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«Report on Working Visit to Turiani Hospital from April 1st till April 14th 2012 Ina Boerma Gerbrig Bijker Tamara Prinsenberg Willem Nugteren 1. ...»

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Report on Working Visit to Turiani Hospital from April 1st till April 14th 2012

Ina Boerma

Gerbrig Bijker

Tamara Prinsenberg

Willem Nugteren

1. Supporting needs (by Willem Nugteren)


Turiani Hospital in Tanzania is running a project on Infection Prevention and (burn) wound

management since several years. The project is supported and mainly financed by the Burns Turiani Foundation in Groningen, the Netherlands. The aim of the project is an accountable reduction of wound infections, including accidental wounds and wounds after elective and acute surgery, through transfer of knowledge and skills. It results in improved hygiene, implementation of basic rules and behaviour for infection prevention, in proper wound handling and wound management in general and in burns more specifically. But it also results in a sufficient number of adequate local teachers to maintain the standards set by the project. These teachers are trained within the project via the principle of ‘Train the Trainer’.

The project implies a working visit to Turiani Hospital of a team from Groningen once or twice per year. This time the team consisted of four members. For the continuation of the project Ina Boerma, Nurse Practitioner, and Gerbrig Bijker, Staff Nurse, both from the Burn Centre of the Martini Hospital in Groningen and the surgeon Willem Nugteren took part.

Tamara Prinsenberg (Research coordinator for the Dutch Burns Foundation) joined the team for an exploration of the possibility for a preventive program on burns in Turiani.

The more detailed programme of this visit is described in the document “Education Plan 2012 Burns Turiani”. As mentioned in the TOR for Tamara the main objective of her visit was “to explore the possibilities for developing and implementing a tailor made burns prevention programme in Turiani”.

Visiting program The trip to Turiani Hospital was not only uneventful, but also enjoyable. The more so by the offer from the hospital administrator, Sr. Julieth to collect the team by car from Dar es Salaam, which we gladly accepted. Going from Morogoro to Turiani we took the shortcut and thus missed the stretch of Working Visit to Turiani Hospital, April 2012 1 some 20 km of the construction of the new road. The progress is slow but steady-going. The narrow bridge in Turiani, lying deep below the high banks of that river, is now overshadowed by a huge concrete construction, a double lane bridge towering up to the height of the banks! But the preparations for the road itself are still some 15 km away. They are clearing the bushes over a width of some 50 meters and have progressed up to Chazi.

On arrival in Turiani Hospital we were received by Sr Gregory Cps, in her typical way, and stationed in the well-known guesthouse. Shortly afterwards we were welcomed by Sr Julieth and Dr Mhando, M.O. i/c. It was a warm and friendly encounter, good to meet again. They were expecting us and were prepared for the forthcoming programme. Despite the exchange of positive feelings of our friendship we also noticed the dark clouds of sorrow that dominate their minds in managing the hospital.

Despite contracts and statements the support that has to come from government and diocese remained insufficient and had a drawback on a proper running of the hospital. Moreover a land issue between the former and new owner of the hospital is hampering adequate planning of required infrastructure for the hospital. Although it is not having an influence on the working relation with the present Cps sisters directly, it forms a threat for a negative input. During this first introductory meeting we discussed the planning for the different activities for the forthcoming days.

Supporting needs According to the Education Plan 2012 lectures, training sessions and workshops were given.

Nurses and doctors were involved in these activities. A summary of the training sessions is given by Ina Boerma in the second part of this report. In Appendix 1 the different medical activities are listed, especially the medical lectures, surgical procedures and consultations.

Moreover several meetings were held. These are listed in Appendix 2.The participants of the meeting are mentioned as well.

The subjects and outcome of the meetings are summarized below.

CDH (Council Designated Hospital) developments It is a tedious process, especially the payment of the budget for recurrent costs. Sr. Julieth is visiting regularly the Ministry in Dar in order to push the process forward. During the second week of our visit she was prompted to go to Dar again.

Due to failure of expected payments and in order to keep the finances in balance they had to raise the prices for treatment and hospital stay up to 50% last January. During our visit on average some 125 patients were admitted, a bed occupancy rate of 70%. This is not too bad, in view of the prices. It is hoped that the government will soon meet its obligations. The stimulating support of the owner, i.e. the Bishop might prove to be crucial to that purpose. The more so since the aim of the hospital is to serve the poor. This was also discussed with the Secretary of the Roman Catholic Medical Board.

Land issue Cps claimed all land beyond the guesthouse including the relative hostel and nutrition unit with surrounding grounds. Such a view deprives the hospital of the needed extensions of infrastructure, more specific for a nursing school. This is contrary to the Memorandum of Understanding between the Cps-congregation and the Diocese of Morogoro. This issue has to be tackled at the level of the signing parties, not at locally level, and soon. As long as the problem remains unsolved it might influence working-relations negatively while hindering the infrastructural developments as scheduled in the Master plan. Notably this plan was developed under the leading guidance of the Cps-sisters.

The issue and the urgent need to handle been brought to the attention of the Vicar-General during a conversation we had together with Dr Mhando, de MO i/c of Turiani Hospital.

Working Visit to Turiani Hospital, April 2012 2 Maternity On behalf of Henk Boldewijn and the Foundation Friends of Turiani the “Step by Step-plan” for the renovation of the Maternity including the building of a new Labour Room was discussed. The remarks on the sequence of steps, logistics and essential provisions were discussed and noted for further communication with Henk. A big problem is the discrepancy between realistic needs and (financial) possibilities. Essential is the resolution of the hanging issue between a potential donor, Manos Unidas, which is able to contribute substantially, and the Diocese of Morogoro. This must be settled finally on short term, as was communicated to the Vicar-General.

Special Care Unit It was confirmed again that the availability of such a unit is very supporting for the services of the hospital. So we will develop further plans for the renovation and the structuring of the indicated part of the Male Surgical Ward.

Nursing school By Wieneke Boldewijn a proposal was written. This will be further discussed during her forthcoming visit to Turiani Hospital in May 2012.

Registration activities by doctors The M.O.’s and AMO’s are very motivated to do the several registrations, enabling evaluation of their work. In the discussion they suggested some additions to the items to be registered. It was decided that the registration of the LSCS will be done by two doctors (Joseph and Nasar) and that Sr Adelphina and Sr Carol will register the neonatal sepsis in the Paediatric Ward and Maternity respectively. It will be proposed to the Board of the Burns Turiani Foundation that a total of 9 doctors will be paid an allowance for the registration activities according to the present contract. As soon as the CDH status has fully materialized the contract is no longer valid and new terms have to be discussed.

MASH The medical student organization in Groningen, responsible for sending periodically medical equipment and materials to the hospital provided a previous list of items that are considered of importance for the hospital. The list was reviewed by the Patron Michael Bassu who added some items. The list will be handed over again to the people of MASH.

Burns Prevention Program Tamara Prinsenberg was very active with interviewing people and filling out many questionnaires.

She got good support for her activities. She will report separately on her findings regarding the possibilities for developing and implementing a prevention programme on burns in Turiani.

The visit was an intensive period of two weeks in which we worked very well together with the management, doctors and nurses of the hospital. The aims of the visit were fulfilled according to the wishes an indicated needs of the hospital enabling us to continue the education plan in the second half of this year.

2. Educational Program (by Ina Boerma) Introduction.

During the visit in 2011 meetings took place between members of the management team, nurses and doctors of Turiani hospital and the Burns Turiani Foundation resulting in a report in which it was conWorking Visit to Turiani Hospital, April 2012 3 cluded that continuous education is essential. Therefore the management of Turiani Hospital asked the members of the Burns Turiani Foundation to continue the program for the next years with special

attention to (see also Education and Learning plan, 2011):

- Training in practice and theory during two week visits twice a year

- Evaluating the registration of surgical site infections

- Financial support of the education of two health care workers

- Support in developing rebuilding plans of one of the wards in order to improve the care for severely injured patients

- Developing a burs injury prevention plan in collaboration with the Dutch Burn Foundation Based on the Education and Learning Plan 2011, members of the Burns Turiani Foundation planned two visits in 2012 and after approval by the management team of Turiani Hospital started with the implementation during their first two weeks stay in April 2012.

The aim of the visit was to improve knowledge and skills in theory and practice by doctors and nurses with special attention to new HCW’s and the trainers (see Proposal program training activities Turiani

Hospital 2012). Subjects were:

- wound care and related factors to improve wound care

- care for adjusting fluids in acute burns

- surgical care in burn wounds and reconstructions after burns

- evaluation of the current protocols in hygiene and wound care

- Advanced Life Support After a very warm welcome we started on Monday with a visit to all the wards and HCW and made an inventory of the wishes, needs and amount of patients with burn wounds or skin contractions. A first meeting with the Patron Michael Basso and his assistant Costa resulted in a definite schedule for the workshops starting the following day. Also meetings with the trainers and a theatre schedule were planned.

All collective efforts during the two weeks led to the following results:

Lessons and workshops The new nurses and clinical officers were divided in two groups. Both groups could participate in 3

workshops during working hours. In total 16 workers attended the workshops. In 6 afternoon sessions the following subjects were dealt with in an interactive way:

- Hygiene and infection prevention: the different micro-organisms and their role in infectious diseases, the importance of protecting patients and HCW’s and how to do so;

- Wound care: wound healing in different circumstances and factors, positive as well as negative, influencing the process of wound healing;

- Case studies: how is hygiene related to proper wound care and how to use the existing protocol?

Used material like the new poster ’Wound Circle: factors related to the wound healing process were hung in the classroom and in all the wards.

A summary of the above described subjects was given in a workshop for doctors and staff nurses and also related to an actual case.

The group doctors and staff nurses were also instructed in when and how to use an Ambu bag. After a lively lesson a new Ambu bag was handed over to the Patron, Michel Basso.

For the new clinical officers we explained in a separate meeting how to use the burn admission form and we took care of a new supply of the forms in the OPD.

Working Visit to Turiani Hospital, April 2012 4 Burn care in practise In the wards several burn cases were admitted especially children (8) with a TBSA between 5 and 18%. Other special wounds we saw were a crocodile bite and a partially amputated hand. Some of the wounds were only a few days old, some of the patients had wounds whom existed for several weeks and even months. They were waiting for surgical procedures. Also patients with skin contractures had arrived on our request and were scheduled for a theatre procedure.

In total 11 patients, all with difficult wounds, were taken care of daily.

It gave us a continuous opportunity in bedside training. We worked together with the nurses in wound dressing procedures, cleaning procedures and we refreshed the knowledge of the iv- drip and best practice in giving the right amount of fluid in the right time. The earlier developed fluid charts were re-introduced and will be used in seriously ill patients. We also had the opportunity to give some patients a splint after skin reconstructions and instructed the nurses in how to use and how to clean the splint.

During the two weeks we took care of a diversity of wounds: fresh and old burn wounds, wounds with necrotic tissue, infected burn wounds, skin grafted wounds, donor sites and non-burn wounds as a crocodile bite and complicated surgical wounds. In order to improve the soaking procedure in burn wounds we donated two bath tubs for children to the children ward. The soaking room of the children ward was brightened up with drawings and balloons. Material like soft balls to practice the disturbed hand function after burns was donated to the nurse/ physiotherapist.

Activities of the Trainers

In total 3 meetings could be scheduled with the trainers of whom 4 were present in the hospital:

Constancia Ndunguru, Hadija Mlangida, Lilian Mlang’a and Anna Kasasa.

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