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Report on the meeting for

Improving Hospital care for children in Fiji and the Pacific

Including the 4-day Trainers’ Course in the use of: The Pocketbook of Hospital Care for Children November 15-19th 2010, Colonial War Memorial Hospital, Suva Background to the Workshop Fiji Islands has moderate child (23.2 per 1000 live births in 2009) and infant mortality rates (15.2 per 1000 live births), and many persisting health system challenges. As part of the Millennium Development Goals the Fiji Ministry of Health has pledged to take steps to reduce child mortality by 2/3rd of what it was in 1990, by 2015 (9.3 and 5.6 per 1000 live births respectively). However, infant and neonatal mortality rates remain unacceptably high, and there continue to be avoidable deaths. A review of the Child Health Service in 2010 recommended improvements in several areas. 1 Recommendations 4 and 7 from this review identified the need to improve the quality of care for sick children and newborns at primary care and sub-divisional (district) hospital. The review specifically recommended the introduction and implementation of the World Health Organization ‘Pocketbook of Hospital Care for Children’ 2 as Standard Treatment guidelines nationally. In Fiji this had been planned and anticipated for over 3 years. The Pocketbook contains best-practice clinical guidelines that are based on reviews of the published literature, covering all childhood conditions commonly seen in district and provincial level hospitals. These include serious infections (such as pneumonia, and diarrhoea), malnutrition, neonatal conditions, trauma, other complex emergencies, surgical conditions, burns and poisoning. These guidelines are an extension of the Integrated Management of Childhood Illness (IMCI) to the first-referral hospital, providing a consistent approach across all levels of the health care system. The Pocketbook is aimed at nurses, non-specialized doctors, paramedical workers, medical students and child health specialists in training.

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This Pocketbook and training materials have been introduced in many countries to standardize and improve quality of paediatric care, including Solomon Islands and Papua New Guinea, China, Indonesia, Central Asia, South Africa and elsewhere. There is widespread acceptance these are the best standard treatment guidelines for paediatric hospital care currently available. The WHO Pocketbook of Hospital Care for Children as standard paediatric treatment guidelines in Fiji The Paediatric Clinical Services Network within the Fiji Ministry of Health believed that implementation of the Pocketbook as Standard Treatment in Fiji would improve the care of sick children in hospitals and lead to care that is more efficient, safe and accessible by all Fijian children, and lead to reduced child death rates. The Paediatric Clinical Services Network has therefore endorsed the WHO Pocketbook of Hospital Care for Children as standard paediatric treatment guidelines in Fiji. Health system issues in Fiji There are 3 divisional hospitals in Fiji (the Colonial War Memorial Hospital in Suva, Lautoka Hospital and Labasa Hospital) – all of these hospitals have a substantial number of beds for children. There are subdivisional hospitals that have smaller paediatric wards and there are also some rural health centres that have a small number of paediatric holding beds. The Pocketbook is aimed at doctors and nurses that care for sick children in these health facilities, but is also appropriate for use in referral hospitals, and has been endorsed by senior staff at Colonial War Memorial Hospital and Lautoka Hospitals as standard treatment in tertiary settings also. One of the key issues raised in the Fiji Ministry of Health Clinical Services Planning Framework, 2005, was the excessive flow of basic paediatric cases from clinics and subdivisional hospitals to specialist paediatric units in divisional hospitals, despite IMCI initiatives designed to strengthen primary level child health care. The main reason identified for this diversion of cases was inadequately equipped facilities and untrained staff outside the divisional hospitals, leading to loss of a well demarcated child health service structure with clear referral roles. One of the aims of the adoption of the Pocketbook as the national standard of paediatric care is to strengthen secondary level paediatric capability in the subdivisional hospitals and better guide the need for referral to divisional hospitals. The Pocket Book has been part of the medical curriculum for undergraduate medical training in Paediatrics at the Fiji School of Medicine since 2005. Its adoption as National Standard Treatment will ensure that this undergraduate training maintains its relevance in the field. Wider significance in the Pacific There has been widespread interest in countries throughout the Pacific in the adoption of the Pocketbook of Hospital Care for Children. There was a national implementation workshop in the Solomon Islands in 2004, and by 2010 over 200 nurses in all of 9 provinces have been trained. This training has been lead by Dr Titus Nasi, Paediatrician with the Ministry of Health at the National Referral Hospital in Honiara. Because of the widespread interest shown in this initiative by other countries,

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representatives from several Pacific Island nations attended the Suva workshop: paediatricians from the Ministries of Health of Tonga, Samoa, Vanuatu and Kiribati. Representatives from Papua New Guinea, Niue and Tuvalu also accepted invitations, but by the time funding was approved there was insufficient time to arrange travel, so they were unable to attend. The Workshop A 4-day workshop was held at the Colonial War Memorial Hospital in Suva, between November 15 and 19th 2010. The participants included 20 doctors and nurses from each division and sub-division of Fiji, plus staff from the nursing college that trains undergraduate nurses and nurse practitioners. Paediatricians from Samoa, Tonga, Kiribati, Vanuatu, and Solomon Islands also participated. The participant list is in Appendix 1. The facilitators were Dr Joseph Kado, Dr Rigamoto Taito (Ministry of Health, Fiji), Dr Titus Nasi (Solomon Islands), Prof Trevor Duke and Dr Andrew Steer (Centre for International Child Health, Melbourne). The course was held over 4 days and combined interactive case-based lectures along with bed-side clinical teaching (see program outlined in Appendix 2). The afternoon of the 4th day of the course was devoted to discussion among the participants around the challenges and barriers to national and local implementation of the Pocketbook in Fiji, and similar discussions for the regional participants were held on the 5th day (see below). The workshop opened with Dr Joseph Kado describing the situation of child health in Fiji. Dr Kado noted that in the recent decade there has been a stalling in progress of infant and child mortality (Figure 1). He also highlighted some of the obstacles to improving child mortality rates and improving quality of care. Dr Titus Nasi and Prof Trevor Duke then described how the Pocketbook had been used in many other countries to provide standards for clinical care, equipment, competencies of nurses and doctors, and in conjunction with the Essential Medicine List for children, provide standards for drugs. The entire course is contained in a DVD, which contains power-point presentations, case notes, videos and clinical photographs. This DVD was first created in 2003-5 for Pacific countries, specifically Solomon Islands and PNG, and has since been modified and translated by WHO and used in countries in Asia. The course facilitators made further adaptations to all the teaching material to make it appropriate to the Fiji context. The course trains health workers in how to use the Pocketbook in everyday clinical practice; it does not aim to teach every fact that is contained within the book. The method is case-based teaching, where the participants use the book to solve clinical problems. The DVD contains a series of clinical cases; these are listed in Appendix 3. These are augmented by several sessions on the children’s wards where cases are seen and the Pocketbook is used to plan their management. These cases raise clinical, organisational, resource and social issues that are commonly faced in everyday clinical practice. The course is participatory and interactive and allows time for deeper discussions of the complex issues that affect the health of children. The course emphasises the processes of care or stages of management, that making a diagnosis and giving treatment are not all that are required for quality services. For quality paediatric care,

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it is essential to have a system of triage, where the sickest children are seen first. Staff need to be skilled in basic emergency treatment, including giving oxygen, fluid resuscitation of children in shock, management of children with convulsions or coma. They need to understand Emergency signs, and know how to recognise them. Nurses and non-specialist doctors in remote hospitals need to understand how to take a history and do an examination, how to make a differential diagnosis, and how to safely give medications. In all assessments of quality of care the lack of supportive care and monitoring are deficient, and the course focuses on this. Supportive care includes: giving oxygen, safe use of intravenous fluids, blood transfusion, nutrition, micronutrients, fever control, treatment of hypoglycaemia and convulsions, prevention of nosocomial infections and apnoea in neonates. Finally, planning discharge is important, not just on the day of discharge, but from early in any admission, to ensure the family understands what is required when the child goes home, how to give treatment, what signs to look for, and when to return. Virtually all hospitalised children need some follow up: whether it is to continue treatment of a chronic illness (such as tuberculosis, HIV, asthma, epilepsy), to determine that all manifestations of the acute illness have resolved (such as pneumonia), to manage physical complications (for example after meningitis), to monitor for growth and development which may have been interrupted by the illness (such as prematurity), or to give the next vaccines that are due. Such follow-up does not need to be at a hospital as some of these tasks can be done a health centre or by an MCH nurse, but all follow-up must be organised by staff in the hospital prior to discharge, and the family and the local health clinic must be aware of the nature and reasons for follow-up. This requires organisation that is often not considered a part of clinical care, but in a district hospital these are skills and knowledge that are necessary for nurses and doctors to have if children are to receive holistic care for optimising outcomes. The participants enthusiastically engaged in all the course sessions, discussing each of these things, and using the Pocketbook to put these principles into practice. Day 4 (afternoon) and Day 5. Discussion of other critical issues in the care of sick children in Fiji and Pacific Island countries Discussions on the 4th and 5th days of the workshop were on the key issues in improving the quality of care for sick children in Fiji,and other Pacific countries. Several priorities were identified. 1. Commitment to the Pocketbook at a variety of levels: Participants recognised that the Paediatric Clinical Services Network had endorsed the Pocketbook as the national standard treatment guidelines. It was felt that strong support from the Fiji MOH, Fiji School of Medicine and Fiji nursing schools was also necessary for successful implementation. For the regional participants, many felt that the Pocketbook would be also be appropriate as national guidelines in their countries. 2. Support for further training courses Participants generally felt that they would now be able to train other health care workers in the use of the book. Many advocated a “piecemeal” approach – that is, breaking the course into half or full day modules rather than teaching the whole course in one 4 day setting. However, it was identified that a central coordinator for a rollout program would be helpful, both at the national level and potentially across the region.

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This coordinator would be helpful with resources, organisation and monitoring of the program. 3. Consideration of other important conditions not included in the book Participants felt that there were a number of commo/important childhood conditions seen in Fiji that are not included in the pocketbook. These included: rheumatic fever, skin infections, drowning, post-streptococcal glomerulonephritis, fish poisoning (ciguatera), child abuse, and delayed developmental milestones. Many participants felt that a “Pacific” version of the book, which included these conditions would be useful, although not an essential pre-requisite for roll-out, as the current version is sufficient. However a Pacific version of the Pocketbook would be something to work towards if other countries were involved. Many felt that separate guidelines for these conditions would be helpful. 4. Equipment and medicines It will only be possible to fully implement the Pocketbook if basic equipment and essential medicines are reliably available. A detailed description of equipment required to implement the Pocketbook is in Appendix 4. It was clear from discussions that some of these commodities are not present in many hospitals, in Fiji and throughout the Pacific. Participants also identified that posters with enlarged versions of the neonatal and ETAT algorithms would be helpful – electronic versions ready for printing have been supplied to the Fiji Paediatric Clinical Services Network (Appendix 6). It is recommended that sufficient numbers of these be printed for all divisional and sub-divisional hospitals. 5. Oxygen supplies Oxygen supplies to sub-divisional hospitals is a particular challenge. Oxygen in cylinders is bought from BOC at high cost, and transport costs and logistics preclude reliable supplies. A program of improving oxygen systems using concentrators and pulse oximeters could be developed, as all provinces have reliable power supplies, via mains power with generator back-up on main-land provinces, or large generators which run all government facilities including hospitals in outlying maritime provinces. This would require scoping, and in the context of other essential equipment in hospitals. Would need engineering capacity in oxygen concentrator maintenance and repair. It would not be difficult to have 1-2 people trained in this, but better done at a national level so service can be provided to all regions. In many countries Governments have contracts with BOC and there is a monopoly. Introducing concentrators is resisted by the gas companies; if there is only a partial adoption of concentrators, cylinder prices can be adjusted easily to keep the costs much the same. For scaling up, need a MoH plan for oxygen, requires maintenance capacity and a coordinated system for maintenance, uniformity of procurement, not buying cheap equipment (false economy and equipment costs are only about 10-20% of long term costs, even if the best quality concentrators are bought), programs of training, supervision and monitoring. Pulse oximeters are rarely available in children’s wards of sub-divisional hospitals and staff have no training in their use, despite pneumonia being the most important cause of hospitalisation and mortality among children. 6. Human resources for child health Participants identified that as well as training existing health workers in the use of the Pocketbook, it may be necessary to train nurses specifically as child health nurses, as

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has been done for midwives, nurse practitioners and public health nurses. Dr Nasi shared his experience in Solomon Islands with the development of a child health nurse training program. Such a program of child health nurses could include training in the Pocketbook of Hospital Care for Children, Neonatal care, IMCI, Expanded Program on Immunization, Infant and Young Child Feeding, Adolescent Health, Child protection and child welfare. 7. Neonatal care. National standards in terms of what can be done at health centres and hospitals at different levels. Criteria for referral of newborns from health centres or the community to hospitals were proposed and discussed, based on a framework developed in the Solomon Islands. This is included in Appendix 5. Where to from here? National plans In 2011 training courses are planned for each of the four Divisions. The courses will be conducted by the trainers who completed the current workshop, with some central support from Master Trainers. As training will be done at a Divisional level, there are now 3-4 trainers in each Division, so this is sufficient capacity to go the next step. As noted by the participants there is a need for a national resource person to oversee the expansion. Incorporation of the training into medical (Fiji School of Medicine) and nursing student (Fiji School of Nursing and Sangaam Nursing School) training will ensure the sustainability of the initiative and the widespread understanding of national clinical standardised care. About 500 Pocketbooks will need to be provided annually to supply all medical students, nurse practitioner students, other health workers and to be readily available in the hospitals. Addressing critical factors in implementation are necessary. This will require a programmatic approach, including 1) survey of currently available facilities to understand the specific deficiencies in each hospital (list of items in Appendix 4), and 2) funding to up-grade facilities with appropriate equipment and commodities in each hospital, based on deficiencies found. Regional Plans Each of the regional participants expressed their plans to implement the Pocketbook of Hospital Care for Children in their country. It was also identified during discussions with the regional facilitators and participants that a central coordinating body could assist with the organisation of further training courses in Pacific Island countries, but at the same time individual paediatricians could begin training in their own countries after appropriate discussion with their Ministries of Health, perhaps with the assistance of WHO country liaison officers. Evaluation

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It is recommended that evaluation be planned prospectively to measure program and impact on child health. At the very least, process indicators: including the number of health care workers trained, professional and geographical coverage of training and progress towards incorporation into nursing and medical training institutions should be documented. Collection of data relating to quality of care including assessment of changes in case fatality rates for specific sentinel diseases such as neonatal ARI and diarrhoea admissions, and referral patterns are also recommended. Acknowledgements We gratefully acknowledge the supporters of this meeting: the Fiji Ministry of Health, the Fiji Health Sector Improvement Program, AusAID, and the World Health Organization. We particularly thank Claire Whelan of JTA International and the FHSIP, and Chandra Dayal of the Ministry of Health for organising this workshop. Meeting report prepared by: Prof Trevor Duke Dr Joseph Kado Dr Andrew Steer Dr Titus Nasi Dr Rigamoto Taito

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1 Figure 1. Child mortality statistics in Fiji 2000 – 2009

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Figure 2. The participants in the 4-day trainers course in the introduction of the Pocketbook of Hospital Care for Children

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Figure 3. Doctors and nurses from Fiji’s subdivisional hospitals use the Pocketbook of Hospital Care for Children to assess a sick child

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Figure 4. The participants in the 4-day trainers course learning to use the Pocketbook of Hospital Care for Children

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Figure 5. Dr Lisiate, Paediatrician from Tonga’s Ministry of Health, discusses the care of a sick child using the Pocketbook of Hospital Care for Children

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Appendix 1. Participant list Participants Fiji participants: Central Division

- Dr Sereana Wood, Medical Officer, Raiwaqa Health Centre - Dr Susana Nakalevu, Subdivisional Medical Officer, Rewa Subdivision - Rosalia Bolabiu, Sister, Navua Subdivisional Hospital

Northern Division - Aliti Boginivalu, Staff Nurse, Nabouwalu Subdivisional Hospital - Sainimili Lomani, Staff Nurse, Taveuni Subdivisional Hospital - Dr Ana Maisema, Medical Officer, Savusavu Subdivisional Hospital - Dr Farem Nisha, Medical Officer, Nabouwalu Subdivisional Hospital

Eastern Division - Dr Frances Vulivuli, Subdivisional Medical Officer, Lomaloma Subdivision - Dr Antoinette David, Medical Officer, Levuka Subdivisional Hospital - Alanieta Ragogo, Nurse Practitioner, Kadavu Subdivisional Hospital - Talaite Onolevu, Sister, Lakeba Subdivisional Hospital

Western Division - Dr Ryan Shankar, Medical Officer, Nadi Subdivisional Hospital - Dr Torika Tamani, Subdivisional Medical Officer, Ba Subdivsion - Dr Eminoni Dakua, Medical Officer, Nadroga Subdivisional Hospital

Nursing Schools - Filomena Dokoni, Tutor Sister, Fiji School of Nursing - Haemarie Taito, Head of School, Sangam Nursing School

Regional participants:

- Dr Litara Esera, Paediatric Medical Officer, National Hospital, Samoa - Dr Lisiate ‘Ulufonua, Paediatric Medical Officer, Tonga - Dr Rosemary Taun, Paediatric Medical Officer, Vanuatu - Dr Turia Tekaai, Paediatric Medical Officer, Kiribati

Facilitators:

- Dr Joseph Kado, Paediatrician, Fiji Ministry of Health, Fiji (Director) - Dr Rigamoto Taito, Paediatrician, Fiji Ministry of Health, Fiji - Dr Titus Nasi, Paediatrician, Solomon Islands Ministry of Health, Solomon

Islands - Professor Trevor Duke, Paediatrician and Director, Centre for International

Child Health University of Melbourne, Australia - Dr Andrew Steer, Paediatrician, Centre for International Child Health University

of Melbourne, Australia - Dr Kate Milner, Paediatrician, Centre for International Child Health University of

Melbourne, Australia

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Appendix 2. Training course program Day 1 – Monday November 15th 2010 Time Activity Presenter

0830-0900 Opening, Welcome Introduction to the aims and objectives of the workshop

Joseph Kado / Trevor Duke

09.00 - 09.45 Assessments of hospital care for children in the region / country: Presentation of deficiencies & strength in the child health service

Joseph Kado

09.45 -10.00 Tea break

10.00 – 11.00 Introduction to the WHO guidelines: Referral Care IMCI Guidelines and Pocketbook of Hospital Care for Children

Titus Nasi / Trevor Duke

1100-1200 Cough and difficult breathing, clinical case Trevor Duke

1200 – 1300 Lunch break

1300- 1400 Oxygen videos and respiratory case video Titus Nasi

1400 – 1500 Diarrhea, clinical case Titus Nasi

1500 - 1515 Tea break

1515-1615 Fever, clinical case Rigamoto Taito

1615-1645 Recap, discussion and questions

Day 2 – Tuesday November 16th 0900 – 1000 Severe malnutrition, clinical case Titus Nasi

1000 – 1100 The child with joint pains, clinical case Andrew Steer

1115 – 1130 Tea break

1130 – 1230 HIV, clinical case Trevor Duke

1230- 1330 Lunch break

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1330 – 1400 Video of signs of Emergency and Priority Signs Joseph Kado

1400 – 1415 Tea break

1415-1615 Clinical practice using the WHO guidelines in Children’s Wards

All facilitators

1615-1645 Recap, discussion and questions

Day 3 – Wednesday November 17th 0830 – 0915 Young infants with infections, clinical case Andrew

Steer

0915 – 1030 The low birth weight baby, clinical case Kate Milner

1030 - 1115 Birth asphyxia, clinical case Titus Nasi

1115 - 1130 Tea break

1130 - 1230 Neonatal resuscitation All facilitators

1230 – 1300 Lunch break

1300 – 1400 Clinical signs of serious neonatal illnesses Trevor Duke

1400 – 1430 Referral criteria for neonatal illness Joseph Kado

1430 – 1500 Tea break

1500 – 1700 Clinical practice using the WHO guidelines in Neonatal Ward

All facilitators

1700 – 1730 Recap, discussion and questions Day 4 – Thursday November 18th 0900-1000 Trauma and burns, clinical cases Rigamoto

Taito

1000-1015 Tea break

1015-1230 Clinical practice using the WHO guidelines in Children’s and Neonatal Wards

All facilitators

1230- 1330 Lunch break

1330 – 1430 Group discussions (5 breakout groups*)

1430 – 1530 Reporting from 5 small group discussions (15 mins Joseph

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each) Kado / Andrew Steer

1530 – 1545 Tea break

1545 – 1700 Summary and suggested ways forward Closing ceremony

Joseph Kado

Day 5 – Friday November 19th 0900-1000 Reporting from regional participants (Tonga, Samoa,

Kiribati, Vanuatu) Joseph Kado

1000-1015 Tea break

1015-1230 Discussion of ways forward for implementation of the Pocketbook in the region

All facilitators

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Appendix 3. Clinical cases covered in detail in the Pocketbook DVD

1. An 11 month old boy with severe pneumonia, severe iron deficiency anaemia of dietary origin and heart failure

2. A pre-term neonate weighing 1.4kg who develops common complication of prematurity

3. A term newborn who develops sepsis related to poor umbilical cord hygiene 4. A term newborn with birth asphyxia who requires moderate resuscitation at birth 5. A 2 year old boy with severe dehydration due to diarrhoea and vomiting 6. A 6 month old boy with a urinary tract infection 7. A 12 month old girl from a large family and poor social circumstances who has

severe malnutrition 8. An 8 month old boy and his 2 year old sister who are HIV-exposed 9. A 10 month old girl with moderate burns 10. An 8 year old boy with multi-trauma after a motorcycle accident.

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Appendix 4 Equipment and consumable requirements to fully implement the guidelines in the Pocketbook of Hospital Care for Children

Equipment and disposables required by Children’s Ward and Neonatal Unit

Availability

Reliable oxygen source: either

Ready access to cylinders with no major times when oxygen not available, or

Well functioning oxygen concentrators with reliable power supply to hospital

Oxygen delivery equipment: sufficient supply of nasal prongs

IV fluids

0.45% NaCl

0,9% NaCl or Ringers lactate / Hartmann solution

10% dextrose for correction of hypoglycaemia

Nebulizer

Spacer device

Weighing scales

Stadiometer (height measuring board)

Monitoring charts

Blood giving sets

Nasogastric tubes

Intravenous fluid giving sets

Intravenous fluid burettes

Short linking tubing (cannula to iv line)

‘3 way’ taps

Cannulas sizes 25, 22, 21, 20, 18G

Needles sizes 25, 21, 16G

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Syringes sizes 1, 2, 5, 10, 20, 50cc

Lancets for taking heel prick samples

Arm or foot boards (home made or ready to use) for strapping cannulas

Thermometers

Stethoscopes

Glucometer

Glucose strips

Urine dipsticks

Urine containers

Lumbar puncture needles

Chest tubes (sizes check), drainage bottles, connecting tubing

Light which can be used for illuminating pneumothorax

Nasogastric tubes sizes 6, 8, 10, 12F

Autoclave or steam steriliser

Sharps disposal boxes

Portable procedure trolley

Clean gowns for staff for procedures

Sterile drapes for procedures

Sterile gloves

Face masks

Sterile minor procedure kits or equivalent contents

Waste disposal containers (for non-infectious and infectious waste)

Contaminated laundry receptacle

Cleaning items (broom, mop, buckets, brushes)

Plain X-ray facilities

Kitchen able to make up nutritious formula for malnourished children:

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F-75

F-100

NEONATAL EQUIPMENT

Neonatal resuscitation equipment

Ambu-bag (self inflating bag) of appropriate size for neonate and older child

Appropriate size masks for LBW infant, term infant, older child

Suction machine and suction catheters

Apnoea monitors

Incubators

Radiant / overhead warmers

Resuscitation table with overhead warmer

Phototherapy system

Spare lamps or bulbs for phototherapy units

Portable suction machines – electric or mechanical

Suction catheters size 6, 8, 10, 12, 14F

Self inflating resuscitation bags (250-400mls)

Round face masks for self-inflating resuscitation bags - size 0 and 1 (term and preterm)

Portable ‘resuscitation trolley

Spare laryngoscope bulbs and batteries

Endotracheal tubes sizes 2.5, 3.0, 3.5, 4.0

Wire or plastic introducers for ETT

Magill’s forceps

Infusion pumps

Syringe drivers (50ml, 20ml, 10ml)

Umbilical catheters

Breast pumps (manual / electric)

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Cups for feeding babies who cannot suck well

Milk freezer and / or fridge

Containers for collecting and storing expressed milk

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Appendix 5 Referral criteria for newborns and older children

Indications for referring newborns to hospital

• Birth-weight between 1-1.5 kg • Birth-weight between 1.5–2.0 kg if:

Respiratory distress or apnoea Signs of sepsis

• Birth asphyxia • Severe respiratory distress • Severe infection

Sepsis Meningitis Osteomyelitis / septic arthritis

• Any infection that does not improve after 48 hours of appropriate treatment • Severe abdominal distension • Signs of shock (>3 seconds for capillary refill, weak pulse, cold hands) • Congenital abnormalities:

Suspected congenital heart Open abdominal lesions Ambiguous genitalia Imperforate anus Bile (green) stained vomiting Frequent vomiting and lots of saliva in the first few hours of life Pain and swelling of the testes or the inguinal area

• Recurrent apnoeas (>3 periods of no breathing for longer than 20 seconds per day) • Coma and / or convulsions • Uncontrolled bleeding despite Vitamin K injection • Pallor • Severe jaundice or jaundice that lasts longer than 2 weeks • Unexplained poor weight gain for more than 2 weeks after birth

Prior to transfer call closest divisional or sub-divisional hospital

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Indications for referring children > 1 month old to hospital

• Emergency (danger) or priority signs that do not improve after 48 hours of appropriate treatment.

o Severe respiratory distress o Obstructed breathing o Convulsions o Impaired consciousness / coma o Difficulty feeding o Central cyanosis o Persistent vomiting o Pallor o Severe swelling of the feet or puffy eyes

• Signs of shock (>3 seconds for capillary refill, weak pulse, cold hands) • Meningitis • Unexplained fever for > 2 weeks of appropriate and adequate treatment • Unexplained weight-loss AND <60% weight for age AND not improving on treatment • Tender and distended abdomen that does not improve after 48 hours of appropriate treatment • Dysentery • Diarrhoea for longer than 2 weeks that does not improve with appropriate treatment • Persistent bone/joint pain or swelling • Surgical problems:

o Intussusception (severe abdominal pain with bloody stool) o Severe burns o Appendicitis (sick child with severe right lower abdominal pain. May begin in the middle of the

abdomen) o Severe injuries

• Unexplained recurrent infections • Uncontrolled bleeding • Passing urine alot • Sudden or progressive onset of paralysis • Severe or unresolving jaundice • Non-febrile convulsions that do not improve with anti-convulsants • Hydrocephalus (abnormal increase in head circumference) • Whiteness of the pupils of the eye(s) • Sudden onset or progressive impairment of vision • Poisoning • Snake bites

Prior to transfer call closest divisional or sub-divisional hospital

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Appendix 6 Posters on Neonatal Resuscitation and Triage of all sick children

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Reference List

(1) Russell F. Child Healthcare Review. 1-72. 2010. Suva, Fiji, Fiji Health Sector Improvement Program.

Ref Type: Report

(2) World Health Organization. Hospital Care for Children: guidelines for the management of common illnesses with limited resources. Geneva: WHO, ISBN 92 4 154670 0 http//www.who.int/child-adolescent-health/publications/CHILD_HEALTH/PB.htm and www.ichrc.org; 2005.