GUIDE FOR CLINICAL PRACTICE IN THE INPATIENT WARD
World Health Organization and UNICEF
|Management of Childhood Illness was prepared by the World Health Organization's Division of Diarrhoeal and Acute Respiratory Disease Control (CDR) and UNICEF through a contract with ACT International, Atlanta, Georgia, USA.|
General Objectives: During clinical practice sessions, participants will:
* see demonstrations of how to manage sick children and young infants according to the case management charts.
* practice assessing, classifying and treating sick children and young infants and counselling mothers about food, fluids, and when to return.
* receive feedback about how well they have performed each skill and guidance about how to strengthen particular skills.
* gain experience and confidence in using the skills as described on the case management charts.
- practice assessing and classifying sick children and young infants according to the ASSESS & CLASSIFY and YOUNG INFANT charts.
- practice identifying the child's treatment by using the "Identify Treatment" column on the ASSESS & CLASSIFY and YOUNG INFANT charts.
- practice treating sick children and young infants according to the TREAT and YOUNG INFANT charts.
- practice counselling mothers about food, fluids, and when to return according to the COUNSEL chart.
- practice counselling mothers of sick young infants according to the YOUNG INFANT chart.
- practice using good communications skills when assessing, treating and counselling mothers of sick children and young infants.
- practice assessing and classifying sick children and young infants according to the ASSESS & CLASSIFY and YOUNG INFANT charts, focusing especially on the assessment of general danger signs, other signs of severe illness, and signs which are particularly difficult to assess (for example, chest indrawing and skin pinch).
- practice treating dehydration according to Plans B and C as described on the TREAT chart.
- practice helping mothers to correct positioning and attachment for breastfeeding.
To make sure that participants receive as much guidance as possible in mastering the clinical skills, the outpatient facilitator and inpatient instructor give particular attention and feedback to the new skill being practiced that day. If any participant has difficulty with a particular skill, the facilitator or inpatient instructor continues working with the participant on that skill in subsequent sessions until the participant can perform the skill with confidence.
Schedule of Clinical Practice Sessions
|Outpatient Sessions||Inpatient Sessions|
Assess and classify cough or
Assess and classify cough or
Check for malnutrition and anaemia
Check for malnutrition and anaemia
Teach the mother to give oral drugs
Advise mother when to
Plan B: Treat some dehydration
Assess and classify additional children
Assess and classify additional
Correct positioning and attachment
Assess and classify young infants
As the inpatient instructor, your tasks include:
2. At the beginning of each session, demonstrate any new clinical skill, such as a new part of the assessment process.
3. Assign each participant to a child. Observe while participants assess and classify the children.
4. Conduct rounds to review the children which participants have assessed and classified. Have all participants practice assessing some signs, to give them more practice with severe signs and signs which are difficult to assess.
5. Show participants any additional children with infrequently seen signs.
6. Summarize the session. Reinforce participants for new or difficult steps that they did correctly, and give them suggestions and encouragement to help them improve.
7. Record the cases seen by participants on a Checklist for Monitoring Inpatient Sessions. Also record clinical signs in additional cases which were seen by the group.
3. Qualifications and Preparation for the Inpatient Instructor
2. The inpatient instructor should have proven clinical teaching skills.
3. The inpatient instructor should be very familiar with the integrated case management process and have experience using it. He or she should have participated in the course Management of Childhood Illness previously as a participant or facilitator.
4. He or she should be clinically confident, in order to sort through a ward of children quickly, identify clinical signs that participants need to observe, and assess and classify children easily according to the ASSESS & CLASSIFY charts. He or she should understand the child's clinical diagnoses and prognosis so as to avoid confusing cases and critically ill children who need urgent care. He or she should be comfortable handling sick children and convey a positive, hands-on approach.
5. He or she must have good organizational ability. It is necessary to be efficient to accomplish all of the tasks in each clinical session, including reviewing 6 cases. The individual must be able to stay on the subject, avoiding any extraneous instruction or discussion. Although teaching 3 to 4 groups of participants requires only 3 to 4 hours, these are very active periods. He or she must be energetic.
6. The individual must be outgoing and able to communicate with ward staff, participants, and mothers. He or she should be a good role model in talking with mothers. (A translator may be provided if needed.)
7. It is helpful if the individual has some training or experience in assessing breastfeeding and teaching mothers to improve positioning and attachment for breastfeeding. Experience with neonates and 1-month-old infants is helpful.
8. If possible, in preparation for this role, the individual should work as an assistant to an inpatient instructor at another course to see how to select cases, organize the clinical sessions and interact with participants. Or another skilled inpatient instructor can join him or her during the first few days of the facilitator training or the course.
9. The inpatient instructor must be available 2-3 days prior to facilitator training, during all of facilitator training, and during all of the course. He or she must be willing and motivated to get up early each morning to select cases in the inpatient ward and prepare for the day's clinical sessions.
10. The inpatient instructor should be available to teach several other courses over the next year.
1. With the Course Director, meet with the director of the paediatric inpatient ward. Explain to the ward director how inpatient sessions work. Describe what the inpatient instructor and the participants would do. Ask permission to conduct sessions in the ward. If there are separate malnutrition, newborn and sick neonate wards, meet with the directors of these wards.
If several wards will be used, first meet with the hospital director to obtain permission, then with the ward staff responsible for each ward needed during the course. In each ward, make sure your arrangements include the senior responsible nurse, not just the doctor in charge.
Ask the ward director for a clinical assistant. This should be someone who works on the ward full time. Ask the director to assign the clinical assistant to come at the time of the early morning preparations (usually at 6:00 or 7:00 am depending on the schedule). Ask for a translator to help interview mothers in the early morning, if needed. (It will often be necessary to provide a stipend to this individual.)
2. Visit the ward. See how the ward is laid out, the schedule of admissions, meals, etc. Find out times patients are available or not available.
3. From this information, plan a possible schedule for the clinical sessions in the inpatient ward:
* during the course (1 to 4 groups of up to 6 participants each; one hour session for each group each day).
5. Study this guide to learn or review exactly what you should do to prepare for and conduct inpatient sessions. Visit the inpatient ward to plan how and where you can carry out your tasks.
6. Obtain necessary supplies for instruction. These include:
* Young Infant Recording Forms
* 6 clipboards and/or sheet protectors
* String or tape to fasten clipboards to foot or head of bed
* Highlighter pens
* Scales for weighing children and infants
* Cups, spoons and clean water (for offering fluid to assess thirst)
* Supplies for treating dehydration according to Plan B and Plan C
7. Meet with the Course Director to review your responsibilities and your plans for conducting the inpatient sessions.
8. Brief any staff that will be in the inpatient ward about what you will be doing, and the training sessions that will take place there.
9. As a trial run, practice what you will need to do on the first morning, that is, select at least 6 children with clinical signs appropriate for the session and prepare Recording Forms for them. Then show these to the Course Director.
10. Supplement medical supplies of the inpatient ward if necessary. You should ensure that treatment of children meets or exceeds minimal standard of care. See Annex A.
11. During the first few days of the facilitator training, select cases and conduct the inpatient sessions with supervision and feedback from the Course Director or an experienced inpatient instructor. This should allow you to obtain experience in this role and to work out any problems, before the course and heavier teaching load begins.
12. Before the course begins, the Course Director will teach you how to use the Checklist for Monitoring Inpatient Sessions. See Annex B.
5. General Procedures: How to Prepare Each Morning
1. Early in the morning on the day of the clinical session, examine all children admitted to the paediatric wards to see if their signs are appropriate for the clinical session. This must be done in the morning as the clinical condition of hospitalized children can change very rapidly, even overnight.
2. Identify children that have the signs relevant to the objectives of the session for that day. Identify fresh cases, that is, cases that arrived within the previous 1-3 days. Their history should be still valid so that it matches their current classifications. Patients with unambiguous clinical signs should be used for demonstration. This is particularly important for chest indrawing where participants learn that, if they are not certain, chest indrawing is not there.
3. Identify children with infrequently seen signs. Because these signs are infrequently seen, you want to show them to participants whenever there is an opportunity, and not wait until the day they are studied. Though children with these signs may not be assigned to participants, you will show the signs to participants at the end of the session. These signs include:
| Sick Children
2 months up to 5 years
Ø very slow skin pinch
Ø stiff neck
Ø measles rash
Ø severe palmar pallor
Ø corneal clouding
Ø pus draining from the eye
1 week up to
Ø nasal flaring
Ø red umbilicus or draining pus
Ø umbilical redness extending to the skin
Ø bulging fontanelle
Ø less than normal movement
Ø not able to feed, no attachment at all, or not suckling at all
Ø many or severe skin pustules
4. Ask the permission of the caretakers/parents to allow their children to be seen by participants that day. Try to arrange that the children will be in their beds during the sessions.
5. Select 6 cases who together have an appropriate variety of signs for participants to assess/classify in the sessions that day plus any other which provide good demonstrations of clinical signs. (Select one case per participant. Select 6 if there will be 6 participants in a group. If the group is smaller, select fewer.) It is important to have a separate patient for each participant to assess and classify during the session. Select children so that there are differing combinations of signs present, resulting in different classifications. Also select any additional children with infrequently seen signs that you will show to participants, or with the signs you are emphasizing during that day's session.
6. Keep a list with brief notes on each of these cases for your own reference during the session. Note the child's name, age, (location in the ward if necessary), and positive signs. However, keep in mind that clinical signs can change rapidly in very ill children from one session to the next.
7. Partially complete a Recording Form for each of the selected children and post it on the child's bed. Obtaining and recording the history in this way will prevent repetitive questioning of mothers and will expedite the assessment and classification.
How to Prepare the Recording Form:
* Highlight all main symptom questions to be covered that day plus their "Ask" questions. Fill in this information based on the mother's responses. (Though occasionally you may need to make up some information, it is better not to fabricate history to avoid confusing participants if they interview the mother.) Do not fill in any information about the child's additional clinical signs or classifications. These will be determined by the participants when they examine the child.
* Draw a line where you want the assessment to stop, or fold under that part of the Recording Form. See the example form which has been prepared as described above.
* Put the form on a clipboard or in a plastic sheet protector and tape or tie it to the foot or head of the bed. Remove or turn over any hospital records that are on or near the bed so that participants cannot see them.
8. Mark the beds of any additional children that you plan to show to participants, for example, by posting a coloured card at the foot of the bed. This will help you locate these children easily.
1. Tell participants the objectives of today's inpatient session. (For the first few days of the course, the objectives of the outpatient and inpatient sessions are the same, but later in the course they are different.)
2. Demonstrate for the participants any new part of the assessment process. Before participants practice a clinical skill for the first time in the inpatient ward, they should see a demonstration of it done correctly. Explain and demonstrate the clinical skill exactly as you would like participants to do it.
3. Assign each participant a case to assess and classify. Tell them how much of the assessment and classification you expect them to do (for example, through assessment and classification of diarrhoea.) Be sure that each participant has a blank Recording Form to use.
4. Observe while the participants assess and classify the cases. Be available to assist or answer questions. Make sure they are circling the child's signs on the Recording Form and writing classifications. Encourage them to refer to the chart booklet or to the chart when they classify the child.
If you see a participant involved in a long discussion with the mother, encourage him to use the history provided and to concentrate on the assessment of clinical signs and the classification.
5. Make sure participant work is not interfering too much with the ward routine, especially provision of treatment. You or your assistant should make sure families understand what is going on.
6. Conduct rounds with the group of participants:
* Ask all the participants to assess certain signs, for example, to determine if chest indrawing is present or absent. (Select certain signs which should be learned or reinforced in the session. Thus, by the end of the session, children with and without the sign are seen by participants, so the distinction is clear.) Give them a chance to examine for the sign, for example, to stand near the child to look for chest indrawing, or to pinch the skin. (The instructor needs to assess the sign at the same time as the participants, since signs may change over time.)
If necessary, ask participants to write their individual assessment on a slip of paper and hand or show it to you, so you are sure they are giving their own assessment, not influenced by others or fear of embarrassment. These problems will vary by group. Be aware that some people are quite shy and do not like to have a joke made if they have made an error. With slips of paper, it is possible to talk about agreement of the group without singling out the wrong answer of any one participant. You will know which participants are assessing correctly and which need more practice.
* Tell the correct assessment of the sign. If all participants did not assess it correctly, demonstrate or let participants assess again. Find out why they decided differently -- where they were looking, when they think breathing in or out is occurring, or other relevant factors. Treat their opinions with respect. Convey the fact that you might be wrong. "Let's look again." "Now is it more clear in this position?" "Abdi was correct to doubt chest indrawing if he was not sure. Let's look in a different position."
Make sure the atmosphere is supportive, so participants do not feel bad if they get a sign wrong. You may say, "It takes awhile to learn these signs. Do not feel bad if you make a mistake -- we all will."
* Ask the participant to tell the child's classifications again. If your assessment of any sign was different from his initial assessment, allow him a chance to decide how the classification should change.
* Summarize the case so that participants understand the correct assessment of the child's signs and classifications. Thank the participant and praise him for any new or difficult tasks that he did correctly. Then move the group to the next case and review the case in the same way.
7. If in the early morning additional children were identified with signs that are infrequently seen (grunting, stridor, severe pallor, etc.), demonstrate these signs to participants at the end of the session. This will ensure that participants will get to see infrequently seen signs, whenever the opportunity arises.
For certain signs such as chest indrawing and palmar pallor, it is important to show children with and without the sign. Putting several children's hands together who have no, some and severe palmar pallor can be very helpful. It is important that participants avoid overcalling signs in normal children. Therefore, include children with noisy breathing from blocked nose, no palmar pallor, etc. Participants need to become confident in saying a sign is not there, not just in recognizing the abnormal signs.
8. At the end of the clinical session, summarize the important signs and tasks covered in the session and refer to common problems that participants encountered (for example, missing chest indrawing, or errors of classification). Ask participants to keep their Recording Forms so that they can refer to them to complete their Group Checklist of Clinical Signs.
Summarize for the participants the important signs and classifications that they saw in the session. Reinforce them for new and difficult steps that they did correctly, and give them suggestions and encouragement to help them improve.
9. After the session, record on the Checklist for Monitoring Inpatient Sessions the cases seen by the participants.
10. During the course, participate in the meeting of facilitators at the end of each day. Report to the facilitators and the Course Director on the performance of each group at the inpatient session that day. Discuss whether participants are seeing all the clinical signs and classifications. Determine if there are children with certain signs that you should try to locate and include in the next day's cases.
7. Specific Instructions for Each Day's Inpatient Session
Following the summary table for some days, there are additional notes about preparing for or conducting that particular session.
After studying this guide and after a day or two of teaching inpatient
sessions, you will know how to conduct the session each day as described
in the previous section, "General Procedures: Conducting the Inpatient
Session." Then you may need only to refer to the appropriate summary for
DAY 2: INPATIENT
General Danger Signs - Cough or Difficult Breathing
|To Prepare||Review the "General Procedures: How to Prepare
Each Morning" and "Conducting the Inpatient Session."
Choose children with general danger signs and/or cough or difficult breathing. Include a child with stridor if possible.
Identify any children with infrequently seen signs.
- Assess and classify cough or difficult breathing.
- Obtain additional practice assessing chest indrawing.
- Record findings on the Recording Form; use the chart to choose classifications; record them.
2. Demonstrate the assessment of a child with cough or difficult breathing (assess general danger signs and cough). Show how to use the information on the child's history which is already written on the Recording Form.
3. Demonstrate a child with no chest indrawing. Then demonstrate a child with chest indrawing.
4. Assign participants to patients. Observe and assist as needed while participants assess and classify.
5. Conduct rounds. Have all participants assess any child with cough or difficult breathing for chest indrawing, and any child with noisy breathing for stridor.
6. Show any children with infrequently seen signs.
|At the end of the session||Summarize the session with participants.
Complete the Monitoring Checklist.
Explanation of how inpatient sessions will work:
Explain that the purpose of seeing patients in the inpatient ward is to give participants several opportunities to see and practice assessing as many patients as possible. In addition, children in the inpatient ward are more likely to have severe signs than the children who come to outpatient clinics. Seeing inpatients will give participants more experience with children with severe signs and classifications.
The inpatient setting is not like the clinic setting where participants usually work. The children in the inpatient ward have already been assessed by staff and are receiving treatment. However, so you (each participant) can get practice, when you are assigned a case, assess and classify that child as if it is an initial visit. Write the findings on a clean copy of the Recording Form. Use the information about the child's history which is recorded on the Recording Form at the foot of the child's bed. Look, listen and feel to assess the child's signs. Classify the child and record the classification on the form.
When everyone has finished their cases, there will be rounds, so that all of you can see all the cases. The group will review the assessment findings and classifications. This is different from clinical rounds you may have experienced. No one will lecture. You need only to present briefly, just as you do to your outpatient facilitator. You should not feel shy. We are all learning.
Your interaction with the mother of your assigned case here will be different than with a mother who comes into your clinic. You may not be asking this mother questions about her child and will not discuss treatment as you would with a mother in your clinic. Remember that when you are managing sick children in your clinic, your communication with the mother is very important. You should practice all your communication skills when you care for children in the outpatient session each day. Of course, you may speak to a mother here, and if you do, you should be kind to her and listen carefully to her answers.
If a child suddenly becomes much sicker, please be sure to alert the ward staff.
Special instructions for teaching chest indrawing:
Do not encourage participants to call chest indrawing when only very subtle indrawing is observed. Teach them that "When in doubt -- it is not there." Chest indrawing should be definite to be called chest indrawing.
If possible, show a child who has chest indrawing when breastfeeding
or because his nose is blocked. Demonstrate that when he finishes feeding
or his nose is clear, chest indrawing goes away.
DAY 3: INPATIENT SESSION>