7.1 Management of patients and attendants in a CTC

7.1.1 Patient flow and distribution

The organization presented in this chapter corresponds to the CTC layout suggested in Appendix 11 with 3 main sectors for patient case management: triage, hospitalisation, observation.

TRIAGE

• All patients that arrive at a CTC go through triage. They are admitted1 (or not) according to the criteria described in Chapter 5.

• Priority is given to emergency cases that are treated within minutes of arrival.
For less severe cases, it is essential to maintain visual contact while they await triage (the patient’s condition may deteriorate while waiting). These patients should not wait more than 10 minutes between arriving and being attended to.

• For patients without danger signs
The doctor/nurse opens an individual patient file and registers patients (cholera case register). Patients are then accompanied by an auxiliary nurse to the appropriate sector for treatment (hospitalisation or observation), with their individual patient file.

• For patients with danger signs (emergencies)
The doctor/nurse immediately inserts an IV line and starts rehydration. The interview, registering and transfer to the appropriate sector are carried out once patients are stabilised.

HOSPITALISATION

• All patients with some or severe dehydration are admitted to this CTC area, which is divided into two sectors: sector for oral treatment only (OT) or sector for IV + oral treatment (IVT).
Patients are treated in OT or IVT sector depending on the triage prescription.

• In OT or IVT sector, pregnant women and children < 5 years are preferably grouped together rather than mixed with the other patients to improve monitoring.

• Patients with severe dehydration that finish IV treatment and switch to maintenance therapy (“recovering patients”) can stay in the same bed, even if their IV treatment has ended: relapse is possible; it is easier to continue patient monitoring if they stay in the same bed. Nevertheless, rapid transfer to the OT sector should be considered to free up the IVT sector when the CTC experiences a high influx of patients (on condition that the patient drinks well and has had the catheter removed). In this situation, it is advisable to consider setting up a post IV treatment sector from the outset (called “Recovery”, see below).

• A patient with some dehydration admitted to the OT sector and whose condition deteriorates is transferred to the IVT sector. The OT sector should not manage patients with infusion.

OBSERVATION

Patients with no dehydration are admitted to this sector and receive treatment under observation for a few hours. As in the hospitalisation sector, pregnant women and children < 5 years are grouped together to improve monitoring.

This distribution of patients covers all treatment needs (treatment of dehydration and prevention of dehydration or maintenance therapy) while paying specific attention to the most vulnerable or complex cases (e.g. young children, pregnant women).

Note that patient sectors can be divided in other ways. Another model could be:

TRIAGE

As above.

OBSERVATION

All patients on oral treatment only are oriented in this CTC area. In this event, the area is divided into 2 sectors:
• Patients on Plan A (prevention of dehydration), and
• Patients on Plan B (oral treatment of some dehydration).
Do not mix these patients to ensure correct monitoring.
Or
Only patients on Plan B (oral treatment of some dehydration) are treated in this area, patients with no dehydration are treated as outpatients (in an ORP or at home2 ). Nevertheless it is important to remember that clinical surveillance, however brief, is strongly recommended for children < 5 years on Plan A, and that in all events a certain number of patients with no dehydration will be admitted for observation.

HOSPITALISATION

All patients on IV treatment are treated in this area.

RECOVERY OR CONVALESCENCE

Patients that have finished IV rehydration switch to oral maintenance therapy under observation, but no longer need a bed. They stay in the recovery area a few hours (for the night if their IV treatment finishes late) until being discharged. This organization makes beds available quicker. However convalescent patients are not yet fully cured and the administration of ORS and fluid loss should be monitored as closely as in “observation”.

The decision of which setup to choose depends on the context, particularly the national model of CTC organization, the size of the population covered, the number of severe cases in proportion to the total number of cases admitted, the overall response capacity (number of facilities available, capacity of ORPs to handle cases requiring oral treatment only, etc.), capacity of the CTC itself (space, maximum number of beds), etc.

Notes:
– In CTUs, there are fewer numbers of patients but the principle of grouping patients by age and category of treatment remains the same (on one side of the room, patients on IV treatment, on the other side, patients on oral treatment, and on each side, children < 5 years together).
– In ORPs it is better to separate dehydrated patients and patients with no dehydration if the premises allow it, and to group together children < 5 years in each treatment category.

7.1.2 Attendants

Adult, autonomous patients can be admitted unaccompanied to the CTC. Often, this can only be applied to adult males and adult women should preferably, or must imperatively, be admitted with an attendant.
Children and adolescents (all minors), pregnant women and anyone that requires assistance (the elderly, disabled individuals, etc.) or is in a serious condition are admitted with an attendant that stays with them throughout their stay.

Allow only one attendant per patient. This same person remains throughout the patient’s stay, in order to limit comings and goings and to avoid exposing more people than necessary to the vibrio. It may be useful to issue attendants authorised to stay in the CTC with a bracelet.

The attendant takes an active role in treatment, e.g. administration of ORS, comfort and monitoring of the patient. S/he can, and should be encouraged to, alert staff in the event of accidental interruption of IV treatment (catheter pulled out, empty infusion bag, etc.) or other situations that do not seem normal. Nevertheless medical staff remains responsible for medical care: monitoring of clinical evolution and treatment should not be delegated to attendants.

As for patients, attendants’ needs are covered by the facility. Logistics officers should take into account attendants’ needs: shelter, blankets, food, water, hygiene, sanitation, etc.
Means should be set up to avoid the attendant being contaminated (hand-washing points, showers, hygiene promotion, etc.).

7.1.3 Communication with patients and attendants

The patient and attendant should receive the following information:

On admission

– Patient’s problem and treatment required:
The explanation will vary depending on the knowledge and concepts of the population and the condition of the patient, but it should be simple and concrete. The aim of treatment is to give the patient the same quantity of water that s/he is losing (or has lost) through diarrhoea, by drinking ORS or IV treatment, depending on the case. The administration of ORS must be explained and understood.

– Description of the installations (potable water, showers men/women, latrines men/women, off-limit areas, etc.) and hygiene rules in the CTC:
• Hand-washing, shower and laundry.
• Dishes (cups, meals) must not be shared between patients and attendants.
• Breastfeeding women: hand-washing and washing of breasts with soap and water (do not apply chlorine solution) before breastfeeding.
• Collection of stools and vomit in buckets.

On discharge

– Maintenance therapy to be continued at home (Section 5.6).
– Means of avoiding cholera at individual and family level.

Depending on the setup and for all facilities (CTC, CTU, ORP), communication is entrusted to health promoters or nursing auxiliaries supervised by nurses, or to the nurses themselves.



Footnotes
Ref Notes
1

If a patient fills admission criteria but decides not to stay (“leaving against medical advice”), s/he must at least leave with ORS for home-based treatment.

2

In the event of home-based care, set up an efficient information service (how to prepare ORS, how to take it, when to return, etc.).