School of Nursing and LLUMC launch Global Connections
Community Hospital of Seventh-day Adventists in Cocorite, Trinidad, West Indies, is the first project for the new international nursing Global Connections program.
Between March 17 and April 7, 2004, Marge Strutt, MN, RN, dialysis apheresis nurse manager at Loma Linda University Medical Center, and Celia Stoltzfus, RN, a LLUMC staff nurse, worked at the Community Hospital of Seventh-day Adventists, Cocorite, Trinidad, West Indies, assisting with the development of a hemodialysis program.
Ms. Strutt and Ms. Stoltzfus’s work at the Community Hospital was the first project for the new international nursing Global Connections program, sponsored by the School of Nursing, Loma Linda University Medical Center Nursing, and other donors through the International Nursing Council. Global Connections seeks to model and inspire a commitment to better nursing practices worldwide. By establishing a long-term nursing partnership with nurses in Seventh-day Adventist hos
Marge Strutt, MN, RN (right), poses for a picture with an introductory dialysis class for Community Hospital staff.
pitals around the world, Global Connections will promote a bond of support and sharing between hospitals.
“Global Connections allows clinical practice nurses to share their talent and skills with other nurses around the world,” says Jan Zumwalt, RN, MS, MBA, executive director of case management and advanced practice nursing at LLUMC.
The Community Hospital in Trinidad was chosen as the first project primarily because of its location, which allows for fairly convenient travel between Loma Linda and Cocorite, and its connections to Adventist Health International and Robert Soderblom, MD, a LLUMC nephrologist, who volunteers his assistance on a regular basis to the hospital.
“By piggybacking our project onto another project, we hope that we can provide more assistance to the hospital,” says Ms. Zumwalt. “I believe it is enriching on both sides.”
Throughout the three weeks, Ms. Strutt and Ms. Stoltzfus worked long hours to provide mentoring to the hospital staff and upgrade the hospital’s dialysis unit to more efficient operational standards.While the hospital had recently refurbished a room for dialysis, complete with a purifying water system and five new machines, they still needed guidance on running the program and addressing such problems as limited staff training, infection control, and an unsanitary water filtration system.
The following paragraphs are excerpts from Ms. Strutt’s e-mails to colleagues, family, and friends, during her three-week trip.
Thursday, March 18—We arrived last night at 11 p.m. local time and were welcomed by large drops of rain—washing through a warm and humid atmosphere. It felt delightful after the 12 hours of travel in the cold, dry, and cramped quarters of airplanes. After one hour going through immigration lines, we crawled into bed at 12:30 a.m.
I am writing you on the laptop at the guesthouse where we are staying. We are in a part of the city that is crammed with modest income housing on postage stamp size lots. The single-story peach colored main house is raised up on about a three foot foundation. A long driveway runs right against the house going to the back and a six-unit apartment building; our room is upstairs, and is tiny but very clean. Claire, the woman that owns this place, is very nice; in fact everyone so far has been very friendly.
The city itself seems somewhat ramshackle and run-down. People are very casual and most people on the streets look somewhat raggedy. Driving appears incredibly treacherous and is on the left side of the road. No attention is paid to stoplights or centerlines in streets. Haven’t seen an accident yet, though.
I spent the day getting familiar with the layout of the hospital and meeting people. The director of nursing, Bernadette George, is called the matron. She arranged for us to use a small office with an older computer. We met with clinical engineering, pharmacy, the chief financial officer, and two of the nurse’s aides who work in dialysis. Our initial plan is to reorganize the charting system, evaluate the dialysis process, and read through the national health code.
Amazing that they get by on so little over here. The hospital was built in the early 1960s, is two stories tall, and is U-shaped. Patient wards are on the second floor along the main corridor where 40 beds are arranged, 4 to 5 beds per ward. Only certain rooms in the hospital are air-conditioned with window units. Patient wards are open to the daily breeze.
Saturday, March 20—This morning I met with the country’s minister of health in his office in the capital city, Port of Spain. He is gung-ho about the hospital doing dialysis treatments on as many government patients as possible. Currently, there are around 400 who are in desperate need. There is no way that the hospital’s five machines can handle all those people.
I worked on the dialysis unit all afternoon. Since it was our first day of treatment, we just watched the nurse to see how he performed his duties and cared for the patients. He works here as needed and only gets paid for each treatment performed. I hope to hire him, or another full-time nurse by next week as the present dialysis treatment schedule depends on whether patients can pay and the nurse can get time off from his regular job.
A lot of work to do. If I wanted to stay, I’d have a job. They would take me in a second, but the wages are very low here, about one-fifth of U.S. wages, while food and housing are about equivalent. It is amazing how people can still live. A nurse working in a government hospital here gets a monthly salary of about US$900. While back at home, nurses are making around US$4,500.
Tuesday, March 23—Celia and I went to Tobago over the weekend. We risked renting a car and spent the afternoon at a beach called Englishman’s Bay dozing under palms, swimming, and snorkeling.
Locals kept asking us if we were going to Sunday School, a weekly event in the small village of Buccoo near our hotel. We showed up at 8 p.m. and found locals selling crafts and food. Entertainment was found at homemade gambling tables with money flying from hand to hand. The only saving grace was a large local steel drum band—they were great!
Oh, I learned how to fix a “tire burst.” I hit a curb and got a flat.
Thursday, March 24—We are starting from scratch in so many areas. Universal precautions are poorly practiced and teaching seems to be by word of mouth, without any standardization. Doctor’s orders are not signed off by the nurses and one can never be sure whether an order is actually completed.
With only two weeks left, we are moving frantically. Our biggest concern so far is infection control. Otherwise dialysis is dialysis, and patients are patients. Patients in general have to go on a government waiting list and may or may not get assistance with dialysis costs; usually they end up having to pay for dialysis themselves. Most can only afford one or two treatments per week, even though they really need three. Also, they cannot afford routine medications that would help them feel better, for example, EPREX, a hormone that the kidney would produce if it were functioning, it helps the bones develop red blood cells. The patients have a rocky course and end up dying much sooner than they ever would in the states just for lack of enough dialysis treatments. This is why Dr. Spann, the Community Hospital medical director, is working so hard on developing cost effective programs; he wants to provide life saving treatments at the lowest possible cost.
Tuesday, March 30—Well, one more week to go. So hot here today and very humid. The whole city is moving slowly and everyone is sagging. It is some type of religious holiday for a minority religious group, but everyone takes the day off; however, Celia and I worked. All computers were down at the hospital because of a power outage. Luckily, dialysis machines are on the generator so we got the dialysis treatments done.
I finally met with the water system contractor regarding the dialysis purified water system. While it appears to have the correct components, no bacteriology testing or chemical analysis is done and there isn’t any plan to change filters or exchange carbon tanks. The city water is collected from rain draining off in the mountains into a reservoir—prime growth for bacteria and algae. Then it is chlorinated before it comes into the city water system. This water has to be purified in the hospital before being used for dialysis treatments. I need to scrutinize the AAMI water standards book for dialysis and do a thorough evaluation of this system, something just doesn’t seem quite right. I also need to develop a water sterilization and system log.
Trinidad is a blend of old and new. The city seems cosmopolitan but the suburbs and rural areas are very poor. The sidewalks are amazingly clean, but very crumbled and patched. I walked to the corner grocery (closed for the holiday) and back. Everyone places garbage in neat little bundles on the sidewalk. Sanitation workers sweep the sidewalks daily and pick up the garbage at the same time. Garbage stays untouched—no stray animals anywhere here, though on the outskirts of town, stray animals abound.
I am getting lonely for home, but not for the pile of work I know is waiting for me. Even though we are in a city and not working on dirt floors or anything like that, it still is quite basic. And everything does move slowly. I’ll be happy if I can get the water system up to par.
We woke up last Sunday morning and decided on a whim to go back to Tobago. Our landlady here called some friends over there and away we went. Joe, a local locksmith, and his three daughters, went to the beach with us. Afterwards, we piled into his van and drove to his home in the hills, where he has lived on 6 acres of land for about 30 years. Later in the evening, Joe took us on a tour of Scarborough, going up to the aged English fort and lighthouse to overlook the city lights. We didn’t have a flat tire this time around, and driving was much more comfortable.
Thursday, April 1—We have made the recommendation that a nurse manager be hired for dialysis. It would be worthwhile for them to pay someone a bit higher rate of pay in order to attract an energetic and committed employee. I spent about two hours with the head of maintenance yesterday afternoon. We reviewed an older copy of the AAMI water book, probably the only copy in the country, and it cost us US$350. I am quite impressed with him. He had a good grasp of chemistry, was trained in the aviation industry as a mechanic, and has two years of college. He is going to be the industry expert on dialysis water systems by the time I leave.
Today, I am going to meet with the head pharmacist to finalize medications to be kept in the dialysis unit, including emergency meds since the pharmacy is closed at night and on weekends. I will also work with the clinical laboratory to discuss how to do bacteriology for dialysis water, according to instructions from the LLUMC clinical laboratory. Then, I’ll outline the whole water system on a computer-generated schematic and mark in the needed fixes and write an infection control program. I would love to work on their charge nurse job description and patient care plan, but don’t think I’ll get that far.
Sunday, April 4—Yes, we have seen Venezuela through the mist. It is only 11 miles away—as close as we will get.
Today what I feared most would happen actually happened; the water system tested positive for chloramines. We had to cancel treatments last night and reschedule them for Monday afternoon. I’m off to meet with Dr. Spann and the water expert.
Tuesday, April 6—We stayed at work last night until 11:30 p.m. trying to wrap things up. I had a late night meeting at a local “dairy bar” (ice cream shop) and did a final report for Dr. Spann and his assistant.
Yesterday in the newspaper, the minister of health said that the government was going to start offering free hemodialysis very soon. If we truly want to get up to U.S. standards and get a government contract we need to get moving.
Today we handed out gifts to everyone. Goodbyes are always bittersweet. They still have not hired a full-time nurse or manager. However, we did let the water contractor go and actually found another from the south end of the island.
What a relief to me! Luckily, the water guy from the south was totally knowledgeable about dialysis water systems. He is going to put together a total plan for upgrading. I pulled him aside and told him how hard Dr. Spann was working to make dialysis affordable to all who needed it. He agreed to provide the parts for the water system at cost, and would just charge for his time. So, my heart is resting much easier. I actually had the time to develop a thorough dialysis manager job description.
Celia and I developed check-off forms for daily tasks for the matron and the dialysis staff. Hopefully that will help keep them on track. We are also suggesting that they start a dialysis technician-training program. We would love to come back and help that get started.
We do not know who will follow through with the work we did. One of the technicians (the least paid employee) seems to have the most interest, and is as sharp as a tack. I know that she will make sure that whatever is in her administration will be done, and done well.
Celia and I are quite excited; we arranged to have five big floral arrangements delivered to the offices of those we worked with most. They should have arrived mid-afternoon, after we all said farewells. I just love surprising people with pleasant things.
We are off to the Caroni Swamp to see boa constrictors hanging from trees and the brilliant red Scarlet Ibis. Tomorrow we’ll be up early to fly home. We will be back, they need help down here, and we have the ability to give it.
Since returning from Trinidad, both Ms. Strutt and Ms. Stoltzfus have expressed interest in continuing their work with the hospital.
“We enjoyed our time with the lovely people at Community Hospital. We were able to get them on the right track so that their program would provide safe patient care. Next time, and there will be a next time, we will work on policy development, using the world wide web as a free resource, and the importance of nursing education,” says Ms. Strutt.
Preliminary plans are being made for Ms. Stoltzfus to return to Trinidad later this summer to assist with hiring and training a dialysis nurse manager.
“Now that the project has been jump-started, we will continue providing ongoing support, and work toward positive outcomes including assuring quality patient care and growing the hospital’s dialysis population,” says Ms. Zumwalt. Janene Jenkins, RN, a retired faculty member from the School of Nursing and clinician at LLUMC, also plans to visit Trinidad and assist with upgrading the intensive care unit.
More information about participating in or supporting Global Connections is available through the School of Nursing website at <www.llu.edu/llu/nursing
> or by calling extension 48440.