Fighting Hepatitis in Cambodia: Patients on Tap

Because MSF/Doctors without Borders projects are set up where the need is greatest, demand for our services is often huge. Theresa blogs from Cambodia about how the team there is coping with the influx of patients at the hepatitis C clinic in Phnom Penh...

When MSF first opened the hepatitis C clinic in October 2016, news of free direct-acting antiviral (DAA) treatment spread through the media. Soon the clinic was mobbed with hundreds of patients every day. There was no way to see them all, so the staff created a waiting list. It’s taken us three months, but the waiting list is finally empty!

So now we’re opening the hepatitis C clinic to new patients. Obviously the word got out, because here’s the scene in front of the clinic on Monday:

Some of these people arrived at 4:30 am to get into clinic. Photo: Theresa Chan.

Which raises the important issue of patient flow. By this I mean the organization of each clinic day so that there are a manageable number of patients receiving our various services. For example, it would be a disaster to start DAA treatment on 100 patients each day, because treatment initiation requires a doctor’s consultation, a counseling session with one of the nurses, a drop-in at the lab, and pharmacy visit to verify the patient’s prescription and to dispense the first bottle of DAAs. In other words, a single treatment initiation ties up the services of a doctor, a nurse, a lab technician, and a pharmacist, and because we don’t have unlimited staff or space, we can’t get through 100 treatment initiations every day.

However, we can see 100 patients per day if they are divided up into screening visits, baseline evaluations, treatment initiations and follow-ups, because these visits require different services. Ensuring roughly even numbers of them every day means we can see plenty of patients without any section of the clinic getting overwhelmed by work.

The waiting room is under control. Photo: Theresa Chan

The trick is to limit the number of patients entering the screening process. Some of these patients will be found to be infection-free, so they will fall out of the clinic process, but most of the rest will proceed on to a baseline medical evaluation and treatment evaluation. Our epidemiologist doodled the process like this:

How to organize patient flow. Photo: Theresa Chan.

(What I like about this illustration is the implication is that the clinic (the fluid reservoir in the doodle) will actually explode if the tap is opened too wide. We can’t have that, can we?)

In addition to doodles, organizing the patient flow requires dozens of pages of spreadsheets to make sure we don’t schedule too many treatment initiations on any given day. We give special attention to the number of patients needing pharmacy services each day, because it is easy for things to get backed up when you have to count dozens of pills and put them into bottles:

All treatment comes down to delivery. Photo: Theresa Chan.

This is the kind of planning it takes to deliver health care effectively. I imagine the doodles and spreadsheets are truly enormous before MSF carries out a vaccination campaign, for example, or opens a cholera treatment center. I’m hoping one of my colleagues posts the pre-cholera whiteboard doodles soon...