Inpatient Therapeutic Care (ITC)

Inpatient Care for SAM children with Medical Complications

Implementation Arrangements
CMAM Components
 • anthropometric measurements and edema check
• triage of emergency cases
• history, medical examination and appetite test
1. Admission • referral to OTC where required
• recording

• emergency medical management

• routine mediciness & additional medicines
• F75
• orientation to caregiver
2. Phase 1 • monitoring of feeds
treatment
• every 12 hr and daily medical and anthropometric monitoring
• recording and assessment of readiness for transition

• transition to RUTF
• continue medical treatments
• monitoring of feeds
3. Transition • every 12 hr and daily medical and anthropometric monitoring
• recording
• assessment of readiness for OTC/Phase 2

• orientation to caregiver
• RUTF till next OTC distribution
4a. Discharge to • referral documentation and communication with OTC
OTC
 • anthropometric measurements and edema check
• triage of emergency cases
• history, medical examination and appetite test
1. Admission • referral to OTC where required
• recording
•emergency medical management
•routine mediciness & additional medicines
•F75
•orientation to caregiver
2. Phase 1 •monitoring of feeds
treatment
•every 12 hr and daily medical and anthropometric monitoring
•recording and assessment of readiness for transition
•transition to RUTF
•continue medical treatments
•monitoring of feeds
3. Transition •every 12 hr and daily medical and anthropometric monitoring
•recording
•assessment of readiness for OTC/Phase 2

• rehabilitation with RUTF (or F100)

• daily monitoring
• health and nutrition education
4b. Phase 2 in
ITC • recording
• assessment of readiness for discharge

• orientation to caregiver
• recording
5. Discharge
from ITC • links to other services
Implementation Arrangements

• Location
• Structure
• Arrangement of Services
• Staffing
• Tools and Materials
• Linkages
Location

• Ideally, the hospital should provide good access

from the catchment areas where outpatient
services for SAM are located.
• As such, the ITC will typically be located at the
District, Provincial or Regional DOH hospitals.
• For the purposes of monitoring and supervision,
the ideal distance from the ITC to the furthest OTC
site should be less than 4 hours.
• As much as possible, this transport time should be
minimized as it is generally the cases of SAM with
life threatening complications that require referral
to ITC.
Structure

• Typically the structure for the ITC will be provided

within the hospital setting and allow for the
separation of the different phases of SAM care.
• If space and staffing allow, the ITC should be
separated from the pediatric ward since patients
with SAM with complications often have poor
immunity and are highly susceptible to cross-
infection. This is particularly important for children
in Phase 1 or Transition Phase care.
Structure

• The ITC unit should typically provide:

– Pediatric care spaces which conform to the
Baby-Friendly Hospital Initiative guidelines
– Storage area for medical / nutritional supplies
– Preparation area for therapeutic milk
– Privacy for caregivers (especially when
breastfeeding)
– A screened area for weighing / assessing
children
– Adequate cooking facilities for caregivers
– Adequate toilet / bathroom facilities for
caregivers
– Children’s play area with age appropriate toys
Structure

• In areas of high inpatient caseload or in

emergency situations the problem of low bed
availability or poor staffing should first be
addressed through the establishment of OTC in
the outpatient department of the hospital and at
RHUs and BHSs.
• The OTC should also provide skilled IYCF
counseling for caregivers with infants aged less
than 6 months for whom RUTF is not suitable.
Structure

• In areas where OTC services are extensive and

access to the District, Provincial or Regional
hospital is poor, decentralized ITC care can be
established at RHUs with adequate facilities,
staff and training.
• In emergencies, it is possible to set up ITC
treatment facilities in temporary structures such
as tents; however this need for the treatment of
SAM is unlikely in the Philippine context.
Arrangement of Services

• 24-hour inpatient hospital care

– This is the ideal arrangement that allows for therapeutic
feeding every 2-3 hours for children in Phase 1 and
transition phase that may be particularly vulnerable.
– Preparing the night feeds during the day, which can then
be distributed at a later time, may reduce the workload of
staff at night. This arrangement may only be used where
the therapeutic milk can be refrigerated.
– Children in phase 2 who cannot be discharged to an OTC
can be cared for on a standard pediatric ward as they are
less vulnerable than children in Phase 1 & transition
phase, can eat RUTF and require less supervision.
Arrangement of Services

• Day care ITC units

– This arrangement should be used only as a temporary
measure where staffing does not allow 24 hour care.
– The schedule of treatment of children in Phase 1 should
minimize the time between the last night feed and first
morning feed of therapeutic milk.
– Children in Phase 1 should be fed at intervals no greater
than 6 hours at night and must be closely monitored
during the day to ensure that ALL of the therapeutic milk
has been taken.
Arrangement of Services

• Where no OTC facilities exist in the community, children

requiring Phase 2 care and who have appetite for RUTF
may be discharged from inpatient care and treated in
the OTC established at the hospital.
– If the caregiver lives a great distance from the hospital,
compliance with treatment as an outpatient until cure may be
facilitated
– Providing local accommodation allowing the caregiver to remain
in the local area
• Request the attendance of the caregiver at the hospital
based OTC every 2 weeks and provide assistance with
transport costs
– The risk of nocturnal mortality in phase 1 due to hypoglycemia
may be reduced by ensuring that the whole ration of therapeutic
milk has been taken during the daytime feeding schedule.
Staffing

• All ITC medical and nursing staff must be trained

in PIMAM protocols before managing SAM
patients
– The personnel of the ITC, the OPD and the
emergency ward should undergo retraining regularly
• There should be a minimum of 1 member of
nursing / midwifery staff plus care assistants
assigned to the ITC unit on every shift.
• Senior nursing or medical staff should not be
rotated at the same time as junior staff. Staff
rotation and inadequate supervision of junior
staff may lead to increased child mortality
Tools and Materials

Anthropometry
• MUAC tape
• Weighing scales accurate to 100g (for children 6 -
59 months)
• Weighing scales accurate to 10g (for children aged
less than 6 months)
• Height board accurate to nearest 1mm
• Child Growth Standards Reference Chart for
Weight for height charts (WHO 2006, for children 0
- 59 months)
• BMI for age charts (WHO 2006, for children aged 5-
19 years)
Tools and Materials

Record keeping
• A separate register is kept for malnourished patients.
• ITC Form is the primary tool used in ITC. Other charts
should not be used.
– Medical and nursing staff use the same multi-chart to record all
the information needed to manage the malnourished patient –
separate charts are not used by different categories of staff.
• The Critical-Care chart, is used for patients with
complications who require more intensive monitoring
during the acute treatment of the complication (e.g.
Hypovolemic or septic shock, hypothermia)
• ITC Monthly report form
• Referral forms (from ITC to OTC)
Tools and Materials

Diet
• Pre-packaged F75 Therapeutic Milk
• Pre-packaged F100 Therapeutic Milk
• Therapeutic Milk look-up tables
• Pre-packaged RUTF
• Cups
• Nasogastric tubes (Size 5- 8)
• Mixer
• Drinking water
• Sugar
• Measuring jugs
Tools and Materials

Medicines
• Routine intravenous / oral antibiotics
• Deworming medication
• Anti-malarial
• Intravenous fluids, Intravenous glucose,
Intravenous magnesium sulfate
Tools and Materials

Examination equipment
• Thermometer
• Stethoscope
• Otoscope

Other equipment
• PIMAM national guidelines
• IYCF counseling materials
• IEC material for health education
• Age appropriate toys
• Beds for caregiver and child
• Impregnated bed nets (for malaria endemic areas)
• Soap
• Kitchen equipment for making / refrigerating therapeutic milk
• Kitchen equipment & eating utensils for caregivers
Linkages with Other Services

Strengthening of PIMAM service linkages

 PIMAM technical guidelines provide specific
referral forms for:
– Referral from the community to OTC
– Referral forms for transfer from OTC to ITC (and
vice-versa)
• These may be used where no referral forms
currently exist (e.g. during emergencies).
However standard hospital referral forms (and
referral from hospital to RHU forms) may be
used provided the relevant information is
presented.
Linkages with Other Services

Strengthening of PIMAM service linkages

 Referral forms are normally given to the
caregiver, however this does not necessarily
imply that the caregiver will be compliant with
the referral. In addition the midwife / doctor
supervising the child’s care at the OTC should;
– Liaise with the referral health facility or hospital by
phone / fax / email to advise them of transfer
– Request a BNS / BHW to follow up the caregiver in
the community after referral to check on compliance
Linkages with Other Services

Strengthening of PIMAM service linkages

 If the caregiver has accepted transfer from OTC
but has not returned for further care, a BNS /
BHW should perform a home visit within a week
to follow up the child and encourage return to
the treatment program if they have not already
done so.
 If a caregiver has refused transfer, the
BNS/BHW shall advise them that the child’s
health is at risk but that, as a minimum,
treatment should be continued as an outpatient.
Linkages with Other Services

Linkages to other Health and Nutrition services

• Wet Nursing/Cross Nursing/Milk bank: Children aged less than 6 months
may benefit from prescriptions of breast milk obtained from a wet-nurse or a
milk bank. Guidelines on milk banking should be consulted for details
• EPI: Children who have not completed the schedule of childhood
vaccinations should either be provided with the vaccinations where the
vaccines are available or be referred to the next EPI session in their local
community
• OPT / GP: Children discharged from OTC should be referred to OPT for
growth monitoring if not already enrolled. Caregivers of OTC discharges
should also be encouraged to participate in local GP activities and receive
vitamin A and deworming appropriate to age.
• Micronutrient supplementation: may be recommended by the clinician but
only after discharge from treatment with RUTF. Giving micronutrient
supplementation during treatment with RUTF may interfere with the nutrient
balance required for proper recovery. After discharge from treatment for
SAM, micronutrient supplementation of complementary foods is
recommended