An elegantly simple free phone application called Vula is revolutionising patient treatment and referrals between primary care facilities and tertiary hospitals in South Africa, providing timely, accurate and detailed information to help save more lives, writes Chris Bateman for MedicalBrief.
Primary care doctors and nurses use the digital information network on their cell phones to get fast and efficient expert consultant input.
They can now also more accurately and appropriately refer patients upwards in the healthcare system, sharing X-rays, pictures, history, path lab records and presenting symptoms via their secure and confidential healthcare practitioner profiles.
Consultants in hard-pressed tertiary trauma centres, which at their busiest – as during the COVID-19 lockdown or current surges – see up to 64 referrals in a 24-hour period, are enthusiastic over the changes Vula has wrought.
Emergency physician Dr Hennie Lategan, Operational Manager at Tygerberg Hospital’s Trauma Unit, says that before Vula, the unit’s phone rang off the hook “around the clock”, tying up medical officers for hours in jotting down referral data and sourcing correct advice.
Beds were taken up by patients inappropriately referred, triage was cumbersome and time consuming, and the entire patient sorting and treatment process was fraught, sometimes costing lives through sheer patient burden.
Since Vula was introduced in July this year, the unit’s ‘referral’ phone had fallen almost silent, enabling those among the 14-strong medical officer corps to get on with urgent triaging and treatment of patients under the guidance of the attending consultants.
Says Lategan, “It’s ground-breaking and has revolutionised the way we work. We’re almost exclusively a referral centre, so it’s the perfect tool.”
Speaking in early December 2020, he said that since July his unit had handled 3,500 referrals, averaging about 15 in a 24-hour period, but with several periods of intense peak demand.
“Not only can our medical officers now get on with their work, but Vula is amazing on many different levels. We can either accept the patient or ask the referring healthcare practitioner to send them to a closer and-or more appropriate institution. We can vet referrals to the best care much sooner.
“We simply can’t afford to see the small stuff here – we have to see the big stuff – and Vula enables that.”
When Lategan is away from the unit, he uses the Vula dashboard to monitor the number of referrals and their progress, allowing him to give his often-worried hospital CEO a real time update on the situation at any given moment.
The application also locks in all interactions and healthcare responses, enabling him to deal with patient complaints more easily, instead of having to rely on confusing and often contradictory verbal, ‘he said, she said’, evidence.
Dr Sue le Roux, an emergency medicine physician who runs the Karl Bremer District Hospital Emergency Centre, says the ‘forced fields’ in the Vula app renders doctors more accountable.
Holds doctors accountable
Their colleague at Cecilia Makiwane Regional Hospital in the Eastern Cape, medical officer, Dr Elisha Rhode, strongly agreed.
He added: “With most medical history and treatment interactions captured, it’s a great medico-legal tool and makes medical practitioners examine patients comprehensively, holding them more accountable for what they say and do.
“It can also deter them from delaying a critical patient referral to the morning just for the convenience of dealing with one less patient in the night. All interactions are visible to the consultants, so you have to give the best possible advice.”
Le Roux illustrated how inappropriate referrals can get – she and other consultants interviewed said this happened most often with GPs, many of whom seemed reluctant to use the Vula tool.
“Just yesterday we had a patient with a ruptured Achilles tendon. He was sent in with just an ultrasound report but no referral, at a time of day when no orthopaedic surgeon was available. Because of how our bookings system works, we had to ask him to go back to the GP and be referred to the ‘right place at the right time’. Vula would really have made that patient’s journey easier. We love Vula. I wish more people were on it.”
She said the conversation recorded in the Vula ‘chat’ benefitted both the referral doctor and the sending doctor as it was an undeletable record and monitored the doctors’ responses.
Besides this, it was a powerful teaching tool for nurses in primary health care clinics and community centres because they learnt more with every interaction.
The app, invented by Cape Town ophthalmologist Dr Will Mapham, was recently nominated for an international healthcare technology award, having already garnered a slew of social innovation, entrepreneurship and tech health awards in Sub-Saharan Africa and further afield.
Mapham said GPs were increasingly using Vula and accounted for 15% of its users so far.
The idea for the app came to Mapham during his community service years and subsequent tenure at the remote Madwaleni Hospital, 100 kilometres from Umtata, which epitomised the equipment shortages and systems dysfunctions plus lack of consultant expertise familiar to doctors countrywide.
A former vice chair of the Rural Doctor’s Association of South Africa, Mapham spent five years in public health and piloted Vula in his chosen discipline of ophthalmology, leading to its use across disciplines countrywide.
In his junior doctoring years, he helped address healthcare staff shortages at his and neighbouring rural hospitals by holding popular slide shows on medical campuses and at congresses, portraying the joys of the Eastern Cape coastal recreational lifestyle, not to mention the practical, hands-on learning and innovation chances that rural doctoring offers.
He is today gifting South Africans through what is often described by Health Minister Dr Zweli Mkhize as a ‘digital first’ approach to addressing the country’s human healthcare resource crisis.
Tygerberg’s Dr Hennie Lategan said tertiary trauma units nearly always struggled for bed space. “When patients are seen and sorted, they often need to go somewhere else. Say for example a patient needs a femoral nail, he can stay with us, taking up a precious bed. However, what he needs, is to be in an ortho unit.
“This app has changed daily practice in our unit – it’s all about the right patient for the right place at the right time.”
He said he and his colleagues normally respond to a Vula request (from referring facilities) within five minutes, “if we don’t, they’re on the phone to us!”
Dr Tamsin Lovelock is an internal medicine specialist and lead clinician at the 336-bed Brackengate COVID-19 facility in Cape Town’s northern suburbs, which is expected to reach maximum operational capacity this week. Admissions quadrupled in the past three weeks, and stratification and outward referral of patients began in earnest on 16 December 2020.
She said the Vula app was proving to be an invaluable tool.
Statistics show that from its opening on 20 July 2020 to 15 December 2020, Brackengate admitted 1,470 patients, discharged 1,014 home and transferred 118 to another facility – with a total of 64 deaths. Bed occupancy on the morning of 15 December stood at 318. Healthcare staff were working for up to 14 hours at a stretch.
The Cape Town International Convention Centre COVID-19 acute care facility closed down on 18 August after the pandemic waned, having treated close to 2,000 patients, nearly 90% of whom were discharged, with some 60 transferred to Brackengate.
Of Brackengate, Lovelock said: “We serve the whole Cape Metro and beyond, with patients coming from as far afield as Worcester and Caledon – infections are not clustered, it’s sustained community transmission.
“Vula is not only convenient for the person who needs to refer but for the person receiving – it’s so organised, the fields are all there to fill in, you don’t have to remember everything, you just push a button and have a look,” she added.
Lovelock said she wished Vula had been available when she was a registrar at Chris Hani-Baragwanath Academic Hospital in Soweto a few years ago.
“I carried a pen and a scrappy piece of paper around, scribbling down details of each referral – I had nightmares I’d lose it. As a super-stressed reg, it would have been brilliant to just have all the info on my phone.
“What I also really like about Vula is that it makes it easier for more junior staff who might be a bit shy to ask for help from someone senior – it’s accessible and non-threatening, especially when the pressure’s on,” she added.
Dr Elisha Rhode, who helped initiate Vula at Cecilia Makiwane Regional Hospital’s surgery department four months ago, said the standardised digital form made it easy to find precise and detailed patient information very quickly.
“It might be a bit smoother off the tongue to use the phone, (when you can get through), but you can so easily be led astray, missing a critical heart rate for somebody with a badly fractured leg, or somebody bleeding out – these vital details can often be omitted over the phone.”
All doctors spoken to agreed that Vula could accurately be described as a lifesaver, never mind smoothing work and information flows. They could not imagine their lives without it anymore, and were even tempted to ask that it be made compulsory, but refrained because South Africa’s constitutionally guaranteed freedom of choice prevents this.
Click here for the Vula website