The Cardiothoracic Outreach Programme--a pilot project

Abstract

Objective: To test the practicality, safety and benefits of major cardiothoracic surgery in two rural hospitals.

Design: Analysis of morbidity and mortality outcomes of a random collection of 35 patients, who underwent diverse surgical procedures. At each visit, the cardiothoracic team of Ga-Rankuwa Hospital-one surgeon, three registrars, two medical officers, six nurses, and four perfusionists-moved all equipment for major surgery, including bypass machines, to two small rural hospitals. Ga-Rankuwa Hospital, as a tertiary hospital attached to a medical school (Medical University of Southern Africa), mounted an outreach programme on a trial basis. The exercise was designed to render assistance, offer decentralised services, and test the skills of the cardiothoracic team in an environment where high-technology procedures have never been undertaken by the local health professionals.

Setting: Two rural hospitals, viz. Tintswalo and Mankweng, in the referral area of MEDUNSA, with no conventional ICU facilities. The support services for operative, pre-operative and postoperative care were very basic. The local personnel consisted only of general nurses and medical officers. None had experience of high-technology or complex theatre work.

Participants: Thirty-five randomly selected patients of both sexes with ages ranging from 11 years to 64 years. Pre-operative diagnoses of diverse cardiac and lung conditions were made. The operations performed comprised 35 major procedures, including open heart operations and major lung procedures. The personnel comprised the MEDUNSA cardiothoracic team, who were assisted by local nurses.

Intervention and outcome: Thirty-five patients underwent 35 major procedures, all under general anaesthesia. Twenty cardiopulmonary bypasses were performed. There was 1 intra-operative death, due to low-output state. Intra-operative morbidity occurred in 2 of the 35 operations. These consisted of a cerebrovascular accident (CVA) (air embolism), and a temporary heart block. Late outcomes (after 1 week) were also analysed; the incidence was 1/35 operations. This was a CVA due to a left atrial appendage clot. Staff morale at the local hospital improved remarkably. The process of teaching the local professional nurses was surprisingly easy. Benefits included a decreased referral rate (100%), lower costs (transport, medicines, operations), excellent patient and community confidence in the work of the hospitals (increased hospital outpatient numbers), and political support (new tools, upgraded facilities and new equipment).

Results: The exercise was a resounding success in both measurable and general terms. All operations were successfully performed, with very low adverse outcomes (morbidity, mortality) and good quality of life for all the subjects. The safety and cost-effectiveness of cardiothoracic surgery under primitive conditions were demonstrated. The standard of patient care improved, and local staff acquired good basic skills in patient care. The referral patterns changed for the better and the confidence of the community in the services was enhanced. The risk/benefit ratio of the exercise was commendable. The feasibility of an extended service was encouraging.