THE CARDIOTHORACIC OUTREACH PROGRAM - A PILOT PROJECT

Objective. To test the practicality, safety and benefits of major card iothoracic surgery in two rural hospitals. Design. Analysis of morbidi ty and mortality outcomes of a random collection of 35 patients, who u nderwent diverse surgical procedures. At each visit, the cardiothoraci c team of Ga-Rankuwa Hospital - one surgeon, three registrars, two med ical officers, six nurses, and four perfusionists moved all equipment for major surgery, including bypass machines, to two small rural hospi tals. Ga-Rankuwa Hospital, as a tertiary hospital attached to a medica l school (Medical University of Southern Africa), mounted an outreach programme on a trial basis. The exercise was designed to render assist ance, offer decentralised services, and test the skills of the cardiot horacic team in an environment where high-technology procedures have n ever been undertaken by the local health professionals. Setting. Two r ural hospitals, viz. Tintswalo and Mankweng, in the referral area of M EDUNSA, with no conventional ICU facilities. The support services for operative, pre-operative and postoperative care were very basic. The l ocal personnel consisted only of general nurses and medical officers. None had experience of high-technology or complex theatre work. Partic ipants. 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 compr ised 35 major procedures, including open heart operations and major lu ng 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 anaesth esia. Twenty cardiopulmonary bypasses were performed. There was 1 intr a-operative death, due to low-output state. Intra-operative morbidity occurred in 2 of the 35 operations. These consisted of a cerebrovascul ar accident (CVA) (air embolism), and a temporary heart block. Late ou tcomes (after 1 week) were also analysed; the incidence was 1/35 opera tions. This was a CVA due to a left atrial appendage clot; Staff moral e at the local hospital improved remarkably. The process of teaching t he local professional nurses was surprisingly easy. Benefits included a decreased referral rate (100%), lower costs (transport, medicines, o perations), excellent patient and community confidence in the work of the hospitals (increased hospital outpatient numbers), and political s upport (new tools, upgraded facilities and new equipment). Results. Th e exercise was a resounding success in both measurable and general ter ms. All operations were successfully performed, with very low adverse outcomes (morbidity, mortality) and good quality of life for all the s ubjects. The safety and cost-effectiveness of cardiothoracic surgery u nder primitive conditions were demonstrated. The standard of patient c are improved, and local staff acquired good basic skills in patient ca re. 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.