CLINICAL PATHWAYS

Clinical Governance Section

Division of Healthcare Management and Occupational Safety and Health (DHMOSH)
Department of Operational Support (DOS)

Wednesday, 23 October 2019

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 CLINICAL GUIDELINE

• Recommendations to assist clinicians in making decisions for the care

of patients in specific clinical circumstances.
• Reflective of current best practice
• Systematically developed through:
– A review of evidence
– An assessment of the benefits and harms of alternative care options
• Ultimately designed to optimize patient care and outcome.1,2, 3

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 CLINICAL PATHWAY

• Translates clinical guidelines into a standardized and structured process

• Details each step involved in the care of the patient, with strict timeframes for
each step and strict criteria for progression to the next step
• Tasks in the pathway are designated to specific professionals/teams
• Adapted to suit local conditions
• Aims to organize and standardize care, in order to improve quality of care and
outcomes for patients
• Clinical pathways may also be referred to as care maps, care pathways,
integrated care pathways and protocols.4,5

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 ADVANTAGES OF A CLINICAL PATHWAY

• Reduces variation in clinical practice

• Ensures care is timely
• Improves efficiency and cost-effectiveness of care
• Enhances interdisciplinary teamwork and collaboration (as all staff
refer to the same pathway), therefore achieving continuity of care for
the patient
• Allows management and assessment of the quality of healthcare
provided.4,5,6,7

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 REFERENCES

➢https://www.aafp.org/patient-care/clinical-recommendations/cpg-manual.html
➢https://www.uptodate.com/contents/overview-of-clinical-practice-guidelines#H1

➢https://nccih.nih.gov/health/providers/clinicalpractice.htm
➢https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2893088/
➢https://pdfs.semanticscholar.org/f88b/10b74fc8538ec1ffea5872a39f44ff57129d.pdf

➢http://www.openclinical.org/clinicalpathways.html
➢https://www.ajmc.com/journals/issue/2016/2016-vol22-n1/care-pathways-in-us-healthcare-
settings-current-successes-and-limitations-and-future-challenges

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 MALARIA CLINICAL
PATHWAY FOR UN CLINICS

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TRIAGE, CLINICAL HISTORY AND EXAMINATION

❖ Urgently assess all febrile/ill patients who travelled to a malaria area in the past 6
months
❖ Take and record a medical history:
• Symptoms (non-specific): Fever or recent history of fever, chills, headaches,
muscle pains, fatigue, nausea and vomiting
PERSON RESPONSIBLE:
• Travel history
• Prophylaxis history
❖ Conduct an examination:
• Vital signs: Axillary temperature >37.5°C
• Diaphoresis
• Severe malaria: Impaired consciousness, prostration, multiple convulsions,
severe anaemia, acute respiratory distress, shock, jaundice, abnormal bleeding

IMMEDIATE (IF THERE IS

CLINICAL SUSPICION OF
MALARIA)

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INVESTIGATIONS

❖ Send to laboratory for specific malaria investigations:

• Microscopy examination of thick and thin films OR
• Rapid diagnostic test
❖ Request other laboratory investigations:
• Bloods: Complete blood count (CBC), urea, electrolytes & creatinine PERSON RESPONSIBLE:

(UEC), liver function tests (LFT), hemoglobin, lactate, glucose, blood

cultures of typhoid or other bacteria)
• Urine: haemoglobinuria

WITHIN 1 HOUR

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REPORTING OF RESULTS
PERSON RESPONSIBLE:
❖ Inform the health professional responsible for patient’s care of the
investigation results

IMMEDIATE

CATEGORIZATION OF PATIENTS
❖ Dependent on the results of the malaria-specific investigations, categorize
patients into one of three categories (as below) PERSON RESPONSIBLE:

❖ If you clinically suspect malaria, and the lab result of the malaria test is
not available within 2 hours, treatment of malaria should be started
presumptively and reviewed later based on test results

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NON-FALCIPARUM MALARIA
❖ Classified as non-falciparum malaria if malaria
test shows absence of P. falciparum and
presence of other malaria parasites (P. vivax, P.
ovale, P. malariae or P. knowlesi)
FALCIPARUM MALARIA
❖ Classified as falciparum malaria if blood
film shows P. falciparum, species

UNCOMPLICATED SEVERE UNCOMPLICATED

❖ No features of ❖ One or more of the following features may involve ❖ No features of
severe impaired consciousness, prostration, multiple convulsions, severe
malaria respiratory distress, shock, severe anaemia, abnormal malaria
bleeding, jaundice, hypoglycaemia, acute renal injury,
acidosis haemoglobinuria, hyperlactataemia and/or
hyperparasitaemia
❖ If the patient has signs and symptoms of severe malaria,
treatment should be initiated immediately regardless of
laboratory test results.

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MANAGEMENT: SEVERE MALARIA
Administer immediately the following treatment:
1. Artesunate IV/IM at 0hrs, 12hrs and 24hrs and once a day afterwards until the patient
can tolerate oral therapy (dose: ≥20kg: 2.4mg/kg bw per dose; <20kg: 3mg/kg bw per
dose) FOLLOWED BY
2. ACT for 3 days (as for uncomplicated malaria)
• Note: If injectable artesunate is not available, use artemether IM in preference to
quinine for treating severe malaria.
PERSON
Other considerations: RESPONSIBLE:

❖ Seek early expert advice from tropical disease/infectious disease unit physician
❖ Consider ICU admission
❖ Consider oxygen therapy, if required
❖ Monitoring:
• Fluid balance
• Blood glucose
• 4-hourly obs until stable
• Repeat CBC if severe anaemia, clotting if abnormal bleeding, urea if renal
failure and electrolyte if acidosis, parasite count daily.

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MANAGEMENT: UNCOMPLICATED FALCIPARUM
MALARIA
Administer immediately the following treatment:
❖ Artemisinin-based combination therapies:
• Artemether + lumenfantrine (dose (mg) given twice daily for 3 days: adult
(≥35kg): 80 + 480; 5–<15kg: 20 + 120; 15–<25kg: 40 + 240, 25–<35kg: 60 +
360) OR
• Artesunate + amodiaquine (dose (mg) given once daily for 3 days: adult
PERSON
(≥36kg): 200 + 540; 4.5–<9kg: 25 + 67.5; 9–<18kg: 50 + 135; 18–<36kg: 100 + RESPONSIBLE:

270) OR
• Artesunate + mefloquine (dose (mg) given once daily for 3 days: adult (≥30kg):
200 + 440; 5–<9kg: 25 + 55; 9–<18kg: 50 + 110; 18–<30kg: 100 + 220) OR
• Dihydroartemisinin + piperaquine (dose (mg) given once daily for 3 days: 5–
<8kg: 20 + 160mg; 8–<11kg: 30 + 240; 11–<17kg: 40 + 320; 17–<25kg: 60 +
480; 25–<36kg: 80 + 640; 36–<60kg: 120 + 960; 60–<80kg: 160 + 1280; ≥80kg:
200 + 1600)
• Note: The choice of ACT is based on the parasite resistance profile in the place
of exposure to malaria.

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MANAGEMENT: UNCOMPLICATED NON-FALCIPARUM
MALARIA
Administer immediately the following treatment:
❖ Artemisinin-based combination therapies (same as for the management of
uncomplicated falciparum malaria) OR
❖ Chloroquine (dose: initial dose of 10mg/kg bw, followed by 10mg/kg bw on the second
day and 5mg/kg bw on the third day)
• Note: In areas with P. vivax chloroquine resistance, treat with ACT.
PERSON
RESPONSIBLE:

Administer anti-relapse treatment for P.vivax and P. ovale:

❖ Primaquine (dose once daily for 14 days: 0.25–0.5mg/kg bw)(except in pregnant
women, women breastfeeding infants less than 6 months, and in G6PD deficient
individuals), after exclusion of G6PD deficiency
❖ Note: For G6PD individuals, consider giving primaquine base at 0.75mg/kg bw once
weekly for 8 weeks, under close medical supervision for potential primaquine-induced
haemolysis). For pregnant and breastfeeding women, give instead weekly prophylaxis
with 300mg chloroquine base for the whole duration of pregnancy and breastfeeding
period.

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NO EVIDENCE OF MALARIA
❖ Negative malaria RDT
❖ No malaria parasite seen by microscopy

MANAGEMENT: NO EVIDENCE OF MALARIA

If clinical suspicion of malaria persists, repeat investigations:
❖ Blood films or malaria RDT daily for 2 more days (a single negative test
does not exclude malaria, however after 3 negative tests, malaria is
PERSON RESPONSIBLE:
unlikely and other illnesses should be considered)

Prophylaxis:
❖ DO NOT Stop prophylaxis even if malaria test is negative

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 ASSESS WITHIN 4
WEEKS

REAPPEARANCE OF MALARIA

❖ For patients with recurrent fever illness and symptoms of uncomplicated

malaria developing within 4 weeks after laboratory confirmation of
diagnosis of malaria:
• Verify completion of effective antimalarial treatment course
• If initial treatment was not properly completed, restart the same
treatment. PERSON RESPONSIBLE:

• If the antimalarial treatment was completed, check blood film slide

for persistent malaria:
• If blood smear remains positive or slide microscopy is not available,
treat with second-line antimalarial treatment
• If blood smear is negative, assess for other causes of fever.

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