the time of COVID 19 in the Ola During Childrens Hospital Freetown, - - PowerPoint PPT Presentation

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the time of COVID 19 in the Ola During Childrens Hospital Freetown, - - PowerPoint PPT Presentation

Jul 07, 2023 1.22k likes •1.59k views

Adapting triage and assessment in the time of COVID 19 in the Ola During Childrens Hospital Freetown, Sierra Leone Dr Nellie Bell MD (Heidelberg), FAPd (Mannheim), DTMPH (Berlin), FWACP (Paed) 1 Background - Sierra Leone and ODCH

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Adapting triage and assessment in the time of COVID 19 in the Ola During Children’s Hospital Freetown, Sierra Leone

Dr Nellie Bell MD (Heidelberg), FAPäd (Mannheim), DTMPH (Berlin), FWACP (Paed)

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SLIDE 2

Outline

  • Background - Sierra Leone

and ODCH

  • Patient flows before Ebola,

after Ebola, in 2019 and now

  • ODCH: Covid 19 Pandemic
  • Conclusion

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SLIDE 3

Background - Sierra Leone

Population:

  • approx. 7 million

50% of population are under the age

  • f 15

Under five mortality rate: 104/1000

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Background – Ola During Children’s Hospital (ODCH)

  • Only tertiary Hospital for Paediatrics in Sierra Leone
  • located in the densely populated eastern part of

Freetown, Sierra Leone

  • part of the University of Sierra Leone Teaching

Hospitals Complex

  • Partial accreditation from WACP for the postgraduate

training in Paediatrics

  • Approximately 12.000 children are admitted annually

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Background – Ola During Children’s Hospital (ODCH)

  • 200 bed facility
  • inpatient beds divided across
  • three general wards (with oncology, nephrology, pulmonology,

neurology subspecialties),

  • a resuscitation/ emergency department,
  • an intensive care unit,
  • an HDU (emergency room)
  • isolation unit
  • a neonatal unit.
  • Outpatient:
  • there are different specialist outpatient clinics (HIV, Tuberculosis,

cardiology, neurology, haemato-oncology etc) held on a daily basis.

  • General outpatient clinics

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SLIDE 6

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Entrance to hospital pre Ebola

Patient flow ODCH before Ebola

Main Hospital

SD SCBU ER- ICU General wards Observation Tb/HIV TFC

Maternity Hospital

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SLIDE 7

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Main Hospital

Isolation

Ebola screening Old entrance to hospital

ODCH: Patient flow during Ebola 2014

Maternity Hospital Triage

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ODCH: patient flow and ETAT shortly after EBOLA In 2015/2016

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Main Hospital GATE

Emergency room

Screening and registration

Maternity Hospital Triage

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ODCH: patient flow, ETAT + training equipment shortly after EBOLA In 2015/2016

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Emergency room

Triage

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Remodelling triage and assessment areas in 2016

  • The redevelopment of infrastructure, assessment and triage procedures in

ODCH was a complex multidisciplinary effort, requiring dedication from doctors, nurses, pharmacists, lab technicians and administrative staff

  • Simple reorganisation of processes and systems has reduced waiting times

and greatly improved the early identification and treatment of sick patients

  • Empowering the nurses in the assessment, prescribing, and treatment of the

sickest patients using ETAT + principles is a feasible and high-quality option for emergency care, where ongoing support and mentorship is available

Clark M, Spry E, Daoh K, Baion D, Skordis-Worrall J. Reductions in inpatient mortality following interventions to improve emergency hospital care in Freetown, Sierra Leone. PLoS ONE. 2012;7(9):e41458. http://dx.doi.org/10.1371/journal.pone.0041458 pmid: 23028427

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2019

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I

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Main Hospital

GATE

New room

IR

Emergency room

Emergency room

Main Hospital

GATE

New entrance for emergency and priority patients

Entrance only for

  • ut patients

Out Patient

  • nly

Triage

Waiting area for non priority patients

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2020

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2020: ODCH- pre Covid-19 in SL

  • ODCH Covid 19 taskforce
  • SOPs
  • Case definition and Patient flow
  • Case Management according to ETAT+
  • General SOP
  • Isolation unit (2 beds) -> Isolation Unit (23 beds)

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ODCH - Fresh start

Hospital was thoroughly cleaned and fumigated Most staff tested and only tested staff allowed to work Number of hospital beds (sometimes only mattresses) downsized with adequate spacing in- between beds Hospital staff trained in IPC and ODCH SOP , case manangemnt and new patient flow. Implementation of the new SOP

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NO Does patient have any of the following:

  • Acute fever or caregiver with acute fever (temperature above 37.5 C) AND

Symptoms suggestive of COVID-19, including persistent cough, shortness of breath, respiratory distress, sore throat, hoarseness, drooling, nasal discharge, congestion, sneezing, or other respiratory symptoms. OR

  • Acute fever AND two of the following: a) rash, bilateral

non-purulent conjunctivitis, mucocutaneous inflammation signs, b)signs of shock or hypotension c) features of myocardial dysfunction, d) coagulopathy, e) acute gastrointestinal problems OR Fever, respiratory symptoms and any of the below

  • Other members of household experiencing related symptoms
  • Inform Disease Surveillance Team:

Sister Theresa A. Kargbo – 076338223/077820985

  • r Night Super-intendant – 076429524
  • Disease surveillance to contact 117 team

COVID-19 PATIENT FLOW OLA DURING CHILDREN’S HOSPITAL

YES Not a Suspected COVID-19 Case

  • Send patient to resus triage area
  • Manage as usual

Suspected COVID-19 Case

  • Give patient and caregiver a surgical face mask
  • Escort patient to the isolation unit triage area

Case management will be informed and patient transferred to treatment centre by Ambulance Transfer (See SOP) Positive Result Negative Result Patient to wash at doffing area and be transferred to ICU/ER (see SOP)

Test for COVID-19

13/05/2020

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SLIDE 19

Toilet

toilet

Storage/ Cupboard

Donning area Doffing/ Washing

Triage and registration COVID screening

Confirmed cases Suspected cases Suspected cases Resus/ER for Non- COVID 19 patients

Nurses station

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ODCH: patient flow and ETAT during COVID 19 Pandemic

Doctors ’ station

Emergency Security and hand washing Wd 3 SD

TFC SCBU

ICU- ER

Main Hospital

Triage

One Screening area and 2 (ETAT) triage areas both staffed by ETAT trained nurses and doctors

Maternity Hospital

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Toilet

toilet

Storage/ Cupboard

Donning area Doffing/ Washing

Weight/Height and registration COVID screening

Confirmed cases Suspected cases Suspected cases Resus/ER for Non- COVID 19 patients

Nurses station

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ODCH: patient flow and ETAT during COVID 19 Pandemic

Compartmentalisation

Doctors ’ station

Emergency Security and hand washing

Main Hospital

Wd 3 SD

TFC SCBU

ICU- ER

Maternity Hospital

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ODCH: patient flow and ETAT during COVID 19 Pandemic Compartmentalisation Plan

Non Covid 19 suspect from Resus Covid 19 suspected Negative from isolation Covid 19 positive Previous Covid 19 positive convalescent now negative SCBU/Stepdow n/ Ward 3/TFC ER/ICU/ TFC Treatment centre or confirmed area Home/ ICU/ER Home

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Bubbles/ Compartments

Doctors

  • TFC/Ward 3
  • SCBU
  • ICU/ER
  • Resus/ SD
  • Isolation/Treatment Centre

Nurses (strictly according to wards) Cleaners (strictly according to wards) Pharmacists Lab technicians/scientists Other HCW

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SLIDE 23

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SLIDE 24 SETTING

INITIAL MANAGEMENT OF PAEDIATRIC PATIENTS WITH

SUSPECTED AND CONFIRMED COVID-19 OLA DURING CHILDREN’S HOSPITAL

Isolate as per SOP BREATHING CIRCULATION Your own PPE must be correct + child and carer to wear facemask Check airway is patent –look from a distance +listen. Do not upset child as this will increase the risk of airborne transmission 04/05/2020 SAFETY AIRWAY HELP Consider joint assessment with a doctor/nurse to avoid double exposure If not patent – use airway manoeuvres , adjuncts +/- suction if necessary if you have appropriate PPE Assess respiratory distress (ask Carer to remove clothes) Check Respiratory Rate Check Oxygen Saturations If above is normal, avoid listening to the chest to avoid exposure but if the above are abnormal listen to the chest with isolation stethoscope →If O2 Sats <92% and/or severe respiratory distress start
  • xygen and sit patient up at 45 degrees if possible.
→ Aim to have one O2 concentrator per patient. If unable to maintain O2 saturations consider using O2 cylinder. →Children with emergency signs, target SpO2 ≥94% →If patient has a co-morbidity start O2 earlier even if O2 saturations >92% (immunocompromised, heart disease, chronic kidney disease or respiratory problems) →If no improvement discuss with senior starting CPAP. Only if healthcare worker has full PPE (including N95 mask). Treat in isolated room. → If patient is in severe respiratory distress, keep nil per OS →If known asthmatic with a wheeze ask carer to give 6-10 puffs
  • f salbutamol inhaler via a spacer +/- low dose steroid
→Antibiotics:
  • Assess Disease Severity using Severity Chart
  • If Pneumonia suspected: If non severe-> start oral
Amoxyl suspension consider adding Macrolide antibiotic such as azithromycin or erythromycin to cover for atypical pneumonia.
  • If Severe/Critical/: Start Ampicillin + Gentamicin
if no improvement after 48h → Start Ceftriaxone or Cefotaxime. DISABILITY EXPOSURE Check Temperature Give Paracetamol if Temperature >38oC. Tepid sponging NOT recommended Check Malaria RDT if temperature high Check AVPU Check RBS if V,P, U or lethargic If RBS <3g/dl give 5ml/kg 10%Dextrose bolus, monitor RBS and give appropriate feeds/ fluids Check for Shock Check Heart Rate Check for Malnutrition (MUAC, Weight, Zscore) Check for Pallor Check for Dehydration + Diarrhoea →If in shock give slow and careful boluses (1st line -=RL). Max. 2 boluses in a well nourished child. →3/4 maintenance IV fluids (1st line =RL but can use NS, DNS, DRL) if oral contraindicated e.g. severe respiratory distress →Monitor input and output and for signs of fluid
  • verload.
→ If oral tolerated, allow breastfeeding infant to breastfeed →If child pale check Hb and MPs → If malnourished manage according to SAM protocols →If Dehydration + diarrhoea manage as per ETAT How to work out ¾ Maintenance fluids: 1) Workout total maintenance fluids as per ETAT+. 2) Divide total fluids in ml in 24 hours by 4 3) Multiply by 3 = total fluids to be given in 24 hours in ml

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General SOP

  • Robust screening of all patients by nurses
  • Strict adherence to Compartmentalisation and patient

flow

  • Wearing of surgical masks if doing patient care
  • Wearing of light PPE cloth mask when going home
  • Wearing full PPE of N95 masks when in the isolation

unit

  • Washing of hands regularly
  • Social distancing
  • Strict adherence of ALL staff to general IPC measures
  • Case management protocol according to ETAT+

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Conclusion 1/2

  • Lessons learnt from Ebola
  • Importance of ETAT + in patient flow
  • Covid 19 Pandemic: Ola During was

caught off guard with a high number of infected staff

  • Robust reorganisation of the hospital was

done introducing compartmentalisation

  • f staff, reviewed patient flow

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Conclusion 2/2

  • Isolation/ treatment unit with Triage
  • Training of staff on IPC measures
  • Continuation of Short and long ETAT courses
  • Continuation of undergraduate and postgraduate

training with academic meetings (via zoom)

  • Proper tertiary hospital, referrals and emergencies

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Thank you!

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