Integrating IMCI & ETAT Guidelines Presentation - INMED

Integrating IMCI and ETAT guidelines: 

Improving Emergency Care in Low Resource 

GECC 

Settings 

Bisanzo, 

Nyakibale Hospital, Rukungiri District Sheila © 

What is 

Known 

Large investments have been 

made in preventa@ve public 

health measures 

• vaccina@ons, nutri@on, 

sanita@on 

• Treatable diseases 

contribute significantly 

to mortality rates, 

especially in children 

72 of 1,000 

• Ideal Emergency Care 

– Immediate assessment of life 

threats 

– Rapid ini@a@on of life saving 

treatment 

– Provide urgent and emergent 

services 

• ALL ages 

• ENTIRE spectrum of health 

services 

Result: 

Emergency Care 

MDG – 2010 report 

• Rural SS Africa 

– Pa@ents wait for hours to 

days to get treatment 

– Unable to find needed 

supplies or medicines 

– Emergent services are 

essen@ally unavailable 

• Very high Mortality and Morbidity from treatable illnesses 

• Preventable deaths especially among children 

Aims 

• Describe the scope of work to be done 

• Discuss the Systems Engineering Framework 

for thinking about how medical care is 

delivered 

• Emergency Care and Triage 

• Integra@ng Management of Childhood 

Illnesses with ETAT 

What Can Be Done 

Establishment of effec@ve Emergency Care 

Malawi, for example… 

• Queen Elizabeth 

Hospital, Blantyre 

• For the sickest kids 

– How do recommended 

triage guidelines 

perform? 

– Care delivery 

– What type of illness? 

– What outcome? 

• 236 children admiUed from 

rural hospital ED 

• 27 died 

• Malaria, pneumonia, 

malnutri@on – main causes 

of death 

• 47 – emergency treatment 

– 31 no treatment (8 died) 

– 16 treatment (5 died) 

– Limita@ons: lack of staff, lack 

of blood 

Robertson, Arch Dis Child. 2001; 85(3):214-7 

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A Model of Healthcare 

Carayon, P., Alvarado, C., Brennan, P., Gurses, A., Hundt, A., Karsh, B., and 

Smith, M., (2003). Work system and patient safety. Proceedings of Human 

Factors in Organizational Design and Management-VII 583-588. 

Nyakibale Hospital 

Resources -‐ People 

© Paul Bauer, MDA 

• Doctor: Popula@on Ra@o in Rukungiri 

– 1:18,500 

• Mid-‐Level Provider (equivalent to PA): 

Popula@on Ra@o in Rukungiri 

– 1:13,500 

• Nurse: Popula@on Ra@o in Rukungiri 

– 1:895 

Nyakibale Hospital 

Environment -‐ Emergency 

Department 

ED Tasks 

Holding area from outpa@ent 

department prior to 

admission 

No Triage system 

Other Elements 

© Sheila Bisanzo, GECC 

ED Tools and Technology 

Broken Imaging 

Laboratory oriented toward 

Outpa@ent care 

Supplies – what supplies? 

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2

ETAT designed for… 

• High admission mortality rates 

• Delays in care 

• Lack of triage system 

• Integra@on with trea@ng childhood illnesses 

What does teaching ETAT look like? 

• 7 Modules 

• 3.5 days 

• Instructor and Course 

book 

– Recommended Timeline 

– Resources 

– Equipment lists 

– Tests 

• Material from Integrated 

Management of 

Childhood Illnessses 

• 7 modules 

– Triage and “ABCD” 

– Airway and Breathing 

– Circula@on 

– Coma and Convulsion 

– Dehydra@on 

– Case Management 

Scenarios 

– Implemen@ng ETAT 

Is Implemen@ng ETAT effec@ve? 

• Adapted ETAT at Red 

Cross War Memorial 

– “Two armed descrip@ve 

study” – ETAT alone 

– Triage data, 

retrospec@ve, Oct 2007 

to July 2009 

– 1309 records 

– 3 categories 

• Emergency, Urgent, Non-‐ 

Urgent 

Oct 2007 AdmiAed 

3.8% (34) 52.9% (18) 

37.5% (338) 32.5% (110) 

58.8% (530) < 10% (52) 

Oct July 2009 AdmiAed 

2.9% (12) 91.7% (11) 

45.9% (187) 36.9% (69) 

51.1% (208) 10% (21) 

Buys et al., S Afr Med J. 2012 Dec 31;103(3):161-5 

What does teaching ETAT look like? 

• Module based educa@on – flexible @meframe 

• Cross-‐discipline training 

ETAT course Emergency Triage only 

ED staff Watchmen 

Pediatricians and surgeons Gate Keepers 

On call physicians Administra@ve Staff 

Health professions teachers Driver 

• Meant to impact en@re hospital! 

Is teaching ETAT effec@ve? 

• Pediatric Resuscita@on 

for nurses working in 

Ghana 

• 1 day of ETAT training 

• Self-‐Efficacy, Ghanaian 

hospital nurses 

• Before and aoer design, 

focusing on self-‐efficacy 

– Survey 

• Increase for 

– Resuscita@on in general 

– Bag-‐Mask Ven@la@on 

– Knowledge of Paediatric 

Resuscita@on 

• Recommenda@ons: 

– More Teaching with a 

focus on nurses 

Brennan et al, Int Nurs Rev. 2013 Mar;60(1):136-43. 

What does ETAT cost? 

• District Hospital Implementa@on of ETAT in Kenya 

• Cost analysis with outcomes data 

• 4 district hospitals -‐ full ETAT training vs 4 hospitals -‐ par@al training 

• 14 process measures to follow quality 

Category IntervenGon control 

Cost/admission (2009 $) 50.74 31.1 

• Improvement in quality (key indicators – actuarial math…): US$0.79 per 

% increase in care 

• Es@mated cost to na@onal health care system? 

– 3.6 million, $39.8 -‐ $398/disability adjusted life year (DALY) 

Barasa, PLoS Med. 2012;9(6):e1001238 

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Does ETAT improve performance? 

• KenyaUa Na@onal 

Hospital, Nairobi 

• Before-‐aoer study 

• 2005 vs. 2009 

• ETAT and IMCI 

• Guideline adherence: 

– Pneumonia, dehydra@on, 

severe malnutri@on 

– Assessment, classifica@on, 

treatment, and follow-‐up 

care 

Irimu et al., PLoS One. 2012; 7(7): e39964. 

Integrated Management of 

Childhood Illnesses 

• Aims: 

– Improving case 

management skills of 

health-‐care staff 

– Improving overall health 

systems 

– Improving family and 

community health 

prac@ces. 

• Mul@ple condi@ons 

working together to 

increase risk for children 

• Macro to Micro 

approach 

– Health policy 

– Hospital organiza@on 

– Ward personel 

– Front line clinic workers 

• Evaluated in many 

countries 

Integra@ng ETAT and IMCI 

http://www.who.int/maternal_child_adolescent/documents/9241546700/en/ 

Does ETAT improve performance? 

Treatment 2005 2009 Significance 

Dose and Frequency 

of Penicillin 

Fluid Resuscita@on 

ETAT+ guidelines 

Feeds for severe 

malnutri@on 

137/265 (51.7%; 

45.5–57.9) 

100/265 (37.7%; 

31.9–43.9) 

25/274 (9.1%; 6.0– 

13.2) 

258/287 (89.9%; 

85.8–93.1) 

177/286 (61.8%; 

60.0–67.5) 

135/197 (68.5%; 

61.5–74.9) 

+38.2% 

+24.2% 

+59.5% 

Outcome 2005 2009 Rela@ve Significance 

Mortality with 

pneumonia 

Mortality from 

shock 

Mortality with 

malnutri@on 

40/265 (15.1%) 19/293 (6.5%) -‐57% 

53/297 (17.9%) 26/294 (8.8%) -‐51% 

82/284 (29.9%) 44/197 (22.3%) -‐25% 

Irimu et al., PLoS One. 2012; 7(7): e39964. 

IMCI course by district density 

Case #1 

• A 5 week old male presents with a fever. Mother reports 

uncomplicated delivery in the village. Child was well un@l this 

morning when mother noted he would not feed. No cough 

• PE: 34.8 170 52 92% on room air 

Gen: Difficult to arouse 

HEENT: normal scalp, fontanelle, no rhinorrhea, MMM, not pale 

Neck: supple, no masses 

Chest: clear to asculta@on 

Heart: tachy, no murmur 

Abd: soo, non-‐tender. Umbilicus appears normal other then reducible 

umbilical hernia 

Ext: no edema 

Skin: no rash, cool to touch 

Neuro: sleeping, poor muscle tone 

5/14/13 

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Case #1 

• What immediate treatment and work-‐up does 

this child need? 

• Does the child need an LP? Why or why not? 

• Would you give an@bio@cs to this child once 

you place the cannula? 

• Would give an@bio@cs if the child has a 

posi@ve BS? 

Emergency Signs 

• Airway 

– Obstructed Breathing 

• Breathing 

– Severe respiratory distress 

– Central cyanosis 

• Circula@on 

These children 

need to be treated 

immediately to 

avert death 

– Signs of shock (cold hands; capillary refill longer than 

3 seconds, weak, fast pulse, signs of severe 

dehydra@on in a child with diarrhea) 

• Disability 

– Coma, Convulsions 


Airway and Breathing 

• Necessitate immediate treatment, call for 

help, blood draw (glucose, malaria smear, 

hemoglobin) 

Assess Treat 

Airway and Breathing Manage airway 

Obstruc@on 

ANY SIGN POSITIVE 

Neck injury? 

Cyanosis Choking? 

Severe respiratory distress Oxygen 

Warm child 

Stages in the management of the sick 

child admiUed to hospital: summary of 

key elements 

• Check for emergency 

signs, assess ABC’s 

• If emergency signs 

found, 

– Call for help 

– Start treatment 

– Stay calm 

– Work as a team 

Ini@al Evalua@on 

Developed from WHO Pocket book 

of Hospital Care for Children 

• Emergency 

inves@ga@ons: 

– Blood glucose 

– Blood smear 

– Hemoglobin 

– Type and cross-‐match? 

• Shock, anemia, bleeding 

Emergency Signs -‐ Circula@on 

Assess Treat 

CirculaGon ANY SIGN POSITIVE 

Support circulaGon 

Cold hands with Stop bleeding 

Delayed capillary refill Give Oxygen 

Weak and fast pulse Warm child 

Not malnourished 

Place IV, 

intraosseus, or 

external jugular 

line 

Malnourished 

Give IV glucose 

Place IV and give 

fluids 

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Emergency Signs: Neurologic Disability 

Assess Treat 

Coma/convulsing Manage airway (mind 

neck injury) 

Coma or 

IF COMA OR 

CONVULSING 

Check RBS – IV glucose 

if low 

Convulsing (now) Posi@on unconscious 

child to avoid 

aspira@on 

Priority signs 

Convulsion = diazepam 

rectally 

• Need prompt assessment 

• No wai@ng in queue – move to the front 

• Get surgical help as needed 

Priority Signs 

Assess 

Severe DehydraGon in 

presence of diarrhoea 


Severe Dehydra@on 

DIARRHEOA plus 

Treat 

Not malnourished 

Lethargy 

TWO SIGNS 

POSITIVE 

Start IV and rapid 

IV fluids 

Sunken eyes Check for severe Severely malnourished 

Very slow skin pinch malnutriCon Do NOT start IV 

Proceed to full 

assessment and 

treatment 

Priority Signs – give pa@ents urgent 

aUen@on 

• Tiny Baby: sick child 

under 2 months 

• Temperature: > 39 C 

• Trauma or other urgent 

surgical condi@on 

• Pallor (severe) 

• Poisoning 

• Pain (severe) 

• Respiratory distress 

• Restless or lethargic 

• Referral (urgent) 

• Malnutri@on with 

severe was@ng 

• Oedema of both feet 

• Burns (major) 

3TPR MOB 

The Young Child with a Fever 

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Fever work-‐up 

• What are the causes of fever in young 

children? 

– Meningi@s – bacterial, viral, fungal 

– Pneumonia – bacterial, viral 

– Malaria 

– Sepsis (bacteremia) – blood infec@on 

– Urinary Tract infec@on -‐ bacterial 

– Viral infec@ons 

The Ill Neonate (< 2 months) 

• ABC’s 

• History 

– Focus on birth history 

– Ask mother if history of genital herpes? 

– Full term? Prolonged labor/rupture of membranes? 

Forceps delivery? Maternal fever during delivery 

• Exam – 

– Examine scalp for abrasions/sings of infec@on 

– Fontanelle exam 

– Umbilicus 

– Gums – for evidence of false teeth extrac@on 

– Rash – herpes, petechiae, pustules 

Neonate with Fever: Treatment 

• Fluid bolus with NS or LR (preferred if diarrhea) 

– 20 mL/kg, repeat aoer re-‐evalua@on 

– Severe Anemia (Hb< 5 g/dL) given 10-‐20 mL/kg whole 

blood 

– If not responding, call doctor 

• An@bio@cs – regardless of results of tes@ng 

– Ampicillin 50 mg/kg; Gentamicin 7.5 mg/kg 

• Give Acyclovir is mother has genital herpes 

• An@malarials if BS is posi@ve or suspect par@ally 

treated malaria 

Why are young children different? 

• Physiology 

– Immune system of newborn not func@onal un@l 2-‐4 

months of age 

– Unable to communicate symptoms 

– Exam is unreliable (lacks sensi@vity) to localize 

symptoms 

– Observa@ons other than heart rate remain normal 

un@l child is close to death 

– Some@mes poor PO in take is only sign of illness 

• Immuniza@ons 

– Have not completed full course 

Neonate with Fever: Work-‐up 

• Place IV, BS, RBS, Hgb, 

– LP for CSF workup is MANDATORY regardless of results 

of other tes@ng 

– Consider CXR if sat < 94, grun@ng, focal abnormal 

breath sounds, tachypnea, or chest indrawing. 

– Consider Urine analysis if no source for fever, and LP 

nega@ve 

– Consider Rapid An@body Test in mother if HIV 

unknown 

• Re-‐assess observa@ons frequently (15-‐20 

minutes) 

Case #1 

• What treatment and work-‐up does this child 

need? 





posi@ve BS? 

5/14/13 

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Case #1 

• What work-‐up does this child need? 

IV, Bolus, LP, BS, RBS, Chest x-‐ray 


YES – immune system is s@ll weak, PE is unreliable 

• Would you give an@bio@cs to this child once you 

place the cannula? 

YES – give Ampicillin and Gentamicin 

• Would give an@bio@cs if the child has a posi@ve 

BS? 

YES 

Case #2 






posi@ve BS? 

Child < 1 year with Fever: Work-‐up 

• Place IV, BS, RBS, Hgb, 

– LP for CSF workup is MANDATORY if no immuniza@ons 

– LP for CSF is MANDATORY if child is ill-‐appearing 

– Consider CXR if sat < 94, grun@ng, focal abnormal 

breath sounds, tachypnea, or chest indrawing. 

– Consider Urine analysis if no source for fever, and LP 

nega@ve 

• Re-‐assess observa@ons frequently (15-‐20 

minutes) 

Case #2 

• A 6 month old female presents to the ED with a fever. Mother 

reports child well un@l this morning. She developed fever and 

vomi@ng, that was not bloody. She has no diarrhea or cough. She 

is up to date on her immuniza@ons 

• PE 38.4 136 80/50 38 95% 

Gen: Awake, looks at you when you approach mother 

HEENT: MMM, NC, fontanelle flat, + rhinorrhea, OP is clear 

Neck: supple 

Chest: clear bilaterally 

Heart: tachycardic, no murmur 

Abd: soo, non-‐tender 

Ext: no edema 

Skin: no rash, hair appears normal 

Neuro: awake, interac@ve, smiles when you play with her. 

Child less then 1 year with fever 

• ABC’s 

• History: 

– Immuniza@ons 

– Signs and Symptoms are more reliable the older 

the child 

– Malnutri@on (can suppress immune response to 

bacterial infec@on 

Child < 1 year with Fever: Treatment 

• If tachycardia, fluid bolus with NS or LR (preferred if 

diarrhea) 

– 20 mL/kg, repeat aoer re-‐evalua@on 

– Severe Anemia (Hb< 5 g/dL) given 10-‐20 mL/kg whole 

blood 

– If not responding, call doctor 

• An@bio@cs only if bacterial focus found 

– Ceoriaxone 50-‐100 mg/kg daily (Meningi@s?) 

– Mandatory if child is toxic looking or severely 

malnourished 

• An@malarials if BS is posi@ve or suspect par@ally 

treated malaria 

5/14/13 

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Case #2 






posi@ve BS? 

Case #3 

• An 8 month old female presents with difficulty in breathing. 

Mother noted cough and “flu” symptoms for 1 day. She has 

also been having trouble breathing that seems to be ge|ng 

worse. Has had trouble breast feeding this aoernoon 

PE 38.7 122 80/40 36 90% 

Gen: crying, irritable child 

HEENT: NC/AT, MMM 

Neck without mass 

Chest with crackles in the base, subcostal recessions 

Hyperdynamic precordium, no murmur, cool hands and feet 

Absomen distended, nontender, spleen @p palpable 

Feet with oedema, and scaly rash over extremi@es 

Hair is red and patchy 

Assessment of the severely 

malnourished child 

• History: 

– Mother with ISS, Child living with grandmother 

– Cessa@on of breast feeding before 1 yr 

– No meat or beans in diet 

• Exam: 

– Observa@ons, may be hypothermic (elevated heart 

rate if dehydrated) 

– AUen@on to height, weight 

– AUen@on to skin, hair, extremi@es (oedema and rash) 

Case #2 


BS, other tests only if BS nega@ve or suspicion for other 

pathology arises 


No, well appearing and fully immunized 

• Would you give an@bio@cs to this child once you place 

the cannula? 

No, child is well appearing 

• Would give an@bio@cs if the child has a posi@ve BS? 

No, child is well appearing 

Approach to the Severely 

Malnourished Child 

• Diagnosis 

– Weight for length < 70% or < -‐3SD (see WHO 

pocket book on Hospital Care for Children, 

appendix 5, p 359) 

– Oedema of both feet (Kwashiorkor – edema from 

low albumin) 

– Visible was@ng (Merasmus – muscle atrophy from 

low protein intake) 

– Red or light brown hair, derma@@s 

– Developmental delay or developmental regression 

Malnourished Child – Work Up 

• RCT, RBS, Hgb, BS 

• Indica@ons for LP: 

– Persistent vomi|ng 

– Convulsions 

– Temperature instability (T > 38 or T < 35) 

– Cranial nerve abnormali@es (disconjugate gaze, 

facial palsy) 

– New confusions or lethargy 

• CXR if signs or symptoms of pneumonia 

5/14/13 

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Malnourished Child -‐ Treatment 

• Careful fluid administra@on if dehydrated 

(10-‐20 ml/kg with observa@ons) 

– Concern for conges@ve cardiac failure due to 

chronic malnutri@on 

– NS or LR are both acceptable 

• An@bio@cs for any child mee@ng criteria for 


• An@malarials if BS posi@ve or suspicion for 

par@ally treated malaria 

Case #3 






posi@ve BS? 

Summary of ETAT 

• Triage – Check for Emergency signs! 

determines pa@ent flow (Airway, Breathing, 

Circula@on, Coma, Convulsion, Dehydra@on) 

• Emergency 

• Priority 

• Queue 

• Pay aUen@on to Priority Signs: 3PTR MOB 

• HIV status important in ill appearing children 

• Malnourished children < 1 yr may not show sings 

of infec@on when sep@c, treatment is similar to 

newborns 

Malnourished Child Admission 

Orders 

• All severely Malnourished children should get: 

– ORS to con@nue rehydra@on if dehydrated 

– 50-‐100 cc addi@onal ORS for every loose stool 

– Ceoriaxone 50 mg/kg 

– HEM (high energy milk) 

• 11 mL/kg every 2 hours 

– Vitamins 

• A dose varies with age 

• Folic Acid 5 mg on day one then 1 mg/day 

50,000 IU if < 6 mnth 

100,000 IU for 6-‐12 mnths 

200,000 IU if > 12 mnths 

• Magnesium 50 mg/Kg IV up to 1 gram total dose (to be 

given slowly over 2 hours) 

• Zinc: 2 mg/kg/day orally 

Case #3 


– RBS, BS, Hgb, LP, CXR, RCT 


– Yes. Two risk factors for meningi@s: Mother with ISS, and 


• Would you give an@bio@cs to this child once you place 

the cannula? 

– Yes, this pa@ent can hide an infec@on that is hard to no@ce 

on clinical exam because of severe malnutri@on 

• Would give an@bio@cs if the child has a posi@ve BS? 

– Yes, the child has severe malnutri@on. 

How to make this possible 

• AUen@on to Environment 

• People 

• Tasks 

• Tools and Technology 

• Follow the process measures Outcomes 

5/14/13 

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Environment 

Partnership with GECC and 

MDA: 

Medicine Cabinet 

Surgical Lamps 

Privacy Curtains 

Triage desk 

Chart System 

Library 

Equipment steriliza@on © Sheila Bisanzo, GECC 

Comprehensive Emergency Care Training 

• Pediatric Emergencies and Malnutri@on Care 

• Commonly used procedures 

– Suturing 

– Lumbar Puncture 

– Seda@ons 

– I and D 

• Symptom based approach to major complaints 

• Trauma care 

• Consulta@ons to physicians 

– Major surgery (laparotomy) 

– Cri@cally ill and not responding to treatment 

Tools and 

Technology 

Do you have what you 

need to do your job? 

Supplies 

Diagnos@cs 

Therapeu@cs 


People – the Emergency 

Nurse PracGGoners 

Intensive training 

Highly skilled 

Excellent outcomes 

Unmatched in Sub-‐Saharan 

Africa 

Ongoing mentorship to 

become leaders 

Mentorship to enable 

propaga@on of the model 

Tasks 

Effec@ve: 

Triage 

Assessment 

Treatment 

Disposi@on 



Effec@ve Integrated Emergency 

Care 

• Reduce morbidity and mortality from acute 

illness and injury 

• Triage of pa@ents 

– Pa@ents for rou@ne follow up or minor illness are seen in 

OPD 

– Sickest pa@ents sent to Emergency Department 

– Can be done by a Nursing Assistant 

• Maximizes efficiency of care 

– Cri@cally ill pa@ents not wai@ng in line 

– Sick pa@ents are resuscitated before going to the ward. 

5/14/13 

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Is it Quality Care? 

• Beginning November 13 th , 2009 

– GECC volunteers help monitor care 

– 72 hour follow up on all pa@ents seen in the ED 

– Telephone calls to ED mentor with targeted ques@ons 

• As of February, 2010 

– 1828 pa@ents seen 

– 432 are children under 5 

– ~90% seen primarily by Ugandan trainees 

Comparison to other Data 

• Nyakibale ED: 2.12% 

• Mortality Rates in AdmiUed Children 

– 4.5% (Soweto, South Africa) 

– 5.7% (Mafikeng, South Africa) 

– 9.9% (Siaya, Kenya) 

– 13.7% (Bissau, Guinea) 

– 17.4% (Lwiro, South Kivo, DRC) 

Sustainable Emergency Care 

• Operate the ED 24 hours a day 

• Eventually expand the training program ? 

– Establish Emergency Care at other District 

Hospitals 

– Scaleable to other countries? 

• What do we need? 

– Enthusias@c physicians with desire to mentor! 

– Volunteers with adult educa@on skills 

Results 

• Pa@ents under 5 years (432) 

– 330 admiUed 

– 199 had malaria (174 admiUed) 

– 105 had malnutri@on (104 admiUed) 

• Mortality in pa@ents under 5: 

– AdmiUed: 7 pa@ents (2.12%) * 

– AdmiUed with malaria: 1 (0.57%)** 

– AdmiUed with malnutri@on: 3 (2.88%) 

Where do we go from here? © Sheila Bisanzo, GECC 


5/14/13 

13

© Paul Bauer, MDA 

Global Emergency Care 

Collabora@ve 

hUp://www.globalemergencycare.org/ 

Partners 

Mission Doctors 

Associa@on 

hUp://missiondoctors.org/ 

5/14/13 

14

Integrating IMCI & ETAT Guidelines Presentation - INMED

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