Not so easy as ABCDr. Colin Gilhooley

Objectives

Introduce myself

Background of Jinja Hospital

Triage

Emergency Care

Dr Sophie Namasopo

Paediatric consultant

Head of Department of Paediatrics

Where do I work?

Jinja Regional Referral Hospital Paediatrics on separate site to main

hospital (SCU at main hospital)

Consultants 3 MO 1 Interns 3 Clinical officers 5 Nurses 19 (+ 5 nursing assistants) 2 lab staff 2 pharmacy technicians

Department of Paediatrics

Patients/day 70-200

Admission/day 30-35

Inpatient mortality 4-6%

Conditions: malaria/pneumonia

Admissions and Deaths 2012

Jan-

12

Feb-

12

Mar

-12

Apr-1

2

May

-12

Jun-

12

Jul-1

2

Aug-

12

Sep-

12

Oct-1

2

Nov-1

2

Dec-1

20

200

400

600

800

1000

1200

DeathsAdmissions

Mortality rate 2012

Jan-

12

Feb-

12

Mar

-12

Apr-1

2

May

-12

Jun-

12

Jul-1

2

Aug-

12

Sep-

12

Oct-1

2

Nov-1

2

Dec-1

20.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

Mortality Rate

Causes of death

Neona

tal

Pneu

mon

ia

Anae

mia

Mal

aria

(BS

+ve

)

Mal

aria

(BS

-ve)

Sept

icae

mia

Other

0%

10%

20%

30%

40%

Number

Number

Triage

100-200 patients/day increased on

clinic days

Performed by student nurses

Overseen by Nurse

Observations:TemperatureWeightMUAC

Triage

100-200 patients/day

Approx 25 – 35 admissions per day

Emergency Dep.

6 cots

10-12 patients in ED

1 nurse

Intern review every morning and evening

Some MO officer cover during day

Emergency Department

1 oxygen concentrator

Recurrent shortage of blood

Reasonable supply of antibiotics

Reasonable supply of antimalarials

Colin Gilhooley

Paediatric Registrar

Work at Nottingham Children’s Hospital

Interest in Emergency Paediatrics

Triage

Triage: Plan

Evaluate

Raise awareness

Implement Changes

Triage Evaluation

Busy = Long wait

If a child was noted to be very unwell would go to Emergency Department.

No formal process for recognising the “sick child”

Raise awareness

CMEs Triage Recognition and treatment of the acutely

unwell child

Posters

Informal discussions

Actions

Changes

Observations Resp Rate Assessment of pallor

Recognition Understanding of emergency signs Understanding of priority signs

Challenges

Student nurses change every 2 weeks. Teach one group and then another group

arrive

Acute presentations sit alongside outpatient reviews.

Accuracy of information.

Where next

Start again!!

Use of pulseoximeter?

Stratify waiting area into acute vs outpatient

The Emergency Department

Emergency Department

Evaluation

Raise awareness

Implement Changes

Evaluation

Unwell children still waited in a queue outside emergency department

Severely anaemic children not always put into oxygen.

Lack of standarised approach to management

Awareness

CMEs Focused on conditions Focused again on ETAT style approach Focused on MoH guidelines

Mentoring Aimed at nurses in ED

Changes

Ask parent/carer why patient has been sent to ED

Coherent approach to presentations, not diagnoses.

Introduction of guidelines

Mortality review and prescription audit

Challenges

Lack of oxygen/blood

MoH guidelines vs work load

Motivation

Where next?

More of the same

Use audits and mortality reviews to monitor change and influence practice.

Identify health workers to continue work for the long term

Questions

Summary

Some improve has occurred Speed of access to ED - anecdotal Awareness

More simple steps can be taken

Long term plan with skilled local involvement still needs to be put in place