Dr Harish Kumar

Dr Harish Kumar
Project Director, Norway India Partnership Initiative (NIPI) Newborn Project

Norway India Partnership Initiative (NIPI) established in 2006 provides catalytic, strategic and innovative support to the National Health Mission for accelerating mortality reduction in new-born child and related maternal health, writes Dr Harish Kumar, Project Director, Norway India Partnership Initiative (NIPI) Newborn Project, for Elets News Network (ENN).

Facility-based emergency and inpatient care can bring down mortality in children who are seriously ill and those who are referred to hospital in time. Under the National Health Mission, district hospitals have been positioned in the continuum of care as the referral health facilities, because these are the most important units in a district with regards to provision of specialist care.

An Assessment of quality of Care for Children in District Hospitals in India, conducted in 2014 across four states of Rajasthan, Bihar, Madhya Pradesh and Odisha showed that none of the 13 district hospitals covered had a system for triage and emergency care for sick children.

Precious time was lost during transfer of children to paediatric ward for treatment initiation. There were no specific guidelines for operationalisation of paediatric care facilities. The staff was not trained in emergency care or in triage, supervision was not in place in the five district hospitals. Moreover, the laboratory services were slow to provide results or did not provide services 24 hours. There was no observation area or high dependency area for the sickest children and resulted in delays of transferring children to the wards and initiating care. It emerged from the report that strengthening emergency paediatric care was as a priority area for intervention.

Strengthening paediatric care under Norway India Partnership Initiative

Norway India Partnership Initiative (NIPI) established in 2006 provides catalytic, strategic and innovative support to the National Health Mission for accelerating mortality reduction in new-born child and related maternal health. The approach used by NIPI is to try out innovations and implement them in the incubator or demonstration mode in some key identified areas before offering them for the country wide scale up.

Implementation process

A comprehensive approach was undertaken in the five district hospitals with the following key steps:

a) Establishment of National or State Technical Advisory Group for strengthening paediatric care

b) Development of Operational Guidelines

c) Gap Support funding for structural adaptations

d) Establishment of Resource Centre Paediatric Emergency Model

e) Sharing implementation results

g) Scale up

Model established at Alwar

There was a visible gap in the paediatric emergency services at the District Hospital Alwar. The paediatric emergency cases were being attended at the emergency services located in the district hospital campus which is about a kilometre away. Precious time was being lost during transfer of children from General hospital emergency to paediatric wards located in the maternal and child health section across the road leading to child mortalities. In order to address these gaps, ETAT initiated in October, 2015 at MCH wing of the District Hospital Alwar.

A ward space (12 metres X 6 metres) located at the entrance of newly constructed MCH wing was identified for ETAT. The civil work for minor changes and partitioning was carried out with NIPI support. The Triage Section, High Dependency Unit (HDU) and Diarrhoea Treatment Unit (DTU) were established. Most essential equipment and drugs required for ETAT and HDU were received from state NHM. The ETAT protocols are prominently displayed for standard treatment as per the diagnosis.

Three Medical Officers (Paed.) and 4 Nursing staff of District Hospital were imparted three days training of ETAT at Kalawati Sharan Hospital, New Delhi during year 2015. One nursing incharge and three staff nurses trained in ETAT/FIMNCI module are deputed to work at ETAT. One paediatrician on rotation basis has been posted during day hours at ETAT (non-OPD hours).

All emergency and priority cases during OPD hours are triaged by ETAT staff and treated immediately at ETAT while sick children during non-OPD hours are treated at ETAT with focus on children presenting with emergency signs. Separate patient case sheet, reporting formats and ETAT registers are being used for proper documentation.

With the establishment of ETAT, the patients are being triaged using the following categories:

Those with emergency signs requiring immediate emergency treatment.

Those with PRIORITY SIGNS, indicating that they should be given priority in the queue, so that they can rapidly be assessed and treated without delay.

Those who have no emergency or priority signs and therefore are NON-URGENT cases.

Impact of ETAT operationalisation

The lag time in treating the severely sick children were reduced resulting in possible reduction of mortality of severely sick children. During year 2016 (Jan-Dec 2016); 12,931 children were treated at ETAT including 1246 children presented with emergency signs and 920 children with priority signs. During year 2017 (Jan-Sept 2017); 16,104 children were treated at ETAT including 1070 children presented with emergency signs and 1029 children with priority signs. 1,555 children in year 2016 and 1981 children in year 2017 (upto Sept 17) were investigated in ETAT itself.

Implementation results across five centres in four states: Across five sites in India, a total of 27,723were children attended of which 3,252 (12%) presented with emergency signs and 4,229 (15%) presented with priority signs.

Scale up: The state of Madhya Pradesh has scaled up in 42 district hospitals with state budgets. Similarly, the state of Odisha is strengthening paediatric care in its five health facilities. The state of Bihar is scaling up in two health facilities.

The catalytic model started under NIPI is now setting the agenda for strengthening paediatric care services across the country.

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