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Table of Contents
SHORT REPORT
Year : 2016  |  Volume : 15  |  Issue : 3  |  Page : 145-153  

Establishing in-hospital geriatrics services in Africa: Insights from the University of Benin Teaching Hospital geriatrics project


Department of Medicine, University of Benin Teaching Hospital, Benin City, Edo, Nigeria

Date of Web Publication23-Aug-2016

Correspondence Address:
Obehi Aituaje Akoria
Department of Medicine, University of Benin Teaching Hospital, Benin City, Edo
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1596-3519.188896

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   Abstract 

Background: Unawareness of the peculiar healthcare needs of the elderly and resource constraints may be some reasons why until recently, Nigerian hospitals have not been equipped with the human and infrastructural resources required to meet older adults' special healthcare needs. There is paucity of specialized health services for the elderly in Africa. Nigeria, with a population of over 170 million, did not have any healthcare facility with dedicated services for the elderly until 2012. The University of Benin Teaching Hospital (UBTH) in Nigeria was established in 1973 and created its geriatrics unit in October 2013. A prepared environment and trained interdisciplinary teams are pivotal in providing effective healthcare services for the elderly. The ongoing UBTH geriatrics project aims to provide specialized interdisciplinary health services to older adults and to provide training and continuing professional development in geriatrics for healthcare staff. In developing our inpatient services, we adopted the acute care for elders (ACE) model and worked in tandem with the "ABCs" of implementing ACE units.
Results: In the face of limited resources, it was possible to establish a functional geriatrics unit with a trained interdisciplinary team. Family participation is central in our practice. Since October 2013, residents and house officers in internal medicine have been undertaking 4- and 12-weekly rotations, respectively. There is also a robust academic program, which includes once-weekly geriatric pharmacotherapy seminars, once-weekly interdisciplinary seminars, and 2-weekly journal club meetings alternating with seminars on geriatric assessment tools.
Conclusions: It is possible to establish geriatric services and achieve best practices in resource-limited settings by investing on improving available human resources and infrastructure. We also make recommendations for setting up similar services in other parts of Africa.

   Abstract in French 

Résumé

Contexte: L'ignorance des soins de santé particulière a besoin des personnes âgées et contraintes de ressources peuvent être quelques raisons pourquoi, jusqu'à une date récente, hôpitaux nigérian ne comportent pas les ressources humaines et infrastructures nécessaires pour répondre aux besoins de soins de santé spéciaux aεnQs. Il y a peu de services de santé spécialisés pour les personnes âgées en Afrique. Nigeria, avec une population de plus 170 millions, n'ont pas de n'importe quel établissement de santé avec des services dédiés aux personnes âgées jusqu'en 2012. L'hôpital universitaire de l'Université du Bénin (UBTH) au Nigeria a été créée en 1973 et créé son unité de gériatrie en octobre 2013. Un environnement préparé et formé des équipes interdisciplinaires jouent un rôle essentiel dans la fourniture de services de soins de santé efficaces pour les personnes âgées. Le projet en cours de gériatrie UBTH a pour but de fournir des services spécialisés de santé interdisciplinaires aux personnes âgées et aux services de formation et de perfectionnement professionnel continu en gériatrie pour le personnel soignant. Dans le développement de nos services aux patients hospitalisés, nous a adopté les soins de courte durée pour le modèle des anciens (ACE) et a travaillé en tandem avec le «ABC» de la mise en œuvre des unités de l'ACE.

Résultats: Face aux ressources limitées, il a été possible d'établir une unité de gériatrie fonctionnelle avec une équipe interdisciplinaire formée. La participation familiale est centrale dans notre pratique. Depuis octobre 2013, résidents et maison des dirigeants en médecine interne ont entrepris des rotations de 4 et 12 semaines-, respectivement. Il y a aussi un solide programme académique, qui comprend des séminaires de pharmacothérapie gériatrique hebdomadaire, séminaires hebdomadaires interdisciplinaires et réunions du club journal 2 fois par semaine en alternance avec les séminaires sur les outils d'évaluation gériatrique.

Conclusions: Il est possible d'établir des services gériatriques et adopter des pratiques exemplaires dans les ressources limitées en investissant sur l'amélioration des ressources humaines disponibles et l'infrastructure. Nous faisons aussi des recommandations pour la mise en place des services similaires dans d'autres parties de l'Afrique.

Mots-clés: Soins aigus pour anciens modèle, Afrique, personnes âgées, gériatrie, soins de santé personnel, équipe interdisciplinaire, Nigéria


Keywords: Acute Care for Elders model, Africa, elderly, geriatrics, healthcare workforce, interdisciplinary team, Nigeria


How to cite this article:
Akoria OA. Establishing in-hospital geriatrics services in Africa: Insights from the University of Benin Teaching Hospital geriatrics project. Ann Afr Med 2016;15:145-53

How to cite this URL:
Akoria OA. Establishing in-hospital geriatrics services in Africa: Insights from the University of Benin Teaching Hospital geriatrics project. Ann Afr Med [serial online] 2016 [cited 2019 Nov 22];15:145-53. Available from: http://www.annalsafrmed.org/text.asp?2016/15/3/145/188896


   Introduction Top


Nearly, 70% of older persons in the world currently live in developing countries [1] and this proportion is expected to increase to 80% by 2050. [1],[2] In both developed and developing countries, the elderly account for a disproportionately large fraction of healthcare utilization, [3],[4] a situation that is, especially concerning in developing countries where health services are mostly paid for out of pocket [5],[6] and where the elderly are for the most part unemployed, lack health insurance and do not have their needs prioritized at family, community, or national levels. [7],[8],[9] Healthcare providers usually focus on disease entities during hospitalizations, with often undesirable outcomes for the elderly, such as loss of independent functioning, reduced quality of life, and increased morbidity and mortality. [10],[11],[12]

Older adults require specific approaches to their care during hospitalizations if adverse outcomes are to be avoided. [13] In the absence of specialized geriatric teams, little (if anything) can be done to improve the outcomes of hospitalization for older adults in developing countries. Unfortunately, there are only a few centers in Africa with personnel who are trained to offer specialized care to older adults. [14] Some of the limitations in this regard include unawareness of the peculiar healthcare needs of the elderly and resource limitations. It is imperative that developing countries such as Nigeria strengthen their healthcare workforce and infrastructure to meet the healthcare needs of older adults, in spite of prevailing resource limitations.

Specialist training in geriatric medicine in Nigeria

Training in geriatric medicine is currently not included in the residency programs of the National Postgraduate Medical College of Nigeria or the West African College of Physicians - The two bodies charged with oversight of specialist medical training in Nigeria and the West African subregion. Between 2004 and 2005, this author sought placement for training in geriatric medicine at the Department of Geriatrics and Palliative Medicine, Mount Sinai Hospital in New York, the United States of America, but that goal could not be achieved because of funding constraints. In 2012, the management of the University of Benin Teaching Hospital (UBTH) approved the release of funds for the payment of tuition fees at that institution, which enabled training. A prior commitment to set up a geriatrics unit in the hospital on return was obtained. Training was completed under very strenuous financial conditions, the pains of which were fortunately offset by additional funding that was provided by the University of Benin, Nigeria.

This paper is presented to highlight some of the gains accruing from the investments made by both institutions. The objective is also to share our initial experiences in undertaking the UBTH geriatrics project, with a view to encouraging other institutions in Nigeria and Africa to commit themselves to improving health services offered to older adults by investing in human capital development.

The need for a dedicated geriatrics ward, a trained interdisciplinary team and our choice of the Acute Care for Elders model

On return from training abroad and before the creation of the geriatrics unit in the Internal Medicine Department of UBTH in October 2013, this author provided consult geriatrics services within the existing medical inpatient structure that consisted of a female and male medical ward and the stroke ward, respectively. We also provided consult services for older adults in nonmedical wards and outpatient care in the Consultant Outpatients Department. At its inception in October 2013 dedicated geriatric units, two residents (a senior registrar and a registrar) and two house officers were deployed to the unit. Academic programs began the same month, with weekly journal club meetings and seminars that focused on geriatric syndromes and geriatric assessment tools. However, we continued to advocate for a dedicated geriatrics ward, hinging our arguments on evidence that dedicated geriatrics units are associated with better outcomes compared with managing elderly patients in traditional medical wards. [15],[16],[17]

Our efforts yielded good results with the approval given by the hospital's management for one of the wards on the ground floor of the hospital to be converted to a geriatrics ward in the last quarter of 2013. Management also approved and sponsored 4 weeks' training for an interdisciplinary team that included 19 nurses, 2 resident doctors, 2 house officers, one pharmacist, one physiotherapist, and one occupational therapist.

The Acute Care for Elders (ACE) model is one of many models of care in geriatrics. It emphasizes patient-centered care rather than the usual focus on diseases/diagnoses, with frequent (e.g., daily) medical reviews, interdisciplinary team rounds, early discharge planning (from Day 0), and team communication with relevant caregivers (e.g., with other physicians and family members). [16] The model also emphasizes prevention of functional decline, cognitive stimulation, and environmental modifications [10] that promote safety, with a homely outlook in the care setting rather than the usual institutional outlook. In addition to these virtues, the ACE model is a low-tech, high-touch model, [16] and well suited to resource-limited health facilities in Africa.

There is much-published evidence from developed countries that implementation of the ACE model is associated with improved outcomes for hospitalized older adults without an increase in hospital costs. [18],[19] The focus of this paper is to describe the establishment of in-hospital geriatric services in a resource-limited setting in Nigeria, using a project management cycle framework. The stages and major outcomes of the UBTH geriatrics project are reported here; clinical audits following implementation are ongoing as part of the monitoring and evaluation phases and those findings will be published differently.


   Project Methods Top


Setting

UBTH is a tertiary healthcare facility located in Benin City, capital of Edo State in Southern Nigeria. It has grown from the 280-bed facility that it was when it was commissioned in 1973 [20] into a 716-bedded facility at the time of this report. Her services are accessed by clients from within the state and surrounding states in Southern Nigeria.

Project phases

Initiation


Acceptance for training in geriatrics at a reputable centre outside Nigeria had to be secured by this author who is employed by the University of Benin and the UBTH, Benin City, in Nigeria. The key deliverable was agreed on: a geriatrics unit would be established on return from training.

Strategic planning

The major activities at this stage were: obtaining timelines for the readiness of the proposed geriatrics ward from the management of the hospital, developing timelines for the selection and training of the interdisciplinary team, developing the training curriculum, identifying and contacting potential team members, identifying and contacting resource persons for the proposed training, developing a budget for the training, and obtaining institutional approval for training. This stage required iterated interactions with the Chief Medical Director of the hospital, the Chairman of the Medical Advisory Committee (who is the Head of Clinical Services), and also with successive heads of the Department of Nursing Services. The heads of physiotherapy and occupational therapy were also engaged. Potential members of interdisciplinary geriatrics team were identified based on recommendations by their supervisors and/or peers and were contacted at this stage. They were given the opportunity to consent or decline inclusion in the team; several declined with reasons ranging from their perceptions of the burden of work that would be required to lack of incentives.

A strengths, weaknesses, opportunities, and threats (SWOT) analysis of existing in- and out-patient services for the elderly in UBTH was undertaken. This, for strategic and logistic reasons, was incorporated into the training of interdisciplinary team. The results of the SWOT analysis provided evidence regarding gaps in services offered elderly persons accessing UBTH for healthcare and provided some of the basis for developing the team's operating procedures.

Design

In project management cycles, the design phase focuses on meeting initially identified requirements. Having chosen the ACE model for the proposed inpatient services, the layout of the existing ward had to be modified to suit the new purpose: schematic diagrams of the proposed floor plan were drawn in collaboration with the Head of Clinical Services and used for the purpose-tailored allocation of ward areas and rooms for outpatient consultation, rehabilitative services, and offices. Initial plans were later modified in collaboration with the interdisciplinary team and management staff as new needs arose.

Implementation

Training of the interdisciplinary team took place in the hospital and lasted 4 weeks (February 17, to March 14, 2014), spanning all weekdays, beginning at 8.00 am and closing at 5.00 pm. We had a half hour break for rest and 1 h break for lunch each day. It was a cramped period of didactics, group activities, video-assisted learning sessions, role plays, and brainstorming sessions. Every day ended with 30 min of critical reflection and debriefing. Each participant prepared bound copies of seminars on geriatric syndromes and/or management approaches, which they presented in PowerPoint in the last week of training, to fulfill the requirements for the award of certificates.

Facilitators for the training were drawn from the hospital's Departments of Internal Medicine, Nursing Services, Pharmacy, Public Health, Physiotherapy, Occupational Therapy, Nutrition and Dietetics, Hematology, Surgery, and Anesthesia. We also had facilitators from the University of Benin's Departments of Nursing Sciences and Social Work, respectively. One facilitator was drawn from a sister teaching hospital outside Benin City. More details regarding the training curriculum and the post-training evaluation will be published differently.

On March 17, 2013, we commenced inpatient services for older adults in the geriatrics ward, with our core ethos being patient-centered care, early rehabilitation, early discharge planning, daily medical reviews and family participation, in a prepared environment.

Operating procedures

In the second week of training, trainees (26 in number) were assigned in groups of 3-4 to conduct participant observational studies of services offered to the elderly in the hospital's medical wards and the Consultant Outpatients Department. The respective groups organized their findings into SWOT diagrams for inpatient and outpatient services, respectively. The SWOT summaries provided a framework for the development of standard operating procedures for the unit by interdisciplinary team. Further details of the observational studies and the SWOT analysis are not within the scope of this paper.

The operating procedures included patient reception and welcome, nurses' activities for morning, afternoon, and night shifts; frequency, structure, content and duration of interdisciplinary academic programs, and activities geared toward promoting healthy nutrition and fostering team spirit among team members.

Monitoring and evaluation

In the face of limited human resources, we had to carefully consider which older adults would be admitted into the geriatrics ward. This required iterated collaboration with the Head of Internal Medicine, and we agreed on criteria for admission or transfer into the ward as follows:



  1. Age 60 years [21] or above, a medical diagnosis, plus any one or more of:


    1. Multimorbidity and/or need for multiple medications
    2. Frailty
    3. Dementia, delirium and/or depression
    4. Previous admission into the geriatrics ward plus
    5. Consent of the primary managing consultant(s).
Some of the change management at this stage required the Head of Internal Medicine to convene meetings of the consultant medical staff to discuss the above criteria, to ensure intra- and inter-disciplinary harmony.

We also developed and revised structured formats for the interdisciplinary rounds (IDRs), nursing handing over/taking over rounds and skin rounds. Job descriptions for our support staff - porters, and cleaners - were also documented and explained.

Based on feedback regarding increasing, excessive, work pressure and staff (dis) satisfaction; we gave the opportunity to staff who wished to opt out of the team between September and October 2014. Two nurses and one porter opted out, of whom one nurse and the porter have been replaced. Evaluations of our services are ongoing.

The above project phases are schematically illustrated in [Figure 1] and [Figure 2]. In [Figure 2], levels of activity indicated on the vertical axis were self-rated on a scale from 0 to 500.
Figure 1: Phases of the University of Benin Teaching Hospital geriatrics project

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Figure 2: Overlapping project phases in the University of Benin Teaching Hospital geriatrics project

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   Results Top


The key deliverable - a geriatrics unit in the Department of Internal Medicine, UBTH - was achieved. The unit is different from other medical wards in the hospital in that it provides the following:

An attractive homely environment

The existing ward was modified to make it more elder-friendly with lower and more attractive beds, brightly painted walls with pictures and paintings, a clutter-free corridor, living potted plants, attractive furnishing in the dining area, television sets, a microwave oven to ensure that meals are served warm, and a blender for preparing smoothies on an as-needed basis. Flowery scrubs were provided for nursing staff by the hospital management.

Geriatric assessments

All patients admitted to the ward have cognitive, functional, and nutritional assessments done and documented within 24-48 h of admission. Interventions are subsequently instituted as appropriate.

Specialized nursing care

Our nurses are mindful of elders' need for autonomy, dignity, and personal comfort while attending to their medical, emotional, social and psychological needs during hospitalization. Nursing care procedures are patient-centred rather than disease- or task-centred.

Interdisciplinary team rounds

Patients are medically reviewed every day including weekends; nursing staff participate in all rounds. IDRs take place on Mondays and Fridays, beginning at 10.00 am. Structured feedbacks from staff and informal patient/family member feedbacks indicate that the IDRs promote holistic patient care and enable early detection of gaps in care. However, they take their toll on staff time and energies and team members still strive to streamline activities during these rounds without compromising on the quality of collaborative input.

The ward round protocol that guides IDRs includes the following:

  1. Patient medical summary, presented by a resident doctor
  2. Nursing summary and nursing care updates - including bowel and bladder movements, presented by a nurse
  3. Vital signs, including reports regarding pain - the 5 th vital sign [22]
  4. Update on referrals to other disciplines (including physiotherapy, occupational therapy, and social work)
  5. Update on investigations
  6. Patient/family caregiver input
  7. Physical examination
  8. Review of tethers, for example, urinary catheters, intravenous cannulas, nasogastric tubes, etc., in line with our principle of zero tolerance for unnecessary tethers
  9. Medication review
  10. Discharge plan
  11. Documentation and update of medical, nursing, and other care plans.
Early discharge planning

We begin discharge planning from the admission day. This is an interdisciplinary effort anchored by the doctors and nurses in the team and driven by our understanding that hospitalization is potentially hazardous for every older adult. [11] We factor into patients' discharge plans their individual morbidity assessments and our assessments of the resources that are available for their care, such as finances, family support, and living conditions. Discharge plans are discussed with patients and/or family members and updated at every IDR.

Comprehensive geriatric assessments

Comprehensive geriatric assessments (CGAs) differ from general medical assessments in many respects. For example, traditional medical assessments often overlook the 5 I's of geriatrics - incontinence, instability, intellectual impairment, immobility and iatrogenesis, [16] which could impact negatively on older adults' functional status and quality of life. [16],[23] We rely on interdisciplinary collaboration for our patients who require CGAs: In addition, to geriatrician assessments, we invite input from our physiotherapist and/or occupational therapist as deemed appropriate. We have also had to invite psychiatrists on some occasions.

Skin examinations and care

All patients admitted to the ward have their skins examined and findings documented by nurses (usually 2) at admission. As a team, we examine the skins of all patients in the ward every Tuesday from 10.00 am. The interdisciplinary skin round is led by a doctor who at the minimum would have undertaken a posting in dermatology. The overarching objective of these rounds is to identify early changes in skin integrity, institute appropriate interventions, and also to monitor the status of pre-existing skin conditions, and the effectiveness of ongoing interventions.

Early ambulation, sensory stimulation, and socialization
"Bed is bad" [24] is our slogan. We prioritize early ambulation, to limit functional decline and provide sensory stimulation. In addition to ensuring a clutter-free ward, patients who are not too ill are ambulated outside the ward at least once a day, sometimes more frequently, depending on available staff/family support. We also encourage patients to have their meals in the common dining room, thus harnessing the additional opportunities that this provides for ambulation, socialization, and sensory stimulation.

Rehabilitation

Inpatient rehabilitation is available for patients who require physiotherapy and/or occupational therapy. Rehabilitation is undertaken within the ward areas or in a side room reserved for that purpose. Patients, however, have to pay for the services before initiation.

No restraints

Changing prior beliefs regarding the use of physical restraints (such as cot sides and tying limbs to the bed) and achieving consensus on our unit policy regarding nonuse of restraints was one of our biggest wins during the interdisciplinary team training. As a policy, we do not use restraints in the geriatrics unit. Our operating procedures require that to put up a cot side, two members of the team - one nurse, not lower in rank than Nursing Officer I and one doctor, not lower than Registrar, must agree on and document the justification(s). Occasional patients who were assessed to be unsafe in bed were managed on floor mattresses: "He that is down needs fear no fall." [25]

Family participation

Our policy is to have one family caregiver - preferably the patient's significant other - at every patient's bedside unless when medical procedures preclude their presence. Family members are also invited and encouraged to make inputs during ward rounds. We particularly encourage them to be open and discuss their concerns and dissatisfactions. There is a side room in the ward reserved for family members' relaxation/recreation.

For complex issues related to patient care such as breaking news about life-limiting illnesses, addressing elder mistreatment concerns, and planning for out-of-hospital care, we convene family meetings. At least two disciplines are represented at each such meeting, most often Medicine and Nursing. On some occasions, we have had more disciplines represented, usually medical Social Work and Physical Therapy.

Spiritual care

We recognize and respect patients' needs for spiritual care. [26],[27] Team members currently provide spiritual care on an as-needed basis in addition to supporting family members' efforts in this regard.

Active support for the dying and bereaved

We integrate palliative care approaches into patient care plans as indicated, often alongside active treatment. We are open, but sensitive to personal and cultural nuances in discussing and managing dying and death. We take bereavement seriously and provide support for family members in the immediate periods following deaths of their loved ones.

Outpatient services

The floor plan agreed on by the team included reserving some of the side rooms in the unit for outpatient services. With this arrangement, doctors in the unit no longer have to leave to run the outpatient clinic in the Consultant Outpatient department. We are thus on hand to attend to issues regarding in-patient care that sometimes arise. This is a plus considering the limited manpower that is currently available. The current arrangement also makes it convenient for us to provide outpatient care on non-clinic days.

Academic programs

House officers present seminars on geriatric pharmacotherapy topics on Monday mornings. Journal club meetings hold for 1 h on Thursday afternoons, alternating with resident seminars on geriatric assessment tools. These meetings precede interdisciplinary seminars where nurses present on all but one Thursday every month. Residents exiting the unit at the end of their 4-week rotations present on one Thursday each month, alongside house officers exiting at the end of their 12-week rotations. All presentations are done in PowerPoint.


   Discussion Top


One of the objectives of this report is to demonstrate that it is possible, even in the face of limited healthcare resources, to cater for the special needs of the elderly accessing care in Nigerian hospitals. The aspects of the UBTH geriatrics project described in this report demonstrate that with institutional and administrative buy-in, it is possible to develop in-hospital geriatrics services in resource-limited settings. This report also underscores the value of locally available technical expertise which can be harnessed in building capacity for geriatric services in Africa.

Aging in the face of poverty, disease and/or disability presents multiple challenges. Unfortunately, the typical older adult in developing countries of the world (e.g., Nigeria) lives in poverty. In addition to poverty, many elderly persons also contend with disease and/or disability. [28] In the face of these challenges and with the lack of organized social support, one would wish that our elderly population could remain in their homes and not need to access healthcare services. The reality, however, is that hospitalization for the elderly will often be inevitable.

It is against the background of the foregoing that preventing hospitalization-associated complications for the elderly should be prioritized. Health systems reforms in African nations need to prioritize health services planning, bearing in mind the emerging demographics regarding the elderly. [28] While we look forward to a future with innovations that will promote out-of-hospital (e.g., home-based) care for our elderly so that the need for hospital services is reduced, we should strive in the present to prevent hospitalization-associated deconditioning in our older adults. This is the main thrust of specialized geriatrics units.

Hospitalization-associated deconditioning [11],[29] refers to multiple physiologic changes that result from immobility (e.g., from bed rest and use of restraints) and which occur during hospitalization. The risk of deconditioning is not limited to prolonged hospitalization; immobility even during brief periods of hospitalization is associated with some deconditioning, for example, 2-5% loss in muscle strength per day of bed rest. [29]

Ensuring that hospital stays for older adults are as short as possible and unaccompanied by preventable deconditioning is crucial in all healthcare settings, not the least those in developing countries like Nigeria. Traditional in-hospital care plans focus on curing diseases and are most often lacking in interventions that address broader challenges such as enforced immobility.

Geriatrics focuses on these broader issues of older adults' health and wellbeing in additional to clinical concerns. Unfortunately, many physicians believe that Geriatrics is no different from general Internal Medicine, [30] especially as a large proportion of the patients they regularly manage are elderly. The term "geriatric" is also often associated with senility even by internists. [30] This has negative implications for the mainstreaming of geriatrics in medical practice and medical education in developing countries. [30] It is little wonder then that most African nations have not prioritized providing specialized care for the elderly.

We hope that hospital managers and leaders in academic medicine in Nigeria will invest in providing access to specialized training in centres of excellence in geriatrics for their staff. The University of Benin and the UBTH invested in the training of this author and since then an initial team of 26 healthcare professionals cutting across medicine, nursing, pharmacy, physiotherapy, and occupational therapy has been trained locally. Training for doctors (house officers, registrars, and senior registrars in Internal Medicine) is ongoing as they undertake rotations in the unit, putting them in better standing to provide patient-centered healthcare to the elderly. Replicating this or similar projects across Nigeria (and Africa) would result in a steadily increasing number of interdisciplinary healthcare workforce who have additional competencies in caring for the elderly.

In planning, designing, and implementing the geriatrics unit in UBTH, we worked in line with the "ABCs of ACE unit implementation" [16] namely:

Agreement

Key stakeholders in the UBTH agreed on the need for specialized care for older adults in a dedicated unit. Team members also agreed on the model of care that was most suited to the needs of the local population.

Building

The project has been and is being built through multilevel, interdisciplinary support. The management of the hospital, successive heads of the Department of Internal Medicine and successive heads of Nursing Services have been pivotal to the achievements till date. We could also not have done without the initial and continuing support of the heads of physiotherapy, occupational therapy, and medical social work. We also built on the experiences shared with us by the UBTH neurosurgical team in their establishing, sustaining, and improving on neurosurgical services in the hospital. [20]

Commence

The project took off from little beginnings with intra- and inter-departmental consult services, outpatient services, and then the creation of geriatrics as a separate unit in the Department of Internal Medicine. Interdisciplinary team training and movement to a dedicated geriatrics ward followed with the implementation of the ACE model of care. Academic programs also commenced and are ongoing for nursing and medical staff.

Document

We have been mindful to document our policies, programs, and procedures. Critical reflections were an integral part of the daily activities for all participants during the interdisciplinary training and were documented. During that training period, weekly summaries were prepared by two nominated group leaders for each of the 4 weeks of training. We often refer to these notes as a reminder of our team goals and of the processes through which we collectively determined to achieve those goals. We have also regularly presented quarterly reports to the head of clinical services in the hospital. This publication is in furtherance of our commitment to document and shares our experiences with a wider audience.

Evaluate

Our procedures and outcomes are being evaluated. Clinical audits are ongoing, the findings of which will be shared in other publications.

Feedback

Feedbacks to team members, the head of the Internal Medicine Department, the management staff of the hospital, and other relevant stakeholders have provided the basis for program adjustments, infrastructural improvements, and for securing additional resources for the unit. Feedbacks are ongoing.

We have presented this report in the hope that national governments, politicians, policy makers, healthcare practitioners, and philanthropists in Nigeria and other parts of Africa will find the impetus to establish specialized in-hospital services to cater for the needs of older adults in the continent.


   Conclusions Top


There is paucity of specialized services for the elderly in Africa, even though specialized geriatrics units have much to add to the care provided for the elderly in our hospitals. Of the different models of care with evidence of improved outcomes for the elderly, the ACE model is an intervention that is feasible for in-hospital care of the elderly in resource-limited healthcare facilities in Africa, if hospital managers would invest in setting up dedicated geriatrics units.

It is against this backdrop that we make the following recommendations for establishing and developing in-hospital geriatrics services in Africa.

Recommendations for in-hospital geriatrics services in Africa

  1. Medical directors of hospitals and other hospital management staff should be engaged to earn their unflinching support for the establishment of dedicated geriatrics units in their respective centres, in spite of resource limitations
  2. Universities could collaborate with teaching hospitals in providing funding for staff who are interested in training in geriatrics in centers outside Nigeria
  3. Hospitals seeking to commence geriatrics services should strive for effective interdisciplinary teams
  4. Documentation and information sharing on establishing effective geriatrics units should be encouraged within and between countries in Africa.
Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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