional linkages with the director of radiology at Lismore Base Hospital in Australia who visits annually and whose department has provided training and technical support. The Director of the service provides some consultation to the private sector. Activity The service performs over 40,000 examinations annually at TTM and around 2,000 at MT2. Medical imaging activity at TTM increased by over 15% between 1997 and 1998, with the largest increase (76%) occurring in ultrasound examinations, particularly obstetric ultrasound, due to the arrival of new equipment.
Activity measure Chest X-ray General X-Ray Ultrasound Other examinations Total 1997 18,604 14,290 2,898 787 36,579 1998 20,486 16,135 5,106 501 42,228 1999 19,228 16,998 3,875 838 40,939
Table 30: Medical imaging activity TTM, 1997-99 (Source: DOH Annual Report + Radiology Service records)
A slight fall occurred in general X-ray activity from 1998 to 1999. This coincides with one general screening room being no longer operational due to equipment failure and screening activities being carried out in a modified general room. The unavailability of gastroscopy services over the past two years has resulted in increased numbers of barium studies being required. Service Delivery Issues There is believed to be some excessive and unnecessary use of X-rays under the current service arrangements (i.e free service): this is seen to increase radiation risk to patients as well as wasting public resources. Key issues relate to facilities and equipment the special studies X-ray room dating from 1980 is no longer functional and requires refurbishing and re-equipping with up to date X-ray equipment and new image intensifier. Services Plan for TTM 49
27/04/01
Relative to Australian standards, the current workload through the general X-ray rooms is excessive. [Standard = 3,700 8,000 screens per room per annum] This suggests that over the coming decade, as the Department develops a wider range of services, there will be pressure for additional x-ray rooms, equipment and staff. Site master planning should allow for eventual expansion of this department. There are growing numbers of requests for patients to be flown to NZ for CT scanning. The lack of a mobile image intensifier for theatre use is a problem and the requested aid funded acquisition is the highest priority for the department. TTM Hospital has three functioning ultrasound machines though one is now outdated and in need of replacement. A new color doppler machine is located in the maternity unit and reserved for its exclusive use. This reduces the efficiency of use of resources in the hospital and limits the development of consistent quality control measures. Radiation safety is a matter of concern, in the absence of a Radiation Safety Act. Current organizational arrangements preclude the radiology department from providing safety and quality control assistance to the Dental Department which relies on equipment which is inadequately maintained and poses a potential hazard to staff and patients in the unit.
Proposed Service The issue of fees for radiological examinations should be considered as a means of discouraging unnecessary imaging examinations. Careful workforce planning and professional development are important to ensure an adequate supply of specialist skills, both medical and technical. Consideration of service enhancements, notably provision for fine needle biopsy. Additional staff and training would be required to support such changes. Replacement of equipment (screening unit, image intensifier and ultrasound unit) and refurbishing of second screening room. A mobile image intensifier is needed for operating theatres and mobile x-ray for ED. Provision for regular replacement/upgrading of other equipment on routine basis. Digital technology should be considered in the longer term to facilitate teleradiology links within Samoa and between Samoa and other Pacific countries. Consideration should be given to expanding the responsibilities of the Radiology and Ultrasound Department to include management and/or supervision and quality control of all x-ray and ultrasound services provided in TTM Hospital.
Establishment of a Radiation Safety Act is seen as essential to ensure that international standards are met before the importation, distribution and use of radiological equipment in Samoa. Staffing Requirements Staffing required at TTM is as follows:
Staffing Radiologist Radiographer (qualified) Radiographer (locally trained) Assistants/technicians Current 2.0 5.0 3.0 6.0 Required 2006 2.0 3.0 8.0 4.0 6.0
Additional staffing is required for MTII.
50
Functional Requirements 2 general rooms (with potential for expansion to three) one large special studies room with modern tomography and image intensification capacity. 2 ultrasound rooms mammography room film processing rooms with appropriate ventilation and safe chemical management facilities associated waiting area and patient change facilities reporting room film and records storage area equipment storage area office for Director, staff room
51
11.4
Rehabilitation
Description The rehabilitation service currently has two physiotherapists and one occupational therapist (OT) with one assistant. The service, which is based downstairs in the orthopaedic block, operates from 8 am to 4.30 pm and longer on orthopaedic clinic days. It provides therapy services to both inpatients and outpatients and trains relatives/carers to implement therapy plans for patients on discharge. As well as providing treatment in the designated physiotherapy area, the physiotherapist treats patients unable to be transferred within the medical ward. Outpatient follow-up is dependent on the patients ability to return to the clinic: this can be difficult for people with disabilities depending on public transport. The workload is principally orthopaedic, but increasing numbers of patients are presenting with strokes (associated with undiagnosed hypertension), amputations and chest conditions. Patients are either referred by doctors or picked up when the physiotherapist is doing ward rounds. The service is also responsible for the equipment pool and receives substantial support from the Thorn ministry in this respect. The service works closely with the prosthetics and orthotics service which is located (with the equipment pool) at a considerable distance in the old timber buildings. Activity The physiotherapy service sees around 15-20 patients per day, mostly outpatients. Each patient receives an average of 4-5 treatments.
Activity measure Outpatients Patients seen Treatments provided 631 2912 1999 Inpatients 362 1732 Total 993 4644
Table 31: Physiotherapy activity, 1999 (Source: Physiotherapy Dept)
Projected Demand Demand for rehabilitation is increasing with rising injury, stroke and disability levels. There are relatively few measures of demand which can reliably predict future growth, however the growing need for rehabilitation services was identified by nursing staff in 1998. In practice, activity is contained by supply factors but could be expected to double with additional staffing. Issues in Service Delivery Much unmet demand exists at community level because of transport barriers which prevent people with disabilities accessing outpatient services. This results in unnecessarily high levels of disability in the population. A community/domiciliary rehabilitation service could improve functional outcomes and reduce disability levels. Therapists could work with community nurses to provide a broader service. 52
The present facility is distant from the medical/surgical/paediatric wards, reducing access by patients in these areas. A therapy area is needed in or near the acute ward area. Distance from prosthetics an issue for limb fittings closer proximity or functional link desirable. Present gym is too small for both physiotherapy and occupational therapy: also lacks office and storage areas. Prosthetic workshop inadequately equipped given expertise of technicians
Proposed Service Expansion of service to provide both centre based and outreach rehabilitation programs, including physiotherapy and occupational therapy. Development of rehabilitation department, with appropriate facilities for treatment of both inpatients and outpatients Access to pool for hydrotherapy.
Staffing Requirements Additional staffing will be required, although in practice, staffing numbers may be limited by workforce availability. If staff or volunteer therapists train community nurses to supervise exercise programs, community nursing numbers may need some adjustment.
Staffing Physiotherapist Occupational therapist Orthotic technician Therapy assistant Current 2 1 1 1 Required 2006 2-3 1-2 2 2
Functional Requirements Physiotherapy gym area with room for 3-4 benches, parallel bars, steps and exercise equipment OT kitchen, bathroom & therapy area Office & sink area Bulky equipment storage Clinic/prosthetics fitting room with work bench Should be accessible from inpatient wards and by outpatients arriving in cars.
53
11.5
Nutrition and Dietetics
Description The Nutrition Service is responsible for three output areas: Preventive nutrition (Nutrition Centre) Clinical nutrition & dietetics Food services for patients (TTM kitchen)
The Nutrition Centre is part of Preventive Health and aims to improve the nutritional status of Samoan people. To this end it is involved in: Nutrition surveillance Food and nutrition education/promotion Data collection, analysis and reporting Nutrition advisory services and special projects.
The clinical nutrition section, part of Clinical Health Services, aims to provide advice and education about special diets for the people of Samoa. It also provides supplementary feeding for malnourished children. The TTM Hospital kitchen, also part of Clinical Health Services, aims to supply safe, nutritionally appropriate food to hospital patients and staff. It also caters for refreshments for visitors and staff. The Chief Nutritionist, based in the Nutrition Centre, manages the Nutrition Service. Within the hospital, there are two posts: one dietitian and one dietary educator. Currently, the dietitian provides dietary counseling on an ad hoc basis and also conducts training about special diets and food safety for health workers. The dietary educator provides basic dietary counseling and education for caregivers of malnourished children, conducts education sessions about infant feeding and healthy diets for people with diabetes and also distributes nutrition education materials for patients. A plan is now in place to expand dietary counseling and education activities, development/distribution of educational materials, and to provide supervision of nutritional standards. Activity
Activity clinical nutrition Dietary counseling individual sessions Group dietary education sessions Health worker training sessions Lectures to trainees Special dietary pamphlets distributed Malnourished children receiving supplementary feeding Performance, 1999 345 16 5 2 1370 46
The kitchen served an average of 610 meals per day: 423 for patients and the remainder for staff (both live-in and duty). 10 types of special diets were provided.
54
Projected Demand The ASDA planning guideline provides for one dietitian per 100 beds: on this basis, two positions would be required to support TTM with some outreach services being provided.2 Given the high prevalence and costs of diabetes, it is reasonable for one position to focus predominantly on the needs of diabetic patients, both inpatient and outpatient. Issues in Service Delivery Need to integrate nutrition service more effectively within clinical service delivery structures some difficulties given current organisational structure. A base within the hospital would help. NC is currently located outside the hospital. Inadequacy of current clinical dietetics service relative to level of need in hospital Difficulty recruiting appropriately skilled/qualified staff. Lack of professional recognition of nutritionists and other allied health staff.
Proposed Service 2 dietitian/nutritionist positions within TTM hospital to target patients needing dietetic input special diets, individual counselling as well as - supervising diets and food service standards for patients in major risk groups - liaison with clinical staff regarding appropriate dietary regimes for patients - provision of training for kitchen staff in special diets, food handling and safety - provision of clinical dietetic services to relevant patient groups in OPD. TTM clinical nutrition staff to be involved in outreach programs (eg with diabetic or child health teams) Provision of nutrition and diet education and information direct sessions and materials posters and pamphlets available within hospital. Development of public awareness of common diets (eg diabetic) through media activities. Maintenance of preventive education strategy targeting community influentials, based at Nutrition Centre.
Staffing Requirements On the basis of Australian standards, the hospital would require 2.0 clinical dietitians to support 200 beds. Given the prevalence of diabetes and nutrition-related disorders, it is suggested that this standard be applied with the clinical dietetics role extending to outreach clinics. If bed numbers reduce, then the outreach role could be expanded.
Staffing (Clinical only) Dietitian/nutritionist Dietary educator Current 1.0 1.0 Required 2006 2.0 0.5- 1.0
Functional Requirements
2
Nutrition centre status quo or equivalent. Garden is integral and essential feature of activities. Room for dietary counselling in OPD. Education area in acute ward area could be shared with other services/functions. Nutrition module linked to HIS
Ideally, MT2 would have some dedicated position(s), but the desirability of a separate service compared with outreach from TTM would need further consideration. Services Plan for TTM 27/04/01
55
11.6
Medical Records
Description The Medical Records service provides reception, patient registration and medical records support for inpatient and outpatient services at TTM. It is directly responsible to the Director, Clinical Services. Services currently provided include: Reception, patient enquiries and clinic appointments Scheduling of special outpatient clinics Registration of all new patients in HIS Preparation of - outpatient record cards - admission and discharge forms for all inpatients - medical records for new inpatients Compiling, filing, maintenance, safekeeping and retrieval of records Collection and management of hospital information, including coding, disease indexing and generation of reports Archiving of old records Training of medical records staff.
Medical records staff also retrieve and collate charts for outpatient clinics provided outside the main OPD ie family welfare centre, orthopaedics and paediatrics. While the main inpatient records storage and processing area is located with the reception area at the main entrance of the hospital, a second area in the general outpatient department provides storage for outpatient files and a base for the 24 hour service provided to the hospital. The computerised Health Information System (HIS) which has been developed and implemented over the past two years has reduced manual activities to some extent and facilitates patient identification, record retrieval and data collection and analysis. The service is staffed by 24 FTE staff, rostered in eight hour shifts to provide 24 hour cover. The Medical Records Officer is supported by a Medical Records Supervisor, 3.0 Senior Medical Records Clerks, 19.0 junior clerical staff and one casual runner. Activity The number of records processed relates directly to the level of patient activity at the hospital, peaking on Mondays and Tuesdays with the OPED caseload. An increase of around 10% is anticipated in inpatient activity over the period to 2006. Issues in Service Delivery Some delays in return of charts from wards, with flow-on effects on ability to make followup appointments, complete coding and data entry. Current facilities present a number of problems: service is split across two sites with resulting inefficiencies, due to the need to improve after-hours access to charts for OPED patients. current inpatient records area is not air-conditioned or secure inadequate for proper storage/care of records, equipment and computer systems. 56
space constraints limit both the processing/compiling area and storage capacity (5 years).
The location of the HIS server in HRPIRD building restricts access to the stand-by generator during prolonged power cuts, so that medical records staff cannot access computer-based information. Workforce is an issue in that there is currently only one qualified MRO in the unit. Another post is needed to provide adequate coverage and technical expertise when the MRO is absent. With only 3 senior MR clerk positions, there are limited promotional opportunities for junior staff.
Proposed Service Development Priority to be given to staff development and recruitment of qualified staff. The establishment of some intermediate staff posts would provide incentives for staff to upgrade skills. If possible, integration of two sites to a single medical records area, of adequate size, airconditioned and secure. Alternatively, retain existing sites but address facility issues of space, air-conditioning and security. Consider separation of reception/enquiries function from other MR activities. Over the next five years, the electronic HIS network is expected to expand to take in wards, clinics and district hospitals. This may reduce manual processing activities but will require increased health information training and technical support. The development of an integrated medical records service would enable staff to be used most effectively across all facilities. Provision of ward clerks to supervise file management, data entry and processing at ward level. Integration of MT2 medical records system with main system at TTM.
Staffing requirements:
Staffing MR officer MR supervisor Senior MR clerk MR clerk - intermediate Clerical assistant Current 1.0 1.0 3.0 0 19 Required 2006 2.0 1.0 3.0 3.0 16
Functional requirements A single medical records dept of adequate size to allow for the following functions: Patient registration Access for OPED staff to records Chart processing and compiling Storage for 7 years of inpatient files and outpatient cards Office for coders 3 terminals MRO office. Supervisor office
The area should be air-conditioned, secure and located centrally so that it is readily accessible on a 24 hour basis by OPED staff but also accessible to wards.
57
11.7
Central Sterile Supply Department
Description The Central Sterile Supply Department (CSSD) provides sterilising services for TTM and to some district and private hospitals in respect of: Operating theatre and other surgical equipment Surgical and obstetric bundles/trays Sterile dressings and bandages (packed in CSSD) Drapes and linen for theatres, delivery ward and procedure areas.
Cotton wool and gauze are manually cut, counted and packed by CSSD staff. An imprest system operates to supply sterile supplies to operating theatres, OPED, delivery ward, HDU and wards, with twice daily rounds made by CSSD staff. The service operates from 7 am to 3 pm on weekdays, 7 am to 1 pm on Saturdays and provides a 24 hour on-call emergency service outside these hours. CSSD is also responsible for ordering and storage of sterilising solutions, surgical supplies and maintenance of sterile stock levels. There are two steam sterilisers, including a large new computer operated unit and an older manual unit, and one autoclave. The service is located adjacent to theatres and is currently staffed by a supervisor and 5.0 FTE staff. On site training is provided to sterilising assistants by the supervisor. The current facility is of adequate size and generally quite functional. Activity In the six month period from June to December, 1999, CSSD sterilised over 63,000 items. Activity fluctuates markedly from month to month, reflecting the impact of visiting surgical teams. Issues in Service Delivery Since CSSD was removed from Nursing Division, supervision and replacement of staff has been more difficult. The issue of supervision has been highlighted since the RN supervisor was badly burned when using the large steriliser. CSSD was without a qualified supervisor for several months and while staff are seen to be competent, the lack of alternative supervision is a concern. Staff training and upgrading of knowledge and skills are needed to manage new equipment and ensure that sterile supply products and practices are up to current standards. In the absence of an automated medical equipment washer, CSSD relies on manual washing of equipment. There is currently no hot water in rinsing/soaking area staff must carry bowls of hot water from a zip boil. Taps are hand, not elbow operated. Basic small equipment is needed, such as a new cutter and an autoclave pack sealer. Trolleys used for collection and distribution of supplies urgently need new wheels. Instruments are reported to be deteriorating more quickly appear to be of a poorer quality than formerly. Delays in replacement occur due to changes in the ordering process.
58
Proposed Service Development Closer links between CSSD and Infection Control are recommended. The current facility is well located and adequate, although the hot water supply and flooring warrant closer attention in terms of infection control. Additional staff are required for preparation of dressing packs if current practices are maintained. There may be some benefit in considering pre-sterilised packs, rather than expanding staff numbers this will depend on the relative cost efficiency of both options. A deputy supervisor is required. Devolution of budget responsibility to unit level would be welcomed.
Staffing Supervisor Deputy supervisor EN/sterilising assistant Current 1.0 1.0 5.0 Required 2006 1.0 1.0 6.0
Functional requirements Current facility is generally adequate in terms of space and work flow, but equipment issues should be addressed.
59
11.8
Biomedical Engineering
Description The Biomedical Engineering (BE) Unit is responsible for testing, servicing, maintenance and repair of all medical equipment provided through hospitals across Samoa, although 75% of its work relates to TTM Hospital. Some repairs are provided on the spot but most equipment is brought in to the workshop. In some cases, usually involving more sophisticated equipment, repairs by external contractors are arranged. The BE unit also works closely with clinicians to advise on the selection and procurement of new equipment. New equipment is thoroughly tested for technical quality in the biomedical engineering workshops before commissioning and hospital staff are trained by BE staff in its use and care. Some equipment is modified to suit local needs. The BE unit currently maintains the oxygen supply and undertakes a number of other aspects of electrical maintenance due to the lack of adequate electrical maintenance support. The major source of BE requisitions is the Radiology service, which accounts for around 40% of all activity. Other areas which generate significant demand include theatres, HDU, Maternity, OPED, laboratories and the dental service. The BE unit currently has 3.0 FTE staff including the Chief Technician and is based in premises located beneath the laundry at the rear of the hospital. The BE workshop incorporates mechanical and electronic workshops and a small reception/office area. Activity Demand for biomedical engineering support has expanded consistently with the growth of technology within health services, particularly at TTM Hospital.
Activity Measure Repairs New equipment installations Training sessions for health staff Litres of Oxygen produced July-Dec 1999 224 27 3 5,480
It is inevitable that demand for BE support will continue to expand, given the expected growth in biomedical technology which is occurring in health services everywhere. Issues in Service Delivery Current staffing is unable to meet demand for service (particularly from radiology) and frequently works overtime to ensure that equipment is available for scheduled clinical activities. A fourth technician post has been vacant for some time. Preventive maintenance cannot be undertaken as required because of competing demands for urgent repairs, so that equipment deteriorates unnecessarily. Workshop is remote from clinical services it supports, work areas are inadequate and not planned to suit the functional needs of BE. Staff training is required on an on-going basis to ensure that new and increasingly complex equipment can be supported locally rather than having to rely on outside 60
contractors. A technical library is needed, including manuals for all biomedical equipment acquired. Available tools and test equipment currently use very old technology these require upgrading with appropriate training for BE staff. Oxygen plant makes considerable demands on BE staff time, although its maintenance is not strictly a BE role. Clerical workload reduces time available for technical activities: very limited clerical support is provided and these activities fall to technical staff.
Proposed Service Development Increase staffing by recruiting additional X-ray technician. Address staff training needs and establish technical library. Consider relocation of workshops to an area closer to X-ray, theatres and clinical areas. Upgrade test equipment and tools to comply with technical demands of new equipment and technologies.
Staffing Chief Technician Technician Current 1.0 2.0 Required 2006 1.0 4.0
Functional requirements Workshop area to incorporate: mechanical repair workshop electronic repairs and equipment testing laboratory office/workspace for chief technician space for technical library bulky equipment storage area other storage area for tools, components, spare parts etc
Electronic and testing workshop to be air-conditioned and anti-static. Loading dock access required to allow for delivery and collection of equipment.
61
11.9
Prosthetics and Orthotics
Description The role of the Prosthetics and Orthotics (P&O) Unit is: to manufacture and maintain prostheses for amputees and other patients requiring artificial limbs to provide prosthetic consultation to patients their families regarding prostheses and their care. to maintain and repair mobility equipment (wheelchairs, crutches).
The P&O unit services hospitals throughout Samoa, although some 80% of work comes directly from TTM hospital. While the service is funded by DOH, assistance with equipment is provided by the Thorn Ministry. The P&O workshop is a free-standing building, located at the western (?) end of the hospital campus and is staffed by 3.0 prosthetists. Activity The only activity recorded is wheelchair repairs. In 1999, an average of xxx wheelchairs were repaired per week. Amputations are reported to be increasing due to increasing levels of peripheral vascular disease and traumatic injury. In previous years, (1970 to 1989) before the workshop was destroyed by cyclones, an average of 3 new artificial limbs and a similar number of leg braces were manufactured each year. Issues in Service Delivery Manufacture of artificial limbs has ceased due to the lack of resources (materials, equipment). This means that amputee patients must either seek private prosthetic service or manage with crutches. At the same time, prosthetic skills are not used effectively. P&O staff require assistance in preparation of budgets and service management to ensure available expertise is used effectively. Current workshop and fitting area is remote from wards and rehabilitation service and access is difficult for people with disabilities.
Proposed Service Development Relocate to area closer to rehabilitation unit and with adequate disabled access. Review staffing to ensure staff numbers and skills are consistent with role of unit and fully utilised. Provide business management support/training to unit to ensure that service delivery is adequately planned.
Staffing Chief prosthetist Prosthetist Technical assistant Current 1.0 2.0 0 Required 2006 1.0 1.0 1.0
62
Functional requirements Workshop with adequate space for prosthesis manufacture and fitting, wheelchair repair, bulky equipment storage, materials storage and office area. Workshop should be located closer to rehabilitation area and have good disabled access.
63

Clinical Services Plan TTM Samoa

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Clinical Services Plan TTM Samoa

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SAMOA HEALTH SECTOR MANAGEMENT PROJECT CLINICAL SERVICES PLAN FOR TTM HOSPITAL

DEPARTMENT OF HEALTH March 2001

TABLE OF CONTENTS Page No.

Services Plan for TTM 27/04/01

Bed equiv. 45 45-50* 40 10 35 6 6** 187 - 192

includes 10 short stay or day surgery beds. includes 4 rehab beds

Services Plan for TTM 27/04/01

Services Plan for TTM 27/04/01

Anaesthetics Introduction of anaesthetic technicians New anaesthetic machines

* Includes ENT and Dental

Services Plan for TTM 27/04/01

HDU No change necessary in facilities

Services Plan for TTM 27/04/01

Services Plan for TTM 27/04/01

Services Plan for TTM 27/04/01

Services Plan for TTM 27/04/01

Services Plan for TTM 27/04/01

Name Tupua Tamasese Meaole (TTM) Hospital

Tausivi, Savaii Upolu Lalomanu, Upolu Savaii

Table 1: Hospitals, Samoa, 2000

Table 2: Health Centres, Samoa, 2000

DEMAND FOR HEALTH SERVICES

Services Plan for TTM 27/04/01

Table 4: Population distribution by Health Region Source: DOH Annual Report

Table 5: Health service utilisation, Samoa 1999 Source: HIS

Table 6: Utilisation rates x Health Region of residence all facilities

Services Plan for TTM 27/04/01

Table 8: Inpatient bed distribution, TTM 1999

Services Plan for TTM 27/04/01

Services Plan for TTM 27/04/01

Consultant/ specialist 1 1 2 1 2 1 0.2 2 1 12.2 12.2

Registrar/ senior registrar 4 3 1 1 1 2 1

Total 6 5 5 4 5 4 1.2 1 1 1 35.2 39.2

Table 9: Medical staffing, TTM and other, March 2001

By comparison, less than half of the nursing workforce is based at TTM.

Principal Nurse 1 Vacant 1 1 3 + 1v

Nurse Manager 6 + 2v 1 3 5 1 16+2v

Total 118 23 35 55 33 1 265

Table 10: Nurse staffing, TTM and other, March 2001

1997 1998 1999

Table 10: Inpatient activity, TTM 1997-99

Services Plan for TTM 27/04/01

Adms 2298 1508 4081 1431 2 192 9512

Beddays 10994 12952 8641 8042 101 1067 41797

ALOS 4.8 8.6 2.1 5.6 50.5 17 4.4

Bed equiv. 38 44 34 28 0 4 147

Table 11: Distribution of inpatient activity by specialty, TTM 1999

Table 12: Distribution of inpatient activity by specialty, TTM 1999

Services Plan for TTM 27/04/01

Average attendance per session 150+ per day 14 34 33 15 20 13 37 15 5 19 16 221

Table 13: Distribution of outpatient activity by specialty, TTM 1999

General OPD Emergency Dressing clinic

Table 14: Distribution of outpatient activity GOPD, TTM 1999

Services Plan for TTM 27/04/01

Services Plan for TTM 27/04/01

Bed equiv. 45 45-50* 35-40 10 35 - 40 6 6** 180-195

Services Plan for TTM 27/04/01

Attendance 118753 104854 97157

Table 16: TTM outpatient attendances, 1995-1999

Projected demand is:

Services Plan for TTM 27/04/01

Services Plan for TTM 27/04/01

Services Plan for TTM 27/04/01

Table 18: TTM medical activity 1998-99