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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 1 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 2 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 3 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 5 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 6 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 7 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) This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 8 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 9 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 10 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 This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 11 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 12 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 14 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 15 Note: Participants should have a triage tool similar to the one on the following page in their student guide. CASE 1 This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 16 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 This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 17 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 This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 18 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?” This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 19 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?” This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 20 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 This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 21 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 This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 22 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 This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 23 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. This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 24 EFG#3 Facilitator Guide: Venipuncture and Simulated Clinical Care This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 25 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. This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 26 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 This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 27 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) This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 28 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 This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 29 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. This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 30 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. This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 31 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. This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 32 EFG#4 Facilitator Guide: Safe Handwashing and Glove Removal This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 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 This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 34 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 This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 35 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. This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 36 This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 37 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. This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 38 EFG#5 Disinfection This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 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.) This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 40 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. This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 41 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. This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 42 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 This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 43 EFG#6 Safe Body Transport and Burial This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 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 This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 45 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. This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 46 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 This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 47 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 This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 48 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. This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 49 EFG#7A Ebola PSS Training Guide This joint work between International Medical Corps and Massachusetts General Hospital 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 This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 51 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. This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 52 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/ This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 53 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 This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 54 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 This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 55 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.” This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 56 · 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 This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 57 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 This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 58 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. This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 59 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 This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 60 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 This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 61 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 This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 62 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 This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 63 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. This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 64 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 This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 65 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 This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 66 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. This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 67 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. This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 68 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. This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 69 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 This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 70 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. This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 71 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. “ This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 72 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 This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 73 • 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 This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 74 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 This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 75 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 This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 76 • • • • • • · 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. This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 77 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. This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 78 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 This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 79 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 This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 80 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. This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 81 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… This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 82 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. This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 83 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 This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 84 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? _______________________________________________________________________ _______________________________________________________________________ This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 85 EFG#8 IFRC 2014 Working in Stressful Situations – Ebola This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 86 This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 87 This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 88 EFG#9 Tabletop Designing a Safe ETU This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 89 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 This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 90 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 This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 91 EFG#10 Mixing Chlorine This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 92 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 This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 93 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 This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 94 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. This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 95 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 This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 96 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 This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 97 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. This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 98 EFG#11 Facilitator Guide: M&E This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 99 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 This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 100 - 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 This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 101 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 This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 102 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: This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 103 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 This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 104 ▪ • 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 This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 105 EFG#XX Facilitator Guide: Outbreak Response This joint work between International Medical Corps and Massachusetts General Hospital contains material developed by MSF, WHO, and CDC 106 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 107