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«Background to the Workshop Fiji Islands has moderate child (23.2 per 1000 live births in 2009) and infant mortality rates (15.2 per 1000 live ...»

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Report on the meeting for

Improving Hospital care for children

in Fiji and the Pacific

Including the 4-day Trainers’ Course in the use of:

The Pocketbook of Hospital Care for Children

November 15-19th 2010, Colonial War Memorial Hospital, Suva

Background to the Workshop

Fiji Islands has moderate child (23.2 per 1000 live births in 2009) and infant mortality

rates (15.2 per 1000 live births), and many persisting health system challenges. As

part of the Millennium Development Goals the Fiji Ministry of Health has pledged to take steps to reduce child mortality by 2/3rd of what it was in 1990, by 2015 (9.3 and

5.6 per 1000 live births respectively). However, infant and neonatal mortality rates remain unacceptably high, and there continue to be avoidable deaths.

A review of the Child Health Service in 2010 recommended improvements in several areas. 1 Recommendations 4 and 7 from this review identified the need to improve the quality of care for sick children and newborns at primary care and sub-divisional (district) hospital. The review specifically recommended the introduction and implementation of the World Health Organization ‘Pocketbook of Hospital Care for Children’ 2 as Standard Treatment guidelines nationally. In Fiji this had been planned and anticipated for over 3 years.

The Pocketbook contains best-practice clinical guidelines that are based on reviews of the published literature, covering all childhood conditions commonly seen in district and provincial level hospitals. These include serious infections (such as pneumonia, and diarrhoea), malnutrition, neonatal conditions, trauma, other complex emergencies, surgical conditions, burns and poisoning. These guidelines are an extension of the Integrated Management of Childhood Illness (IMCI) to the first-referral hospital, providing a consistent approach across all levels of the health care system. The Pocketbook is aimed at nurses, non-specialized doctors, paramedical workers, medical students and child health specialists in training.

1 This Pocketbook and training materials have been introduced in many countries to standardize and improve quality of paediatric care, including Solomon Islands and Papua New Guinea, China, Indonesia, Central Asia, South Africa and elsewhere.

There is widespread acceptance these are the best standard treatment guidelines for paediatric hospital care currently available.

The WHO Pocketbook of Hospital Care for Children as standard paediatric treatment guidelines in Fiji The Paediatric Clinical Services Network within the Fiji Ministry of Health believed that implementation of the Pocketbook as Standard Treatment in Fiji would improve the care of sick children in hospitals and lead to care that is more efficient, safe and accessible by all Fijian children, and lead to reduced child death rates. The Paediatric Clinical Services Network has therefore endorsed the WHO Pocketbook of Hospital Care for Children as standard paediatric treatment guidelines in Fiji.

Health system issues in Fiji There are 3 divisional hospitals in Fiji (the Colonial War Memorial Hospital in Suva, Lautoka Hospital and Labasa Hospital) – all of these hospitals have a substantial number of beds for children. There are subdivisional hospitals that have smaller paediatric wards and there are also some rural health centres that have a small number of paediatric holding beds. The Pocketbook is aimed at doctors and nurses that care for sick children in these health facilities, but is also appropriate for use in referral hospitals, and has been endorsed by senior staff at Colonial War Memorial Hospital and Lautoka Hospitals as standard treatment in tertiary settings also.

One of the key issues raised in the Fiji Ministry of Health Clinical Services Planning Framework, 2005, was the excessive flow of basic paediatric cases from clinics and subdivisional hospitals to specialist paediatric units in divisional hospitals, despite IMCI initiatives designed to strengthen primary level child health care. The main reason identified for this diversion of cases was inadequately equipped facilities and untrained staff outside the divisional hospitals, leading to loss of a well demarcated child health service structure with clear referral roles. One of the aims of the adoption of the Pocketbook as the national standard of paediatric care is to strengthen secondary level paediatric capability in the subdivisional hospitals and better guide the need for referral to divisional hospitals.

The Pocket Book has been part of the medical curriculum for undergraduate medical training in Paediatrics at the Fiji School of Medicine since 2005. Its adoption as National Standard Treatment will ensure that this undergraduate training maintains its relevance in the field.

Wider significance in the Pacific There has been widespread interest in countries throughout the Pacific in the adoption of the Pocketbook of Hospital Care for Children. There was a national implementation workshop in the Solomon Islands in 2004, and by 2010 over 200 nurses in all of 9 provinces have been trained. This training has been lead by Dr Titus Nasi, Paediatrician with the Ministry of Health at the National Referral Hospital in Honiara.

Because of the widespread interest shown in this initiative by other countries,

–  –  –

The Workshop A 4-day workshop was held at the Colonial War Memorial Hospital in Suva, between November 15 and 19th 2010. The participants included 20 doctors and nurses from each division and sub-division of Fiji, plus staff from the nursing college that trains undergraduate nurses and nurse practitioners. Paediatricians from Samoa, Tonga, Kiribati, Vanuatu, and Solomon Islands also participated. The participant list is in Appendix 1. The facilitators were Dr Joseph Kado, Dr Rigamoto Taito (Ministry of Health, Fiji), Dr Titus Nasi (Solomon Islands), Prof Trevor Duke and Dr Andrew Steer (Centre for International Child Health, Melbourne).

The course was held over 4 days and combined interactive case-based lectures along with bed-side clinical teaching (see program outlined in Appendix 2). The afternoon of the 4th day of the course was devoted to discussion among the participants around the challenges and barriers to national and local implementation of the Pocketbook in Fiji, and similar discussions for the regional participants were held on the 5th day (see below).

The workshop opened with Dr Joseph Kado describing the situation of child health in Fiji. Dr Kado noted that in the recent decade there has been a stalling in progress of infant and child mortality (Figure 1). He also highlighted some of the obstacles to improving child mortality rates and improving quality of care.

Dr Titus Nasi and Prof Trevor Duke then described how the Pocketbook had been used in many other countries to provide standards for clinical care, equipment, competencies of nurses and doctors, and in conjunction with the Essential Medicine List for children, provide standards for drugs.

The entire course is contained in a DVD, which contains power-point presentations, case notes, videos and clinical photographs. This DVD was first created in 2003-5 for Pacific countries, specifically Solomon Islands and PNG, and has since been modified and translated by WHO and used in countries in Asia. The course facilitators made further adaptations to all the teaching material to make it appropriate to the Fiji context. The course trains health workers in how to use the Pocketbook in everyday clinical practice; it does not aim to teach every fact that is contained within the book.

The method is case-based teaching, where the participants use the book to solve clinical problems. The DVD contains a series of clinical cases; these are listed in Appendix 3. These are augmented by several sessions on the children’s wards where cases are seen and the Pocketbook is used to plan their management. These cases raise clinical, organisational, resource and social issues that are commonly faced in everyday clinical practice.

The course is participatory and interactive and allows time for deeper discussions of the complex issues that affect the health of children. The course emphasises the processes of care or stages of management, that making a diagnosis and giving treatment are not all that are required for quality services. For quality paediatric care, 3 it is essential to have a system of triage, where the sickest children are seen first.

Staff need to be skilled in basic emergency treatment, including giving oxygen, fluid resuscitation of children in shock, management of children with convulsions or coma.

They need to understand Emergency signs, and know how to recognise them. Nurses and non-specialist doctors in remote hospitals need to understand how to take a history and do an examination, how to make a differential diagnosis, and how to safely give medications. In all assessments of quality of care the lack of supportive care and

monitoring are deficient, and the course focuses on this. Supportive care includes:

giving oxygen, safe use of intravenous fluids, blood transfusion, nutrition, micronutrients, fever control, treatment of hypoglycaemia and convulsions, prevention of nosocomial infections and apnoea in neonates. Finally, planning discharge is important, not just on the day of discharge, but from early in any admission, to ensure the family understands what is required when the child goes home, how to give treatment, what signs to look for, and when to return. Virtually all hospitalised children need some follow up: whether it is to continue treatment of a chronic illness (such as tuberculosis, HIV, asthma, epilepsy), to determine that all manifestations of the acute illness have resolved (such as pneumonia), to manage physical complications (for example after meningitis), to monitor for growth and development which may have been interrupted by the illness (such as prematurity), or to give the next vaccines that are due. Such follow-up does not need to be at a hospital as some of these tasks can be done a health centre or by an MCH nurse, but all follow-up must be organised by staff in the hospital prior to discharge, and the family and the local health clinic must be aware of the nature and reasons for follow-up. This requires organisation that is often not considered a part of clinical care, but in a district hospital these are skills and knowledge that are necessary for nurses and doctors to have if children are to receive holistic care for optimising outcomes.

The participants enthusiastically engaged in all the course sessions, discussing each of these things, and using the Pocketbook to put these principles into practice.

Day 4 (afternoon) and Day 5. Discussion of other critical issues in the care of sick children in Fiji and Pacific Island countries Discussions on the 4th and 5th days of the workshop were on the key issues in improving the quality of care for sick children in Fiji,and other Pacific countries.

Several priorities were identified.

1. Commitment to the Pocketbook at a variety of levels:

Participants recognised that the Paediatric Clinical Services Network had endorsed the Pocketbook as the national standard treatment guidelines. It was felt that strong support from the Fiji MOH, Fiji School of Medicine and Fiji nursing schools was also necessary for successful implementation. For the regional participants, many felt that the Pocketbook would be also be appropriate as national guidelines in their countries.

2. Support for further training courses Participants generally felt that they would now be able to train other health care workers in the use of the book. Many advocated a “piecemeal” approach – that is, breaking the course into half or full day modules rather than teaching the whole course in one 4 day setting. However, it was identified that a central coordinator for a rollout program would be helpful, both at the national level and potentially across the region.

4 This coordinator would be helpful with resources, organisation and monitoring of the program.

3. Consideration of other important conditions not included in the book Participants felt that there were a number of commo/important childhood conditions seen in Fiji that are not included in the pocketbook. These included: rheumatic fever, skin infections, drowning, post-streptococcal glomerulonephritis, fish poisoning (ciguatera), child abuse, and delayed developmental milestones. Many participants felt that a “Pacific” version of the book, which included these conditions would be useful, although not an essential pre-requisite for roll-out, as the current version is sufficient. However a Pacific version of the Pocketbook would be something to work towards if other countries were involved. Many felt that separate guidelines for these conditions would be helpful.

4. Equipment and medicines It will only be possible to fully implement the Pocketbook if basic equipment and essential medicines are reliably available. A detailed description of equipment required to implement the Pocketbook is in Appendix 4. It was clear from discussions that some of these commodities are not present in many hospitals, in Fiji and throughout the Pacific. Participants also identified that posters with enlarged versions of the neonatal and ETAT algorithms would be helpful – electronic versions ready for printing have been supplied to the Fiji Paediatric Clinical Services Network (Appendix 6). It is recommended that sufficient numbers of these be printed for all divisional and sub-divisional hospitals.

5. Oxygen supplies Oxygen supplies to sub-divisional hospitals is a particular challenge. Oxygen in cylinders is bought from BOC at high cost, and transport costs and logistics preclude reliable supplies. A program of improving oxygen systems using concentrators and pulse oximeters could be developed, as all provinces have reliable power supplies, via mains power with generator back-up on main-land provinces, or large generators which run all government facilities including hospitals in outlying maritime provinces.

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