We highlight Lambert Ingabire, Director of Pharmacy at King Faisal Hospital, who is a central figure in our program’s success. He has worked with our team for more than 10 years and helped us achieve the milestone of sourcing > 90% of medications in Rwanda thereby moving us closer to our goal of sustainability. Ensuring medication availability (while crucial) is just the first step to ensuring safe and effective medication use for our patients. Lambert is committed to advancing comprehensive pharmacy support for the cardiac surgery program.
Note from Team Heart: From the very first trip, Pharmacy was critical to our success. Through the years we have a loyal group of experts with vast experience in Cardiac Surgical Critical Care.
Pharmacy plays a critical role and in the US we often take them for granted. They have always been part of our team. But in Rwanda, pharmacy is just beginning to establish their role as part of the clinical care team. This creates some challenges in the intensive care unit (ICU) as things move fast and medications, while life-saving, also need to be handled with extreme caution.
Pharmacy Updates by Becca Nashett
Hello Team Heart Pharmacists,
It’s a busy time of year but I wanted to provide a debrief from the November 2022 trip and describe how we are progressing towards an independent Rwandan Cardiac Surgery program, especially from the medication safety and clinical pharmacy perspective. Overall, it was wonderful to see the progress since my last trip in 2018 where Team Heart was bringing most of the cardiac surgery medications from the US and performing nearly all of the pharmacy care and support ourselves. Progress!!!
Team Heart only needed to bring a very limited number of donated meds for the November trip. This eliminates the arduous task of ordering and packing of medication, and requesting documentation that is not part of the normal US process for donations to carry. Our donor institutions have been wonderful, but a huge sign of progress of the program emerged as King Faisal Hospital is now regularly procuring more than 90% of medications and these are billed through the normal hospital process for reimbursement.
Denise, one of our star Rwandan ICU nurses, organized a shelf of limited “ICU Stock” meds, fluids (Lactated Ringers, 0.9% Sodium Chloride), and supplies for urgent use. These were kept very separate in the back room, and a daily running list of meds and supplies used for each patient was taped to the shelf. The pharmacist or nurse could then quickly record what they were taking and for which patient. Billing sheets were sent to the pharmacy every 1-2 days. The sheet includes the patient name, IP number, and age so they can identify the patient correctly. This not only increased patient safety by improving access to medications, but improved nurse efficiency by decreasing the time they had to be away from the bedside–as it is often the nurse who has to run to pick up supplies or medications from central pharmacy in urgent situations.
We were able to bring Lambert and the pharmacy team a label printer that can print barcodes in addition to regular medication labels. This will improve inventory management and increase patient safety. It promotes the importance of clear labeling for medications that includes consistent information. The ability to batch print standardized labels will also allow labels to be affixed to the medication preparation as soon as it is made so that it cannot be confused with another.
The code (or resuscitation) cart has a bit of a different focus because of limited in-country availability of certain medications. Pre-mixed syringes are not yet available, although Lambert and his team are searching. This is something that can be further addressed in our ideas for sustainability with med kits on the unit.
Sustainability:
This was a very high-energy trip with the Edwards team consulting on the supply chain! Lambert, Bonnie and I had the opportunity to formally discuss the minimum pharmacy requirements for an independent Rwandan Cardiac Surgery program. With Rwandan stakeholders a fantastic, comprehensive document for supply chain management was developed that resides in the Team Heart Pharmacy Google Drive folder for easy access.
The major actionable item we are trying to operationalize for the next trip is a standardized med kit that includes all the essential supplies needed for 24-48 hour post-op ICU care, which would be supplied for each patient. The goal is to help ensure all urgent medications are available on the unit and used safely by including instructions for admixture. Each day the kit could be returned to the pharmacy in exchange for a new one. The billing process would be simplified as well by simply deducting what had been used from each kit.
Another undertaking will be editing and updating the “Rwanda Cardiac Surgery Guideline.” This document was gold – it was new to many of the team who had not traveled recently, but definitely wanted a copy when they saw me referring to it. It is critical this document is updated and implemented successfully. Many thanks to Yihan Lin for taking the lead on this and for Alysia and Sara for updating and suggesting key changes. Each change is approved by the Rwanda hospital team and it becomes our pathway to recovery for the patients.
Key leaders, Shadrack in Nursing and Lambert in Pharmacy, were very involved and committed to creating a new document that increases medication uniformity across ICUs. This document can also be shared with anesthesia to ensure patients coming from the OR are on infusions that have concentrations consistent with those used in the ICU. Again, improving patient safety and nurse efficiency with the help of the team involved!
Compounding: Since nurses mix medications at the bedside, a focus on this trip was teaching nurses how to properly compound and label IV medications. Since medications must be made just before administration to reduce infection risk, it is important that compounding technique is consistently reinforced. We added this to the mastery list as King Faisal Hospital nurses agreed this is a high priority for them.
Thank you for reading this far. It really was a fantastic trip and I look forward to the improvements that we can continue making together.
Cheers, Becca
WHO WE ARE:
Becca Nashett is a pharmacist at the University of Vermont Medical Center. This is her second trip with Team Heart but she has been involved in procuring supplies since 2014 for surgical development trips.
Kate Sullivan Woods is a pharmacist from Australia working with Team Heart since 2018. This is her second trip.
Bonnie Greenwood is our Lead pharmacist from Lahey Hospital and Medical Center. She ordered and packed our medical supplies for 2008 and has traveled more than 10 times. She has collaborated with the Rwanda National Pharmacy Council and serves as an advisor for a local start-up, Irebe Biotech.
George Shortis is a pharmacist from Australia. He has traveled with Team Heart more than 17 times and is a Senior Advisor. He is the co-founder of Open Heart International, delivering cardiac care around the Pacific rim.
