guidelines for the integrated management of severe acute malnutrition

More documents

Recommendations

Info

ACF-In Guidelines for the integrated management of SAM Transport 38 TRANSPORT OF SICK PATIENTS Very ill malnourished children may be brought to an OTP distribution site or health centre and the protocol requires them to be “referred” to an in-patient facility (see the referral form annex 11). Transport of these patients to an in-patient facility that is a long distance away, over poorly maintained roads is a major problem; not only because of the time delay in starting treatment and the expense to the parents but also because of the damage that the transport itself does to the child. Nurses are very reluctant to take responsibility for the care of very ill children in the periphery and readily “refer” them to a secondary or tertiary institution; frequently they do not arrive. “Transport trauma” is a real phenomenon 40 . Very ill children who are transported deteriorate dramatically when they travel crowded together in a vehicle and physically agitated. It is commonly found that malnourished children who are relatively well before transport, deteriorate and die soon after arrival after a long or difficult journey. If patients are to be transported then: • The vehicle must drive slowly • the vehicle must not be crowded • The vehicle should stop for 5 min ever 20-30 min during the drive to lessen the effects of motion sickness on the sick child. • There must be water available to drink • The child should be nursed by the mother. This is rarely possible by public transport. In view of the deterioration and death of ill malnourished children that are transported in an inappropriately manner, it is often less dangerous for the child to be managed in situ rather than be transported, even if the staff are relatively inexperienced and the facilities are sub-optimum or even very poor. The sicker the child and the more that child requires good in-patient care, the more dangerous it is to transport the child over long distances; it is not possible to resolve this dilemma. For very sick children even taking them to another department (e.g. for x-ray), excessive manipulation or washing the child can cause serious deterioration; vehicular transport is a much greater trauma. It is recommended that the child, where possible, be stabilised at the OTP or nearest health centre before transport. The provisions in this protocol for the management of severe malnutrition for in-patients and its complications should be followed as far as feasible. The medical staff in the referral centre should be contacted by telephone. They should take responsibility and “cover” the nurse in the field, reassure the nurse that it is the correct course of action not to transport the child and give advice. The nurse must explain to the caretaker that the child is critically ill and may die, but that the danger of transporting the child to the hospital is greater than trying to stabilise the child at the health centre 41 . Again the mother’s choice should be followed 42 . If this situation is common then an in-patient capability should be established in a nearly health centre. 40 Even healthy animals that are crowded together into a vehicle and transported can experience a substantial mortality with major changes in their metabolism found at autopsy. It is common for parents to have motion sickness when travelling. 41 In developed countries there are specialised intensive care teams and ambulances or aircraft to transport such patients: even with these facilities the transport itself increases mortality in most studies. 42 It the child is kept at the health centre against the parent’s wishes, and the child dies, the nurse could be blamed for the death by the community.
ACF-In Guidelines for the integrated management of SAM Transport 39 It is desirable to de-centralise in-patient care as far as possible (as well as out-patient care). Referral hospitals and paediatric expertise is not needed for most cases of malnutrition –their role is mainly for diagnosis and management of those children who fail to respond to treatment. Payment of transport is a major problem for most parents and it should be the task of the focal point of the district to support (lend money, subsidise or pay for) essential medical transport (with verification) from the village to the IPF. The other problems are the bad roads, vehicle break-down, the distance involved and seasonally impassable roads (flooding etc. during the rainy season) 43 . The nutrition Focal Point should regularly evaluate the outcome of patients that have been transported under difficult circumstances. Detailed analysis of death during and for 48h after transport should be undertaken by the District Nutrition Officer and actions taken. Solutions include using local or international NGOs, establishing a community fund, having an ambulance, establishing a phone consultation to treat patients without transport, establishing a local IPF to manage acute complicated malnutrition in situ, etc. 43 Even a mobile team may not be able to reach the village at some times of the year – this should be anticipated and provision made (stocks of RUTF and training of villagers).
Page 1 and 2: �� ACF INTERNATIONAL GUID
Page 3 and 4: ACF-In Guidelines for the integrate
Page 37: ACF-In Guidelines for the integrate
Page 89 and 90:
ACF-In Guidelines for the integrate
Page 91 and 92:
Page 93 and 94:
Page 95 and 96:
Page 97 and 98:
Page 99 and 100:
Page 101 and 102:
Page 103 and 104:
Page 105 and 106:
Page 107 and 108:
Page 109 and 110:
Page 111 and 112:
Page 113 and 114:
Page 115 and 116:
Page 117 and 118:
Page 119 and 120:
Page 121 and 122:
Page 123 and 124:
Page 125 and 126:
Page 127 and 128:
Page 129 and 130:
Page 131 and 132:
Page 133 and 134:
Page 135 and 136:
Page 137 and 138:
Page 139 and 140:
Page 141 and 142:
Page 143 and 144:
Page 145 and 146:
Page 147 and 148:
Page 149 and 150:
Page 151 and 152:
Page 153 and 154:
Page 155 and 156:
Page 157 and 158:
Page 159 and 160:
Page 161 and 162:
Page 163 and 164:
Page 165 and 166:
Page 167 and 168:
Page 169 and 170:
Page 171 and 172:
Page 173 and 174:
Page 175 and 176:
Page 177 and 178:
Page 179 and 180:
Page 181 and 182:
Cover photography: © ACF, Anne-Dom
show all

guidelines for the integrated management of severe acute malnutrition

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?