oi evidence check- imai district clinician manual october 26-27, 2010 1 |1 | linking imai with...
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OI evidence check- IMAI District Clinician Manual October 26-27, 20101 |
Linking IMAI with palliative care in M/XDR-TB
Linking IMAI with palliative care in M/XDR-TB
Aka "Using IMAI tools for palliative care of M/XDR TB"
Drs Akiiki Bitalabeho and Sandy Gove
for the IMAI team and palliative care expert group
OI evidence check- IMAI District Clinician Manual October 26-27, 20102 |
Palliative care: symptom management (during acute and chronic care) and end-of-life care
OI evidence check- IMAI District Clinician Manual October 26-27, 20103 |
IMAI and Palliative CareIMAI and Palliative Care
The first IMAI PC tools were field-tested in 2003.
Palliative care is integrated in all IMAI materials and trainings- for every symptom, consider the specific treatment required and and symptom management.
All cadres of health workers should be trained in palliative care.
Included in pre-service, in-service and second level training materials. Aim is to ensure knowledge and skills for palliative care at all levels and for all health workers.
Clinical mentoring to assure quality of care.
Palliative care in the community: Target is community-based caregivers, community health workers, family and patient (self-management).
Health centre
Community-based care
Central/RegionalHospitals
District hospital
Emphasis on decentralization, to headtoward univeral access, equity.
Health centre
Community-based care
Central/RegionalHospitals
District hospital
Relevant IMAI PC tools for 3 levels
Chronic care approach prepares clinical teams to partner with the patient
Patient centeredPatient self-management is supported by:• Education and booklets• Preparation of treatment and prevention supporters for ART and TB (adherence)•Peer support groups•Involvement by expert patients/lay providers – as trainers, on clinical team
Technically sound home-based care with good supervision by facility teams
Patient self-management and caregiver booklets, cards for each ART regimen
Flipcharts for patient education
IMAI-IMCI tools empower patients and communities
Central, Regional,
University,
DISTRICT HOSPITAL
COMMUNITY
Clinical care- nurses, pharm techs; ART aid.Sometimes clinical/ health officer
Community-carers, family-based care, self-management, community health workers, peer support groups, CBOs
Doctors/health officers/ inpatient RN
Specialisedreferral
HEALTH CENTRE
Drugs, diagnostics, commodities, logistic support
National, Regional and District Management- includes tools to map services, NGOs
Referral, B
ack-Referral; C
linical mentoring;
Supervision by facility
Emphasis onstrongfacility-
community link
IMAI/IMCIIMAI/IMCI
OI evidence check- IMAI District Clinician Manual October 26-27, 20108 |
Simplify for
lower cadres
Integrate (multiple
interventions)
Operationalize-Sequence of treatment,
care and prevention
Developtools
Harmonized
Normative guidelines + Country experience + Evidence check
ARTCotrimoxazoleClinical staging
PITC policyPositive prevention
PMTCTOI management
PaediatricsSTI
Antenatal, Postpartum, L&DGender
TB, TB-HIVMalaria treatment
IT bednets
Chronic careMental healthIDU, alcoholOral health
Cancer- palliative careSafe water
Safe injectionsNutrition
IMAI/IMCI tool development
Acute Care Chronic CarePalliative Care:Symptom management
WHO IMAI- IMCI- IMPAC integrate:
Prevention integrated with care and treatment (by age, serostatus- all)Support for healthy pregnancy & childbirth (IMPAC)
Infant, child nutrition & development (IMCI-HIV)
• General principles• Chronic HIV Care with ART and Prevention
• PreART care, ART• PMTCT• Positive dignity, health and prevention
• TB care with TB-HIV Co-management• MDR TB
Not disease specificAll ages
HIV+, HIV-PITCTB casefinding OI'sCough, difficult breathingSTI'sDiarrhoeaSkin problemsMental health, alcoholNeurological problemsFever/malaria
IMAI general principles of good chronic care: applicable for long-term
TB, TB-HIV, MDR-TB management
1. Develop a treatment partnership with your patient.2. Focus on your patient’s concerns and priorities.3. Use the 5 As—Assess, Advise, Agree, Assist, Arrange.4. Support the patient education and self-management.5. Organize proactive follow-up.6. Involve "expert patients", peer educators and support staff at
your health facility. (lay providers)7. Link the patient to community-based resources and support.8. Use written information—registers, treatment plans, patient
calendars, treatment cards—to document, monitor, and remind.9. Work as a clinical team (and hold team meetings). 10. Assure continuity of care.
Simplification and decentralization of treatment delivered through primary health care
TB led the way with decentralized delivery at health centre and community level based on decades of experience
Home-based palliative care/hospice approaches when IMAI started often did not involve the health centre
In a short 6 years, HIV care and ART have caught up • Now substantial experience and success with delivery by nurse-led teams in
health centres and district outpatient clinics, with strong community-based treatment support
• This has gone to scale in a number of countries> 300 health centres in Ethiopia, hundreds of health centres in Tanzania use country-
adapted IMAI tools to decentralize ARTMore than 50 countries with high HIV burden have adapted IMAI-IMCI toolsAlmost all countries have adapted Palliative Care guideline module but not as
extensively implementedTB-HIV co-management including TB-ART co-treatment now simplified for
primary health care delivery – also used expert patient trainersSimplified MDR TB management, based on same chronic care approach, now can
be supported at district hospitals and select accredited health centres
Management of MDR-TB: A field guide
• In the context of a national response to MDR- and XDR-TB
• Target: health workers in TB clinics in district hospitals and some accredited health centres
• Draws on the experience of Partners In Health (PIH) in Lesotho-
- active training and service delivery
Based on the Emergency Update 2008 of Guidelines for programmatic management of drug-resistant tuberculosis WHO/HTM/TB/2008.402- companion document to these guidelines
• Diagnose MDR-TB• Initiate second-line anti-TB
drugs• Monitor MDR-TB treatment• Chronic care approach using
IMAI general principles of good chronic care (long-term care); defined sequence of care.
Other relevant IMAI tools
Guidance and tools:Psychosocial support– see Chronic HIV CarePeer support groupsTherapeutic peer supporting groups Clinical mentors- prepared to support symptom management, as
well as specific disease managementExpert patient trainers– to train and later on clinical team
(importance for stigma reduction)3 interlinked patient monitoring systems
Learning programmes: Preservice Inservice (first level palliative care training course)Continuing education; support for self-learning Relevant evidence collection
OI evidence check- IMAI District Clinician Manual October 26-27, 201014 |
Role of district clinician in district networkRole of district clinician in district network
The implementation of many clinical interventions for public health at primary care level requires district hospital clinicians able to manage:
uncomplicated as well as complicated patients
those who fail initial empirical treatment interventions
those with severe illness requiring urgent treatment and inpatient care, including inpatient management of pain and other symptoms
OI evidence check- IMAI District Clinician Manual October 26-27, 201015 |
Palliative carewithin the IMAI DCM
Palliative carewithin the IMAI DCM
Part of the second level learning programme
Fieldtested in 5 countries (Zambia, Tanzania, Uganda,
Ethiopia, India-currently occurring in Rwanda)
Volume 1 submitted to GRC
OI evidence check- IMAI District Clinician Manual October 26-27, 201016 |
Target audience and assumptions(stable from start of development;
matches child pocket book) :
Target audience and assumptions(stable from start of development;
matches child pocket book) :
Limited resource settings ONLY
HR assumptions: – Targets medical officer, clinical officer, senior nurses, and other senior
health workers working at a district hospital in limited resource setting. – Multipurpose practitioners such as a medical or clinical officer but do not
have specialist clinicians such as an internist, paediatrician or psychiatrist (although it may be possible to consult with one).
Limited essential drugs (see drug section at end of the Manual; this is subject to adaptation based on the national essential drug list).
Limited equipment No mechanical ventilation for medical patients
Limited laboratory and other investigations
OI evidence check- IMAI District Clinician Manual October 26-27, 201017 |
Volume 1Quick Check and Emergency treatments
Manage Severely Ill Patient- including TB patients in severe respiratory distress, septic shock
(approximately the first 24 hours of care)Manage Acutely Injured Patient Infection Control, Procedures
Drugs- all including for palliative care
Volume 2
Acute, subacute illnessMultisystem diseases: OIs, NTD, Kaposi sarcoma
Chronic management: HIV/ART : including TB-HIV co-management
TB: TB treatment, DR TB PMTCT-FP
Alcohol, other substance usePrevention
Palliative care- applicable to DR TB, special considerationsPatient monitoring, pharmacovigilance, notifiable diseases
Symptom managementIn other sections of
District Clinician Manual
Symptom management• What is the same, what is different for PLHIV, DR TB, cancer?
End-of-life care• What is the same, what is different for PLHIV, DR TB, cancer?
Psychosocial support• What is the same, what is different for PLHIV, DR TB, cancer?
Programmatic approach• What is the same, what is different for PLHIV, DR TB, cancer?
Symptom management appears throughout
IMAI District Clinician Manual
OI evidence check- IMAI District Clinician Manual October 26-27, 201021 |
Some improvements to IMAI DCM suggested yesterday by expert review
Some improvements to IMAI DCM suggested yesterday by expert review
Difficult breathing in chronic lung conditions- include continuous oxygen
Decisions on end of life care– Decision on discontinuing DR TB treatment
• Team, not individual clinician• Choice of the patient, with full information especially of toxicity, resources, quality of life • No blanket decision on failure of treatment
Will examine issue of polypharmacy in palliative care and drug interactions with DR TB treatments
Expect further input to happen on management toxicity from M/XDR TB treatment
Statements on human rights (with current references) at start of palliative care chapter
Expecting other inputs from this meeting
Control bronchospasm:– Give salbutamol by metered-dose inhaler with spacer or mask or, if available, by nebuliser.
Stop bronchodilators if the patient is not able to use them anymore, or if breathing is very shallow or laboured.
– Consult to consider giving prednisone 40 mg by mouth daily for 5–7 days. Relieve excessive sputum:
– If cough with thick sputum, give steam inhalations. – If more than 30 ml/day, try forced expiratory technique (“huffing”) with postural drainage.
For bothersome dry cough, if an opioid not already being used, give codeine phosphate 30 mg four times daily, if no response, oral morphine (2.5– 5 mg)
For cough or difficult breathing
In end-of-life care, a small dose of morphine can reduce dyspnoea. Monitor respiratory rate closely, but do not let fears of respiratory depression prevent trying this drug.
– For a patient not on morphine for pain – give morphine sulphate 2.5 mg everyfour hours.
– For a patient already on morphine – increase the dose by 25%. If this does not work, increase by another 25%.
To relieve symptoms of heart failure and to treat pitting oedema, give furosemide 40 mg daily. To relieve anxiety or terminal agitation, consult to consider giving diazepam.
If patient is terminal and is dying from COPD, lung cancer, AIDS, or any terminal pulmonary problem (but NOT acute pneumonia or TB that can be treated with antibiotics), there are additional measures to relieve dyspnoea:
Health centre support for home-based care:Medication/medical
Additional hospital palliative care relevant for M/XDR TB
• Oxygen (if adequate supply)
• Additional analgesic options- IV morphine
• IV/subcutaneous infusion
• Differential diagnosis and skilled management of symptoms
OI evidence check- IMAI District Clinician Manual October 26-27, 201025 |
IMAI tools to support implementation of palliative care
IMAI tools to support implementation of palliative care
Will be progressively updated as the GRADE-based WHO guidelines on pain and other symptom management are produced (if funding and interest from donors and partners)
– These GRADE reviews will happen over years
Integrated tools serve as efficient 'vehicle' for implementation of palliative care for HIV, TB, cancer, COPD patients
OI evidence check- IMAI District Clinician Manual October 26-27, 201026 |
Updating the IMAI District Clinician ManualUpdating the IMAI District Clinician Manual
Annual print of updated manual (every July Vol 1, December Vol 2)
New WHO guideline
Section revised
Update of applicable section of manual- on EZ collab- within 3 months
New WHO guideline
Section revised
Advantages of 'sharing' IMAI-IMCI palliative care tools
Co-sponsorship and co-supervision can bring real advantages.
Using the same simplified guidelines, training, and management support for palliative care for HIV, cancer, TB, COPD, other conditions
Stronger implementation through shared programmes of work, between several international and national programmes
More coverageMore opportunity to maintain quality
Responds to reality of greater integration at district level:District management team members often 'cover' several programmesHealth workers multipurpose
Patients need integrated, holistic care; most have more than one problem. Integrated clinical management provides better care.
IMAI is very open to collaboration and improvement of the tools and to better serving TB patients and their families
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