I visited the dietetic department at King Edward VIII Hospital in Durban. This large city centre teaching hospital serves a varied but mostly deprived population. The HIV clinic is also large, with 3000 adult and 2000 paediatric patients receiving treatment. King Edward VIII has a large state-of-the-art Intensive Care Unit, many adult and paediatric wards, and a busy outpatient department as well as the HIV service; the nutrition and dietetic service for the entire hospital is provided by a team of just three: 2 dietitians, Jane Downs and Bronwyn Bruton, and a dietetic assistant. Jane Downs has worked at the King Edward for some time now, and is one of South Africa's best known dietitians. During my three days with Jane and her team I developed a huge admiration for them all, and especially for Jane.
Jane and Bronwyn start work at 8am. Outpatients arrive at the Nutrition and Dietetic Department from 9 – this allows Jane and Bronwyn just 1 hour to see the most urgent inpatients. As a result, most ward-based nutrition care is protocol-driven. Nutritional supplements and liquid feeds for those unable to eat are prepared for delivery to the wards.
The dietitians sit at a desk in the centre of a large room, with filing cabinets and storage set around the edge. Down the corridor is the waiting area for outpatients, and a few consulting rooms. As patients arrive, medical records in hand, the nutrition assistant ascertains whether the patients has been weighed or not (usually not), weighs them, and brings the records to the dietitians' desk. Gradually the pile of records increases, despite each patient having a brief consultation. Due to pressure of numbers Jane and Bronwyn can spend only 5 or 10 minutes with each patient, although those attending for the first time will be given special attention where possible.
I naively asked when lunch break was. Patients are seen straight through from 9am until all have been seen. Sometimes this can be as early as 2.30 or 3pm, but usually later. A quick sip of Rooibos tea is the only sustenance available for the dietitians working through their caseload of up to 80 outpatients each day. On my second day at the clinic I made a feeble attempt to bolster the team's energy levels by bringing biscuits and nuts.
At the end of the working day, there is little time left anything other than the most urgent admin tasks. Jane does not finish work then, however. She works late into the evening updating her knowledge, writing articles for publication, or working on submissions to the hospital management motivating for funding for dietetic staff or provision of nutritional supplements. Currently there are vacancies for dietitians at different levels of experience, and in addition to this Jane has submitted a plan for developing the nutrition department to meet the needs of the hospital. However funding to fill the vacant posts has not been released. Incredibly, despite obvious high rates of malnutrition amongst patients attending the hospital, and evidence to show efficacy, management question the use of nutritional supplements.
Jane has developed an excellent protocol for treatment of malnourished HIV patients. Adults with a BMI of less than 22, and children below the 50th centile are eligible, with a wider range of supplements being available for those with a greater degree of malnutrition. For example, a nine year-old I observed who's weight-for-age and weight-for-height were both well below the 3rd centile was given a supply of high protein and energy drink powder (Ensure Plus), vitamin and mineral enriched porridge, and vitamin and mineral enriched peanut butter (Sibusiso). Once nutritional status returns to more normal levels, supplement provision is reduced.
As in the UK, some South African patients are unable to eat orally and require feeding through a tube. Long-term feeding requires placement of a tube through the abdomen wall into the stomach – a gastrostomy – and liquid feeds can be administered through this. In the UK plastic pouches of sterile feed are prescribed which provide all the energy, protein, vitamins and minerals the patient needs. These pouches of feed are delivered directly to the patient's home. In South Africa there is no state funding for prescribed tube feeds. At King Edward VIII Hospital, the dietitians are able to supply some powdered feeds to a limited number of patients if certain conditions are met. This is unusual, however, and as with other centres, most patients must make up liquid feeds themselves. This is done by blending milk, fruit, vegetables etc, and syringing the mixture through the gastrostomy tube. Many patients cannot afford to buy fruits or vegetables, do not have money to buy blenders or other equipment, and may not have electricity or running water. There is a high risk of contamination here, along with the likelihood of inadequate nutrition and blockage of the gastrostomy tube. Remember that immunocompromised people are already at a higher risk of developing food-borne infections. Other ready-to-use liquid foods such as amageu may be used, but again, this is just carbohydrate and is relatively expensive.
I was struck by the dedication and good humour of the dietetic team. Their support for each other was inspirational to see. I sincerely hope the King Edward VIII Hospital managers appreciate the asset they have in their dietetic department, and begin to release funding for the badly-needed vacant posts. I also hope that funding for nutritionally balanced, ready-to-hang tube feeds will be seen as a priority.
(Extracted with permission from www.hivnutrition.org.uk)