For want of a nail . . . the battle was lost

The Health Minister of South Africa, Dr. Aaron Motsoaledi joined the HASA and Best Care . . . Always quality improvement summit and gave a thoughtful overview of the challenges facing this country. Hearing one of his remarks took me back to a public hospital visit I made earlier in the week.

Here was his comment:

We have an extremely under-resourced public health care system that is serving 78% of the population, struggling to meet quality standards.

You may recall my praise for the work of several staff members at Charlotte Maxeke Johannesburg Academic Hospital.  Their focus has been on reducing ventilator associated pneumonia in the neuro-ICU.

One aspect of the VAP bundle implemented by Phindi and her staff is too enage in "closed suctioning" of the ventilator to remove biological material in which infections can breed.  This is accomplished with the kind of apparatus seen here.  It simply attaches to a port on the tracheal ventilator tube.

If the closed suction equipment is not used, an "open suction" approach is used, which requires removal of portions of the ventilator.  While the literature suggests that both approaches are equally efficiacious, experience in this hosptial suggests otherwise.  Simply put, in this hospital's environment, it is difficult to respect general precautions in the sanitary-epidemiological regime and barrier nursing techniques.

Accordingly, the staff at Charlotte Maxeke hospital have concluded that the closed suction approach is preferable.

Here's the rub.  A closed suction device of the sort shown above costs 150 rand (about $15).  After a certain amount of time during the budget year, the hospital runs out of them and cannot afford to buy more.  The rate of VAP seen by Phindi and her staff correspondingly rises.  This is the case notwithstanding that the avoidance of VAP brings financial benefits to the hospital well in excess of that price (reduced length of stay, avoiding antibiotics, and so on)--but the budget decisions for these supplies are centralized in a purchasing agency that is subject to other pressures.

So here's a concrete example of Dr. Motsoaledi's remark, "an extremely under-resourced public health care system . . . struggling to meet quality standards."

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My headline reference quotes Benjamin Franklin:

For the want of a nail the shoe was lost,
For the want of a shoe the horse was lost,
For the want of a horse the rider was lost,
For the want of a rider the battle was lost,
For the want of a battle the kingdom was lost,
And all for the want of a horseshoe-nail.