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SAMJ: South African Medical Journal

On-line version ISSN 2078-5135
Print version ISSN 0256-9574

SAMJ, S. Afr. med. j. vol.98 n.1 Cape Town Jan. 2008




Multidisciplinary teams - the rural way forward



There are few district hospitals in South Africa more isolated and rural than the 146-bed Zithulele Hospital snagged in a dusty web of rutted roads atop one of the rolling coastal hills near Coffee Bay, 99 km from Mthatha.

Which is what makes it such an excellent example of what can be done in the face of seemingly insurmountable logistical, staffing, equipment and housing challenges that health care staff across the country so often endure or accept as 'normal'.

The most striking thing about Zithulele is the quality and commitment of its senior clinicians, two vocation-driven married couples who picked up the baton from their path-finder community service predecessors, Rebecca Smith and Thandi Wessels.

Over the past 2 years they've built a holistic team driven by solid working relationships and vision and serving a drainage area of some 143 000 people.

Zithulele's staff has grown from what deep rural district hospitals country-wide will recognise as 'about the usual' - 1 senior medical officer and 2 community service doctors.

Now it's the exception: 7 doctors, 2 occupational therapists, 2 pharmacists (the first in its 50-year history), a physiotherapist, a social worker and a dentist. At the core of this team are Ben and Taryn Gaunt (chief and principal medical officers, respectively) and Karl and Sally le Roux (senior medical officers), all committed to long service and making a difference to the community and its health.

The perinatal mortality rate has stabilised and is slowly decreasing, despite the 33% increase in deliveries.

Sally manages the ARV site, Karl services the outlying clinics and helps with the overall ARV programme, while Taryn oversees paediatrics and students. Ben looks after maternity and team management.

Between them they have CMSA diplomas in obstetrics and gynaecology (2), child health, anaesthetics (3), and HIV management, and 2 have spent a 'significant amount of time' in surgery, orthopaedics and emergency medicine.

'We don't know everything but we have an idea about most things. We specifically gained those skills with this purpose in mind,' says Ben.

Recruitment - 'look for long-term intentions'

Vital extra recruitment came via proactive use of personal networks with an eye for long-term intentions, a provincial policy that attempts to look beyond 'traditional community service placement', and an ever-improving hospital profile.

Ben and Karl were at Cape Town's Westerford High School and the same UCT med class together. Taryn and Sally were also in the same med class. That they have ended up together merely emphasises how powerful word of mouth is when it comes to recruitment and retention.

The catalyst for the Gaunt couple choosing Zithulele was an enthusiastic former comserve doctor, Will Mapham (then stationed at Madwaleni Hospital several valleys away). Mapham presented an inspirational slide show at the 2004 Rural Doctors Association Conference, depicting the wonderful recreational and professional opportunities available in the pristine coastal area - and word filtered back to the Gaunts.

A ward round at Zithulele today is an eye opener. The entire hospital's clinical staff moves from bed to bed in a tightly focused knot as the incumbent head of each discipline (most of whom built their departments from scratch) details the patients' relevant history and progress.

These 'grand rounds', as Ben calls them, on Thursday and Friday mornings, end with an equally 'grand tea', where individual cases are discussed in a convivial atmosphere before everyone returns to their work station for the day. 'Getting people's input, especially from allied health professionals, in decisions, in policy and in leadership matters really helps improve people's sense of belonging,' he says. Ben believes allied health professionals are too often ignored and that rural hospitals can lead the way in correcting this.



Turnaround on mother and child care

Their mainstream services are turning into models of achievement, with maternity leading the field. In 2005 they did 748 deliveries, the following year 912 and their current 12-month average is 1 000, testimony to growing community trust and the quality of care offered. The perinatal mortality rate has stabilised and is slowly decreasing, despite the 33% increase in deliveries.

A 2-hour caesarean section service was introduced in July 2005, along with monthly perinatal mortality meetings. The hospital was approved as a 'Saving Mothers Saving Babies' site in May 2007 and there has been increasing uptake of tubal ligations (sterilisations) since these were first offered in November 2005. In paediatrics, bed availability increased from 12 in July 2005 to 22 currently, and monthly mortality meetings began in May 2006.

An 'outstanding' malnutrition protocol was developed along with a variety of other neonatal guidelines. Ill neonates are frequently managed on site under Taryn's supervision. The paediatric ward boasts a large colourful mural and (donated) soft toys are unusually plentiful.

'Journal clubs' for CME

Last year the doctors began weekly 'journal clubs', where the latest guidelines and research on topics relevant to their daily practice are presented and discussed.

Monthly resuscitation training for nurses began in January 2006, with knowledge improvement tested every 6 months with a 'fun quiz'.

The team has initiated their own disability grant clinic and convinced social workers in nearby Mqanduli and Elliotdale to work with them.

When it comes to equipment, government-facilitated donation from the people of Japan has resulted in multiparameter monitors, infusion pumps and syringe drivers, servo cribs and incubators, pulse oximeters, resuscitation trolleys, an autoclave and a phototherapy unit.

UCT medical students donated urns and electric beaters to mix starter and catch-up formula for malnourished children while a fundus camera is available for full-time use as part of the retinopathy screening study in conjunction with Walter Sisulu University.

The hospital pharmacy saw its first-ever pharmacist in May 2006 and she was complemented by the first community service pharmacist in January last year. They are now helped by 4 auxiliary workers who are receiving on-the-job training.





The pharmacy has gone from organised chaos to proper stock-monitoring, packing and dispensing procedures, better stock availability and a vastly improved range of medicines. Mixtures are made up on site, an after-hours emergency cupboard was set up and the pharmacists are voluntarily on emergency call.

The most creative example of taking care to the people is Dr Allie Pillay's community imbizos where he publicly conducts tooth extractions, resulting in an immediately increased patient load.

Clinic support and outreach 'fundamental'

An occupational therapy (OT) department was established in February 2006 (full-time senior OT, comserve OT, and 2 assistants), and it has already begun an outreach service to clinics and is training community health workers, with increasing numbers of wheelchairs and buggies being sourced for disabled people.

The physiotherapy department began a month earlier, staffed by a comserve physiotherapist who had 470 patient sessions under her belt within the first 3 months. The therapists are an integral part of the disability grant assessment team and have helped source vital equipment. Many of these new staffers are using pre-existing equipment properly for the first time ever.

Radiography has 3 long-term staff who often voluntarily work extra hours to improve outpatient department service delivery. Over 570 ultrasound procedures conducted in the year since obtaining the machine have led to far fewer referrals. The radiographers now shoot an average of 500 X-rays per month as more doctors see more patients. Difficult images are e-mailed out for feedback. New equipment here also includes a digital X-ray machine and processor as well as X-ray viewing boxes in all patient areas. A service agreement with the supplier has led to improved service and response times when equipment malfunctions.

The hospital's ARV site, accredited in 2006, now has a director, chief professional nurse, senior professional nurse, nurse assistant, administrative officer and data capturer, plus 6 volunteer counsellors who receive stipends. With 160 patients on ARVs and a weekly support group attended by on average 75 people, plus a vegetable garden initiative (supported by the local provincial department of agriculture), the programme is being increasingly accepted. One measure of this, according to Ben Gaunt, is the small numbers of staff starting to come for testing and beginning ARV treatment.

The hospital's on-site social worker helps to identify needy patients during ward rounds, and conducts home visits in addition to maintaining regular contact with her colleagues in Mnqanduli and Elliotdale.





Public tooth pulling wows the crowds

The community service dentist began in January last year and works in a room in the outpatient department, creating awareness of his services with posters and pamphlets around the hospital, while visiting outlying clinics thrice weekly. The most creative example of taking care to the people is Dr Allie Pillay's community imbizos where he publicly conducts tooth extractions, resulting in an immediately increased patient load.

Laboratory services is one area where relationship building has yielded gratefully embraced and faster results and increased job satisfaction for doctors. The 3 on-site lab technicians work with the CMO and regional NHLS manager. An expanded range of tests includes a chemistry analyser for on-site renal and hepatic function checks.

Zithulele was revilatised in 2005 with new high-quality acute wards and many more functional beds, creating a need for more senior medical posts as work pressure on nurses increased, albeit in pleasant surroundings.

Accomodation, the bug-bear of rural hospitals everywhere, was vastly improved with a new nurses' home and living quarters for professional staff due for completion in January 2008.

Says Ben Gaunt, 'we're not just here to earn a salary or even just to practise medicine, but to make a difference'.

Zithulele actively seeks out medical students for electives and has been so successful that they are usually fully booked from May to December. Allied health students were hosted for the first time late last year and are also housed in a well-equipped rondavel.

The senior clinicians believe investing in interns pays off in eventual recruitment.

Section 21 support company set up

Conscious of the 'bigger picture', the team has also set up a Section 21 company called the Jabulani Rural Health Foundation to provide support for the development of Zithulele and the community it serves. It will give health care support on HIV, TB, child health and maternal health, start job creation and skills placement, health care education, child education support (a school for talented maths and science students is envisaged), bursary support and adult education and literacy.

Land for the building of a nutrition rehabilitation centre was donated by a local family and a funding proposal is being finalised, while an 'Adopt an HIV patient' programme to boost support-group attendance and ARV compliance is running.

The local chief and community gave the foundation a prime spot in the village to build a foundation headquarters with a pre-school, library, training centre and accommodation quarters planned.

Another aim is to improve the supply of essential medicines to Zithulele's referring clinics by custom-designing a programme with the local service authority and provincial and district pharmacists, assisting with financing it, if necessary.

More vehicles to enhance the hospital's many outreach projects are in the pipeline.

Says Ben Gaunt, 'we're not just here to earn a salary or even just to practise medicine, but to make a difference'.

What about when bureaucracy makes them want to pull their hair out?

'We try and take the long-term view, or take time out when we can't see the view,' he replies. His advice to other hard-pressed deep rural health care leaders is simple - 'find a vision, build a team and go for it'.

As the challenge in the sign-off to his e-mail eloquently says, 'If you don't have a dream, how will you ever have a dream come true'?

Chris Bateman

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