Overseas Report – Diagnostic Imaging in Ghana
Matt Ward, Integrated Radiological Services, Liverpool.
Take a good look around you, just for a second. It’s surprising that no matter who we are professionally in the radiological sector, with all its challenges and pressures, we take an awful lot for granted. This is obvious once you take a step outside the Western developed nations’ healthcare environments. How’s this for my first step then? A trip to Ghana in order to establish some basic quality parameters in line with SoR and IPEM practice.
As a physicist with radiation protection advisors IRS Ltd in Liverpool, I’ve always seen good protection and medical physics input into the diagnostic sector as an evolutionary process, and have enjoyed seeing our community across Europe cope with very rapid change, even in my short 6 year career thus far. IRS has shared partnerships with diverse research groups, students, institutions and business. One of our latest ventures comprises RPA and technical support to Mr Eric Ofori, a Ghanaian engineering graduate, now PhD student at the University of Liverpool. His PhD remit: to review and propose key quality improvement areas for imaging services in Ghana.
Eric, his supervisor, Dr Diane Scutt, and I put a small project together in June 2008 to run workshops, take survey measurements, and shadow clinical practice for two weeks, primarily in the Greater Accra region of the country. Before we’d even stepped off the plane late one Thursday night, it was obvious how different even the most routine tasks were going to be in this climate. Sub-Saharan conditions meant relentless heat, plus day-to-night in half an hour or less (which, incidentally is about how long it took to drive a few measly kilometres around Accra city centre between hospitals). I was taken aback between surveys and excursions by the cacophony created on the roads – 4x4s and compact, panel-beaten taxis generating a strange sense of automotive symbiosis with their incessant horn blaring and apparent fearlessness in the face of near misses at every junction. Ghana’s infrastructure could be described as forward-looking and optimistic but nonetheless under-funded, overstretched and partially completed services in many sectors. We must not forget that this nation only employs five radiologists in total – a useful reminder to anyone who’s about to let intermittent air conditioning and power cuts ruin their day!
The novelty of the over-laden, barely street-legal people-carriers and produce wagons dimmed into my own internal mental noise by the weekend of 13th June, as formal work plans, status updates and introductions were made to us by the Ghanaian Radiation Protection Board under Professor Cyril Schandorf, Philips Medical Systems courtesy of Mr. Warren Dodd, and The Ghanaian Health Ministry and Korle-Bu teaching hospital. It was clear from the likes of Philips that multinationals’ installation and maintenance standards are universally sacrosanct, regardless of geography. The RPB can also not be faulted in terms of the requirements to test, manage and protect population groups. My gut feeling as I exited these meetings though was “beyond the top brass, is the education and resource adequate to fulfil these best intentions?” I mean, how many times have we heard lack of time, information, or suitable test kit as an excuse for unfulfilled tasks on our own turf? Clearly at the departmental level, there was some probing to do, and as visiting physics and radiography representatives, Diane and I were well positioned to support Eric’s ongoing review.
An incredible weekend of excursions passed, with some sobering and dignified tours of slavery monuments on the Gold Coast, interjected with beautiful drives through bountiful plantations and crashing Atlantic shoreline. As residents in Korle-Bu hospital digs, it was nice to return to touring the imaging department over a quiet weekend to take a few photos without disturbing corridors full of locals, who had been queuing up all week for various clinics. Again, the sense of pride in Ghana counterbalanced by developing nation challenges hit home when I read a feature article in the Sunday papers about the MRI scanner coming back on-line after some months of power supply and cooling problems.
By Monday 16th June, Diane and I were keen to begin our workshops on quality standards, which included both SoR and IPEM-based reviews (our guidelines and testing manuals survived the trip over too, thank goodness). An amazing effort had been made by Eric in the build-up to this meeting, in terms of recruiting attendees for the informal seminar-led approach, which was kindly hosted by the Korle-Bu staff. It was clear from a review of IPEM Report 91 that before equipment performance could even be considered, quality of equipment supplies needed to be assured! We learned that it was not atypical across the country to encounter multiple vendor film types, colour sensitivities and even speed classes on a single site, with the products often changing from one month to the next! In a country where forty degree heat, variable water pressure and purity are the norm, my review of recommended action levels for processor and AEC testing seemed somewhat academic.
Beyond equipment issues, which were investigated more thoroughly during surveys over the forthcoming week, it emerged from the workshops that managerial authority and communication in a typical local imaging department could be improved. Overall responsibility for radiology remains with a radiologist or clinician, and whilst Korle-Bu has the advantage of being a teaching hospital, student access to techniques whilst training is severely limited due to there being increasing numbers of graduates, but no placement opportunities beyond Korle-Bu (where typically only three of eight x-ray units were ever operational during our stay).
The workshop attendees took credence of remedial and suspension levels, with a view to applying what they could in their locale. We were even fortunate enough to share in traditional spiritual prayer more than once during the day, since one of the Ghanaian radiographers was a particularly vocal Reverend! The most important part of the day was the open discussion between the delegates, each with their own experiences, questions and interests. Their common theme; recognising and establishing quality models for each imaging process.
As far as ensuring quality outcomes in terms of radiographic training, and consequently effective patient care, it was clear that great opportunities exist for improvement. For example, the burden on Korle-Bu as the sole dedicated teaching hospital could be relieved by circulating students through other hospitals in Greater Accra. Indeed, during the workshops and visits to hospitals during our visits, we were advised that the principle regional hospital for Accra was Ridge Hospital, where the senior imaging staff suggested that they would be happy to monitor students and newly-qualified personnel. This emerged based on their disappointment that a large amount of time after graduation was spent not just teaching students aspects of technique which they missed during their limited placements, but also retrospective correctional actions owing to bad habits (or limited good habits) acquired before employment.
The student community attended our workshop as a willing, intelligent body with a strong grasp of responsibility and sense of self-worth, but without enough practice in such basic areas as patient positioning; hence the admittance that too many mistakes break through to practice in the field. How do we set standards to address this and define what is normal? Reject analyses and clinical audit were raised with the group. Both the IAEA and Professor Schandorf have reviewed typical reject rates in developing nations, including Ghana. Looking at these average values as a starting point is a key factor to include in any departmental QA programme. Can estimated reject rates of 20% be reduced by half, say, with departmental QC alone? Or does the problem start with the resources available at the teaching level? Synergy across the academic and professional borders seems essential.
Efforts have been made by the IAEA through large-scale research and publications to introduce protection frameworks analogous to those we take for granted in Europe. The information available from them and other international bodies is accessible and scientifically comprehensive. That said, the impetus required once an initiative, project, or specific recommendation has been absorbed locally is such that in the medium to long term, their implementation seems uncertain. Without consistent legal enforcement or state funding, even the most willing clinical and scientific community will drift away from best practice, or at the very least, lose any sense of consistency and harmony. As I spoke of taking things for granted, of course, I remain aware beyond my trip that imaging safety and quality are a rawer, cruder and inevitably smaller tranche of healthcare than we could consider in the UK.
At first, I found the disparity between the information and involved study of the IAEA, Professor Schandorf and colleagues, and the real-time resources available on the shop floor to be somewhat disheartening. But on reflection, I think that I have been looking at things in a blinkered fashion. Just as a few emails and discussions on optimisation led to Eric taking me to Ghana, so a few initiatives such as cheap (or free?) access to e-learning, journals and a flatter communication structure could make huge leaps and bounds in terms of developing nations not just meeting basic standards, but competing professionally worldwide in the labour market. Tools such as IRS QADDS, the e-learning for healthcare-supported RITI programme and Phil Cosson’s Virtual Radiography application all spring to mind. These have been widely covered in the UK, including in RAD; Cosson’s Virtual Radiography application was recently a prize winner from Google R&D labs. It strikes me that equipping students with these types of tool is a more effective use of resources than having 10-20 radiographers, week in, week out, stood on the corridors of Korle-Bu hospital attempting to crane their necks around doors observing into x-ray rooms (oh, with no lead lining or environmental monitoring, by the way, but you understand the priorities by now…).
Whilst I was in Ghana, I was able to tour about half a dozen hospitals comprising between one and six x-ray units in total. The survey data I acquired from Philips and Siemens units was not dissimilar to that of a typical system in the UK. In order to monitor the whole imaging chain, I have been able to upload survey and patient radiation dose data from every hospital I visited into a QADDS web database. Eric’s forthcoming thesis in 2009 will review this as a snapshot of the status quo, some 10 years after Schandorf et al published their own work in BJR. It will be interesting to know who I met in Ghana is living up to their stated best intentions! Will the correct application of screens and filtration make a difference? What about reject rates? Only with active participation and unbiased sharing of workflow, equipment and performance data will the community be able to apply relevant targets and actions.
The trip showed me very early on that the guidance notes, test reports and other criteria we adhere to do not transpose easily to the African economic healthcare model. Eric’s PhD model will have to be a broad, experimental framework, in which existing standards and recommendations are tested and applied only where deemed effective and beneficial to Ghana.
I must thank Dr Mike Moores and Integrated Radiological Services R&D projects, Keith Thomson at Southern Scientific (for the loan of a very robust and now well-travelled Unfors Xi Platinum test kit!), Eric Ofori, Di Scutt and the University of Liverpool for allowing me to conduct this review. Trips like this open your eyes professionally, culturally, educationally, and I have returned reminded that before we regard ourselves as learned professionals with prescribed ways of working, we must first accept that we shall always remain as students!
IPEM Report 91 – Recommended Standards for the Routine Performance Testing of Diagnostic X-Ray Imaging Systems (2005). ISBN 1 903613 24 8
Schandorf, C., Tetteh, G K. Analysis of the status of X-ray diagnosis in Ghana. British Journal of Radiology (1998), 71, pp 1040-1048.
IAEA Technical Report 547 “Dosimetry in Diagnostic Radiology: An International Code of Practice”. (2007). ISSN 0074-1914.
IAEA Technical Document 1423 “Optimisation of the radiological protection of patients undergoing radiography, fluoroscopy, and computed tomography” (2004). ISSN 1011-4289.