In response to poor quality health care WHO produced a set of guidelines for the clinical management of children in district level hospitals, described in: Pocket Book of Hospital Care for Children (published 2005).
These technical guidelines extend the IMCI approach from primary care to hospital level. Like IMCI, the Pocketbook emphasizes the importance of case management of common diseases. It is designed for use by health personal (doctors, senior nurses and other senior health workers) in first referral care (such as the district or provincial hospital), where facilities are available for inpatient and outpatient management. The ‘hardware’ requirements are some basic investigations, and essential drugs, such as antibiotics and (in many locations) antimalarials, and fluids, necessary for the management of common conditions. The WHO guidelines provide outline the management of the seriously ill child from the arrival to the hospital until discharge home, with appropriate plans for follow up. The guidelines contain flow charts and tables that outline the diagnostic and treatment process. They include diagrams and descriptions of practical procedures that are commonly required for the safe management of seriously ill children with common conditions.
WHO has produced these guidelines as part of an evidence-based approach to case management. The guidelines emphasize the importance of the processes or stages of care: triage, emergency treatment, history and examination, differential diagnosis, monitoring and supportive care, discharge planning and follow-up. These processes of care are relevant to all serious illnesses.
Implementation of WHO guidelines
For implementation of the WHO guidelines health workers need to be introduced to these concepts. This program of introduction uses a clinical or problem-based learning methodology to train doctors, senior nurses and senior health workers from first referral care hospital in how to use the WHO Pocket Book in everyday clinical practice. The process of implementation can involve a workshop or course that brings together health workers involved in the care of children, and uses a CD-ROM and other material specially developed by WHO.
The implementation of WHO clinical guidelines as Nationally-endorsed Standard Treatment ideally requires several processes: identification of the limiting factors in quality of hospital care for children; engagement with the Ministry of Health, universities and colleges of health education and with paediatric associations; discussion of other strategies that are necessary to improve quality of care; adaptation and translation of the WHO clinical guidelines and CD-ROM.
Often the implementation of the WHO clinical guidelines will follow a process of assessment of the quality of paediatric care in hospitals in the country. When this has been done, the communication of the results of such an assessment process is an important part of the workshop program. Also, having discussion among the participants on where the limiting factors to quality of care are in their hospitals and their regions can help focus participants on the use of clinical guidelines and other strategies as vehicles for improving the quality of care.
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Good hospitals are vital social institutions
The quality of care provided in hospitals and other health facilities, and the nature of interactions between health systems, families and communities have major implications for child health, human rights, poverty alleviation, and development. Hospitals are institutions than can either contribute to improvement in these areas, or sadly in some situations, make them worse. Which way this goes depends on a variety of factors, including quality of clinical care, staff attitudes towards and communication with patients, the way minority groups are treated, fee structures, the degree to which there is holistic and continuity of care, palliative care, mental health and social support, staff morale, etc. We should aim to develop hospitals as core social institutions that not only provide high quality clinical care, but minimize the impact of poverty and social disadvantage on health and development.