Where is Janga? Geographically, in Western Africa. Economically, on the border to poverty. Religiously, in Muslim northern Ghana. Anyone wanting to visit Janga needs lots of time and a good reason. But the health of Janga’s people is a very good reason.

(Published: June 2015)

There are more than enough diseases here: malaria, AIDS, tuberculosis, yellow fever, typhoid and hepatitis. But it’s a long way to the next hospital. To ensure basic medical care, Fresenius Vamed was contracted by the government of Ghana to build a polyclinic in Janga.

“I live here on the clinic grounds – I’m here with some workers and some patients around me,” Margaret Mahama, the midwife at the clinic, says as she greets us. A short time later, as we pass a terraced area at the front of the building where a few dozen people are waiting patiently, she explains, “This is the outpatient department.” Patients come from near and far. Sick people, pregnant women, mothers with their children. They come for help and for advice on how to help themselves.

In the last two years, Mahama has helped bring some 700 babies into the world, and she proudly shows us her delivery room and some of the wards. “This child is suffering from malaria, and we admitted her,” she says, looking at a small baby strapped to her mother’s back. “She went for treatment, and today she is going home.”

Patients come from near and far. They come for help and for advice on how to help themselves.

 

People with serious diseases are referred to the closest district hospital. There is one in Gushiegu. Fresenius Vamed adapts each facility to fit local needs. If the company has not been hired to run the hospital on the government’s behalf, Fresenius Vamed employees train the personnel and accompany them through the start-up phase. Plans for medical infrastructure are not approved without guarantees that equipment will be used and maintained properly once a facility has been turned over: This is not something that can be taken for granted in developing country projects.

 

Interpreters able to speak local dialects are available to patients during treatment. They help patients overcome their fears and their religiously based skepticism regarding modern, high-tech medicine. Clinics like the ones in Janga and Ghushiegu create many skilled jobs on a permanent basis for people who want to join in building Ghana’s future.

“I’ve just been signalled that there’s a woman in labor, so I have to go and see how I can help her,” says Mahama as we prepare to leave. What the future will bring is something the children of Janga have yet to experience. But what women like Margret Mahama have done for them, and continue to do for them – well, everyone here knows what that is, starting from the time they are born.

The loud beeping from the monitor pierces the room. The patient's heart rate is accelerating, his breathing is labored, and he is starting to cough. Also, the right side of his face is swollen.

(Published: December 2016)

"Do you have any allergies, Mr. Schönfeld?" the physician asks, bending over and carefully feeling around the patient’s neck. "No allergies," comes the reply, in a slurred voice. But with the patient’s blood pressure dropping rapidly, Nurse Romy Wiessner asks if support should be called in. At a nod from Assistant Physician Dr. Roland Hiersemann she rushes to the telephone, and calls into the handset: "We need backup in the emergency department!”

Wiessner, on returning to the patient's bedside, rolls up his sleeves and inserts an IV cannula. When she withdraws the needle there is a drop of blood on it. Usually, this would be unremarkable, but in this case it is technical ingenuity: Mr. Schönfeld is not made of flesh and blood, after all, but of plastic, wires and electronic components.

In the Simulation Center at HELIOS Hospital Hildesheim in northern Germany, doctors and nursing staff train not on real patients but on high-tech patient simulators – mannequins such as Mr. Schönfeld that look like patients and can talk, breathe and perspire. They have a pulse, and you can take blood samples from them. Sometimes they even cry.

That they react like real patients is in no small part due to Stephan Düsterwald, the center’s medical director, and his team. During each training session they huddle in a small room behind a glass panel and control the patient simulator’s reactions – making the heart beat faster or the eyes blink, for example. "We can simulate life-threatening situations in a realistic environment without harming a patient,” Düsterwald explains. “In these stressful situations here, unlike in real life, mistakes are expressly allowed."

"A little while ago it was only a piece of plastic, but just now it was my patient."

Just as the second team of doctors, headed by Dr. Martin Köhler, arrives, the oxygen level in the blood of the “patient” drops sharply: He is in critical condition. Dr. Hiersemann calls out to check that adrenaline has been given, as ordered, and looks around the room, but no one answers. The other team members busily fetch drugs, attach oxygen and measure blood pressure again, while continually glancing up at the monitor. Still there is no improvement, so the doctors quickly administer an anesthetic and begin an intubation – which proves to be difficult because of the extreme swelling of the throat. As Dr. Köhler carefully inserts the breathing tube into the windpipe, Dr. Hiersemann sets his stethoscope on the patient simulator’s plastic chest, and after a few seconds confirms the tube is in the correct position. The mechanical ventilation is started and the treatment team looks relieved as the blood’s oxygen level starts to increase.

Suddenly, the beeping of the monitoring screen stops and there is silence. Düsterwald and his team enter the room, ending the 15-minute training session. Slowly, the participants start to relax. "It felt completely real," Dr. Köhler says in a tone of near-disbelief, as he instinctively goes to a dispenser and rubs some disinfectant into his hands. "A little while ago it was only a piece of plastic, but just now it was my patient."

Everyone makes mistakes: Every 30 minutes on average when performing routine duties, and much more frequently – as often as twice a minute, according to studies – during more complex, higher-stress tasks.

“Professionals also make mistakes,” says Düsterwald. “We record all the training sessions with a digital audio video system, which enables us to detect even slight irregularities and analyze with the participants how they could have been avoided. And this way we ultimately improve the safety of our patients. Our doctors and nursing staff can draw on a vast wealth of knowledge and experience, and even in the most serious situations the knowledge needed to solve the problem is often in the room. We just need to make sure the right measures are actually carried out on the patient. Communication within the team and with the patient plays an important role, so that is something we focus on during the training sessions."

Afterward, the participants gather for a debriefing and to view a few key scenes from the video. Enough time has passed for them to watch with a good measure of objectivity, and they not only congratulate each other on successful diagnoses but are able to openly make some constructive criticisms. "The handover to the second team of doctors could have been more coordinated," says Bastian Overheu, the Simulation Center’s deputy director. "It was no longer clear who was leading the team. A short break, using the 10-for-10 principle for example, and the situation could have been straightened out."

According to this principle, doctors and nurses should continue to take short breaks – especially when things are hectic – even for as little as 10 seconds every 10 minutes. That is enough time for the physician in charge to announce the treatment plan out loud, ensuring that everyone on the team has the same understanding of the situation, and to ensure that good ideas from the nursing staff do not go unheard.

“Good teams often have, implicitly, the same understanding of a situation,” explains Düsterwald. “They communicate almost without words. Misunderstandings are rare, but they can occur, so it is always good to let colleagues know that you have heard questions or instructions. That is a simple and important safety mechanism that we pass on to all our participants.”

At Fresenius Helios, simulation training for all doctors and nursing staff in higher risk areas, such as intensive care medicine and anesthesia, became mandatory this year. Specialists from emergency medicine, obstetrics and the cardiac catheterization lab undergo regular training. Other concepts are planned for gastroenterology and surgery. All participants take courses conforming to unified standards, and in fully equipped operating and treatment rooms.

More than 600 separate training days are held annually in HELIOS’s simulation centers in Hildesheim and two other German cities, Erfurt and Krefeld. The company has invested a total of about €2 million in the three facilities. A special feature of the Simulation Center in Krefeld is a fully integrated simulation ambulance: to make it as realistic as possible, the “vehicle” has the full original interior and even comes complete with rear and side doors.

Hygiene in hospitals is essential for the survival of patients, and efforts made by hospitals to ensure high standards of hygiene are enormous. Yet cases of bacteria spreading between patients and hospital wards continue to occur, even in wealthy, technologically advanced countries.

(Published: July 2017)

For example at the HELIOS Hospital Duisburg, in western Germany: This maximum-care facility, a university teaching hospital with more than 1,000 beds and 24 specialist departments, was hit by a wave of infections caused by multiresistant bacteria. Mistakes had been made in hygiene management, plunging the hospital into a crisis. Since then, important lessons have been learned. This article illustrates how improvements have been made and rigorously implemented. Hygiene standards in the hospital are now at their highest level ever.

August 13, 2013, was a perfect summer Saturday in Duisburg, but at HELIOS Hospital Duisburg a storm was raging. “Alarm on spreading bacteria in hospital,” read one headline. Another warned readers of a “skyrocketing increase in MRSA infections” at the hospital. MRSA – methicillin-resistant bacteria – has been identified by the World Health Organization as one of the antibiotic-resistant “superbugs” that pose a huge threat to public health worldwide. The outbreak caused many people to lose confidence in the hospital. The number of patients dropped – and so did the employees’ morale.

An important element in the sustained success has been a regular dialogue between all involved staff.Today, less than four years later, HELIOS Hospital Duisburg has one of the best infection-prevention records in the HELIOS Group, which regularly makes its hygiene data public. For Dr. Holger Raphael, the hospital’s Managing Director since mid-2013, this gives cause for satisfaction but not complacency. “We managed to turn things around that time,” he says. “But preventing infection is a never-ending story, particularly in light of the increase worldwide in antibiotic resistance. Our first priority now is what it always has been: to keep reminding ourselves of what is at stake.”

The storm clouds that burst in 2013 were present before Fresenius Helios acquired the hospital in late 2011. Infections do not increase overnight – most are a result of inefficient organization, poor quality medical care or a lack of knowledge among employees. Further complicating matters, HELIOS Hospital Duisburg has several clinics spread across the city of 490,000 people, an industrial center at the intersection of the Rhine and Ruhr Rivers. This necessitates countless daily “patient transports” between the clinics, and can make it more difficult to share information.

“For a long time there was a lot of uncertainty about how to deal with multi-resistant pathogens,” explained Ankica Gagro, who is now Head Nurse in the Cardiology Department . “There were few uniform standards, so, over time, many departments established their own procedures.” The result was that standards varied from ward to ward, even though the conditions and pathogens were identical. Many employees lacked a channel for communication and access to information.
When the “germ scandal” hit, the integration of the hospital into the HELIOS Group was still incomplete. Improvements in hygiene management had not yet been fully implemented. When the bacteria appeared, the pace of change was accelerated in affected departments: Hospital management and Dr. Natalie Pausner, the new Senior Hospital Hygienist, analyzed and prioritized the problems. Renewed energy was put into carrying out long-established procedures more thoroughly.

 

 

“We immediately brought all employees working in areas with close patient contact into the review of the situation and improved our hygiene guidelines,” recalled Dr. Markus Schmitz, Chief Physician for Anesthesiology and the hospital’s Medical Director since early 2013. “The staff then received intensive training. From this point on, a bottle of disinfectant became standard equipment in the pocket of every physician and care employee.”
At the same time, acute problems were recognized and put onto the agenda more quickly. One example was reporting over-use of antibiotics, which can increase bacterial resistance. “That year we also began to extend antibiotic rounds, during which doctors review antibiotic use, to all departments, and to screen all patients for MRSA when they were admitted to hospital,” said Dr. Schmitz. Steps were taken to ensure laboratory results were obtained faster. A weekly internal conference was started where every death in the hospital was discussed with all involved medical personnel. This gave doctors clues on how to better treat similar cases in the future.
An important element in the sustained success on improving hygiene has been a regular dialogue between all involved medical and managerial staff. Doctors Pausner and Schmitz, for example, meet every four weeks and send a monthly report with the hospital’s latest infection data to hospital management and all chief physicians. Among measures launched on their initiative was the introduction in 2015 of short-sleeved shirts for doctors, to prevent transmission of bacteria that can cling to long sleeves.

HELIOS Hospital Duisburg has adopted many more measures to ensure that hygiene standards will continue their steady improvement. The hospital participates in data collection programs organized by a national center and operates an in-house data bank for pathogens, both of which help to pinpoint areas to implement or improve hygiene measures. All hospital wards are better targeting the placement of disinfectants. There is also a standard range of products and techniques for cleansing patients of bacteria. Every specialist department has doctors and nurses responsible for hygiene. An online training module for continuously updating hygiene training and practices has been launched.

“In addition,” said Dr. Pausner, “we flag patients with multiresistant pathogens much more visibly, both in their electronic file and also directly at their bed.” Doctors and their teams regularly update other employees via the intranet and, in acute cases, proceed promptly to the ward. Other hospital staff can make frequent use of the information and share it with colleagues, which helps maintain a focus on hygiene and infection prevention. Constant increased awareness of hygiene issues by hospital staff has probably been the most important and beneficial lesson to have come out of the difficult days of summer 2013, said Dr. Raphael.

A new baby is one of life’s greatest gifts, but for Jaqueline and her husband, Evgeny, the birth seemed almost like a miracle. Jaqueline had been struck by a car as she rode a motor-scooter home from her job in hotel management in 2013, and then spent 28 days in a coma. Her spleen was ruptured and had to be removed; worse still, the severe blood loss caused a shock that led to permanent kidney failure.

(Published: February 2016)

Jaqueline, who also suffered numerous broken bones and a cerebral hemorrhage, had to undergo more than 10 operations at HELIOS Hospital Hildesheim, near Hanover in Germany. In total, she spent about half a year in the hospital.

But while her bones eventually healed, Jaqueline has needed dialysis since the accident to replace her kidney function. Three times a week, for four hours each time, she is connected to a dialysis machine that pumps her blood through a specialized filter – a dialyzer – to remove toxins.

These regular dialysis sessions not only drain a patient’s strength, but cause hormonal changes that affect ovulation. For this reason, the vast majority of women on dialysis cannot conceive. “Only about 1 percent of female patients of child-bearing age will be able to get pregnant,” explained Dr. Burkhard Kreft, Chief Physician of the Nephrology and Dialysis Clinic at HELIOS Hospital Hildesheim. “And even when dialysis patients do manage to get pregnant, about two-thirds of them will lose the child. For Ms. Sinicyn to get pregnant the natural way was very unusual. That made us all the more happy when this sweet, healthy baby was born.”

The challenging situation for dialysis patients who want to have a baby was confirmed by Professor Bernard Canaud, Chief Medical Officer of Fresenius Medical Care, the world’s largest provider of renal care. “Worldwide, only a few hundred cases have been reported of dialysis patients who were able to deliver a live birth despite prematurity, low birth weight and other related health issues,” said Prof. Canaud.

It was not an easy pregnancy for Jaqueline – and was a challenging one for her doctors. Since pregnancies among dialysis patients are so rare, the doctors had little specialist literature outlining other specialists’ experiences. And as taxing as dialysis can be for the patient, it is even more so for the unborn baby. To avoid complications, the frequency of Jaqueline’s treatments had to be doubled at certain times: in order to prevent her urea level from rising to a point that would be potentially hazardous to the fetus, she had to undergo as many as six, four-hour dialysis sessions weekly instead of the usual three.

The big day finally arrived – two months early. After a delivery by Cesarean section in HELIOS Hospital Hildesheim, the newborn Angelique – only 41 centimeters (16 inches) in length and weighing just 1,230 grams (2.7 lbs.) – was rushed to the ward for premature babies. In an incubator, she was attached to a respirator and fed through a stomach tube.

“We visited her every day and spent as much time as possible by her side,” said proud father Evgeny. Finally, two months after the birth, the day finally came when he and Jaqueline could take Angelique home with them. She had doubled in weight, and could now be fed from a bottle.

“We are really happy and grateful that the little one is doing so well,” Jaqueline said. “We’re happy just to be a completely normal family, and loving the time together.”

 

Pictures: © HELIOS Hospital Hildesheim and Kai Kapitän

Privatize a hospital? Anyone wanting to do that needs not only a good concept, but also strong nerves. Resistance in the general population and among employees can be enormous.

(Published: June 2015)

This was the case in the German city of Krefeld when Fresenius Helios acquired the money-losing municipal hospital, Klinikum Krefeld. Initially, there were a lot of preconceptions and fear.

“We demonstrated against it because we wanted our hospital to remain municipal,” recalled Birgit Gillmann, head nurse in the Department of Radiology and Palliative Medicine at the hospital, which is now HELIOS Hospital Krefeld. “We thought they would cut jobs and fire us and we’d no longer be able to care for our patients; we thought it was only about profit. But, fortunately, it turned out to be exactly the opposite.”

HELIOS decided to tear down the old building. Putting up a new one took five years. More than €200 million was invested by HELIOS in the modernization. “We have a magnificent new building, working conditions are excellent and our patients and employees feel very well taken care of,” said Gillman with relief. The hospital now offers more jobs than it did when it was publicly owned. In those days it was close to insolvency: There was only enough money on hand to pay employees for another three months.

“Some people in this city used to carry notes saying, ‘In case of emergency, don’t take me to Klinikum Krefeld. Anywhere but there,’” said Reiner Micholka, Managing Director of HELIOS Hospital Krefeld, about the time before privatization. Since then the hospital’s reputation has improved enormously – also among its employees.

“Before, I didn’t know the managers personally,” said Gillmann about this welcome change. “They were all busy in their offices. I didn’t know how to approach them, and they never came to see us. They never visited the wards or came around to inspect anything. Now, that’s all changed. Suddenly the managers are there, and want to look around. I was quite surprised that they already knew our names. Not only that, but it’s more enjoyable to work for a company that isn’t running at a loss and that isn’t about to close down – a company that’s profitable.” Mayor Gregor Kathstede of Krefeld is also happy about the benefits of the privatization. “It was clear to me that I’d have to push through this idea in Krefeld,” he said. “It took a lot of energy and a little time – but it was the right decision.”

There’s not much conversation in the locker room at 6:30 a.m., as the six women change into the blue uniforms worn on the Intensive Care Unit. The handover from their overnight colleagues proceeds quietly — it was an uneventful night. But the day ahead? On the ICU, it’s impossible to know.

(Published: March 2015)

ICU head nurse Mandy Stockmann is busy handing out assignments. “When possible, we team up the less experienced people with the veterans,” she says. By any standard, Stockmann is a veteran: she has been heading the 67-member ICU nursing team at Fresenius Helios Hospital Bad Saarow, just east of Berlin, since she was 26.

Each member of the Bad Saarow ICU team is trained to deal with the life-threatening emergencies that can strike the ICU’s critically ill patients at any time. Many have just had major surgery or have advanced pneumonia. Others have suffered a serious heart attack or stroke, or devastating brain or internal injuries.

“We treat every patient like they were our own mother or father.”

Stockmann turns to hurry “downtown” — the English name the nurses have given the busy central corridor running between the ICU unit’s two wings, with their total of 36 beds. Downtown is where the doctors and nurses gather for their “morning rounds” to see the patients. The beeping of sophisticated medical equipment deployed throughout the ICU, along with the hoses, cables and flashing monitors — it can all seem daunting. For the ICU patients surrounded by — and often attached to — these life-saving machines, it is crucial that they sense the staff’s compassion, and special attention is given to treating them as gently and kindly as possible. “We treat every patient like they were our own mother or father,” says the head of the ICU, Dr. Uli-Ruediger Jahn.

“How was your night? Do you have any pain?” Jahn quietly asks a patient. During the morning visit he is highly focused, and expects the same from the staff. “This is the most important time of the day,” Jahn explains. “It’s the only time that the different specialist doctors all come together as a multi-disciplinary team. Everyone really has to listen closely.”

12:30 p.m.: Just after noon, the colleagues gather in Jahn’s office. Their faces etched in concentration, they examine the X-rays of patients as colleagues outside continue to closely monitor patients. The frequent checking of vital signs and medication levels, the carrying out of specially ordered tests such as lung endoscopies, as well as respiration therapy and the various measures needed to support patients’ circulatory systems: these are among the regular duties in the ICU workday.

“Interdisciplinary cooperation takes on a different level of significance in the ICU,” and the nursing staff is on the front line of care, says Dr. Stefan Wirtz, the hospital’s Chief Physician for Anesthesiology, Intensive Care Medicine, Emergency Care Medicine and Pain Therapy. After all, he points out, it is the nurses who spend the most time with the patients, watch over them day and night, and notice even the smallest changes in their condition. “You can only do medicine well when you work in friendly cooperation with your colleagues,” Wirtz adds. “That’s true for doctors and for the nursing staff.

5 p.m.: Another long day ends for Mandy Stockmann at 5 p.m., and she turns to the important business of properly winding down. “Symbolically, it’s important to leave all your private worries in your locker when you start your shift, and then put work problems or your concerns about the patients aside, along with your uniform, at the end of your day,” Stockmann explains. “And I really long for peace and quiet, so I turn the phone off for an hour when I get home.”

The night shift takes over at 10 p.m., with nurse Uwe Bogner as shift leader. This night soon sees him racing over to a nearby station to assist colleagues in helping a very heavy patient back into bed. Then word comes in that a planned emergency operation is being canceled because the patient is too weak, and all the equipment that the staff had brought out and set up for post-surgical care must now be put away. Other nurses, meanwhile, organize things for the day shift, while the physician on call attends to a patient who cannot come to rest; everyone knows that fear and anxiety do most of their visiting at night. The night shift is drawing to a close in the Bad Saarow ICU when Uwe Bogner approaches a patient to clear his throat of fluid that could obstruct breathing. The nurse knows the sedated patient will not be able to answer, but he takes a moment to speak to him all the same. “Good evening, Mr. K,” Bogner says softly. “Hope I didn’t startle you.”

6:30 a.m.: The unit is quiet. Three doors down, Uwe Bogner’s colleagues have arrived for the early shift and are quietly changing into their blue ICU uniforms.

Dr. Uli-Ruediger Jahn has assumed the position of Chief Physician for Anesthesiology, Intensive and Emergency Medicine and Pain Therapy at HELIOS Hospital Uelzen, in northern Germany. The Intensive Care Unit and the clinic for Anesthesiology and Pain Therapy have since become separate specialist departments within HELIOS Hospital Bad Saarow. Dr. Stefan Wirtz is Chief Physician, and Ali Allam is Senior Consultant, in the Intensive Care Unit.