South African Family Practice - Volume 49, Issue 1, 2007
Volume 49, Issue 1, 2007
Challenges to creating primary care teams in a public sector health centre : a co-operative inquiry : original researchSource: South African Family Practice 49 (2007)More Less
Background: Effective teamwork between doctors and clinical nurse practitioners (CNP) is essential to the provision of quality primary care in the South African context. The Worcester Community Health Centre (CHC) is situated in a large town and offers primary care to the rural Breede Valley Sub-District of the Western Cape. The management of the CHC decided to create dedicated practice teams offering continuity of care, family-orientated care, and the integration of acute and chronic patients. The teams depended on effective collaboration between the doctors and the CNPs.
Methods: A co-operative inquiry group, consisting of two facility managers, an administrator, and medical and nursing staff, met over a period of nine months and completed three cycles of planning, action, observation and reflection. The inquiry focused on the question of how more effective teams of doctors and clinical nurse practitioners offering clinical care could be created within a typical CHC.
Results: The CHC established three practice teams, but met with limited success in maintaining the teams over time. The group found that, in order for teams to work, the following are needed:
A clear and shared vision and mission amongst the staff. The vision was championed by one or two leaders rather than developed collaboratively by the staff. Continuity of care was supported by the patients and doctors, but the CNPs felt more ambivalent. Family-orientated care within practices met with limited success. Integration of care was hindered by physical infrastructure and the assumptions regarding the care of "chronics". Enhanced practitioner-patient relationships were reported by the two teams that had staff consistently available.
Significant changes in the behaviour and roles of staff. Some doctors perceived the nurse as an "assistant" who could be called on to run errands or perform tasks. Doctors perceived their own role as that of comprehensively managing patients in a consultation, while the CNPs still regarded themselves as nurses who should rotate to other duties and perform a variety of tasks, thus oscillating between the role of practitioner and nurse. The doctors felt responsible for seeing a certain number of patients in the time they were available, while the CNPs felt responsible for getting all the patients through the CHC. The doctors did not create space for mentoring the CNPs, who were often seen as an intrusion and a threat to patient privacy and confidentiality when requesting a consultation. For the CNPs, however, the advantage of practice teams was considered to be greater accessibility to the doctor for joint consultation. The identification of doctors and CNPs with each other as part of a functioning team did not materialise.
Effective management of the change process implied the need to ensure sufficient staff were available to allow all teams to function equally throughout the day, to be cognisant of the limitations of the building design, to introduce budgeting that supported semi-autonomous practice teams and to ensure that the staff were provided with ongoing opportunities for dialogue and communication. The implications of change for the whole system should be considered, and not just that for the doctors and nurses.
Conclusion: Key lessons learnt included the need to engage with a transformational leadership style, to foster dialogical openness in the planning process and to address differences in understanding of roles and responsibilities between the doctors and the CNPs. The unreliable presence of doctors within the practice team, due to their hospital duties, was a critical factor in the breakdown of the teams. The CHC plans to further develop practice teams, to learn from the lessons so far and to continue with the co-operative inquiry.
Source: South African Family Practice 49 (2007)More Less
Background: Information about drug utilisation among outpatients in Serbia and Montenegro is scanty, and no publications on the topic are available. The objective of this study was thus to evaluate and compare patterns of drug utilisation in the Zabljak municipality.
Methods: Prescriptions for outpatients (n=456) and dispensing records from a local pharmacy in Zabljak for a three-month period were reviewed retrospectively.
Results: The leading diagnoses were infectious diseases of the respiratory system and hypertension. The total number of defined daily doses (DDD) per 1 000 inhabitants per day was 178.75. Cardiovascular drugs (41.139 DDD/1 000/day), drugs for the gastrointestinal system (36.881 DDD/1 000/day) and antibacterial drugs (18.318 DDD/1 000/day) were the most frequently prescribed drugs.
Conclusion: The total number of drugs utilised per 1 000 inhabitants per day was within the acceptable range. However, the pattern of diagnosis did not correspond to the pattern of drug utilisation. There is a need for intervention in order to promote the rational selection and use of drugs among outpatients in Serbia and Montenegro.
Source: South African Family Practice 49 (2007)More Less
Background: The Road to Health Card (RTHC) provides a simple, cheap, practical and convenient method of monitoring child health. The RTHC could assist in improving health through vaccine compliance and early identification of growth faltering. The purpose of this study was to assess whether the RTHCs are completed and interpreted adequately at primary, secondary and tertiary care levels in South Africa.
Methods: The study was carried out at a primary, secondary and tertiary care centre. A questionnaire was administered to 100 subjects at each centre to obtain demographic information, information on whether the RTHC had been brought along and, if not, why it had not been brought.
Results: Most children were brought to the centres by their mothers. The RTHC was not brought to 48% of the consultations; of these respondents, about 72% thought that bringing along the RTHC was not necessary. Health workers seldom asked to see the RTHC in the primary and secondary care settings, but 50% of them did so at Ga-Rankuwa Hospital (p = 0,002). In only eight cases overall were the children below the third percentile of weight for age. Approximately 20% had incomplete immunisations.
Conclusion: Many parents believe that the RTHC is only required for visits to the Well-baby Clinics, and not for consultations. The RTHC is not often asked for at consultations; the fact that this is more often done at the tertiary care centre may be the result of the service being supplied by paediatricians-in-training. Health workers should ask to see the RTHC in order for mothers to understand the importance of the information contained in it. The study showed that the RTHC is not used to its full potential.
The situation in private general practice was not investigated, but is not expected to differ much from that described in this article. Although many family physicians do not offer immunisations as a service, they all deal with sick children and if the general practitioner asks mothers to produce the RTHC and then discusses its reference to her child?s current problem, the mothers are more likely to understand the importance of the RTHC as a tool in monitoring child health.
The substitution of Phentolamine with an equal amount of Chlopromazine as an alpha-blocker in vasoactive cocktails used for intracavernous injection therapy for the treatment of erectile dysfunction : original researchSource: South African Family Practice 49 (2007)More Less
Introduction: This brief report describes the replacement of phentolamine mesylate with an equal amount of chlorpromazine HCl in vasoactive drug mixtures used as intracavernous (IC) injection therapy for treating erectile dysfunction (ED). Phentolamine, amongst other drugs, had been used in drug injection therapy for the treatment of ED, but was replaced as single drug therapy by more effective drugs, such as alprostadil (prostaglandin E1). It has, however, still widely been used as alpha-blocking agent in vasoactive drug cocktails. Phentolamine has a synergistic effect with alprostadil, papaverine and atropine in drug combination cocktails. These injection mixtures are very effective for treating ED and are commonly known as bimixtures, trimixtures and quadmixtures. The vasoactive drug, phentolamine, was withdrawn from the market in South Africa. Chlorpromazine (a phenothiazine) was suggested as an alternative alpha-blocking agent to be used in drug cocktails for the IC treatment of ED.
Methods: Three hundred and sixty-four (364) patients were questioned and evaluated during follow-up visits to an ED clinic after phentolamine mesylate was replaced with an equal amount of chlorpromazine HCL in their regular IC injection preparations. The collected data is based on results from self-administration at home.
Results: No significantly unusual adverse effects or altered efficacy of the new preparations were reported. The patients noted a change in the colour of the drug mixtures that contain chlorpromazine and papaverine. Despite this slight change in colour, the effectiveness of the mixtures remained the same if a use-before date of three months was adhered to.
Conclusion: The results indicate that phentolamine mesylate can effectively be replaced with an equal amount of chlorpromazine HCL in IC drug cocktails for the treatment of ED.
Author L.J. MathibeSource: South African Family Practice 49, pp 5 –6 (2007)More Less
Conducting small randomised controlled trials (RCTs) 'nested' in routine clinical practice is ideal for family practitioners, non-academics and young researchers, who often are required to complete a 'small-scale' research project for their master's (MMed) theses. These trials have the potential to produce good outcomes that could promptly change clinical practice and behaviour. In this paper, the author discusses the advantages and disadvantages of conducting RCTs nested in routine clinical practice, as well as ways of improving their quality.
Author H.R. SchneiderSource: South African Family Practice 49, pp 19 –26 (2007)More Less
Guidelines come and go, and each successive guideline hopefully brings with it an improvement in the understanding, diagnosis and management of the condition in question. The Montreal definition and classification of gastro-oesophageal reflux disease (GORD) is an excellent, well-constructed guideline, compiled by world authorities on the subject, after exhaustive consultation. The aim of any guideline is to achieve wide recognition and ensure uniformity in approach.