Download 1 - International Medical Corps

Multi-Agency
Training
Collaborative for the
Ebola Response in
West Africa
Facilitator Guides
Printed Version 1
March 2015
This training course is a joint work developed by International Medical Corps and
Massachusetts General Hospital. Comments should be directed to:
[email protected] or [email protected].
This training course is based on materials from: the World Health Organization (WHO), Doctors
Without Borders (MSF), the U.S. Centers for Disease Control and Prevention (CDC), clinical
feedback from International Medical Corps health care workers deployed to the Ebola outbreak,
and additional resources specifically referenced for the launch of the multi-agency training
collaborative (MATCO) to support the Ebola response in West Africa. None of these agencies
officially endorse this joint work but have granted use of their materials in order to provide the
best response possible to those suffering from the Ebola virus disease.
Technical Development Lead: Hilarie Cranmer, MD, MPH
Other contributors to specific sections: Adam Levine, Miriam Aschkenasy, Audrey Rangel, Dziwe
Ntaba, Hernando Garzon, Inka Weissbecker, Elizabeth Talbot, Janet Meyers, Kirsten Johnson,
Kristina Bayingana, Maya Bahoshy, Pranav Shetty, Sambhavi Cheelampati, Vanessa Wolfman,
Patricia Henwood, Elvis Ogweno, Carmen Paradiso, Peter Wallis, Samuel Grindley, Nikola
Usenovic, Jason Obten, Kelly Buchanan-Gelb, Megan Vitek, Rosa Nin Gonzalez.
© International Medical Corps, Massachusetts General Hospital
All rights reserved.
All requests for permission to reproduce or translate these materials – whether for commercial
or for non-commercial distribution– should be addressed to:
[email protected]. The designations employed and the presentation of the
material in this publication do not imply the expression of any opinion whatsoever on the part of
International Medical Corps or Massachusetts General Hospital concerning the legal status or
authorities of any country, territory, city or area or concerning the delimitation of its frontiers
or boundaries. Dotted lines on maps represent approximate border lines for which there may
not yet be full agreement.
The mention of specific companies or of certain manufacturers’ products does not imply they
are endorsed or recommended by International Medical Corps or Massachusetts General
Hospital in preference to others of a similar nature that are not mentioned. Errors and
omissions excepted, the names of proprietary products are distinguished by initial capital
letters.
This joint work between International Medical Corps and Massachusetts General Hospital
contains material developed by MSF, WHO, and CDC
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ALL REASONABLE PRECAUTIONS HAVE BEEN TAKEN BY INTERNATIONAL
MEDICAL CORPS AND MASSACHUSETTS GENERAL HOSPITAL TO VERIFY THE
INFORMATION CONTAINED IN THIS PUBLICATION. HOWEVER, THE
PUBLICATION IS BEING DISTRIBUTED WITHOUT WARRANTY OF ANY KIND,
EITHER EXPRESSED, IMPLIED OR STATUTORY. THE RESPONSIBILITY FOR THE
INTERPRETATION AND USE OF THE MATERIAL IN THIS PUBLICATION LIES
WITH THE READER. DUE TO THE DYNAMIC NATURE AND COUNTRY-SPECIFIC
CONTEXT OF THE EBOLA CRISIS, CERTAIN INFORMATION CONTAINED IN
THIS PUBLICATION MAY BECOME OUTDATED OR NO LONGER ACCURATE. IN
NO EVENT SHALL INTERNATIONAL MEDICAL CORPS OR MASSACHUSETTS
GENERAL HOSPITAL BE LIABLE FOR DAMAGES ARISING FROM THE USE OF
THIS PUBLICATION.
This joint work between International Medical Corps and Massachusetts General Hospital
contains material developed by MSF, WHO, and CDC
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FACILITATOR GUIDES
Table of Contents:
EFG#1 Exercise Facilitator Guide PPE Donning and Doffing…………….………4
EFG#2 Exercise Facilitator Guide Triage Scenarios………………………………13
EFG#3 Exercise Facilitator Guide Venipuncture and Simulated Clinical Care…25
EFG#4 Exercise Facilitator Guide Safe Handwashing and Glove Removal ….….33
EFG#5 Disinfection.…………………………………….…………………………….39
EFG#6 Safe Body Transport and Burial……..……………………………………..44
EFG#7A Ebola PSS Training Guide…………………………………….…………..50
EFG#7B Ebola PSS Pre - Post Test……………………………………….…………82
EFG#7C Ebola PSS Training Evaluation……………………………….…………..84
EFG#8 IFRC 2014 Working in Stressful Situations-Ebola………..……………….86
EFG#9 Tabletop Designing a Safe ETU……………………………………..………89
EFG#10 Mixing Chlorine…………………………………………….……….………92
EFG#11 Facilitator Guide M&E……………………………………………………..99
EFG#XX Exercise Facilitator Guide Outbreak Response…….……….…...………106
This joint work between International Medical Corps and Massachusetts General Hospital
contains material developed by MSF, WHO, and CDC
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EFG #1
Facilitator Guide:
PPE Donning and Doffing
This joint work between International Medical Corps and Massachusetts General Hospital
contains material developed by MSF, WHO, and CDC
4
Goal
Learn to safely dress in (don) and remove (doff) personal protective equipment (PPE) in
order to reduce risk of exposure to bodily fluids from Ebola-infected patients and
contaminated PPE while working in the high-risk area of the Ebola treatment unit (ETU).
Learning Objectives
1. The ritual of donning and doffing is just as important as the equipment itself
2. Donning of PPE should be assessed by a separate person to ensure that the full
complement of PPE has been placed correctly
3. Doffing of PPE must be observed by a separate person to minimize risk of
exposure to bodily fluids or contaminated PPE
4. Hand hygiene is a critical aspect of personal protection
Setup
Two separate mock ETUs will be needed to allow for two cohorts of 15-16 trainees to
practice concurrently. Each mock ETU should include:
1) Low-risk changing area for women (enclosed for privacy) with cubbies or hooks
for storing street clothing and personal items
2) Low-risk changing area for men (enclosed for privacy) with cubbies or hooks for
storing street clothing and personal items
3) Area for donning high-risk PPE, including shelves or boxes for storing PPE
4) Area for doffing high-risk PPE, including a tap stand with chlorine or water, trash
can for disposable PPE, buckets or boxes for reusable PPE, and a line drawn on
the ground to designate separation of low- and high-risk areas
Note: If mock ETUs are not available, then a large room with adjoining bathrooms for
men and women can be used instead. The large room can be separated with tape or
string into donning and doffing areas while the bathrooms can be used as low-risk
changing areas.
This joint work between International Medical Corps and Massachusetts General Hospital
contains material developed by MSF, WHO, and CDC
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Supplies and Equipment
Low-risk PPE
1. Scrubs
2. Rubber boots (assorted sizes from 39 – 46)
WHO PPE
1. Nitrile inner gloves (small, medium, and large)
2. Outer gloves
a. Latex surgical gloves for clinical staff (assorted sizes from 6.0 – 8.0)
b. Heavy duty rubber cleaning gloves for non-clinical staff
3. Disposable, impermeable gown to cover clothing and exposed skin
4. Half dome N-95 mask
5. Face Shield
6. Head Covering
7. Heavy waterproof apron
MSF PPE
1. Nitrile inner gloves (small, medium, and large)
2. Outer gloves
a. Latex surgical gloves for clinical staff
b. Heavy duty rubber cleaning gloves for non-clinical staff
3. Protective suit, either Tychem or Tyvek, with wrist and ankle elastic, covered
zippers, and adhesive neck flap seal. Suit may have built in hood, but this is not
used and is instead rolled up behind neck.
4. Hood (Custom made hood with cape and built in mask)
5. Duckbill N95 mask
6. Heavy waterproof apron
Other Supplies (Optional)
1.
2.
3.
4.
5.
6.
Anti-fog drops
Duct tape
Tap stands for washing hands
Foot basins
Spraying machines for simulating spraying
Mirror for PPE donning area
This joint work between International Medical Corps and Massachusetts General Hospital
contains material developed by MSF, WHO, and CDC
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Instructions
Please note that for exercise purposes only certain items will be reused. As the
facilitator you will need to let participants know at the beginning of the exercise which
items will be reused. You should also point out the buckets or receptacles for each type
of reusable supply, in addition to trashcans that should be used for disposable items
only.
At the start of the exercise, participants will be divided into two cohorts of 15-16 trainees,
both of which will train concurrently in one of the two mock ETUs. To start, all trainees in
each cohort should enter the appropriate low-risk changing area and change into scrubs
and boots as per the instructions below.
Next, participants will move to the high-risk PPE donning area, and will be divided again
into two groups of 7-8 trainees. The facilitator will read out the step-by-step instructions
for donning the WHO PPE, as detailed below. While the first group of trainees is
dressing in WHO PPE, the second group will be acting as safety monitors or “buddies,”
helping the first group to dress in their PPE and checking to make sure they have done
so correctly.
After the donning process is complete, everyone will move to the high-risk doffing area
and the second group of trainees will take the role of sprayers, guiding the first group
through the process of PPE removal as per instructions below, under the supervision of
the facilitator who will help keep everyone on track. In order to save time, all 7-8
participants in the first group should be doffing at the same time. The entire WHO PPE
donning and doffing process should take about 40 minutes.
Afterwards, the groups will switch, and the second group will don and doff WHO PPE
while the first group acts as safety monitors/sprayers. This should take another 40
minutes, for a total time of 1 hour and 20 minutes.
At this point, there can be a 20-minute break for participants to rest and drink some
water. Afterwards, the entire process will be repeated using the MSF style PPE for
another 1 hour and 20 minutes.
Remind participants to never rush through this process. Donning should be done slowly,
methodically and meticulously. Emphasize that donning should never be done alone; it
always requires someone to double check that it is done correctly, even for highly
experienced staff. Doffing should be done with the same rigor and should be done with
the assistance of a sprayer/safety monitor every time.
This joint work between International Medical Corps and Massachusetts General Hospital
contains material developed by MSF, WHO, and CDC
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Below are specific instructions for participants for each area.
A. Low-Risk Donning
1.
2.
3.
4.
5.
6.
7.
Remove all jewelry, including watches, rings and earrings
Ensure all hair is tied back
Secure glasses with eyeglass retainer
Change into scrubs and rubber boots
Place clothing and personal items in cubby or hang on rack
Be sure to use the bathroom if necessary
Ensure cell phone is not in pocket of scrubs
B. High-risk Donning - WHO
1. Assemble all PPE.
a. Inner gloves (nitrile)
b. Outer gloves
i. Clinical staff – latex surgical gloves
ii. Non-clinical staff – rubber cleaning gloves
c. Disposable impermeable gown
d. N-95 half dome mask
e. Face shield
f. Waterproof apron
g. Head covering
2. Put on inner gloves.
3. Put on disposable impermeable gown over the scrubs and inner gloves, keeping
the front as smooth as possible. Ask buddy to help tie in the back. If there are
loops for the thumbs, they should be used.
4. Put on the mask over nose and mouth and pinch metal at bridge of nose to
ensure a tight seal.
5. Put on face shield (if goggles are being used instead, make sure to simulate
placing anti-fog drops on inside of goggles).
6. Put on head covering over ears and straps of mask/face shield
7. Put on apron. Buddy should tie in back using an easy to untie bow knot and show
the participant the string to pull later to untie the knot.
8. Put on outer pair of gloves over the surgical gown sleeve (if duct tape is used to
tape outer gloves to gown, demonstrate how to leave a small folded tag for easy
duct tape removal later)
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contains material developed by MSF, WHO, and CDC
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9. Buddy should evaluate the PPE to ensure it is on correctly.
C. High-risk Doffing – WHO
1. Step into buckets with 0.5% chlorine solution (these can have actual chlorine or
just be empty) and then step forward up to line on the ground.
2. Sprayers should simulate spraying participants’ front and back.
3. Wash gloved hands with 0.5% chlorine solution and throw some chlorine solution
on top of the tap. (Again, this can be actual chlorine or just empty stands used to
simulate the process of washing hands.)
4. Remove outer pair of gloves and discard into appropriate receptacle.
5. Wash gloved hands with 0.5% chlorine solution and throw some chlorine solution
on top of the tap.
6. Remove apron and place into appropriate receptacle.
7. Wash gloved hands with 0.5% chlorine solution and throw some chlorine solution
on top of the tap.
8. Remove gown carefully, making sure not to touch the outer front part of the gown,
and discard into appropriate receptacle.
9. Wash your gloved hands with 0.5% chlorine solution and throw some chlorine
solution on top of the tap.
10. Remove head covering and discard into appropriate receptacle
11. Wash .gloved hands with 0.5% chlorine solution and throw some chlorine solution
on top of the tap.
12. Remove face-shield by grabbing the band in back of the head and discard into
appropriate receptacle.
13. Wash gloved hands with 0.5% chlorine solution and throw some chlorine solution
on top of the tap.
14. Remove mask from behind the head and discard into appropriate receptacle.
15. Wash gloved hands with 0.5% chlorine solution and throw some chlorine solution
on top of the tap.
16. Sprayers should simulate spraying front, sides, back and bottom of boots as
participants step over the line.
17. Remove the second pair of gloves using aseptic technique.
18. Wash hands with 0.05% chlorine or soap and water.
This joint work between International Medical Corps and Massachusetts General Hospital
contains material developed by MSF, WHO, and CDC
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D. High-risk Donning – MSF
1. Assemble all PPE.
a. Inner gloves (nitrile)
b. Outer gloves
i. Clinical staff – latex surgical gloves
ii. Non-clinical staff – rubber cleaning gloves
c. Ty-Chem or Ty-Vek suit
d. N-95 duck bill mask
e. Goggles (and anti-fog solution and wipes)
f. Waterproof apron
g. Hood with cape
2. Prepare hood. Using his or her hand, participants should make a horizontal slit in
the face mask section of the hood so that the N-95 mask can fit inside the hood.
Note: the size of this slit should be large enough for the N-95 to penetrate the
hood but NOT larger.
3. Prepare goggles with anti-fog solution. Spray goggles with solution and wipe with
tissue (spray glasses also if you have them). Set on table to dry.
4. Put on first pair of nitrile gloves.
5. Put on Ty-Chem suit over the rubber boots and gloves.
6. Secure Ty-Chem suit (unless it will be reused for training purposes). There are 4
closures.
a. Pull up zipper and be sure it is zipped fully
b. Remove adhesive strip from left side and cover the zipper
c. Remove adhesive strip from right side and cover the zipper
d. Remove adhesive strip from the collar strap and secure
7. Put on N-95 mask. Secure the 2 bands in back of the head, with one over the ears
and one under the ears. No band should be placed across the ears. Fasten bridge
to nose.
8. Put on hood and ensure the duck bill extends through the slit.
a. Buddy should help fasten the hood in back of head and secure the top 3
ties behind head using bow knots.
b. Secure the 4th and lowest tie by bringing it down under the arms and
fastening it across the chest using a bow knot.
9. Put on waterproof apron. Buddy should tie it in back with a bow and show
participant the string to pull to untie. Ensure the front is smooth.
10. Put on prepared goggles so that no skin is exposed between the goggles and the
hood. If available, look in the mirror, to make sure goggles and mask cover your
entire face.
11. Put on second pair of gloves over the Ty-Chem sleeve.
This joint work between International Medical Corps and Massachusetts General Hospital
contains material developed by MSF, WHO, and CDC
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12. Buddy should evaluate PPE to ensure that it is on correctly and no skin is
exposed.
E. High-risk Doffing – MSF
1. Step into buckets with 0.5% chlorine solution (these can have actual chlorine or
just be empty) and then step forward up to line on the ground
2. Sprayer should simulate spraying participant front to back including the arms,
hands, and everything below the shoulders with 0.5% chlorine (emphasize to
never spray face).
3. Wash your gloved hands with 0.5% chlorine solution and throw some chlorine
solution on top of the tap to disinfect it before turning tap off.
4. Remove your outer pair of gloves and place in appropriate receptacle.
5. Wash your single gloved hands with 0.5% chlorine solution and throw some
chlorine solution on top of the tap.
6. Lean forward, reach back and untie apron. Lift it forward over your head by strap
to remove it, then drop it into appropriate receptacle.
7. Wash your gloved hands with 0.5% chlorine solution and throw some chlorine
solution on top of the tap.
8. Bend forward to remove your goggles. Grab both sides, pulling forward and over
and then off of your head. Simulate dunking three consecutive times in 0.5%
chlorine, and then drop into appropriate receptacle.
9. Wash your gloved hands with 0.5% chlorine solution and throw some chlorine
solution on top of the tap.
10. Untie the three ties in back of your head and the tie across your chest which
secure the hood (In the field you can break them, but not during the
exercise). Bend forward and remove the hood by grabbing it from behind your
head and pulling it off. Place in appropriate receptacle.
11. Wash your gloved hands with 0.5% chlorine solution and throw some chlorine
solution on top of the tap.
12. Remove Ty-Chem suit by simulating opening adhesive closures, unzipping, and
pulling suit off upper body without touching the outside. Push down, touching only
the inside. Once the suit is down past the knees removal will proceed without
hands by moving feet, with boots still on, up and down to remove.
13. The sprayer will simulate spraying the suit and the participant will then place it into
the appropriate receptacle, touching only the inside.
14. Wash your gloved hands with 0.5% chlorine solution and throw some chlorine
solution on top of the tap.
15. Bend forward to remove N-95 by pulling the mask from sides out and off your
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contains material developed by MSF, WHO, and CDC
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head and throw away (DO NOT reach behind head).
16. Wash gloved hands with 0.5% chlorine solution and throw some chlorine solution
on top of the tap.
17. Sprayers should simulate spraying front, sides, back and bottom of boots
18. Remove the second pair of gloves using aseptic technique.
19. Wash hands with 0.05% chlorine or soap and water.
This joint work between International Medical Corps and Massachusetts General Hospital
contains material developed by MSF, WHO, and CDC
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EFG#2
Facilitator Guide:
Triage Scenarios
This joint work between International Medical Corps and Massachusetts General Hospital
contains material developed by MSF, WHO, and CDC
13
Goal
This exercise will provide participants with an opportunity to practice navigating the triage
process. Even if most clinicians working in an ETU will not be responsible for conducting
triage themselves, they may be asked to advise others on triage decisions or they may
have to respond to triage errors (either admission of patients to the ETU who should not
have been admitted or non-admission of patients who should have been admitted.)
Learning Objectives
1) Learn the clinical criteria for a suspect case of Ebola and how to apply those
criteria in real world situations
2) Understand the differences between the triage process in an ETU and that of a
regular health care facility
3) Incorporate gender, linguistic and cultural considerations in the triage process in
order to avoid missing or misinterpreting information
4) Respect the vital importance of the triage process to the management of an Ebola
outbreak, despite it being an imperfect process. Not admitting an Ebola-infected
patient to the ETU can propagate the epidemic, while admitting a non-infected
patient places them at risk of acquiring Ebola.
Setup
Participants should be split into two groups, each consisting of 5-7 people. If available,
the facilitator can simulate an actual ETU triage setting by setting up a double barrier of
1-2 meters distance between participants and facilitator. However, this exercise can also
be done in a normal room with participants sitting in a semicircle of chairs and the
facilitator sitting somewhat removed from them.
In each case, the facilitator will play the role of the patient presenting for triage (as well
as their family member), while the participants will take turns playing the role of triage
provider. At the start of each case, the facilitator will select a participant to act as the
triage provider. If more than one facilitator is present per group, one can play the role of
the patient and the other the role of the family member.
This joint work between International Medical Corps and Massachusetts General Hospital
contains material developed by MSF, WHO, and CDC
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Equipment and Supplies
Chairs for facilitator and participants
Gloves and masks for participants to wear (optional)
Thermometer (optional)
Instructions
Begin by introducing the exercise to participants:
1. We are in a rural part of Liberia that has been hard-hit by Ebola.
2. I (the facilitator) am a patient presenting to the triage area at an ETU.
3. You (the trainee) are a clinician responsible for triaging patients (participants will
rotate leading the interview for each case). However, the whole group should work
together to ask questions and make the triage decision.
4. Your student guide includes an example of a triage algorithm and has space for
each case to make notes if you’d like.
5. As the patient, I will give you some basic information about me and why I have
come to the ETU.
6. It’s up to you to ask me questions to get the information you need to make a triage
decision.
7. Use the algorithm and case definition to guide your decision.
8. You may (pretend) to ask me to take my axillary temperature. I will let you know
the reading (or tell you the thermometer is broken).
9. At the end of each case, you must make one of the following triage decisions and
explain why you made the decision:
a. Admit patient to the suspect ward of the ETU
b. Transfer patient to a local non-ETU health care facility
c. Discharge patient home to their community
Explain to participants that these scenarios are all based on real ETU situations. Each
case should take about 10-15 minutes (leave a little extra time for the final two cases,
which involve additional discussion at the end). Answers are provided below to
participant questions, but the facilitator should make up answers to other questions they
ask based on the particulars of the case.
This joint work between International Medical Corps and Massachusetts General Hospital
contains material developed by MSF, WHO, and CDC
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Note: Participants should have a triage tool similar to the one on the following page in
their student guide.
CASE 1
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Patient ID: 40-year-old man brought to ETU by his family
Patient responses to trainee questions:
“I don’t even know why I’m here. My family made me come.”
“I do get tired sometimes but who doesn’t. I probably just have malaria.”
“I do have stomach pain and I feel like a want to throw up, but can’t”
“Yes, my throat hurts.”
“No one in my village is sick.”
“No one in my family is sick.”
“No recent deaths in my village.”
“I did visit a friend for a couple days in another village before he died last week. I didn’t
go to his funeral though.”
“Yes, when I was visiting my friend I stayed in his house.”
Note: If trainee takes temperature it is 38.5°C
Facilitator:
“What is your assessment of the patient and what is your triage decision?”
Probing questions:
“Does the patient meet the clinical criteria for a suspect case?”
“Does the patient have epidemiologic risk factors?”
“Why did you make that decision?”
Answer:
1. Patient has had CONTACT with a sick person who later died.
2. Patient has 3 or more SYMPTOMS including fever, nausea, abdominal pain, and
sore throat.
3. Therefore, patient is a suspect case.
Triage decision:
Admit to ETU for evaluation
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contains material developed by MSF, WHO, and CDC
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Key points to discuss:
1. Patient had no real explanation for why he was there
2. You may have to ask many questions and specific questions to find out if the
patient has had contact with a confirmed or suspected case.
CASE 2
Patient ID: 18-year-old woman
Patient responses to trainee questions:
“I feel sick.”
“I have had diarrhea and stomach pain for a few weeks.”
“No, I haven’t had a fever or chills.”
“No one in my family is ill and no one has died in my family.”
“No one I know is sick.”
“I have not been to any funerals recently.”
“I am on my period, but normal flow, in fact it is almost over and very little bleeding.”
Note: If trainee takes temperature it is 36.5°C
Facilitator:
“What is your assessment of the patient and what is your triage decision?”
Probing questions:
“Does the patient meet the clinical criteria for a suspect case?”
“Does the patient have epidemiologic risk factors?”
“Why did you make that decision?”
Answer:
1. Patient has had NO CONTACT.
2. Patient has diarrhea but no other symptoms.
3. Therefore, patient is not a suspect case
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contains material developed by MSF, WHO, and CDC
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Triage decision
Discharge to community or refer to another hospital or health care clinic depending on
perceived severity of diarrhea
Key points to discuss:
1. As clinicians you may be tempted to try to diagnose, examine, or test patients for
other diseases.
2. However, this is triage and decisions must be made quickly, and you are only
determining whether to admit to the ETU or not.
CASE 3
Patient ID: Mother brings in her 6-month-old infant with a fever
Mother’s responses to trainee questions:
“My baby girl is really hot and I’m very worried because there have been some recent
deaths in my village.”
“She is 6-months-old and is breast-feeding normally.”
“No one in our home is sick, and because of the illness in the village we have stayed
home alone together.”
“No, she has not had any diarrhea or vomiting.”
“She cries sometimes, but stops when I comfort or feed her.”
“She is nursing well.”
Note: If trainee takes child’s temperature it is 38.5°C
Facilitator:
“What is your assessment of the patient and what is your triage decision?”
Probing questions:
“Does the patient meet the clinical criteria for a suspect case?”
“Does the patient have epidemiologic risk factors?”
“Why did you make that decision?”
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Answer:
· Patient has had NO CONTACT.
· Patient has a fever but no other symptoms of Ebola.
· Therefore, patient is not a suspect case.
Triage decision
Refer to another hospital or health care clinic.
Discussion Point:
What about the mother’s health?
It may be wise to ask her questions about her symptoms, as she maybe too worried
about her baby to think about herself.
She could be a contact for the child if she has had symptoms of Ebola.
CASE 4
Patient ID: 34-year-old man perspiring heavily
Patient responses to trainee questions:
“I don’t feel well. It’s been hard on my family because I sell charcoal for a living and
haven’t been able to work.”
“Sometimes my body is hot and sometimes I get cold and start shaking.”
“I am so tired all the time; it’s hard to leave my bed.”
“Some have died in my village, but I haven’t been to any of their funerals because I
haven’t felt well enough to go.”
“I don’t know what they died from, but I did not have any contact with them for a while.”
“Yes, my stomach has been running and hurting very bad for almost 2 weeks. It is very
tiring to vomit so much.”
“I have had running stomach, but no blood.”
Note: If trainee takes temperature it is 37.2°C.
Facilitator:
“What is your assessment of the patient and what is your triage decision?”
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contains material developed by MSF, WHO, and CDC
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Probing questions:
“Does the patient meet the clinical criteria for a suspect case?”
“Does the patient have epidemiologic risk factors?”
“Why did you make that decision?”
Answer:
1. Patient reports NO CONTACT with confirmed cases BUT
2. Patient has history of FEVER and three other Ebola-associated symptoms
(nausea/vomiting, diarrhea, and intense fatigue)
3. Therefore, patient is a suspect case.
Triage decision:
Admit to ETU for evaluation
Discussion Point:
What about the fact that he is a salesman? What about his family at home?
May want to further probe for contacts.
CASE 5
Patient ID: 18-year-old man struggles to get into triage and requires assistance from
ambulance staff who brought him. He looks tired and is sweating. He is holding his head
with his hand.
Patient responses to trainee questions:
“I have a terrible headache that won’t go away. “
“I have had this headache for 3 days.”
“I feel weak and tired”
“I have been feeling hot and some chilliness, but I don’t know if I have a fever.”
“My grandmother died 2 weeks ago here at this ETU. Don’t you remember? I carried her
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here because she was so weak.”
Note: If trainee takes temperature it is 38.1°C
Facilitator:
“What is your assessment of the patient and what is your triage decision?”
Probing questions:
“Does the patient meet the clinical criteria for a suspect case?”
“Does the patient have epidemiological risk factors?”
“Why did you make that decision?”
Answer:
1. Patient has had CONTACT with a confirmed case.
2. Patient has SYMPTOMS including fever (history of subjective fever or chills
counts), weakness, and headache.
3. Therefore, patient is a suspect case.
Triage decision
Admit to ETU
Additional Challenge:
Ask trainee to explain to the patient the decision to admit to the ETU.
Patient Response:
“No, no I can’t stay. I have to go home to take care of my father, who is also ill.
Facilitator:
What would you do?
Key Discussion Points:
You may not be able to force them to stay in the ETU (for legal or logistical reasons), but
you can try and persuade them of the importance to their own health and that of their
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community. You can sometimes call other family members, pastors, community leaders,
or county health officials to convince the patient. Use your psychosocial officer to help as
well.
If the patient still refuses, there are steps you can take such as: send them home with a
health/home protection kit and signal the contact tracing team to follow him daily and
continue to encourage him to come to the ETU.
CASE 6
Patient ID: 24-year-old woman, 7 months pregnant, history of caesarean delivery with
previous pregnancy
Patient responses to trainee questions:
“I feel like I am in labor now. I am scared because I have been bleeding for 2 days. I
went to the hospital, but they sent me here.”
“The bleeding is from down below. There’s lots and lots of it. My dress is soaked.”
“My husband and sister died of Ebola a week ago.”
“I don’t know if I have a fever. I do feel tired though.”
“We all lived together, but now there is no one to help me with the baby and I have no
where to go.”
Facilitator:
“What is your assessment of the patient and what is your triage decision?”
Probing questions:
“Does the patient meet the clinical criteria for a suspect case?”
“Does the patient have epidemiologic risk factors?”
“Why did you make that decision?”
Answer:
1. Patient has had CONTACT with confirmed cases.
2. Patient has SYMPTOMS of vaginal bleeding, likely a miscarriage.
3. Therefore, patient is a suspect case.
Triage decision
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Admit to ETU for evaluation
Key Discussion Points:
1. How will you manage this patient? Sometimes there are no good solutions or
options. Should be a team decision. Must consider the health and safety of the
HCW in the ETU and the integrity of the ETU.
2. What is the prognosis for the woman and the fetus? This is a dire situation for the
woman and the fetus. Ebola in pregnancy is uniformly fatal for the fetus and
usually also fatal for the mother.
3. What are the options for managing this delivery? Surgery is not an option, not
even for retained placenta. Could assist with normal delivery but will be extremely
high-risk.
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EFG#3
Facilitator Guide:
Venipuncture and
Simulated Clinical Care
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Goal
Learn to safely obtain blood from a patient for diagnostic purposes and to safely package
the sample for transport to a diagnostic lab. Learn to manage common clinical scenarios
within the ETU.
Learning Objectives
1. A risk assessment must be done prior to the delivery of any care in an Ebola
treatment unit (ETU), especially before invasive procedures such as placing an
IV or drawing blood.
2. Invasive procedures always require 2 people: one to perform the procedure and
the other to assist in handing out material and controlling the patient.
3. Preparation is critical to providing care safely in the ETU:
a. Ensure all supplies have been collected and all sample tubes are labeled
prior to entry into the high-risk area.
b. Ensure a sharps container is nearby.
4. Personal and patient protection always comes first in the ETU:
a. NEVER recap a used needle.
b. Wash your gloved hands before and after obtaining blood.
Set Up
The mock ETU should have areas designated as low-risk and high-risk. In the low-risk
area, there should be a cabinet or shelves with supplies for drawing blood and placing
IVs, as well as for labelling tubes. Inside the high-risk area there should be at least two
cots, one with a blood draw dummy and one empty for use by a simulated patient. There
should also be sharps containers, trash bags/cans, and a tap stand to simulate washing
hands with 0.5% chlorine.
There should also be PPE dressing and undressing areas in the mock ETU. Participants
will already have practiced PPE dressing and undressing on Day 1, but you can ask
them to do it again for this simulation in order to simulate the experience of drawing
blood and managing patients while in full PPE.
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Equipment and Supplies:
1.
2.
3.
4.
Gloves
Mask
Goggles
Dummy for blood draw (this can be a full mannequin or just rolled up sheets to
simulate arms).
5. Sharps container
6. Trash bags/cans for non-sharp waste
7. Laboratory sample tube (EDTA tube or plastic tubes with rubber caps, vacuumextraction blood tubes or glass tubes with screw caps)
8. Blood sampling systems (either IV catheter and syringe, or butterfly needle and
syringe, or vacuum extraction system with holder)
9. Tourniquet
10. Skin antiseptic solution: 70% isopropyl alcohol
11. Gauze pads
12. Adhesive bandages
13. Marker for writing on laboratory sample
14. Plastic bags for sample transport
15. Bucket for sample transport
16. Sprayer for spraying sample bags
17. Extra buckets for patient vomit
18. Sample lab slips
19. Pens
20. Truck or raised area to act as ambulance bed
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Instructions
The clinical/MHPSS group can be split into two smaller groups for this exercise. The first
group will practice safe blood draw and specimen packaging with the dummy in the first
cot while the second group practices common clinical scenarios with the live human
actor in the second cot. The live human actor can be one of the trainers or someone
else.
Participants should be asked to prepare all of their supplies in the low-risk area before
entering into the high-risk area. They can be given plastic bags (PPE packaging) to carry
in their supplies. You can choose to have them dress in full PPE before entering the
high-risk area, or not, based on time and supply constraints. However, at a minimum
they should be wearing the double gloves, mask, and goggles that they would typically
wear in high-risk.
As always, participants should be assigned buddies before entering into the high-risk
area of the mock ETU. Detailed instructions for each of the clinical scenarios are below.
Safe Blood Draw
1. Patient Selection
a. Blood should be collected as soon as possible from suspect patients to
further triage them into confirmed cases or potentially negative cases
b. Only patients who have had symptoms for greater than three days AND
have a negative PCR by an approved lab can be discharged
2. Assemble all materials for drawing blood before donning PPE
a. EDTA tube for blood draw
b. Tourniquet
c. Antiseptic solution
d. IV catheter and syringe or vacuum extraction system
e. Gauze pads
f. Adhesive bandage
g. Plastic bags for sample transport
3. Label tube for blood draw and plastic bag with patient’s name, ID, gender, age,
and date
4. Optional: don MSF PPE with a partner and ensure equipment is on correctly
before entering high-risk. Alternatively, just don the double gloves, mask, and
goggles.
5. Enter the high-risk area and identify the patient (dummy)
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6. Perform a risk assessment
a. Is the patient safe to draw blood from?
b. Where is the sharps container located?
c. Where is the hand hygiene station?
d. What is the protocol for a needle stick injury?
7. Discuss the procedure with the patient
8. Wash your gloved hands with 0.5% chlorine.
9. Set up the blood draw area so that equipment is easily within reach
a. Place the sharps container directly next to you
b. Instruct your partner to hold the labeled blood collection tube, chlorine
sprayer, and labeled plastic bags
10. Sterilize the patient’s arm with antiseptic solution
11. Place the tourniquet above the insertion site
12. Hold the arm distal to insertion site with one hand and place needle into vein with
the other
a. Make certain that neither your hand or your buddy’s hand are near the
needle insertion site
b. Warn the patient one last time that you are about to stick them and that
they must hold perfectly still
13. If you are using an IV catheter to draw blood:
a. Thread the IV catheter and remove the needle
b. Safely discard the needle into the sharps container, making certain first the
nobody is between you and the container
c. Draw blood from the catheter with the syringe
d. Secure the IV catheter and cap it
e. Ask your buddy to pull the top off the EDTA tube and hand it to you
f. Hold away from body and qquirt blood from the syringe into the EDTA tube
WITHOUT a needle and then firmly replace the purple cap
g. Immediately discard the syringe in biohazard bag
14. If you are using a vacuum extraction system to draw blood:
a. After you insert the needle with the vacuum extraction holder attached, ask
your buddy to hand you the EDTA tube
b. Place the EDTA tube in the vacuum extraction holder carefully with one
hand while holding the needle firmly in place with the other
c. Your hand holding the needle should rest against the patients arm so if
their arm moves your hand will move with it
d. Once the tube is full, remove it from the vacuum extraction holder and hand
it to your buddy
e. Remove the needle and discard immediately in sharps container, making
certain first that nobody is between you and the container
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f. Do NOT recap the needle!
g. Place a gauze bandage over the needle stick site and secure with adhesive
tape
15. If the patient bleeds profusely from the needle stick place additional gauze over
the puncture site and hold pressure for 5 minutes then secure the bandage with
tape and instruct the patient to hold pressure over the site.
16. Wash your gloved hands with 0.5% chlorine.
Specimen Packaging
1. Hold the collection tube out so your partner can spray the outside of the tube with
0.5% chlorine solution
2. Place the sprayed labeled blood collection tube into the labeled plastic bag and
seal the biohazard bag.
3. Spray the outside of the sealed labeled biohazard bag with 0.5% chlorine
4. On exiting the high-risk area, the plastic bag should be carefully dropped into a
bucket with a small amount of 0.5% chlorine at the bottom, being careful not to
splash.
5. If the sample will be transported far, it should be transferred from the bucket to a
cooler and the cooler should be sprayed with chlorine.
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Safe Ambulation
In this scenario, the trainer should play a patient who has just been brought by
ambulance and will need to be admitted to the suspect ward of the ETU. The patient is
awake, but very weak and unable to walk without assistance. Two participants at a time
should practice aiding the patient from the ambulance to their cot in the ETU. This should
be about 10 meters, but can vary based on the set up of the mock ETU. On the way, the
patient can try do something disruptive, such as pretend to vomit or pass out completely.
1. Approach the patient with your buddy. Introduce yourself to the patient and
explain that you will be helping them back to their bed in the ETU.
2. Ask the patient to sit on the edge of the truck bed.
3. One person should stand on either side of the patient and place one arm
underneath the patient’s armpit to help them to the ground.
4. Keeping one arm under the patient’s armpit, grasp the forearm of the patient with
your other hand. In this way you can help support and guide the patient while also
preventing any wild movements of their arms.
5. As you walk with the patient, take slow and even steps. Be sure to stay on their
side, so if they vomit or cough it will not be on you.
6. When you reach the patient’s cot, lower the patient to a seated position on the
edge of the cot.
7. One participant can lift up the patient’s feet onto the cot while the other helps
lower their upper body onto the cot.
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The Agitated Patient
The participants will only be given information that this scenario is about practicing
administering IV medication. However, in this scenario, the trainer should play a patient
who is agitated and confused. The patient is wandering around the high-risk area,
occasionally stopping to vomit on the floor. The patient may be dragging an empty bag
of IV fluid around behind them. The participants should practice calming the patient down
and leading them back to their bed. You can run the scenario a couple different times, in
one case where the patient is easy to guide back to bed and can then be given a
sedative safely through their IV. In another scenario the patient becomes more violent,
and rips out their IV and then runs towards the door. In this case the participants should
stand aside and let the patient go and not try to physically stop the patient.
1. Breaking glass vials is the most common way that clinical staff are exposed to
injury in an ETU, even more common than a needle stick injury. Glass vials
should NEVER be brought into the high-risk area.
2. Instead, break the glass in the low-risk area and draw the medication up in a
syringe. Also draw up a syringe with saline flush.
3. Carry both syringes with you into the high-risk area along with your other supplies.
4. Wash your gloved hands with 0.5% chlorine.
5. Approach the patient, introduce yourself and explain that you need to give them
some medicine through their IV.
6. If there is a capped needle on the syringe, remove it carefully and drop it in the
sharps container.
7. Uncap the IV catheter and insert the syringe. Slowly inject the medication.
8. Afterwards flush the catheter and recap it.
9. Discard both syringes in the biohazard bag.
10. Wash your gloved hands with 0.5% chlorine.
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EFG#4
Facilitator Guide:
Safe Handwashing and
Glove Removal
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33
Goal
To learn some basic yet effective ways to reduce the risk of transmitting Ebola to
yourself or others while working in the Ebola Treatment Unit.
Learning Objectives
1. Practice excellent hand washing, the most important personal behavior for
mitigating the risk of infection within the ETU.
2. Learn how to safely remove gloves in order to reduce your risk of selfcontamination within the ETU.
3. Learn other protective behaviors that can reduce your risk of self-contamination
within the ETU.
Set Up
This exercise will ideally be performed outside, ideally in small groups of 5-7 participants.
All that is needed for set up is a tap stand with 0.05% chlorine and a bucket beneath the
tap.
For the second part of the exercise, you will pour the bucket on the ground to create a
muddy puddle.
Supplies and Equipment
1.
2.
3.
4.
Tap stand with 0.05% chlorine
Bucket
Gloves (small, medium, large)
Trash bag/can
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Instructions
Hand Washing
Everyone knows how to wash their hands. In this exercise you will emphasize to
participants how to wash their hands as though their life depends on it. Each participant
should practice excellent hand washing, focusing on the areas of the hands commonly
missed (see chart below). Time each person and let them know at the end how long they
actually spent washing their hands. Make sure each person disinfects the tap before and
after washing their hands.
Areas of the Hand Frequently Missed During Typical Hand Washing
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Procedure for Washing Hands Properly
Be certain to cup some
chlorine in your hands at
the end of your hand
washing and drop onto tap
before turning off.
Safe Glove Removal
For this exercise, pour some water or the excess chlorine in the bucket onto the dirt to
create a puddle of mud. Each participant should then be instructed to put on gloves and
coat them in mud (being careful not to get any on their wrists or arms. Make sure they
coat the front and back of their gloves.
Next they should practice the procedure below of safely removing their gloves,
attempting to do so without getting any drop of mud on their hands or wrists.
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Protective Behaviours in the ETU
For this final part of the exercise, you should go around the group and quiz each person
on what they would do in each of the common situations listed below. Participants will
have the scenarios on the left but not the answers on the right in their student guide.
The Following Happens to You in the
High-risk Area of the ETU:
What Would You Do?
Your nose itches
Restrain from touching your nose or mask.
Vomit spatters on your apron
Wash off with 0.5% chlorine as soon as
possible.
You have to cough or sneeze
Do not touch your mouth, mask of shield.
Just cough or sneeze through the mask.
You start to feel very, very hot
Notify your buddy and exit as soon as
possible.
You cannot find your buddy
Call out his or her name.
There is a fly or insect in the goggles
Do not remove or touch the goggles. Notify
your buddy and exit as soon as possible.
You need to urinate
Notify your buddy and exit together when
mutually convenient.
Your goggles fog and you cannot see
Notify your buddy and exit as soon as
possible.
You feel faint
NOTIFY YOUR BUDDY OR THE CLOSEST
STAFF MEMBER AND EXIT TOGETHER
IMMEDIATELY.
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EFG#5
Disinfection
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39
Goals:
•
To safely clean and disinfect patient care areas, including contamination caused by any
body fluid.
Key Points:
• Hand hygiene is essential for protecting staff and patients.
• Cleaning and disinfecting is a high-risk activity. PPE is essential.
• All waste from a high-risk zone (ETU, house of a confirmed or suspect case) is
considered highly contaminated.
• Waste must be safely collected, handled, transported to, and disposed of in a secure
location inside the high-risk zone.
• Soap, chlorine, and UV light destroy the Ebola virus.
• Spills of bodily fluids must be cleaned and disinfected immediately.
o Do NOT use a broom, because sweeping might disperse virus particles.
o Spraying must also be done carefully to avoid any aerosolization of particles.
• Trash must be appropriately sprayed with 0.5% chlorine and double bagged.
• The only things that should leave a High-risk zone are:
o Personnel, suspect patients with negative test results, and confirmed patients who
have recovered and meet discharge criteria
o Dead bodies in body bags
o Boots
o Goggles
o Reusable aprons
o Reusable heavy duty rubber gloves
o Scrubs
CHLORINE is your FRIEND
• 0.5% for anything that is dead or non-living (exception—immediate response to certain
PPE breaches)
• 0.05% for things that are alive (living human tissue/skin, things humans touch)
• The virus can survive in areas where chlorine does not reach, such as inside solid
organic waste (stool, emesis, blood clots, etc.)
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Set up:
This occurs in a simulated ETU.
Participants divide into small groups, don PPE and run through the exercise in full PPE.
Instructor needs for Each ETU needs:
Instructors may serve multiple roles, but each location needs at least 3 instructors.
1. Instructor for donning
2. Instructor for doffing
3. Instructor for spraying, cleaning, and disinfecting within the ETU
Supplies:
PPE
Prepared chlorine solutions in 0.5% and 0.05% - well labeled
6-12 Commode buckets labeled
12 chucks
2 mops
6 Buckets filled with soapy water labeled
6 Sprayers
6 Cups
6 Latrine buckets labeled
6-12 Cots
Trash bags
6 Rolls of paper towel
Mannequins/patients
Fake vomit (cat food)
Set up:
Place commode buckets under the cots and fake vomit on the floor. Have other supplies ready
and available in the ETU.
Briefing: Prior to donning PPE the Instructor will briefly describes all practical exercises for that
day to the participants, this includes review of expected activities and key points. Then the
participants will don PPE with the aid of an instructor. The participants will have practiced
donning and doffing PPE the day before, so refer to the detailed description in the exercise. The
instructor should try to intervene only when they see something that needs to be corrected.
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Exercise:
1) Don PPE - Follow High-risk protocol
2) Disinfection of diarrhea or vomit in a commode bucket: In groups of 2-4 prepare to clean
a commode bucket filled with vomit or stool.
a) Select a sprayer or someone to pour the chlorine.
b) Gather materials needed to disinfect: 0.5% chlorine solution cup for pouring.
c) Walk to cot with a dirty commode bucket underneath.
d) Get the commode bucket out from under the cot.
e) Carefully spray or pour 0.5% chlorine solution on the floor under the bed and any area
the bucket touched.
f) Carefully pour 0.5% chlorine solution with a cup around the edge of the bucket and
anywhere the vomit or diarrhea touched. Avoid any splashes.
g) Carry the commode bucket to the patient latrine and discard.
h) Wash the commode bucket with soapy water and discard into the patient latrine.
i) Rinse the commode bucket again with 0.5% chlorine.
j) The commode bucket is now ready to use again.
k) Wash gloved hands with 0.5% chlorine solution, pour some chlorine solution from
your cupped hand over the tap.
3) Disinfection of bodily fluids on the floor: In groups of 2-4 prepare to disinfect vomit from
the ETU floor.
a) Select a sprayer or someone to pour the chlorine.
b) Gather materials needed to disinfect: 0.5% chlorine solution, cup for pouring, paper
towels, trash bags, sprayer, bucket of soapy water.
c) Moisten chuck (by spraying or lightly pouring) with 0.5% chlorine solution. Do not soak.
d) Place chuck over the spill and wait about 15 (virtual) minutes for absorption
e) Spray the inside of a trash bag with 0.5% chlorine
f) Carefully remove any organic solids with the chuck and discard into the sprayed trash
bag - (do not wipe the floor).
g) Tie a knot in the top of the bag and place in a second disposal bag. Spray with 0.5%
chlorine solution and seal the second bag. Place in the waste disposal area.
h) Spray or pour 0.5% chlorine solution onto the floor, covering the area completely, and let
stand for 15 (virtual) minutes. Be sure not to splash.
i) Remove excess chlorine solution with paper towels, and discard in the waste bin for
infected waste
j) Wash area with soap and water. However, depending on the type of floor
k) chlorine may be your only step.
l) Wash gloved hands with 0.5% chlorine solution, pour some chlorine solution from
your cupped hand over the tap.
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4) Disposal of burnable waste: All waste from a high-risk zone is considered highly
contaminated.
a) Liquid waste and waste water may be disposed of in the dirty latrine.
b) Other types of waste, including burnable waste, solid organic waste (e.g., food waste),
and sharps may be disposed of in a single incineration area. This means an area that has
been identified at the ETU to burn waste. You will need to know where this area is and
what the ETU protocol is for removing waste from the high-risk area to the incineration
area once you have secured it (double bag).
c) Trash bags containing burnable waste should be sealed when full by tying the ends of the
bag in a knot. Make sure not to overload bags.
d) Spray 0.5% chlorine around top of the bag containing the burnable waste
e) Place this sealed trash bag inside a second trash bag and seal by using the ends of the
bag to tie in a knot.
f) Double bagged trash may then be transported to the burning area for disposal.
g) Wash gloved hands, pour some chlorine solution from your cupped hand over the
tap.
5) Doffing of PPE – High-risk protocol
6) Debriefing - instructor lead discussion on the participants activities
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EFG#6
Safe Body Transport
and Burial
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44
Goals:
• To be able to safely transport a suspect or confirmed case from a truck into the highrisk facility or from the suspect to the confirmed areas within a high-risk zone in the
ETU.
• To be able to transport a body safely to the morgue.
• To be able to transport a body to the burial team.
Key Points:
• Health care worker safety is a priority.
• Patients should be transported in a separate section of vehicle than the HCW.
• Confirmed Ebola cases should be moved immediately to the high-risk area to avoid
transmission of the virus to others.
• Dead bodies contain very high levels of virus and are extremely contagious and must
be handled properly.
Location:
This occurs in the area immediately outside an ETU and in a simulated ETU.
Participants divide into small groups, don PPE and run through the exercise in full PPE.
Instructor needs for Each ETU: Instructors may serve multiple roles, but each location
needs at least 3 instructors.
• Instructor for donning
• Instructor for doffing
• Instructor for supervision of patient transport in and out of the ETU
Supplies:
PPE
Prepared chlorine solutions in 0.5% and 0.05% - well labeled and in sprayers and washing
stations
6-12 Cots
Sheets
Mannequins/patients (at least 3)
Body bags
Simulated back of truck or ambulance/or outside area
+/- stretcher
Waste bags and bins
Mirrors
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Set up:
A white board or flip chart needs to be prepared with sign out information. This includes
several similar sounding names of patients, one of which needs to be moved from the
suspect ward to the confirmed ward and one of which who has died overnight.
Body bags and sheets need to be available near where participants are donning PPE. One
mannequin or person/actor is outside sitting by a tree or in the back of a simulated pick up
truck or ambulance. One mannequin or person/actor needs to be in the suspect ward on a
cot. One mannequin needs to be in a cot in the confirmed ward. Chlorine regular large spray
bottles and hand washing stations need to be located throughout.
Briefing: The instructor will explain that during the exercise today participants will practice
transporting patients. This includes moving a patient from an ambulance or vehicle to an
ETU, within an ETU from the suspect case section to the confirmed case section, and a
deceased patient from confirmed to the morgue. Finally they will move the patient to be
buried.
Patient transport is a 3 or 4 person job so the participants will be divided into groups of 3 or
4. The team should prepare viral hemorrhagic specific body bags prior to high-risk donning
and moving into the high-risk zone. Preparing the body bags means labeling them with the
patient name and virus type. Participants should simulate preparing a body bag by acting as
if they are writing the name of the deceased patient on the body bag. They will receive a sign
out from the team before them and will be given the names of the patients that will need to
transported and/or moved to the morgue and then handed off to the burial team.
Exercise:
1. Receive Sign out.
a. The participants will be put in front of a white board or flip chart with several
similar sounding patient names with updates. They will be told which patient is
moving from the suspect to the confirmed ward and which patient has died
overnight.
b. During the time they are getting their sign out they will be interrupted to go
help move someone from the ambulance into the ETU.
2. Triage and transport a patient from outside the ETU to inside the ETU.
a. Staff should be in full PPE when transferring a patient from the vehicle into the
high-risk zone and should don PPE. Normally a patient would go to triage but
for the purpose of this exercise they will be transported to the high-risk zone.
Depending on the ETU protocol and if you know in advance if the patient is
Ebola positive will determine if they go to triage or into a specific ward. Either
way, full PPE is required.
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b. Assess the situation – have they been triaged? Assed for any physical
obstacles and for safety of staff
c. Assist patient exiting the back of vehicle taking caution as patients are often
extremely weak
i. First have them sit on the edge of the pick-up then help them from
there
ii. If the patient cannot walk they will need to be transported using a
stretcher
d. Have a bucket available for liquid waste in case the patient is vomiting, If the
bucket is used it will need to be emptied into the appropriate latrine for highrisk waste, cleaned, and disinfected with 0.5% chlorine solution.
e. Wash gloved hands with 0.5% chlorine solution and rinse the tap.
3. Move a patient from the suspect case area to the confirmed case area.
a. Staff should be in full PPE when transferring a patient from a suspect ward to
a confirmed ward.
b. Assess the situation for physical barriers and safety.
c. Verify you have the correct patient and inform them of what you are about to
do
d. Assist patient into the high-risk zone and if the patient can’t walk, carry them
on a stretcher
e. The area where patient was located needs to be disinfected with 0.5%
chlorine.
f. The stretcher (if used) needs to be disinfected with 0.5% chlorine
g. Wash gloved hands with 0.5% chlorine solution and rinse the tap.
4. Move a deceased patient from the confirmed case area to the morgue.
a. Simulate labeling a body bag prior to entering the high-risk zone
b. Staff should be in full PPE
c. Assess the situation
d. The clinician should confirm the patient has died by looking for respirations
and checking for pulse.
e. Put a screen around the bed of the deceased patient to preserve privacy
f. Mobile patients should leave the room if able
g. Carefully spray the body with 0.5% chlorine and the surrounding area. Vomit
and diarrhea should be soaked with 0.5% chlorine and covered with a chuck.
Protocol for cleaning waste should then be followed (see prior exercise on
this). Spray 0.5% chlorine on bed, walls, and floor of the deceased patient.
h. Cover the body with a sheet
i. Saturate sheet on the body, and all exposed parts of the body with 0.5%
chlorine solution
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j. Place the body bag on the floor or stretcher next to the body and open
k. Spray 0.5% chlorine solution into the inside of the body bag
l. Place body and any sheets, blankets, and/or clothing inside the body bag
i. Depending on the type of body bag one person will hold the bag open
and one person will stay with the sprayer.
ii. The other two/three lift the body and place into the body bag
m. Wash gloved hands with 0.5% chlorine solution and rinse the tap.
n. Zip bag closed with both zippers ending up by the head (so that it is easy to
show the patient’s face to the family)
o. Spray 0.5% chlorine on the body bag, the bed, walls, and floor of the
deceased patient.
p. Transport the body bag to the morgue inside high-risk zone. The body bags
generally have handles to carry or use a stretcher if available.
q. After body is moved, spray 0.5% chlorine on an area larger than where the
body bag was on the floor.
r. Remove all patient effects and place into trash bag and tie.
s. Spray the bag with the patient’s effects.
t. Double bag, tie and spray again. Take to burn pit.
u. Wash gloved hands with 0.5% chlorine solution and rinse the tap.
5. Transfer off of dead body to the burial team
a. Staff from the Ebola unit should be dressed up in full
b. Walk to the morgue via low to high-risk path and put the prepared body that is
in the body bag on a stretcher
c. Carry the stretcher outside the mortuary and the Ebola unit via the special exit
for corpses
d. The coffin (if used) should be placed at the special exit for corpses and the
burial car/pick up should be parked close to it.
i. If a coffin is used:
1. Spray the coffin inside with 0.5% chlorine solution.
2. Put the body in the coffin, close securely/spray outside.
ii. If no coffin is used:
1. The body may need to be put in 2 body bags depending on local
protocol.
2. The second body bag needs to be sprayed inside, and then
place the first body bag with the body inside the second body
bag.
3. Close the second body bag and spray the outside of the second
body bag.
e. After the body is put in the coffin or second body bag then spray the stretcher
thoroughly (if used)
f. The Ebola unit team will return dressed to the Ebola ward and the Burial team
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will continue the safe burial procedures.
g. Ebola team doffs PPE
Debriefing: Discuss with the participants the particular challenges of this exercise and
answer questions.
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EFG#7A
Ebola PSS
Training Guide
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contains material developed by MSF, WHO, and CDC
50
International Medical Corps Training Course
Psychosocial Support for Ebola
Exercise Facilitator Guide
International Medical Corps MHPSS Focal Point Dr. Inka Weissbecker, Global Mental Health and
Psychosocial Advisor, International Medical Corps Technical Unit (HTU)
1. Psychosocial Programming for Ebola- Overview
Duration
60 min (#7)
Target Group
All staff
Learning Objective
·
·
·
·
To understand and reflect the range of psychosocial
stressors and concerns (for patients, families, health
staff)
To understand International Medical Corps MHPSS
approach and underlying principles (IASC Guidelines
and Pyramid)
To understand the place of the International Medical
Corps PSS team and activities and PSS approaches and
interventions
To reflect and plan how aspects of PSS can be
integrated in the daily work
Practical Applications
Liaise with International Medical Corps PSS team effectively
(e.g. to work together on improving MHPSS considerations
across all activities and services)
Resources
Inter-Agency Standing Committee (IASC, 2007) Guidelines
on Mental Health and Psychosocial Support in Emergency
Settings.
Student handouts and materials
International Medical Corps 2014 MHPSS Capacity Statement
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1.1. Introductions and Overview
Introductions and Overview
Exercise: Introduction and Expectations
Materials needed: Notebook and pen
(for trainer to take down notes from
participant feedback)
Participant Instructions:
Ask participants to:
Introduce themselves
Name at least one thing what they think PSS is, and one
thing they would like to learn as part of the PSS and Ebola
course segment and why (e.g. based on previous
experience with PSS, anticipated challenges etc.)
Trainer Instructions:
Make any notes of expectations.
After exercise clarify expectations- e.g.
what this segment will cover/not cover,
additional resources
WHY should PSS be an integral part of the Ebola response?
Only if people trust the ETU and feel respected, accepted and connected with families and the human
beings around them, communities and families will be willing to have their loved ones transported to the
ETU which is necessary to contain the spread of virus. Moreover, PSS can be important for recovery (e.g.,
when patients don’t feel like eating), child protection and long-term well-being.
PSS Aspects of Ebola
Trainer Instructions:
Before showing the slide and going over content ask what why they think PSS aspects are important as
part of the Ebola response.
Use easel or white board for major points
People affected by Ebola and their families face various stressors including health related fears, and fears
about contamination or spreading the disease. People suspected or confirmed of having Ebola have to face
not only fear but also isolation in medical facilities. People who have been medically cleared as well as
family members and health care providers may also face social isolation, rumors, exclusion and even
violence in their communities. Important rituals of grieving such funeral and burial practices may be
disrupted. Health care staff are confronted with stressful working environments of witnessing considerable
suffering and grief among people affected and their families. They have to battle their own fear and
concerns about the disease.
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General EVD consequences affecting whole communities
Social networks and supports:
• Social network deterioration
• Many social norms are disrupted, e.g. Hospitality, Greetings, (Physically expressed)
• Climate of suspicion, physical isolation
Fear and panic:
• People are often afraid of being infected, and want to protect themselves and those they
love
• Poor knowledge about how to prevent EVD, and lack of resources to set up protective
measures, can lead to and exacerbate panic. This can lead to fear, stigmatization, blame,
discrimination and to stigmatization of those who have been in contact with the sick or
have been handling dead bodies
• Those most at risk of experiencing stigmatization and being shunned by the community
are not only families and patients released after EVD health care workers and
volunteers”.1
• Anxiety and alertness, watching each other (community watch team)
Emotional distress (e.g. trauma, re-traumatization):

Retraumatization (more than 40% of Liberian adults have PTSD and/or
depression because of the war!):

“During the war people saw a lot of things, you stay in the house and you watch
your family die, during the war it was because of guns or hunger, they could not
afford medicine, now it is worse, because they saw it before, they try to patch their
life, have a new family, and Ebola comes in and makes them even more hopeless.
Ebola separates families like during the war, people get missing, you cannot visit
each other, you cannot hug each other, not shake hands…”
Disruption of daily life and routines

Closures of facilities and institutions (e.g. schools, public facilities)

Children sitting at home not knowing what to do, as schools are closed

Economical impact (e.g. breakdown of many income possibilities)

Having Ebola dominating all life; “One of the stressful things in community is handwashing,
every time your mind goes there, it is stress, because they think about Ebola

Restrictions of movements, many community don’t accept strangers anymore and restrict
when someone is sick.

Many people describe Ebola as a war we are fighting. Politicians want to have elections, but
citizens say we cannot have elections when a war is going on, no public gathering etc.

Emotional Support, “Care giver rule” (how to deal with sick people) etc.
1
http://pscentre.org/information-battles-fear-and-stigma/
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
Orphaned and separated children in the community
EVD related consequences that especially affecting patients and families
Before the admission to the ETC
•
•
•
•
•
•
•
•
Fear and uncertainty about the unknown and EVD
Misinformation/rumors lead to → confusion and fear
Fear of EVD because many experienced losses of relatives, friends, colleagues
Fear of being discriminated, stigmatized, blamed/accused by neighbors
Initial feelings often fear, denial, shame
Loss of social supports
Moral dilemma for families or neighbors: announcing that someone is sick or hiding a
patient
Loss of belongings (e.g. items are burnt to contain and prevent further infections and the
people in the community may talk about and void affected families.”2)
During the stay at the ETC














Most who stop eating and drinking (often teenagers) rather argue that they will vomit anyhow

Guilt or shame when feeling they are endangering their family or cannot support them
Experiencing and witnessing EVD related pain and suffering:
Pain from the IV and blood test


2
Isolation from usual social support systems:
Fear of being abandoned by loved ones
Having to leave children behind or be separated if one is positive the other negative
Fear and anxiety:
Anxiety due to very strange environment, strange people (e.g. in Liberia, it has been noted
that people in PPE look like a “killer bean” who is a someone who is bad, kills others in a
cartoon movie for children)
Other food and clothes than they are used to
Being separated from community, family, lack of information about their wellbeing
fear to suffer, fear to die
Sadness, hopelessness and grief:
Complex grieving, many of the patients in the ETU have also had many family members
die already from Ebola.
Sadness and feelings of hopelessness.
Hopelessness; they wonder what they have to live for or go home to if many of their family
have already died.
Unmotivated to engage in the treatment; may stop taking their medication, may stop eating
and drinking; What is the point? God will protect me!
http://www.newvision.co.ug/mobile/Detail.aspx?NewsID=634297&CatID=4
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





Heavy symptoms (physical and psychological), loss of control, dependency
Witnessing other patients dying in ETC
Being close with people they don’t know, you see people suffer and die
ETC related stressors:
Confinement: restricted to move freely
Isolation/equipment that hamper communication
After being discharged or related to burial












Reduced family and community support and connectedness
Intimacy problems: no sex (without condoms) for 3 months (e.g. a wife said they don’t bathe
together anymore, don’t sleep in same bed)
Common rejection from family, community: Isolation for 21 days because community does
not trust (Certificates need to have stamps and look official)
Stigma
Loss of job, livelihood
Restructuring of life with less family members than before, e.g. when head of household
and/or many family members died
Physical problems
Continued weakness, heartrate, getting used to moving around, everything is a bit slower
For the family:
Afraid for the health status of the patient for their own health
Difficulties of not respecting the socio-cultural rituals for funerals
Mourning practices not carried out
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Quotes from Liberia:
“Cremation is not normal, it is stressful, there is no closure. Normally you mourn, see where the family buries the
person. With cremation the process is incomplete, there is this gap, maybe this person did not die. Normally, you
touch a body and say your final words. Now just the burial team comes and takes them away. People want the
government to stop burning bodies, Otherwise afterwards there will be problems. At least, they should give the
ashes to the families. But it is not done. The health team could accompany them, but there is no explanation.
People appreciate, that here in the Bong ETU people are buried, they say, At least when the person dies, we can
see the grave. “
“Traditional burial practices in Liberia: Traditionally, it is important to escort the spirit of a person who dies.
There are rituals such as cutting the hair and a special bath. On the day of burial, the last child or grandchild has
to take the blanket from the body and run a distance with it without looking back. The elderly person or sister
speaks to the body “I am sending you to…” and they put things (e.g. pots, food) with the body, saying “we know
that you were hungry, so we give you that”. Sometimes they give money. Now: where is the spirit of this person
going? The ancestors live somewhere. Sometimes people have dreams and receive messages from the ancestors,
but now there are no such dreams, the spirits are lost, wandering around, cannot find their ways. This is one of
the battles that we are gonna fight, the spirits are all over and will come back to disturb. More younger children
might become pregnant because the spirits want to return.
Many people wait after Ebola to do these ceremonies. Someone said: so many people in the family die, we cannot
make ceremonies for each one every week, we wait until all is over and we make one big one for all who will
have died.
After massacres when the government opened the mass graves, people who knew that their family members were
in there, many did this ritual. This can be done many years after the death.”
“My uncle died in the burial time. They took out the bones and carried the bones. It is very important. It plays on
the mind.
If a person died in the car accident, the car got burnt, they go to the site, even if it was just a piece of the cloth, or
they lie cloth or iron or anything there and say to the spirit please enter into this, we want to carry you to the
home and then they carry it. Someone died in USA, they wanted to do this ritual, it is important. “
Protection issues:

There are child protection issues (e.g. children orphaned or stigmatized/excluded due to
Ebola)

There is some fear that the blood of survivors might be used to treat or cure Ebola, then
children who survived might be exploited

Other vulnerable groups or individuals (Widows with children, persons with disabilities,
severely distressed persons) may have specific difficulties to be reintegrated
·
Example: A psychosocial support worker from Uganda described that “clients once discharged were in danger of
social segregation, stigma and possible violence A member of the community intimated to me how our visit the day
before saved the client’s life because they would have been afraid to have ‘such a person’ in their community.”
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·
WHO recommends “In areas of intense transmission (e.g. the cross border area of Sierra Leone, Guinea,
Liberia), the provision of quality clinical care, and material and psychosocial support for the affected
populations should be used as the primary basis for reducing the movement of people, but extraordinary
supplemental measures such as quarantine should be used as considered necessary. 3
Why this training?
= It’s the responsibility of ALL the team members:



to support the patients/relatives and community in the different steps by providing clear
information and basic emotional support
to detect the people in need of psychological support and of more specialized mental health
care (patients, family, colleagues)
to work in a multidisciplinary approach and understand roles of psychosocial support staff
1. 2. Global Guidelines and International Medical Corps’ Approach to MHPSS
MHPSS Guidelines
What is MHPSS?
•
Any type of local or outside support that aims to:
–
–
protect or promote psychosocial well-being and/or
prevent or treat mental disorder
3
WHO Statement on the Meeting of the International Health Regulations Emergency Committee Regarding the 2014 Ebola Outbreak in
West Africa.WHO statement
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From: IASC MHPSS Guidelines 2007
Guideline
Description
Inter-Agency
Standing
Committee
(IASC,
2007)
Guidelines on Mental Health and
Psychosocial
Support
in
Emergency Settings.
These are the MOST important guidelines to know about: Guidelines
provide practical advice for including MHPSS within various areas such as
coordination, monitoring and evaluation, human rights, human resources,
community mobilization, health services, nutrition, water and sanitation,
shelter and education.
ALL IASC guidelines available at:
http://www.who.int/mental_health/emergencies/
Inter-Agency Standing
Committee (IASC, 2010)
Mental Health and Psychosocial
Support in Humanitarian
Emergencies: What should
humanitarian health actors
know?
Optional additional guidelines for working in health care settings:
Guidelines provide guidance on coordination, assessment, community
mobilization and support, psychological considerations in general health
care, addressing needs of people with severe mental disorders, psychotropic
medication, health information systems, people in institutions, alcohol and
other substances, linking with other healing systems, post recovery activities
by the health sector and human resource considerations.
Slide: IASC Pyramid
Trainer Instructions:
Explain layers of IASC pyramid and what they mean to illustrate the broad range of MHPSS Interventions
Trainer Instructions:
Explain principles of International Medical Corps MHPSS approach
Slide: International Medical Corps general MHPSS Program Approach
International Medical Corps has considerable capacity and experience in MHPSS: International Medical
Corps takes a comprehensive approach to health programming by including psychosocial considerations
and psychosocial support services in the provision of health care. International Medical Corps has
implemented mental health and psychosocial programs as part of general health care in more than 20
countries.


Foundation in global guidelines and best practices
Active contribution to an use of latest MHPSS tools and documents
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






Close collaboration with global agencies and working groups (e.g. WHO, IASC)
Engagement in MHPSS Advocacy
Integrated programs across the spectrum of support (e.g. health, nutrition)
Covering relief to development continuum
Building sustainable local capacity (e.g. holistic approach to training)
Respecting cultural practices
Creating innovative solutions and evaluating outcomes
Trainer Instructions:
Explain that there are various guidelines and briefly mention what they are and that International Medical
Corps is actively contributing to them and following them
Take home points: Why PSS as part of Ebola response?
o EVD and EVD responses affect norms, behaviors, cognitions and affects of communities, patients,
families, health staff).
o PSS can help to accept the reality, cope with the stress and find solutions for specific problems
o Acceptance of and trust in ETUs is crucial for getting patients out of communities to contain virus
o International Medical Corps follows global MHPSS guidelines and takes an integrated approach
recognizing importance and added value of PSS
1.3. HOW? PSS Programming for the Ebola Response
International Medical Corps’ PSS Approach and Interventions as part of the Ebola response
Trainer Instructions:
After explaining cross-cutting PSS approach, ask participants about their own thoughts how PSS
consideration can be or already are part of their own work.
Examples:
for all the team members it is the small things that you do that can make a difference “ you can smile with
your eyes” through the PPE.
For the Hygienests, be patient and take the time to explain what they are doing and why - these little things
can make all the difference to the patients and families.
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PSS is provided to:




Patients - as part of compassionate care to reduce their fear and suffering and ensure their
dignity,
Their families - to ensure their comprehension of what is happening to the patient and reduce
the impact of stress, fear and stigma. As well, to facilitate the psychological process of
learning of their family member’s illness, hospitalization, death, burial, and their
bereavement
Health care workers - to help them cope with the stress brought on by caring for patients
with a hazardous disease and the isolation from their community that providing this care
may cause
The community - to facilitate understanding of the disease, encourage acceptance of
outbreak control measures, and reduce the social isolation of patients, their families,
survivors, and health care workers.
Composition of psychosocial team and tasks:
•
PSS Coordinator and -PSS national staff collaborate in programming, adapting, conducting,
monitoring and evaluating PSS.
International Medical Corps PSS activities as part of the Ebola response:
Mapping and referral

Conduct a situational analysis regarding: current staffing and psychosocial needs and
potential considerations, 4Ws mapping of currently available mental health and
psychosocial supports and services by other organizations and agencies.
• Support the development of referral pathways to other organizations and agencies for
specialized MHPSS services and other basic needs
Treatment center activities and considerations

Improve environmental psychosocial considerations at health facilities

Inform family members about status (test result, discharge, death) of their patient

Orient visiting family members, be available for support if needed and/or refer them to a
triage talk if they seem to have symptoms

Organize and accompany burials (taking pictures of body and burial to give to family
members)

Provide PSS to patients and family members and in the community

Educate discharged patients, visitors and community members about Ebola and Ebola
prevention

Organize discharges, reintegration of children into their communities
Training of ETC staff
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Train all staff in basic PSS (including PFA, PSS considerations as part of their work,
staff self-care)

Train and supervise local PSS staff in basic psychosocial support (including PFA, basic
psychosocial support sessions for patients and family members) via expat PSS Coordinators

Community Activities

Conduct community level outreach to reduce stigma and increase social support and access
to basic needs for affected people and their families

Provide information to community members how the ETU operates
Staff support

Provide suggestions for supportive work environment

Mediate conflicts and help with (psychosocial) problem solving

Hold workshops for staff on stress management

Provide individual counseling sessions to staff for very basic PS support whenever
necessary

Refer and connect to more specialized support (e.g. mental health) if needed

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2. Psychosocial Support and Interventions for Patients and Families
Duration:
90 min (PPT #12)
Target Group
All staff
Learning Objective
Understand basic principles of psychosocial support including
psychosocial considerations and Psychological First Aid (PFA) for
patients and families
Know when patients and families may need specialized
psychosocial mental health support
Know relevant PSS aspects for setting up and running an ETU
Practical Applications
Interacting with patients and families in a supportive way while
working
Liaising with PSS team as needed to provide support and referral
for patients and family members with PSS and MH needs
Resources
WHO (2014). Psychological First Aid for Ebola. PFA materials
available at http://tinyurl.com/PFA-Eb
IFRC (2014). Psychosocial support during Ebola outbreaks,
International Federation of Red Cross Red Crescent Societies
Reference Centre for Psychosocial Support, August 2014. Available
at: http://reliefweb.int/report/world/psychosocial-support-duringoutbreak-Ebola-virus-disease
MSF Training materials (FHF Guidelines and PPT)
Student handouts and materials
WHO (2014). Psychological First Aid for Ebola. PFA materials
available at http://tinyurl.com/PFA-Eb
IFRC (2014). Psychosocial support during Ebola outbreaks,
International Federation of Red Cross Red Crescent Societies
Reference Centre for Psychosocial Support, August 2014. Available
at: http://reliefweb.int/report/world/psychosocial-support-duringoutbreak-Ebola-virus-disease
IFRC 2014 Common stress reactions after Ebola
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2.1. Signs of psychological distress and mental health problems
Stress reactions in the context of Ebola
Although Ebola affects everyone in some way, people can experience a wide range of reactions. They can feel
overwhelmed, confused or very uncertain about what is happening. They can feel fearful and anxious, or numb and
detached. Some people may have mild reactions, whereas others may have more severe reactions.
Examples of common psychological distress reactions include:
Physical symptoms
Feelings and thoughts
Behaviors
shaking, headaches, tiredness, loss
of appetite, aches and
pains that have a non-medical basis
insomnia and nightmares;
Ebola related fears:
Fear of being isolated from the family, of
being sick, suffering or dying (and of the way
in which one dies, e.g. “I don’t want to die
alone!”)
Fear of sickness and sick people
Fear of symptoms and diseases that are
normally easily treated
Fear of falling ill and dying and therefore
they do not approaching health workers or
utilising health
facilities (hospitals, health centres, clinics)
Fear of losing livelihood (not being able to
work during isolation, being fired because
employer is
afraid of contamination etc.)
Fear that their blood will be collected or that
organs of their body will be put in plastic
bags to be sold
Other reactions:
crying, sadness, depression and grief;
anxiety and fear;
being “on guard” or “jumpy”;
worrying that something bad is going to
happen;
irritability and anger;
guilt and shame (for surviving, infecting
others, or for not being able to help or
save others);
confusion, emotional numbness, or feeling
unreal or in a daze;
Feeling of helplessness
· Mistrust and anger of everyone associated
with the disease
appearing withdrawn or very still
(not moving); not responding to
others, or not speaking at all;
disorientation (not knowing their
own name, where they are from,
or what
happened); Stigmatisation and fear
of patients and health care
workers/caregivers
Refuse approaches by volunteers;
threaten them verbally or
physically
· Fleeing and hiding in the bush
when ambulances or other
vehicles involved in the epidemic
response approach
· Refusal to go to hospital/ bring
family members to ETU
Telling others that patients at ETU
will not be fed, that the sick are
abandoned by their
families and no one else will care
for them in the isolation centre
· Refuse to care for orphaned
children due to fear of
contamination
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Stress reactions in children:
Children and young people may experience similar distress reactions as adults (see Section 3.3 in PFA
Guide). They may also experience the following specific distress reactions:
•
•
•
Young children may return to earlier behaviours (for example, bedwetting or thumbsucking), cling to carers, and reduce their play or use repetitive play related to the
distressing event.
School-age children may believe they caused bad things to happen, develop new
fears, become less affectionate, feel alone and be preoccupied with protecting or
rescuing people in the crisis.
Adolescents may feel “nothing”, feel different or isolated from their friends, or
display risk-taking behavior and negative attitudes.
•
Children or adolescents may give up and stop eating and drinking, especially
as sore throat, lack of appetite and vomiting as well as diarrhea are common
symptoms of Ebola
Normal Stress Reactions
Stress reactions including fear are normal reactions to dangerous situations and can include fight/flight and
freeze.
When we are facing an emergency, we feel fear. Fear functions as a signal for our brain to produce a
natural substance called ADRENALIN. Adrenalin is the signal that will trigger our body to respond and
survive.
DANGER  FEAR  BRAIN: ADRENALIN  SURVIVAL
Stress and fear reactions are normal and healthy levels of fear can keep you alert and safe but unhealthy
levels can lead to problems and problems functioning.
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When we are very afraid, we can experience:
•
•
•
•
•
•
•
Our hair standing on end
Our pupils (eyes) dilate
We sweat to regulate our temperature
Our mouth is dry
We breathe faster to get more oxygen
Our heart beats faster to pump more blood
All our blood goes to our brain and muscles.
NO DANGER  FEAR  ADRENALIN  ANXIETY
When we continue to feel fear, because we have become more
sensitive to noises, tremors and other potential dangers, BUT it
is NO LONGER A DANGEROUS SITUATION, we can
experience the following:
Anxiety, tension, trouble sleeping or concentrating
Flashback of the past danger, nightmares
Confusion, feelings of guilt, sadness, irritability or anger.
Some of these fears and reactions spring from realistic dangers,
but many reactions and behaviors are also borne out of rumours
and misinformation. It is important to try to correct
misconceptions, at the same acknowledging that the feelings
and subsequent behaviour is very real, even if the underlying assumption is false.
In general, how someone reacts depends on many factors, including:
o
o
o
o
o
o
o
the nature and severity of the stressful situation or event
experience with previous distressing events;
support they have in their life from others;
physical health;
personal and family history of mental health problems;
cultural background and traditions;
age (for example, children of different age groups react differently).
It is also important to remember that Ebola changes how people normally provide support to each other
(e.g., by not being able to touch people) and how people cope with the death of a loved ones (e.g., by not
being able to engage in traditional burials). This can severely worsen people’s distress.
The way in which International Medical Corps staff sets up services and supports and interacts with
patients and families can help mitigate distress and help people cope
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What are signs that people may need more specialized mental health and psychosocial support?
Most people will recover emotionally over time, especially if they receive support from others and help in
meeting their basic needs. However, people with severe and/or long-lasting distress may need more
support.
Please consult with the International Medical Corps psychosocial team particularly if they:
•
•
Cannot function in their daily life, e.g. not being able to care for themselves or their children
(not eating or drinking, not able to make simple decisions).
are a danger to themselves or others (e.g. talk of or try to harm themselves, talk about hurting
others or act violently)
Ensure that severely distressed people are not left alone and try to keep them safe until you can contact the
relevant mental health and psychosocial support staff.
2.2. Providing basic psychosocial support -Psychological First Aid (PFA)
[please refer to PFA guidelines for explanatory text for the following sections]
Facilitator Instructions: Ask participants what comes to mind when they hear the phrase
‘Psychological First Aid’?
What is PFA (see PFA Guide)? (and what it is not)
When is PFA provided?
Where is PFA provided?
o
o
Communities
Health Facilities
Respect Safety, Dignity and Rights
Providing PFA
Good Communication with people in distress
o
o
Things to say and do
Things not to say and do
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Exercise: Good communication
Materials needed: Easel or Whiteboard
Participant Instructions:
Trainer Instructions:
What are some of the signs to say and do or to not say and List responses on an easel or whiteboard, clarify
do?
and add (see PFA guide for Ebola page 26 and
list below)
Basis of communication skills: Attitudes
•Ensure the self determination of the patient (involvement in the care, in the decisions, provision
of information, etc.)
•Treat the patient with respect and humanity (avoid victimization, pity, banalisation)
•Empathy ≠ sympathy
•Adopt genuine attitude (includes being transparent with clinical limitations)
•Be non judgmental
•Show consistency and reliability (eg. avoid loud voice, changes in moods or attitudes)
•Avoid reacting with disbelief or confrontational/argumentative attitudes
•Be sensitive to body language (yours and patient’s one)
•Be aware of cultural norms and beliefs
Basis of communication skills: listening and paying attention
•Provide patient-tailored information, explanation and choice (when possible)
•Avoid authoritative instructions/leading questions (favor open-ended questions )
•Answer with gestures and words to show that you are listening
•Use patient’s words
•Be sensitive in tone, phrasing & sequencing of questions
•Respect silence
•Normalize reactions: “Many people feel…”/de-stigmatize
•Be sensitive to the emotional state/reactions: accept and acknowledge them. Watch for signs
of distress
•Put your own limits
•Provide closure: anticipate the next step if possible-reassure if needed
= MOST OF THE PATIENTS HIGHLIGHT THE VALUE OF FEELING HEARD AND UNDERSTOOD
AS AN IMPORTANT ASPECT OF THE TREATMENT.
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Communication in difficult situations:
Steps for breaking bad news
A. Advance preparation



B.
-arrange adequate time and privacy
-review relevant data
-emotionally prepare for the encounter
Building a therapeutic relationship

-identify patient preference regarding disclosure of bad news
C. Communicate effectively



determine patient’s knowledge and understanding of the situation
proceed at patient’s pace, allow silence and tears, answer questions
avoid medical jargon
D. Dealing with patient and family reactions

-assess and answer to emotional reactions/empathise
E. Encouraging/validating emotions


-offer realistic hope based on patients goals
-deal with your own needs
Dealing with people who are agitated or fearful- Helping people feel calm (PFA guide, page 33)
Some people in a crisis situation may be very anxious or upset. They may feel confused or overwhelmed,
and may have physical reactions such as shaking or trembling, difficulty breathing, or feeling that their
heart is pounding. The following are some techniques to help very distressed people feel calm in their
mind and body:








Keep your tone of voice calm and soft.
Try to maintain some eye contact with the person as you talk with them.
Remind the person that you are there to help them. Remind them that they are safe, if it is
true.
If someone feels unreal or disconnected from their surroundings, it may help them to make
contact with their current environment and themselves. You can do this by asking them to:
Place and feel their feet on the floor.
Tap their fingers or hands on their lap.
Notice some non-distressing things in their environment, such as things they can see, hear
or feel. Have them tell you what they see and hear.
Encourage the person to focus on their breathing, and to breathe slowly.
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PFA Principles for Ebola: Prepare, Look, Listen, Link (refer to PFA guide for more detailed text)
Preparing to help
Look
Listen
o
Eyes ›› giving the person your undivided attention;
o
»» Ears ›› truly hearing their concerns;
o
»» Heart ›› with care and showing respect.
Link (with information and support) and help people cope
o
o
o
o
Help people address basic needs and access services
Helping people who are likely to need special attention
Help people cope with problems
o
Encourage positive coping
o
Discourage negative coping
Give information
o
Ebola virus disease
o
Loved ones
o
Their safety
o
Their rights and responsibilities
o
This also includes their responsibility to follow the guidance of local
authorities and health workers.
o
Services and supports
People who may be vulnerable and need special help include: (see PFA guidelines page 42 for detailed
text)
1. Children, including adolescents.
o
How carers can help children
2. People with health conditions or disabilities.
3. People at risk of discrimination or violence.
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PFA Simulation
Exercise: Practicing PFA
Materials needed: Easel or Whiteboard
Participant Instructions:
Get into pairs of three and role play a PFA scenario.
One person is a health care provider or other ETC staff
(depending on trainee group)
Trainer Instructions:
Discuss- what did observers observe?
How did health care providers feel, what was
easy/difficult?
How dis patients feel, what was helpful/not
helpful for them?
Scenario 1: One person plays a woman who has come to
the ETC to check on her husband, she is agitated and
worried
Scenario 2: One person plays an agitated unmotivated
adolescent on the ward
One person observes and makes notes about
communication and steps of PFA
Relaxation and Breathing Exercises
Exercise: Relaxation techniques
Materials needed: Easel or Whiteboard
Participant Instructions:
[see PFA guide]
Trainer Instructions:
Lead participant through simple breathing
exercise, have them give feedback afterwards.
2.3. Psychosocial Considerations and Approaches in Setting Up and Running the ETC
Psychosocial considerations for running an ETC and patient care are important in making patients and
families as comfortable as possible throughout the process.
The ECT design and set up
Considerations for Admission (in the communities, with the ambulance & at the center)

Accompany, and support patients and family members who are fearful of entering the
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





Unit.
Accompany/show the space-how it’s distributed
Provide information about the disease and its transmission, infection control
procedures, care provided for the patient in the Treatment Unit, visiting rules, MSF
activities; etc.
PSS staff provide initial psychological care for patients and their relatives.
If not already done, inform families that their homes will be disinfected, and explain
how this will be done.
Arrange for the distribution of any NFIs
Inform family members when patient has reached the treatment center
Patient space and equipment





Ensure dignity and decent living conditions (e.g. Ensure Dignity in practical ways like have
lappa cloths for patients who’s trousers/skirts maybe dirty and they need a change of clothes
to ensure dignity)
Ensure reliable lighting is organized for the wards to improve safety and make life easier
for the patients by helping to reduce their fears.
Ensure decent inpatient living conditions, preserve the dignity of the patients, and see that
suffering is alleviated.
Provide radios within the wards to help the patients feel less isolated for the length of their
stay.
Provide a cellphone that all patients can stay in contact with their families and can call the
doctors or nurses at night in case of emergencies
Patient Activities

Ensure that there are activities - groups to distract those patients that can come outside.

Provide activities and games and books/magazines etc as many patients report feeling very very
bored. In Liberia International Medical Corps shows movies every evening (projecting movies on
big screen)
PSS support
•
•
Set up an appropriate space to provide psychological care to patients and their families. E.g.,
in the Bong Liberia ETU we built a PSS place close to the fence to the patients, put a table
between the two low fences on which we place water, fruits etc. Here we can interact with
groups of recovering patients without PPE or anything but space between the faces
Due to restrictions on how long staff can remain in PPE there is often long periods of time
when there are not staff on the ward and then patients are alone, there can be frustrations
and problems between the patients and if someone dies then they can spend hours on the
ward with a dead body: or the patients tend to be the people there when the people are dying
and they are the ones supporting them - this is difficult and can lead to a feeling of
hopelessness for them. Radios could be a good way of reducing this but it is going to be a
real problem.
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Considerations for Patient Care




Give tests results/regular updates
Organize caretakers if children or vulnerable persons are positive
PSS staff provide continued PSS for the patient and relatives
Provide spiritual support, e.g. we have a pastor in the psychosocial team, he makes
devotions every morning and goes in to pray with and for the very sick patients if
they wish so
Communication







Ensure persons who are inside the Unit can communicate easily with those outside.
Arrange family visits
Keep family informed about patient’s medical condition
If a child with Ebola is admitted to hospital, they should be able to have safe and regular
contact with one trusted family member.
Use phones to give psychosocial support : a phone could be made available at the
treatment centre for patients’ use only, so relatives can talk to their loved ones
If the persons condition improves then start working with the family and the messages
they want to take to the community to reduce stigma and aid in the persons reintegration
back home.
If the patient’s condition worsens, inform the family
Considerations for Discharge




Give out solidarity kit and organize transportation home
Accompany the patient to his/her home if possible, or have local social workers informed.
Explain to neighbours about the patient’s recovery in order to prevent or reduce potential social
stigmatisation (rejection, death threats, aggression, destruction of personal belongings, etc.)
Ensure a schedule of calls or home visits for psychological follow-up.
Psychosocial Considerations for Grieving and Burials
Burial rituals are very important in many of the affected communities. It is often believed that there is a
direct relation between the respect paid to a deceased and the prosperity of their descendants. Preventing
people from performing the rituals can cause anger, frustration, resentment and fear.
Quote from Sierra Leone: “the new psychosocial hire in SL and he stated that the way Ebola kills is also
cutting the relationship and the link between the living and the dead i.e. the link between the living and
their ancestors, which is such an important part of African beliefs and has never really happened before
in SL. In the war you could see the bullets and you could accept that someone had died where they stood
quickly. But with this sickness and the fact that sickness is so common in Africa yet this one kills you
quickly and alone and with no chance for the family to show how much you love the person, or send
messages to the ancestors has huge implications to the culture. “
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If possible, arrange for the family to be close to the patient at the time of his or her death

Notify relatives in the event of the death of the patient, and be available to provide
information and support to them, give out bereavement kits.

Explain special procedures/provide support in arranging the burials

Ensure that the family is fully involved in preparation for the burial.

Ensure respect for traditions (songs, dances, timing of ceremony, etc.) without
compromising safety.

Allow relatives to view the body and to give personal belongings to be placed in the grave

Offer supportive presence during the funerals, have a pastor available to pray at the grave if
wished

It is important to establish a dialogue with the local communities and especially the local
religious leaders to explain the situation and discuss alternative, safer ways of honouring
the dead.

Facilitate and assist in the bereavement process.

Provide support in arranging the burial, taking account of the safety precautions.

If people are struggling to accept that they cannot bury their loved ones in a traditional
ceremony, encourage them to think of alternative ways that they can honour, remember and
grieve for them.

Consider engaging religious leaders in helping to develop alternative rituals that are safe for
the mourners (see Annex for space to record local alternative rituals for safe mourning).

PSS team will follow-up with emotional support of families if needed to help them in the
mourning process

Draw a map of the graveyard with information of the buried people in case that a storm etc.
may damage the signs

Make pictures of the body in the bodybag and of the burial, offer them to the family
PSS Considerations for activities in the community
Detection of patients and transfer



In conjunction with the mobile medical team PSS staff provide explanations to the family
and the neighbours about the treatment and the eventual recovery of the patient in order to
prevent or reduce possible social stigmatisation. (e.g. Liberia Team will use a flipbook
with pictures of the ETU to address specific fears and explain that the ETU takes good
care for patients who can stay in contact with their family and have a chance of survival)
Inform families that their homes will be disinfected, and explain how this will be done
take the time to get good communication links and contacts with the immediate family and
the wider community.
Home Based Support and Risk Reduction
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•
In the event that the patient refuses to come to the treatment unit or cannot taken in the ambulance,
it may be necessary to arrange for their care at home.
•
•
Psychological support in this setting aims:
•
To facilitate an understanding of the disease and promote acceptance of outbreak control activities
within the community.
•
To improve the quality of care for the patient and the family in collaboration with other team
members.
•
The medical team with support from PSS staff would:
o Assist the family in selecting a caregiver.
o Provide psychological support to the family while there is a patient in the house.
o Explain the benefits of, and offer the patient admission to the FHF Treatment Unit.
o Provide information about the disease, infection control procedures, and the HBSRR
programme to neighbours and the community.
To promote acceptance of the International Medical Corps service and improve collaboration with
beneficiaries.
Re-integration and connection to services and supports
• Reintegration of survivors
• Child protection issues
• Collaborations with contact tracers, community health workers or volunteers and other relevant
actors
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3. Staff Well-Being
Duration
30 min (EFG #8)- this should probably be at least 1 hr
Target Group
All staff
Learning Objective
·
·
·
To recognize own signs of work stress
To know own personal positive coping strategies (and
avoid negative coping)
To know when and how to seek help for psychological
distress
Practical Applications
Dealing with stress on the job in positive ways, helping
colleagues deal with stress, reaching out for help if needed
Resources
Antares Foundation Managing stress in humanitarian workers Guidelines for Good Practice (2006, 2nd edition). Guidelines
for organizations ranging from staff selection, and monitoring
to ongoing support and post assignment support. The Antares
website also has several other resources and links
http://www.antaresfoundation.org
Headington Institute. Psychological and Spiritual Support for
Humanitarian Relief and Development Workers. Various online
resources for humanitarian and relief workers (e.g. selfassessment tools, advice on coping with stress). Information
Available at: http://www.headington-institute.org/
Caring for volunteers: A tool kit, IFRC Reference Centre for
Psychosocial Support, http://pscentre.org/wpcontent/uploads/volunteers_EN.pdf
IFRC (2014). Psychosocial support during Ebola outbreaks,
International Federation of Red Cross Red Crescent Societies
Reference Centre for Psychosocial Support, August 2014.
Available at: http://reliefweb.int/report/world/psychosocialsupport-during-outbreak-Ebola-virus-disease
Student handouts and materials
2014 Staff well-being handout for Ebola
IFRC 2014 Working in stressful situations-Ebola
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3.1. Job Stressors
Exercise: Job stressors
Materials needed: Easel or Whiteboard
Participant Instructions:
What are the things that can make your job stressful as
part of the Ebola response?
Trainer Instructions:
List responses on an easel or whiteboard
What are sources of stress?
Staff stressors
Emergencies are always stressful, but there are specific sources of stress that are particular to an Ebola
outbreak. This is true for both delegates and volunteers responding to the crisis and the affected population
in general. These stressors include:







Strict bio‐security measures (e.g. physical strain of protective equipment (dehydration, heat,
exhaustion), physical isolation (not allowed to touch others, even after working hours),
constant awareness and vigilance needed, pressure of the strict procedures to follow (lack
of spontaneity)
Risk of being contaminated and to contaminate others
Common symptoms can be mistaken for Ebola (e.g. developing a simple fever, diarrhea or
other symptoms) and lead to fear of being infected.
The high mortality rate, late stage symptoms of Ebola and rapid deterioration of patients
may be shocking, both for medical and non‐medical staff
Having to deal with conflicting public health priorities and the wishes of the patients (e.g.
not willing to be isolated or treated) and the needs of the families (e.g. burial traditions).
Stigmatization of staff and volunteers working with Ebola patients
The consequences of the outbreak in communities and families: deterioration of social
network, local dynamics and economies, patients abandoned by their families, surviving
patients rejected by their communities, possible anger/aggression against health structures,
staff and volunteers etc.
Communities and families interacting with health care staff and volunteers are often experiencing Ebola
related fears and concerns, which leads to hostility and exclusion. As a result, local volunteers and staff,
many of whom will be living in affected communities, are likely to be under great stress during the
epidemic. Due to their engagement in responding to Ebola they are often excluded from their ordinary
social network and their families. Additionally, volunteers report experiencing that they are believed to be:
•
•
· disease carriers, those who are responsible for spreading the virus
· contagious, and therefore not welcome in their homes and in their family
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•
•
•
•
•
•
· responsible for the deaths
· paid by the Red Cross to bring the disease
· the enemies of hunters selling bush meat
· suspicious people who poison people
· used by white people (against black people)
· informants who receive bonuses for every piece of information given
As a result of the above volunteers are being threatened and insulted (e.g. called "Ebola") and are accused
of not providing the necessary tools (soap, chlorine) to protect people. Volunteers also experience hostility
from community/village stakeholders. It is important that volunteers receive sufficient support such as
incentives, transportation, food and protective and visibility materials and that supervision and peer
support systems are put in place.
Quote from SL: Many, even experienced Emergency responders, are saying that this is different to other
responses as there is so much fear, if you feel even slightly ill you imagine that you have Ebola. You must
be alert all the time to dangers, risks, which is tiring, and if you make a mistake there is life and death at
stake, all of which makes it mentally exhausting unlike other responses per se. Also for national staff there
is the fear of putting your family at risk etc.
3.2. What are Signs of Stress?
What signs of stress do people commonly experience?
Exercise: Recognizing signs of stress
Materials needed: Easel or Whiteboard
Participant Instructions:
What are some of the signs of too much stress that you
have observed (in yourself or others)?
Trainer Instructions:
List responses on an easel or whiteboard.
Learning point: Signs of stress differ from
person to person. It is important to know and
recognize your own signs of stress.
People who are working in Ebola affected areas may be experiencing fear of being sick, suffering or dying
(and of the way in which one dies), fear of sickness and sick people, fear of symptoms and diseases that
are normally easily treated, mistrust and anger as well as sadness and despair from witnessing human
suffering and death from Ebola.
People may also experience psychological stress reactions (e.g. fear, anger, nightmares, loss of
concentration, irritability, sadness, guilt, trouble sleeping). Those types of experiences and reactions are
normal and most people will feel this way. These reactions can appear immediately, after a few
days or in some very rare cases, weeks or months may pass before the stress reactions appear.
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Know your signs of stress and excessive burnout
Excessive stress is the reaction to any challenge, demand, threat or change that exceeds our coping
resources. Stress chemicals can trigger physical reactions that can linger for days, weeks, or sometimes
months. In addition to triggering physical reactions, stress hormones and chemicals affect brain chemistry
and impact the way we think and feel. Over time, as our bodies, emotions and minds are affected by stress.
PHYSICAL
EMOTIONAL
THINKING
BEHAVIORAL
Sleep disturbances
Changes in appetite
Stomach upsets
Rapid heart rate
Fatigue
Muscle tremors and
tension
Back and neck pain
Headaches
Inability to relax and rest
Being easily startled
Mood swings
Feeling “overemotional”
Irritability
Anger
Depression
Anxiety
Emotional numbness
Discouragement and
loss of hope
Alienation and loss of
sense of connection
Poor concentration
Confusion and
disorganized thoughts
Forgetfulness
Difficulty making
decisions
Dreams or nightmares
Intrusive thoughts
Cynicism
Risk taking (such as neglecting
security measures)
Over-eating or under-eating
Increased smoking
Listlessness
Hyper-alertness
Aggression and verbal outbursts
Alcohol and/or drug use
Compulsive behavior (i.e.
nervous tics and pacing)
Withdrawal/isolation
Promiscuity
Trainer Instructions:
After going over the signs of stress, ask participants to consider the following questions:
• Have you noticed any of these general signs of stress lately? Are there others you have experienced?
• When you are under pressure, which of these signs of stress tend to appear first?
• Which is the one that you should NOT ignore?
When do I need help from a mental health professional?
Stress related experiences and reactions may last a few days, a few weeks or a few months and occasionally
longer depending on the severity of the situation and other individual and environmental factors. Being able
to cope with stress and with the understanding and the support of colleagues, friends and family, stress
reactions usually pass more quickly and the vast majority of people recover on their own. Occasionally,
people continue to experience severe distress over longer periods that makes it difficult to function in their
day to day lives (e.g. at work, relationships). In those cases, professional assistance from a psychiatrist,
psychologist or counselor may be helpful. This does not imply craziness or weakness. It simply indicates
that the particular experiences were just too powerful or difficult to manage and it is ok to ask for help.
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How can I take care of others and myself?
Everyone shares the desire to give the best of their professional and personal skills to the Ebola Response.
Health care and humanitarian workers tend to minimize how they are affected by the work conditions and
the difficulties that they witness. We think we must be strong, “hold it together” and cannot afford to rest.
If we don’t keep going, who will? These constitute great intentions as well as probably a large part of the
drive that pulls us through in a very challenging time.
However “the road to burn out is paved with good intentions” If we let this noble drive blind us to the
reality of our own limits and needs, we accumulate excessive stress without recharging enough. We
become overly anxious, burdened and we get sick. Even if the staffing and resource needs for the Ebola
response are overwhelming, the reality is unfortunately that we cannot do as much as we would like to and
that we need to look after ourselves as well. Here are a few of things you can do:
Prepare before you go
Before accepting an International Medical Corps assignment to go on mission to the Ebola operation, it is
natural to have some concerns. These may include concerned family and friends, personal fears, lack of
knowledge about the disease, transmission, treatment, not knowing what it will be like on the ground, etc.
In order to make it easier to prepare, consider:






Family and friends may be concerned about your safety during the mission and their own
safety when you return. Take these concerns seriously, help them gain information, and talk
openly about the concerns and dangers – both those that are real and those that are imagined.
Having the support of understanding of those closest to you will make the mission much
easier
Learn about Ebola: The more you know about the disease, the facts on the ground, how to
avoid contamination, required security measures etc. the more calm and confident you will
feel. Learn about Ebola through various resources such as WHO as well as International
Medical Corps training and resources. Make sure you know how to use protective
equipment, know who your local security officer is, and follow security instructions etc.
Complying with security measures is not only a matter of your own personal safety but that
of everybody you come into contact with.
Be critical: There is much misinformation and over dramatization in the media coverage
about Ebola. Make sure you get your information from trustworthy sources.
Consider your own personal physical and mental health and ability to work in a high stress
environment
Make an honest decision about whether you are ready to help in this particular crisis
situation and at this particular time
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Use positive ways of coping
Exercise: Finding positive ways of dealing with stress
Materials needed: Easel or Whiteboard
Participant Instructions:
What are some of the things you have done in the past to
deal with stressful events or situations in your life? Are
there any you may be able to use while working as part of
the Ebola response? Write down at least 3 strategies.
Trainer Instructions:
Ask participants to share some of their
strategies before moving on to the list below/.
It is important to let people make their own decisions based on what they think would be best for them.
Everyone has their own way of coping. For some people, it is helpful to continue their work and daily
routines. Others may want to take time off to be with friends or family. Use positive coping strategies and
avoid negative strategies. Think about what has helped you cope in the past and what you can do to stay
strong. Here are a few suggestions. Please review them and find out which ones are most helpful to you in
general as well as which ones you want to add to your routine:
Positive Coping Strategies
Negative Coping Strategies
Regular exercise, and sports or recreational activities (even if for short
periods)
Getting enough sleep
Healthy eating
Drinking water
Laughter
Relaxation techniques including breathing exercises (e.g. progressive
muscle relaxation) meditation or yoga
Religious activities and practices
Talking about experiences and listening/talking with others
Reading books or magazines
Enjoying time with nature
Listening to music
Watching movies
Reflection: journaling, writing, meditating, poetry
Contact with friends and family over email phone or skype
Nurturing relationships with the group
Having balanced priorities
Having realistic expectations
Asking for help or seeking counselling support if needed
Using alcohol or drugs to selfmedicate
Smoking
Sleeping a lot
Excessive eating or not eating
enough
Avoiding and detachment from
family and friends, Social
isolation
Negative thinking, blaming
Avoiding responsibilities
Violent behavior, loosing temper
Neglecting personal hygiene
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Help create a positive and supportive work environment
As a team member, check in with fellow helpers to see how they are doing, and have them check in with
you. Find ways to support each other. As a manager or team leader, there are many things you can do
to facilitate a supportive work environment including:







Scheduling regular breaks and time off for staff
Demonstrating team building skills and mutual support
Acknowledging and rewarding well performing staff
Supporting and demonstrating positive coping
Scheduling times off work for team to support one another (e.g. meals together, games)
Identifying staff experiencing high stress or burnout and encouraging them to take a break
or return home if needed
People who have experienced very stressful situations should have the opportunity to talk
about what happened to others who they trust and who will listen, but they should never be
forced to talk or share their experiences. Note that “psychological debriefing/group
debriefing sessions” (where people are asked to share their experiences in a group) for those
who have experienced stressful incidents (or “critical incidents”) are no longer
recommended and research suggests that such practices can sometimes do harm.
Things to consider after your assignment is over

Taking time for rest and reflection is an important part of ending your assignment as part of the
Ebola response. The difficult work and needs of people you have met may have been very
challenging, and it can be difficult to bear their pain and suffering. After helping in a crisis situation,
take time to reflect on the experience for yourself and to rest. The following suggestions may be
helpful to your own recovery.

Talk about your experience of helping in the Ebola response with a supervisor, colleague or
someone else you trust.
Acknowledge what you were able to do to help others, even in small ways.
Learn to reflect on and accept what you did well, what did not go very well, and the limits
of what you could do in the circumstances.
Take some time, if possible, to rest and relax before beginning your work and life duties
again.



If you find yourself with upsetting thoughts or memories about the event, feel very nervous or
extremely sad, have trouble sleeping, or drink a lot of alcohol or take drugs, it is important to get
support from someone you trust. Speak to a health care professional or, if available, a mental health
specialist if these difficulties continue for more than one month.
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EFG#7B
Ebola Psychosocial Support Training
Pre-Post Test
Name: ____________
Date: __/__/____
Organization: O International Medical Corps
O Other: _____
Staff Role: ________________
Gender: O Male O Female
1) Perceived Competencies
Very Low
Low
Medium
High
Very High
1.Ability to respond supportively to patients or family
members who are experiencing significant anxiety and
agitation
1
2
3
4
5
2. Ability to reduce psychological distress for patients,
family members and community members as part of my
own work/role
1
2
3
4
5
3.Ability to know when I should refer a patient or family
member to the psychosocial team
1
2
3
4
5
4. Ability to take care of myself and prevent burn-out
1
2
3
4
5
Please rate your perceived…
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2) Psychosocial Support Knowledge
List three things you can do as part of your job/role to make patients and family
members more comfortable:
1.
2.
3.
List three things you can do or say and three things to not do or say when confronted
with a very anxious and agitated patient or family member:
Things to do or say
Things to not do or say
1.
2.
3.
1.
2.
3.
List three things that you can do to help yourself and/or others prevent work-related
stress and burn-out
1.
2.
3.
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EFG #7C - Ebola Psychosocial Support (PSS) Module
Training Evaluation
Date: __/__/____
Organization: O International Medical Corps O Other: _____
Staff Role: _____________________
Gender: O Male O Female
Please take a few minutes to provide us with your feedback on the training you have just
completed. Your ratings and comments will be analyzed by International Medical Corps
training managers and used to refine and improve future training courses. You do not need
to write your name on this evaluation form; your feedback can be anonymous. Thank you.
1. On a scale of 1 (strongly disagree) to 5 (strongly agree), how would you rate the
psychosocial support (PSS) training components on the following dimensions?
The PSS training:
1
Strongly
disagree
2
Disagree
3
Neither
4
Agree
provided me with new information
and new skills
will help me do my day to day work
better
assisted me in knowing how to
work effectively in my
International Medical Corps team
was well organised
was taught professionally
was interesting and stimulating to
take part in
is something I would recommend
to colleagues coming into this
setting
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5
Strongly
agree
2. Which aspects of the PSS training module did you find most useful in preparing you for
your work and why?
•
_______________________________________________________________________
•
_______________________________________________________________________
•
_______________________________________________________________________
3. Which parts of the PSS training module did you find least useful and why?
•
_______________________________________________________________________
•
_______________________________________________________________________
• _______________________________________________________________________
4. How could the PSS training be improved?
_______________________________________________________________________
_______________________________________________________________________
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EFG#8
IFRC 2014 Working
in Stressful Situations
– Ebola
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EFG#9
Tabletop
Designing a Safe ETU
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Goal: Ensure basic understanding of how the structure of an ETU maintains safety for health
care workers (HCW), patients, and others and be able to recognize unsafe practices.
Prerequisite: Participants will have had a lecture on the Design and Function of an ETU.
Key Points:
• Health care worker safety is a priority
• Meticulous adherence to ETU protocols is critical for safety
• The design of an ETU supports safety of the health care worker, patients, and others
• Understanding the principles underlying the design of an ETU enhances HCW
adherence to safe practices
• Understanding the design of a safe ETU helps HCWs to recognize unsafe practices
Supplies Needed:
•
•
•
•
3 whiteboards, poster boards, or flip charts
6 Sharpies
9 Sticky pads
List of items to put in the design of the ETU
Set Up:
Each group will have sticky notes, sharpies, and either a white board or poster board with
the
ETU structure outline pre-drawn. Each of the items listed below should be written onto a
sticky note, and the note should be placed by the group on the ETU structure. The goal is to
lay out an ETU that meets safety recommendations.
Break into 3 Groups: Groups of up to 10-12 participants with a group leader
Group 1 Scenario: Convert an existing school building into a safe ETU
Group 2 Scenario: Convert a field with a tent into a safe ETU
Group 3 Scenario: Convert an empty warehouse into a safe ETU
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Instructions:
Facilitator gives the groups their scenarios and structure outlines (~15 minutes). The groups
are then instructed to take 45 minutes to design a safe ETU.
On the sticky notes, write the items listed below and place them appropriately in their ETU.
Some items will have multiple locations, if so create multiple sticky notes.
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Double fence (can be drawn directly on structure outline)
Entry and Exit points for
o Staff
o Patients
o Visitors
Kitchen
Office
Lab
Psych support office
Pharmacy and PPE storage
Latrines
o Low-risk zone latrine
o High-risk zone—suspect patients latrine
o High-risk zone—confirmed patients latrine
Laundry
Triage station
Chlorine prep station
Low-risk PPE Donning and Doffing station
High-risk PPE Donning station
High-risk PPE Doffing station
Morgue
Burnable waste disposal
High-risk zone—suspect patients area
High-risk zone—confirmed patients area
Low-risk zone
Hand washing stations (0.05% chlorine & 0.5% chlorine)
0.5% chlorine footbaths
0.5% chlorine tubs
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EFG#10
Mixing Chlorine
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Goals:
•
•
To understand the use of different chlorine concentrations.
To prepare chlorine solutions safely.
Key Points:
• Soap, chlorine, and UV light all destroy the Ebola virus.
• 0.5% chlorine is for anything that is dead or non-living (exception—immediate response
to certain PPE breaches) See below section “keep in mind”.
• 0.05% chlorine for things that are alive (living human tissue such as bare skin and things
humans touch) See below section “keep in mind”
• The virus can survive in areas where chlorine does not reach, such as inside solid
organic waste (stool, emesis, blood clots, etc.)
• All health facility staff – including waste disposal and laundry, should wear full PPE when
disinfecting and cleaning supplies and equipment.
• Chlorine solutions should be prepared daily.
• HTH stands for High Test Hypochlorite or High test Chlorine.
Background Information:
Calcium hypochlorite Ca(OCL)2 is commonly used for drinking water disinfection and most
commonly comes as chlorinated lime, bleaching powder, high test hypochlorite (HTH), or calcium
hypochlorite tabs.
HTH is a white powder that is more highly concentrated form of calcium hypochlorite – usually 65
to 70% and is considered more a stable form.
Loss of potency may be accelerated by light, warmth, humidity, and ventilation therefore proper
storage is important. Storage of powder should be in a cool, dry, dark place and in a closed,
corrosion-resistant container.
**IF NOT PROPERLY STORED CHLORINE IS COMBUSTABLE** Please be sure to store
according to the manufactures guidelines for the product you are using.
Chlorine is a hazardous substance and care must be taken when handling it. It is highly corrosive
and can cause burns and damage to the eyes if a splash occurs. Gloves and protective eye
wear should be worn when preparing solutions.
Key references:
http://www.cdc.gov/vhf/ebola/hcp/mixing-chlorine-solutions.html
http://www.who.int/water_sanitation_health/hygiene/emergencies/fs2_19.pdf
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Keep in Mind (from CDC Website):
The strong solution (0.5%) includes a higher concentration of HTH* chlorine that can be used for
disinfecting surfaces, objects, medical equipment, and gloved hands.
Warning: Washing bare hands with the strong solution (0.5%) can cause chlorine burns
on hands.
Other uses include
o Floors: Use a rag soaked in 0.5% to carefully clean up any body fluids. Then follow up
with soap and water. If there is a lot of fluid, use a rag or towel to wipe up the fluid
before using the chlorine solution (followed by soap and water).
o Toilets and bathroom: Let chlorine solution stand on surface for 15 minutes before
wiping off.
o Mattress covers: Let chlorine solution stand on surface for 15 minutes before wiping
off.
o Visibly soiled linens: Soak fully and deeply in solution for 10-15 minutes before
washing with soap and water.
o Foot baths
o Contaminated waste for disposal
o Corpses: Wipe body, body bag, and coffin.
o Layers of packaging for transporting blood samples: Spray each layer before packing
into the next layer.
o Medical equipment, including thermometers
o Plates, cups, and eating utensils
The mild solution (0.05%) is a more gentle solution of HTH* chlorine that can be used for
washing bare hands in settings where other methods, such as soap and running water or alcohol
based hand rubs, are not available or cannot be used.
Mild solution can also be used to disinfect other things that come into direct contact with the skin
or body, including:
o Patient bedding and clothing that is not visibly soiled: soak for 30 minutes
o Everyday cleaning of surfaces and floors when there is no visible body fluids
Supplies:
Gloves, Goggles, Facemask for personal protection
2 plastic buckets per teams of 2-3 participants
Markers and flip charts/paper
6 containers of Bleach Solution 5.0%
High Test Hypochlorite (65%)
Tablespoon or soupspoon
8 gallons of water
6 rolls of masking tape
6 Sharpies
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9 cups for measuring (measuring cup or 1 liter bottles)
A stick for stirring
Standard bleach solution is provided as 5.0% Chlorine. At this strength it could be lethal for staff
and patients, so care must be taken to prepare the solutions properly. Since chlorine solutions
lose potency over time and in the sun, these must be prepared every few hours.
Set up:
Below are the 2 strengths of chlorine used in ETUs and mixed from two different sources:
 Set up protective equipment, buckets, stir sticks, HTH and/or bleach, measuring
spoon/cup, markers, tape and have copious water available nearby.


0.5% Chlorine solution is used for disinfecting and cleaning, but not on the skin.
0.05% Chlorine solution is used for washing hands.
Briefing:
Review the preparation of the two bleach solutions used in ETUs. Participants will prepare both
the 0.5% and the 0.05% from either the household bleach 5% concentration and/or the HTH.
Use visual aids and have each group draw out or write out the procedure after it has been
reviewed in the briefing.
Remember chlorine is very strong.
Always wear gloves, face mask, and either goggles or a face shield when handling
chlorine granules and strong solutions. Make sure the exercise is performed in a well
ventilated area.
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Exercise: Carefully supervise participant groups as they mix up the two different dilutions of
chlorine.
1. How to prepare 0.5% dilution from 5% Chlorine:
a. Determine starting concentrations – normal household bleach is 5% sodium
hypochlorite (but strength can vary)
b. Mark on the inside of the mixing bucket/container the 9 parts water level
c. Mark on the inside of the mixing bucket/container the 1 part bleach level (above
the 9 parts line)
d. Pour water into bucket first (to the 9 parts level), and then bleach (to the higher
line), being careful not to splash any of the solution
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2. How to prepare 0.05% dilution from 0.5% Chlorine:
a. The 0.5% chlorine solution made above will be used to make the 0.05% solution
b. Mark on the inside of the mixing bucket/container the 9 parts water level
c. Mark on the inside of the mixing bucket/container the 1:10 part bleach level
(above the 9 parts line)
d. Pour water into bucket first, and then the 1:10 bleach solution, being careful not to
splash any of the solution
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3. How to prepare 0.5% dilution from HTH:
a. Fill a plastic bucket with 20 liters of water.
b. Add 10 heaping tablespoons (1 tablespoon = 14 grams) of High Test Hypochlorite
(HTH).
c. Stir the solution with a stick
4. How to prepare 0.05% dilution from 0.5% Chlorine:
a. Fill a plastic bucket with 20 liters of water.
b. Add 1 heaping tablespoons (1 tablespoon = 14 grams) of High Test Hypochlorite
(HTH).
c. Stir the solution with a stick
5. Label clearly and save buckets to use in the ETU disinfection exercises.
a. Remove the disinfectants everyday or whenever the solutions become cloudy or
bloody. Replace the solution with a fresh supply.
b. Disposal of liquid waste can be done in an isolated latrine or toilet.
6. Debrief lead by the instructor.
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EFG#11
Facilitator Guide:
M&E
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Introduction
This guide is developed as a facilitator guide for people conducting training on monitoring and
evaluation and quality assurance in an ETU.
The guide will aid them to train others in basic concepts of data collection, indicators measurement,
developing an M&E plan, performing data quality control and using data for decision making and
reporting.
Prerequisites
Participants will have heard lectures about the current outbreak and about Ebola—transmission,
clinical presentation, testing, triage, WASH related activities and management of an ETU. They
should have a good understanding of the different activities that are conducted in an ETU even if
not from their specific sector of intervention.
Target audience
Clinical staff, WASH staff, logistics, all staff involved in data collection and monitoring at ETU level.
In addition, this session is important for program managers and M&E officers who are going to be
involved in management, monitoring of project implementation and reporting.
Goal
To ensure that all trained staff has sufficient knowledge about data collection, programmatic
monitoring and evaluation and quality assurance; to provide awareness about key information that
needs to be recorded to measure operational achievements.
Structure of the training:
The training will be structured in 3 sessions:
• Introduction about the session, training objectives and overall topics of the training (15 min)
• SESSION 1: Data collection (approx. 1 hour with Q&A)
• SESSION 2: Measuring operational performance (approx. 1 hour with Q&A)
• SESSION 3: Quality assurance (approx. 1 hour with Q&A)
• Q&A session
(to include coffee breaks)
Key points:
• Why M&E and quality assurance for at an ETU is important: to monitor International
Medical Corps results at facility level; for accountability purposes: to be able to give
feedback to our donors and supported countries and show what International Medical
Corps is doing with funding for the Ebola response; to follow up on trends related to
attendance at health facility level; to ensure that work done is following the necessary
quality standards for management of an ETU; monitor unintended consequences of our
work as an indicator of quality of services.
•
M&E for an emergency response, in general, needs to be simple: no complex systems,
no unnecessary data to collect, go with basic measurement tools
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- The difficulty of M&E for Ebola response at an ETU is mostly related to documentation (how
documentation is done, filed, shared, used for analysis) because of the risks of contamination
with EVD; activities related to M&E need to be restricted in terms of physical sharing of
documents and contact between staff for monitoring.
SESSION 1: DATA COLLECTION
Introduction exercise:
Divide the audience in 4 small groups:

Medical,

WASH,

Logistics,

Managers
The trainer asks each group to identify the key information they think is important to collect about
an Ebola response at an ETU. Groups work for 15 minutes, and record the key information on
paper or flip chart. One group member will present to the plenary on behalf of his/her group.
The trainer will tie the groups’ thoughts into the next part of the course.
Course parts:
A: Type of data collected in an ETU
In this section, the facilitator will explain each variable that should be collected through the M&E
system in place at the ETU.
Data to be collected in an ETU is organized in four categories:
Patient
Health Staff
ETU environment
Medical supplies and pharmaceuticals
Please note that this section doesn’t include clinical management related data. But if the program
includes a research component, it will be necessary to add patient related clinical information.
Data to be collected is about:
 Patient
o Demographic data:
 age
 sex
 home place (home county)
 place where the illness started (illness county)
 If patient is pregnant or not
 if the patient is a health worker or not
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o
o
o
Arrival data:
 Patient identifier
 Date of arrival
 If patient was referred or not to the ETU (by a district health officer or other)
 How did the patient come (type of transport – ambulance, self, International
Medical Corps, other)
 Any other relevant information
Patient information during his/her stay:
 Date symptoms started
 Laboratory test results
2 types of tests can be performed:

Performed on suspected cases – 2 tests can be done. The second
test is to rule out a false negative

Performed on confirmed cases – 3 tests can be done. Second and
third tests to confirm cure outcome before discharging a patient if
test negative.
 If psychosocial support was provided or not
Outcome of patient:
 Final diagnosis (confirmed Ebola, suspected Ebola, other)
 Disposition (Discharged cured, Deceased, Discharged negative,
Abandoned treatment, Referred)
 Date of disposition

Health care staff
o Demographics
 Age
 Sex
 Position/role in the ETU
o Impact of training
o Topics of training
o If health care staff got infected or not

ETU environment/WASH
o Infection control education and psychosocial support
 Psychosocial support provided or not to relatives, health workers
 If family received education session for infection control
o
Rehabilitation/construction work
 If facility renovated/built
 Capacity of the ETU (number of beds)
 Information about water supply

Functioning of water taps
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o
o

Chlorination activities
 Residual chlorine testing results on a daily basis (right strength or not)
Burials
 Existence of a burial team (and number)
 Availability of burial equipment
 Number of safe burials done per week
Key information about burials includes the existence of a burial team and
number of people in the team, availability and use of burial equipment and
the number of safe burials done per week. This data provides information
for quality assurance of burial related activities and use of established
quality standards.
Medical supplies and pharmaceutics
o Consumption of medicines and medical supplies (tracer drugs, PPE kits, etc.): this
information can be used as a proxy measure of implementation of specific activities
at ETU level, but requires establishment of benchmarks.
B: Data management
Data are usually collected using data collection tools. In the context of an ETU, the use of data
collection tools that can be shared by staff for monitoring is restricted to non-contaminated areas.
• Data collection tools (in non-contaminated areas)
o Warehouse tracking forms and reports: data collection forms to report on medical
supplies and pharmaceuticals taken from the warehouse to be used in the ETU.
o Tally sheets for chlorination activities: monitoring of the quality of chlorination will
ensure that chlorination is done properly to limit risks of contamination in the ETU.
o Health facility reports:
o Other?

Data analysis for decision making:
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SESSION 2: MEASURING OPERATIONAL PERFORMANCE
A: Indicators of performance
Exercise: In plenary, ask participants: “If you want to collect the data we just discussed, and to
monitor our performance running an ETU, what would a donor want to know about International
Medical Corps’ operational performance?, can you give examples of performance indicators”
The trainer will tie the group’s thoughts into the next part of the course.
Course:
Operational performance monitoring is essential to support effective response. Donors are paying
more and more attention to the effectiveness of emergency response. The best way to
demonstrate effectiveness is through solid and frequent performance monitoring, showing results
and level of achievement.
Performance monitoring for a project implemented in an ETU will help us respond to the following
key questions on effectiveness of our interventions:
Are we conducting the planned activities?
Are we achieving the expected results and targets?
Are we implementing in a timely and cost effective manner?
Performance indicators are measures that help us responding to these questions. In order to have
performance indicators it is important to collect the most relevant data that can be used for
monitoring of project performance. Indicators are determined by the type and nature of data
collected.
For each key activities in an ETU, we have a set of performance indicators that will inform the
project performance and overall effectiveness in responding to Ebola.
Present the key indicators of performance to be reported per sector of activities and give an
explanation/definition of each indicator. Indicators below are organized by level of results to
measure: at process, output (direct result of activities) or at the level of outcome (result that shows
a change of status, or of a behaviour, quality and access improvement).

Clinical Case Management
o Output level indicators
▪ Number of persons screened for EVD, disaggregated by sex and age
▪ Number of suspected cases tested and confirmed to have EVD
▪ Percentage of suspected cases tested and confirmed to have EVD
▪ Number of confirmed EVD patients admitted in the ETU, disaggregated by
sex and age
▪ Number of patients leaving the ETU, by cause (discharged, abandoned
treatment, transferred, deceased), disaggregated by sex and age
o
Outcome level indicators
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▪
•
Case fatality rate at supported facility for EVD, disaggregated by sex and
age
Health system support
o Input indicators
▪ Presence of safe transport systems to Ebola treatment center
▪ Number of treatment beds at the ETU
▪ Number of staff
o
Output level indicators
▪ Number of health care facilities supported and/or rehabilitated by type (e.g.,
primary, secondary, tertiary)
▪ Number and percentage of health facilities submitting weekly surveillance
reports
▪ Number of tests performed per week
▪ Number of health care providers trained by type (e.g. doctor, nurse,
community health worker, midwife, and traditional birth attendant) and topic
of training, disaggregated by sex and national/international
▪ Number of people trained in psychosocial support, by sex
▪ Number of psychosocial support sessions provided (by psychosocial
officers) to EVD patients, families, and health workers, by sex and age group
o
Outcome level indicators: outcome level indicators for health system support
provide information about quality of services and compliance to quality standards
▪ Staff to bed ratios

WASH related activities
o Process and Output Indicators
 Number and percent of deceased cases buried safely by the ETC burial
team

Medical supplies/pharmaceuticals related indicators
o Output level indicators
 Number of supplies distributed by type (e.g. medical kits, equipment, and
consumables)
 Ex: Number of Solidary/Bereavement Kits distributed
 Ex: Number of infection protection supply kits distributed
o
Outcome level indicators
 Number and percent of health facilities, out of stock of selected essential
medicines and tracer products for more than one week
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EFG#XX
Facilitator Guide:
Outbreak Response
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Exercise Facilitator Guide: Outbreak Response
Goal
To review all the various components of an Ebola outbreak intervention in order to
provide participants with an appreciation of how their individual roles and activities fit
within the larger epidemic response framework.
Learning Objectives
1. Overview of the various components of an Ebola outbreak intervention.
2. Review of relevant local contextual factors in Liberia and/or Sierra Leone,
including functioning of incident management system and county surveillance
system.
3. Discussion of coordination mechanisms within an Ebola outbreak response.
Instructions
For the first part of the exercise, break the large group into 9 small groups of 3-4 people
(each person can work with their closest neighbors). Each small group should get one of
the outbreak response handouts with a different component of the response circled.
Each small group should then spend the next 15 minutes brainstorming a list of activities
included under that component of the outbreak response. For each of these activities,
they should list the primary challenges likely to be faced in carrying out the activity.
For the second part of the exercise, the trainer should go through each activity in turn in
the PowerPoint presentation and have each group stand up and take 3 minutes to
present its list of activities and challenges. At the end, the trainer should discuss the
various roles and backgrounds of participants and how they fit into the various
components of the outbreak response.
This joint work between International Medical Corps and Massachusetts General Hospital
contains material developed by MSF, WHO, and CDC
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