BASIC PAEDIATRIC PROTOCOLS

Facilities must have basic equipment and drugs in stock at all times, and adequate staff skilled in paediatric care. Sick children coming to hospital must be immediately triaged, assessed and if necessary, provided with emergency treatment as soon as possible. Assessment of diagnosis and illness severity must be thorough and treatment must be carefully planned. All stages should be accurately and comprehensively documented. The protocols provide a minimum standard and safe approach to most but not all common problems. Care needs to be taken to identify and treat children with less common problems rather than just applying the protocols. All treatments should be clearly and carefully prescribed, usually based on a measurement of weight, on patient treatment sheets with doses checked by nurses before administration. (Please write dose frequency as 6hrly, 8hrly, 12hrly etc. rather than QID, TID, etc.) The parents / caretakers need to understand what the illness and its treatment are. They provide invaluable assistance in caring for the child. Being polite to parents considerably improves communication. A child who requires inpatient management should not be discharged against medical advice but should be transferred to another facility to continue appropriate care. The response to treatment needs to be assessed. Severely ill children must be reviewed within the first 6 hours of admission and progress documented. Correct supportive care - particularly adequate feeding, use of oxygen and fluids - is as important as disease specific care. 10) Laboratory tests should be used appropriately and use of unnecessary drugs should be avoided. 11) An appropriate discharge and follow up plan needs to be made as the child leaves hospital. 12) Good hand hygiene practices and good hygiene in the patient’s environment improves outcomes for all sick children. 6 Specic Policies • All children and newborns admitted to hospital requiring medical treatment should have their own inpatient number, and admission should be recorded using a standardized paediatric or newborn admission record form & inpatient registers. • Treatments, including supportive care, should be fully and clearly prescribed. • Medical records are legal documents and entries should be clear, accurate and signed with a date and time of the entry recorded. • All paediatric admissions should be offered HIV testing using HIV testing services and also be screened for TB. • All newborn admissions aged ≤14 days should receive Vitamin K unless it has already been given. • Routine immunization status should be checked and missed vaccines given before discharge. • Every child with condition(s) that cannot be managed effectively with the available resources receives appropriate, timely referral, with seamless continuity of care. • Assess for abuse, neglect or any other form of maltreatment and refer to the social worker • All infants and children should have a developmental assessment and those with special needs should be managed or referred appropriately. Admission and assessment • All admitted children must have weight recorded and used for calculation of fluids / feeds and drug doses. • Length / Height should be measured with weight for height (WHZ) recorded and used to assess nutritional status for children. • Mid-Upper Arm Circumference (MUAC) should be used for nutritional assessment for children > 6months of age. • All vital signs should be taken and recorded including Temperature, Oxygen saturation, Pulse rates and Respiratory rates which must be counted for 1 minute, and Blood pressure. • Consciousness level should be assessed on all children admitted using the AVPU scale or an alternative such as the GCS ( Glasgow coma scale) adapted for children. • All sick children should have their blood glucose checked. If not possible and AVPU <A, treat for hypoglycemia. • The sickest newborns / children in the ward should be near the nursing station (acute area) and prioritized for re-assessment / observations. 7 Infection prevention and control (IPC) • Good hand hygiene saves lives and can be achieved by handwashing with soap and running water OR hand rubbing with alcohol-based rub (70%). • Gloves do not protect patients and are not a substitute for hand hygiene • If hands are visibly dirty, they must be cleaned first with soap and water. • The alcohol hand-rub must be allowed to dry off to be effective. The ve moments of hand hygiene All equipment used for patient care should be decontaminated appropriately according to the current National IPC guidelines. 8 Hand hygiene technique Duration of the entire procedure: 40-60 seconds 0 1 2 Wet hands with water; Apply enough soap to cover all hand surfaces; Rub hands palm to palm; 3 4 5 Right palm over left dorsum with interlaced f ingers and vice versa; Palm to palm with fingers interlaced; Backs of fingers to opposing palms with f ingers interlocked; 6 7 8 Rotational rubbing of left thumb clasped in right palm and vice versa; Rotational rubbing, backwards and forwards with clasped f ingers of right hand in left palm and vice versa; Rinse hands with water; 9 10 11 Dry hands thoroughly with a single use towel; Use towel to turn off faucet; Your hands are now safe. 9 Clinical audit and use of the protocols 1. 2. 3. 4. Clinical audit is aimed at self-improvement and is not about finding who to blame. Hospitals should have an audit team comprising 4 to 8 members, led by a senior clinician and including nurses, admin, lab technicians and nutritionists etc. 1-2 people, usually MO or CO interns and nurses should be selected on a rotating basis to perform the audit and report back to the audit team and department staff. The aims are for hospitals to diagnose key problems in providing care. It is essential that identifying problems is linked to suggesting who needs to act, how, and by when to implement solutions. Follow up on whether progress is being achieved with new audits should be done to identify new problems and plan new actions etc. Deaths and surviving cases should be audited weekly as per the facility audit and review cycle below. Step 6 Monitoring & Evaluation Step 1 Identifying cases Step 2 Collecting Information Facility audit and review cycle Step 5 Step 3 Implementing change 5. Analysing Information Step 4 Recommending solutions Use the audit framework tool (Table 1), to identify modifiable administrative factors, health worker related factors and patient oriented factors in collecting relevant information in step 2 of the audit review cycle. 10 Clinical Audit Protocols Table 1: Audit framework tool Administrative Factors Health Worker Related Factors ⬜ Absence of guidelines to guide on diagnosis and management plan ⬜ Absence of guidelines on appropriate use of equipment & supplies ⬜ Lack of medication ⬜ Lack of transportation/ referral mechanisms and delay in transportation within and in-between facilities ⬜ Inadequate Human Resource for Health capacity and high staff turnover ⬜ Lack of knowledge in case management, interpretation of investigations etc. ⬜ Delay in executing management plan & increased turnaround time for tests/investigations & in reviewing of results ⬜ Medical errors: incorrect medication, administration, poor monitoring practices Patient Orientated Factors ⬜ Poor accessibility to health facilities ⬜ Delay in seeking treatment for child ⬜ Refusal of treatment for child. ⬜ Poor communication across cadres, departments and with parents/caregivers ⬜ Poor documentation practice ⬜ Delay in decision for referral within facility & In- between facilities. 6. Use an audit tool to compare care given with recommendations in these protocols and other guidelines (e.g. for TB, HIV/AIDS) and the most up-to-date reference materials for less common conditions. 7. 8. Look at assessments, diagnoses, investigations, treatments and whether what was planned was done correctly and recorded. Check doses and whether drugs / fluids / feeds are correct and actually given and if clinical review and nursing observations were adequate - if it is not written down it was not done! This data can be used to provide accountability for results and compel decision makers to pay due attention and respond to the problems