guidelines for the integrated management of severe acute malnutrition

ACF-In Guidelines for the integrated management of SAM Out-patient 49
Transfer Out to In-patient care
Outpatients who develop the signs of a serious medical complication (pneumonia, dehydration, etc. -
see table in section on admission triage) should be offered transfer to the in-patient facility for
management of their condition until they are fit to return to OTP.
In addition, if the patient being treated as an outpatient and develops any of the following s/he should
be transferred to the in-patient facility:
� Failure of the appetite test
� Increase/development of oedema
� Development of re-feeding diarrhoea sufficient to lead to weight loss.
� Fulfilling any of the criteria of “failure to respond to treatment”:
• Weight loss for 2 consecutive weighings
• Weight loss of more than 5% of body weight at any visit.
• Static weight for 3 consecutive weighings
Reasons for failure to respond should be checked; since causes such as sharing the food at home
could be solved without referral to in patient.
� Major illness or death of the main caretaker so that the substitute caretaker requests in-patient
care or is incapable or unwilling to look after the malnourished child
When transferred to the in-patient facility, standard in-patient treatment should be applied; however,
the routine drugs are individually prescribed depending upon what has already been given, the cause
of the transfer and the nature of the complication.
A transfer form with a return sheet has to be sent to the in-patient facility and should contain the
summary of the treatment given and the Sam-Number (See section on Monitoring and evaluation).
The OTP should also phone the IPF nutrition supervisor, if possible, to inform the IPF about the
transfer. When the patient is returned to the OTP similar contact should be made to avoid losing the
patient during the transfer. These calls should be recorded on the patient’s chart.
Failure to respond to treatment (out-patients)
It is usually only when children fulfil the criteria for “failure to respond” that they need to have a full
history & examination or laboratory investigations conducted. Most patients are managed entirely by
less highly trained staff (adequately supervised) on a routine basis. Skilled staff (nurses and doctors)
time and resources should be mainly directed to those few children who fail to respond to the standard
treatment.
Failure to respond to standard treatment is itself a “diagnosis” that should be recorded in the records
and the patient put into a different category. For out-patients this diagnosis often warrants referral to a
centre for full assessment. If inadequate social circumstances are suspected as the main cause of
failure in out-patient management an appetite test, home visit or supervised trail of feeding should be
performed before transfer to the in-patient facility.
Table 9: Failure to respond for Out-Patients
Criteria for failure to respond
Time after
admission