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IMPROVING THE QUALITY OF HOSPITAL CARE FOR CHILDREN An overview of the WHO Pocketbook, and implementation of the training

course

2000 MANAGEMENT OF THE CHILD WITH A SERIOUS INFECTION OR SEVERE MALNUTRITION

Why do we need guidelines for treatment?


Much scope for improving the quality of care for children in peripheral hospitals Most care for sick children is done by nurses or nonspecialist doctors Standardized clinical care is most efficient Need to have a benchmark for identifying where care can be improved Resources (drugs, equipment etc) to implement guidelines Skills and knowledge of clinical staff Systems and organisation

Why the WHO Pocketbook?


Expanded contents (not just serious infections and severe malnutrition) Doctors at District hospitals have to deal with all conditions (neonatal, surgical etc) Can be carried around in your pocket!

Layout of Pocketbook
Chapter 1: Triage and Emergency conditions Emergency Priority None of the above signs Chapter 2. Diagnostic approach to the sick child Syndrome based Differential diagnosis Simplified for settings without specialised staff Chapter 3. Problems of the neonate and young infant Chapter 4. Cough or difficult breathing Chapter 5. Diarrhoea Chapter 6. Fever

Layout of Pocketbook
Chapter 7. Severe malnutrition Chapter 8. Children with HIV/AIDS Chapter 9. Common surgical problems Chapter 10. Supportive care Chapter 11. Monitoring the childs progress Chapter 12. Counselling and discharge from hospital Bibliography Appendices Procedures Drugs IV fluids Assessing nutritional status Job aids and charts Toys and play therapy

Emphasis on the processes of care

Triage Emergency treatment History and examination

Laboratory investigations, if required


Diagnoses (main and secondary) Treatment

Monitoring and supportive care


Reassess Plan discharge

Follow-up

Charts that describe emergency management

Example: differential diagnosis of cough or difficult breathing


Pneumonia Bronchiolitis Malaria Severe anaemia Cardiac failure Tuberculosis Pertussis Foreign body Croup..

Signs and severity of pneumonia

Examples of radiological changes

Chapter 11 - Monitoring
Patients details

Vital signs
Fluid balance Clinical signs, complications and findings Treatments Feeding/ nutrition Outcome

Appendix 1. Practical procedures e.g. insertion of chest tube

Appendix 2: Table of drug dosages

Appendix 2: Layout drug tables


Drug Recommended dosage in mg/kg/dose and number of doses per day Calculated volumes for 5 weight categories Route of administration Common formulations Footnotes: cautions, deviations from general recommendations

Equipment
Oxygen source and delivery devices

Scales and measuring board


Monitoring charts Blood giving sets NG tubes Chest tubes (x-ray)

IV fluids and delivery devices


Nebulizer and/or spacer Heater

(kitchen)

Laboratory tests
Haemoglobin determination (Hb or haemotocrit (PCV))
Blood film for malaria parasites Microscopy of CSF and urine Blood glucose (reagent strip) Blood grouping and cross-matching HIV testing

Standards: Drugs
Essential drug list exists in all hospitals
Drugs on the list are adequate for the management of most common conditions Essential drugs are available and accessible on the ward and in the emergency area Drugs are not expired Drugs are managed so that oldest drugs are used first The cost of drugs is no impediment for use Polypharmacy is not practised

Standards: supplies and equipment


Essential supplies and equipment are available immediately, and are adequate sizes for use in children
Essential equipment is safe and in working order The cost of supplies and equipment is no impediment for use Essential laboratory tests are available

Clinical Standards e.g. Pneumonia treatment


Health workers correctly diagnose pneumonia and recognise severity
Antibiotics are given only to children with cough for true indication (pneumonia not colds / URTIs)

Appropriate doses and duration of antibiotics are given for pneumonia


Polypharmacy is not practised Supportive care is provided, including oxygen when necessary Monitoring occurs Discharge planning occurs Follow-up is done when necessary

Summary
The Pocketbook gives evidence-based guidelines for the management of all common conditions of children
Requires a minimal amount of essential drugs and basic laboratory facilities Provides appropriate standards of care Emphasises the processes of care, not just drug treatment

Prerequisites for such a course


Decision to implement WHO Clinical Guidelines
Understanding of health service problems Usually from systematic hospital assessments

Adaptation (if necessary) of: WHO Clinical Guidelines to match local disease patterns Training package (CD-ROM teaching materials) to address problems found by hospital assessments

CD ROM
Aims to help teach health workers how to use the Guidelines in everyday clinical practice
Clinical cases illustrating each chapter in Clinical Guidelines manual PowerPoint presentation Clinical case notes Photographs, diagrams and videos illustrating important clinical signs and procedures

The course structure and aims


Emphasis on the processes of care:
Triage Emergency treatment History and examination Laboratory investigations, if required Diagnoses (main and secondary) Treatment Monitoring and supportive care Reassess Plan discharge Follow-up

The training methodology


Problem-based cases introducing the major Pocketbook chapters
Clinical practice on how to use the Guidelines in everyday paediatric care (work on the childrens ward)

Focus on the major problems identified in local quality of care surveys


Discussions about improving quality of care and problem solving

The training methodology


Participatory
Interactive Clinically based Remember the target audience Dont worry about not knowing something! Have fun!