Voir page 318 le resume en francais. En la pagina 318 figura un resumen en espanol.
Hospitals in developing countries often provide both preventive and curative care together. A model combining an immunization clinic, antenatal clinic and a children's outpatient clinic is common. This allows for opportunistic immunization of children who attend when their mothers are seeking antenatal care, and fewer staff are required to run three clinics together than each clinic separately. But this model fails to address the needs of the critically ill child because triage is difficult. This model also puts infants at risk of cross-infection from sick children. It may also make it difficult for staff to know where to focus their efforts and attention.
The Queen Elizabeth Central Hospital is a 1100-bed government teaching and referral hospital in Blantyre, southern Malawi. It serves the local district and receives referrals from the southern region of the country. There are 180 paediatric beds. Prior to the changes described in this article, the children's unit treated about 90 000 patients a year, of whom 12 000 were admitted. The department had a walk-in outpatient and emergency unit called the Under-Fives Clinic, which was housed in an old building that had been converted from garages. The staff consisted of two or three medical assistants, the same number of nurses, one patient attendant, one "home craft worker" (who helped with feeding malnourished children, and counselling) one receptionist and cleaners. Children attended for routine immunizations or for care of acute or chronic medical problems. Trauma was managed in a separate adult casualty unit. Most of the children attending the emergency department live within the Blantyre area; 10% of patients are referred from other health units. Inpatient mortality was seasonal and ranged from 11-18% during malaria season to 9-12% during the dry season (Paediatric Department, Queen Elizabeth Central Hospital, unpublished data from routine weekly audits held since 1991). A third of patients who died did so within 24 hours of admission (Paediatric Department, Queen Elizabeth Central Hospital, unpublished data from weekly audits).
The Under-Fives Clinic was providing an inadequate service. We analysed the situation and listed several deficiencies. These are summarized below.
* Acute medical services, outpatient services and immunization services were offered in one place. This made it difficult to assess and prioritize children by need.
* Injured children were managed elsewhere.
* Staff in the Under-Fives Clinic were not trained in emergency care or in triage.
* There was no senior supervision in the clinic.
* There were no written protocols or wall charts to help in managing care, and emergency equipment was inadequate.
* Laboratory services, which were based in another building, were slow to provide results.
* There was little space for resuscitation or to offer privacy.
* There were delays in transferring children to the wards and in initiating care.
* There was no observation area and, as a consequence, some admissions were made inappropriately.
* Cooperation between the inpatient and outpatient services was lacking.
* Morale among staff was low.
Addressing the problems
No funds were available for new buildings or for more staff, so we reviewed our resources and defined our needs. It took 4 years to identify funding to allow us to make changes to the building. The training took 2 weeks initially but is continually updated. Introducing the new scheme for patient flow through the department took 2-3 months.
Training in triage and emergency care
A senior paediatrician who had management experience in an accident and emergency service reviewed the functions of the department, the training needs of staff and the need for space and equipment. …