guidelines for the integrated management of severe acute malnutrition

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ACF-In Guidelines for the integrated management of SAM Monitoring and evaluation 122 programme for severe malnutrition. In the SFP there is a special category of children who have recovered from SAM; it is important that their SAM number is recorded in the SFP registration book. “Died”: A patient dying during its stay in the OTP programme AND those who have died in transit from the OTP site to in-patient care but have failed to reach the IPF 191 . If the child was previously reported as “unknown” and is subsequently found to have died, this should be notified in the monthly report, the registration book and the IPF/OTP chart and a “change of category” note made. “Unknown”: This category is for patients failing to attend the OTP programme for 2 consecutive visits where it is unknown whether the patient has defaulted, moved away or died 192 . Subsequently a home visit may determine the true cause of absence from the programme, in which case a “change of category” note can be made on a subsequent monthly report. “Defaulter”: A patient who is absent for 2 consecutive weightings (14 days in out-patient), confirmed by a home-visit for the out-patient component of the programme (by the outreach worker or community volunteers). “Transfer-out” 193 • Transfer-out from one OTP to another OTP. A patient transferred to another OTP, because it is nearer to his/her home. The patient leaves the OTP in which first registered, but is NOT a discharge from the programme: in the new OTP the patient will be recorded as a “transfer-in” and will retain the same SAM number. • Transfer-out to In-patient care. A patient transferred to an In-patient facility, who has already been given a SAM-No. S/he will be admitted to the IPF as a “transfer-in” and not as a new admission and will retain the same SAM-No. When the patient has finished the in-patient care and comes back to the OTP, s/he will be recorded as a “return” in the OTP registration book. “Non-response-refused-transfer”: Simple non-response to treatment is NOT a category of discharge from OTP. All patients that fail to respond to treatment should be referred to the in-patient facility for diagnosis and further management. This category is ONLY used for patients that are referred to the inpatient facility and refuse to be transferred. This normally occurs when the reason for failure to respond is social. The outreach worker and community volunteers should always make a repeat home visit if transfer is refused for non-responding children. The refusal should be recorded in the outcome; the case should be discussed with the village chief and if necessary reported to the District Nutrition Officer/Medical officer of health. 191 This is a very difficult category to complete. Patients leave the OTP and do not arrive at the IPF; where there is no proper coordination between the programmes the data are simply missing. The number of children transferred-out from all the OTP sites in the catchment area should match with the number of transfer-in recorded in the IPF. The discrepancy should equal the number who “did not arrive”. Some of whom will have died in transit. Follow up by home visiting of those who did-notarrive should be attempted to determine the number of “transport deaths”. Note: the did-not-arrive children should equal the “did-not-return” plus the defaulters/deaths from the in-patient facility. These data can be determined when all the reports are compiled by the District Nutrition Officer (or the NGO if they have control of the whole programme). If the “did –notarrive” category contains several children then an investigation should be mounted to visit the parents at home and determine the reasons for non-arrival (no transport, registration money required, died, etc.) 192 In many programmes all these children are reported as “defaulters” and there is no provision for reporting an “unknown” outcome. The parents of children who die do not return to report the death to the OTP; and busy staff are unlikely to find the OTP chart and record the death. Death reporting is thus haphazard and serendipitous. This leads to biased data, an incorrect view of the success of out-patient management and failure to detect and correct errors in the application of the triage procedure (in particular the application of the appetite test). The death rate in OTP for most published data is therefore a MINIMUM death rate. The maximum death rate is the sum of the dead and defaulting rates! Some independent home follow up studies have shown that more than 10% of “defaulters” are actually deaths. 193 These are NOT “discharges” from the programme –simply (temporary) “discharges” from the OTP. The term “discharge” is used in both ways and leads to confusion.
ACF-In Guidelines for the integrated management of SAM Monitoring and evaluation 123 “Wrong Admission”: Where it is found that a patient who does not fulfil the criteria for SAM has been inadvertently admitted to the programme and given a SAM number. This patient should be discharged as soon as convenient and listed in all the records as a “wrong admission”. The SAM number is NOT then assigned to another patient. But the report must indicate the number of wrong admissions to the OTP. Type of admission to an in-patient facility “New admission”: This is where a patient has not been under treatment elsewhere – such patients are screened in the out-patients/ casualty/ emergency departments or spontaneously come to the inpatient facility seeking treatment. This category also includes infants of less than 6 months who are not treated in OTP and will not return to OTP. They do not have a SAM number and one should be assigned. “Transfer-in” from an OTP to an In-patient facility. This is where a patient has been under treatment at an OTP site and has been sent to the IPF for in-patient care 194 . This includes patients who failed their appetite test, those who have complicated malnutrition and those that have failed to respond to treatment. These patients are NOT counted as a new admission as the patient has been under care in the OTP; the child should already have a SAM number which will be used by the IPF. Type of discharge 195 and transfer from an in-patient facility “Transfer-out” to OTP. This is where a child originally admitted as a new case is transferred to OTP to complete his/her treatment. The SAM-no will have been given by the IPF. “Return” to OTP. This is where a child who has originally been transferred from the OTP is returned to the OTP programme. He will already have a SAM N° given by the referring OTP. “Died”: A patient that has died while he was in the in-patient facility AND those who have died in transit to OTP but have failed to reach that facility. “Defaulter”: A patient that is absent for 2 consecutive weighing (2 days in in-patient) “Cured”: This category should apply mainly to the less than 6 month old infants. The other patients should be recorded as transfer-out to the OTP for completion of treatment. To have many “cured” children is wrong unless there is no OTP in the area. “Medical-referral” 196 : This category is used for patients with another serious underlying illness (e.g. Hirsprung’s disease going for surgical correction, inborn errors of metabolism etc) or undiagnosed failure-to-respond to treatment that are referred for specialist diagnosis, treatment and follow up 194 All patients that are seen at an OTP site are “registered” even if they are immediately transferred to an in-patient facility without any specific treatment being given – they will have been examined, a diagnosis of SAM made and been fully assessed and judged to require in-patient care – this constitutes “admission” to the programme. As they have been given a SAM number at the OTP site, they MUST have a transfer form which states the findings of the OTP team and what, if any, treatment they have had. They will not be given a new SAM number at the IPF, but will be registered and reported as a “transfer-in”. 195 These are NOT “discharges” from the programme –simply “discharges” from the in-patient facility. The term “discharge” is used in both ways and leads to confusion. 196 This is sometimes referred to as “medical-transfer”. It is better to reserve the term transfer for movements within the programme with continuing care of the malnutrition and an expectation that the patient will continue under the care of the malnutrition team. If they remain in the same in-patient facility (albeit with other programmes treating the patient – e.g. TB or HIV) then they should be reported as still being under-care of the malnutrition team and included in the monthly report as such.
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Cover photography: © ACF, Anne-Dom
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guidelines for the integrated management of severe acute malnutrition

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