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Case Management SOP Kambia District Ebola Response May 2015.
HP
Case Management SOP
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References:
a. Quarantine SOP
b. Labs SOP
c. Surveillance SOP
d. Alerts SOP
1. Introduction
Prompt and aggressive case management of EVD cases has been shown to increase the chances of
survival of the infected and positively impacts on the communities’ perceptions of the EVD response.
The case management pillar is activated by effective surveillance to identify potential cases in the first
instance. Case Management encompasses the isolation (quarantine), confirmation (labs), transport (to
healthcare facility), treatment and ultimately discharge or burial of patients. The aftercare of patients is
covered by the Protection pillar.
The main purpose of the case management pillar is to accurately track the progress of suspect patients
from notification through appropriate treatment to discharge as a survivor or burial. To be effective as
a pillar Case Management must unite the efforts of stakeholders from a variety of contributing
organisations in an effort to counter the spread of Ebola and ultimately reach zero cases. Effective
information management is key to enabling management of cases and it is the responsibility of all
stakeholders but centralised within the DERC.
This standard operating procedure details the procedures to be followed by the case management pillar
in handling cases from identification through treatment to discharge or burial (end to end).
1.1. Terms of Reference. The case management pillar provides the following services
a. Ensure an efficient and safe running of Ebola Treatment Units, Community Care Centres and
Isolation / Holding facilities.
b. Monitor and implement recommended standard infection control guidelines and practices
c. Ensure a safe and efficient transport system for suspected cases from the community and low
level health facilities to the Ebola Treatment Centres
d. Assess the IPC measures at the Ebola Treatment Centres, advise on strengthening protection of
health care workers and on the prevention of health care associated infection within the affected health
zones and ensure that effective action is taken.
e. Developing SOPs / Protocols / Guidelines
f. Collection and provision of data to enable accurate tracking and processing of patients and
deaths.
1.2 Higher Level Roles and Responsibilities. The case management pillar comprises of:
Case Management SOP
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a. DHMT
(i) Provide leadership for all matters related to clinical case management in the district.
(ii) Chair the case management pillar meeting
(iii) Case management patient Information Owner
(iv) Co-ordinate investigation and transport of suspected cases to ETC / CCCs.
(v) Co-ordinate blood/swab sample testing and passage of results
(vi) Facilitate communication between patient and community (reassure).
(vii) Provide discharge and death certification and liaise with protection pillar
(viii) Where necessary liaise with burials teams
(ix) Provide mortuary affairs
(x) Provide chain of custody and accountability of samples.
b. World Health Organisation.
(i) Provide technical support to DHMT on case management issues with a focus on adherence to
standards.
(ii) Assist with co-ordination of case management
(iii) Co chair the case management pillar
(iv) Provide technical support and leadership
c. UNICEF
(i) Co-ordinate and support the CCCs.
d. IMC
(i) Clinical management of the EVD cases at the ETC
(ii) Provision of peripheral services
(iii) Liaison with other service providers
e. Marie Stopes.
(i) Support the operation of CCCs
(ii) Conduct IPC supportive supervisions in the Patient Holding Units PHUs
f. AU.
(i) Support the clinical management of the patients at the ETU alongside IMC
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(ii) Disinfection of households where an EVD case has occurred
(iii) Provide decontamination services as required
1.3. DERC Roles and Responsibilities.
a. District Surveillance Officer (DSO).
(i) Tracks and communicates suspect and confirmed patient details to entitled agencies.
(ii) Maintains the key information boards in the DERC (line listing)
(iii) Co-ordinates patient transfers and transport on discharge.
(iv) Manages end of quarantine procedures.
(v) Tracks samples and swabs, communicating results.
b. District Burials Supervisor (DBS).
(i) Receives and records death alerts in the deaths ledger / database.
(ii) Tasks Burial Teams
(iii) Tracks swab results
(iv) Activates Surv teams and Soc Mob.
(v) Liaises with Quarantine Officer upon receipt of +ve swab.
c. District Quarantine Officer (DQO).
(i) Tasks Quarantine security duties.
(ii) Tracks details of quarantines.
(iii) Co-ordinates quarantine support activities with Soc Mob, Surveillance, Nutritionalist and
Decontamination Teams.
(iv) Notifies DSO and FLO upon completion of quarantine periods.
d. Families Liaison Officer.
(i) Liaises with families affected by EVD, signposting assistance.
(ii) Notification of death to Families
(iii) Assists with Quarantine closure procedures.
e. WHO Epidemiologist.
(i) Oversees all data collection
(ii) Provide data analysis to support DERC decision making
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f. Labs.
(i) Inform sample collection techniques
(ii) Process swabs / samples received from DHMT
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Case Management Process
Case management commences with a suspect patient meeting case definition and concludes with
discharge of a non-EVD patient or discharge of an Ebola Survivor.
Admissions
Patients meeting suspect or probable EVD case definition are to be admitted to a CCC, holding centre or
ETC.
All patients not meeting suspect or probable EVD case definition are to be referred to PHU’s or the
District Hospital.
Any patient who appears very ill (eg –very weak, unable to stand, wet symptoms, bleeding,
unconscious) should be immediately transferred to a higher level of care. Completing CIF and EVD
testing will be done while the patient is at the ETC. All patient transfers should be arranged through
the Case Management desk at the DERC.
1. Transfer to ETC if meets case definition or cannot be determined. (Use EVD Ambulance)
2. Transfer to Kambia Government Hospital (KGH) if does not meet case definition. (Use non-EVD
ambulance)
Any patient who tests positive for EVD in a CCC should be transferred in a safe and timely manner to the
Kambia ETC.
Any patient whose condition deteriorates whilst in a CCC should be transferred to Kambia ETC without
waiting for EVD test results.
The DERC remains responsible for providing transport for all transfers. Please contact the Case
Management desk at the DERC in the event transport is required.
Collection of Patients – From the Community
EVD
Suspect EVD patients will only be collected during daylight hours, due to the challenges of safely
doffing PPE in the dark.
The DERC remains responsible for providing transport for all transfers. Please contact the Case
Management desk at the DERC in the event transport is required.
In the event of the community not being reachable by ambulance, the COS in the DERC should
be contacted. The DERC will begin a “Difficult Evacuation” planning process and a decision on
appropriate Evacuation will be communicated to those involved.
For patients who are too unwell to mobilise to the ambulance independently, the DSO should
inform the DERC when requesting for Ambulance and all efforts will be made to provide
supporting personnel in PPE to support move the patient into the ambulance.
Non-EVD
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Stable non-EVD patients will only be collected in daylight hours.
Movement of Patients between Healthcare Facilities
All stable patients should be transferred during daylight hours.
Unstable patients can be transferred at all hours providing lighting and staffing is available at
the EVD facility to allow safe transfer and PPE doffing.
Exceptions to night-time transfer of unstable patients will be made if considerations of physical
safety of the ambulance crew (difficult access/terrain, heavy rain) is thought to outweigh the
patient’s need. These decisions should be referred to the COS who will consult WHO Pillar
lead/DHMT though the DERC.
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Treatment
In a CCC treatment follows the Guidelines set out in The Guidelines (Clinical Managment of
patient in the Ebola treatment Centres and other centres in Sierra Leone 2014).
The ETC will keep the DERC updates of progress/changes in clinical picture to allow
maintenance of the flow of information to necessary parties.
Should any alterations be made in treatment from the guideline, this is between the Clinical
Lead at the Treatment Centre and their Governing bodies.
ETC
Any suspected cases will be triaged at ETC, against case definition. If met the patient will be
admitted, if not the patient will be discharged.
On admission the patient will be placed into suspect/probable wards based wet/dry symptoms.
A blood sample will be taken. If positive the patient will be moved to the confirmed ward, if
negative and further sample will be taken 48hrs later. Again if positive at this time the patient
will be moved to the confirmed ward, if negative discharge will be arranged.
On arrival at the ETC the ambulance is to wait at the vehicle entrance. All persons are to wait
inside the vehicle and only move as directed by the ETC staff. ETC workers in PPE will collect
patient info/CIF form as well as information on whether they are ambulatory or stretcher
bound, wet or dry.
The patient will then be assisted into the ETC. If the patient is not walking, there may be a small
delay as more persons don PPE in order to take stretcher case in. Medical staff will triage the
patient on other side.
The ambulance driver is to remain in the vehicle throughout this process. Ambulance will be
fully disinfected by the ETC’s dedicated WASH team. Ambulance under direction of WASH can
then leave the ETC and continue with normal duties.
All treatment within the ETC follows the Guidelines for Clinical Care of Ebola patients 2015.
ETCs will notify the District Surveillance Officer of all patients’ progress in order to ensure that
transport, reception and support can be provided to the patient on discharge or a safe and
dignified burial for patients who have succumbed to Ebola.
Death alerts from the ETC are not to be recorded as a new case.
Parents/Caregivers in the ETC
If children are admitted to the ETC it is recognised that a parent or family member may wish to
stay with their child. This is discouraged due the risks associated with the parent caregiver
being within the red zone, however, the ETC will provide the family will all the information to
allow them to make an INFORMED choice. Should the parent/caregiver choose to stay, they will
enter a 21 day quarantine period on the day they leave the ETC. If they do not stay, the ETC will
provide the child with a “care giver” who is a survivor, and will look after the child throughout
their stay. Regular updates on the patient’s status will be passed to parents.
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Discharge
Discharge of Survivors
Once a patient is well enough following discharge, and 2 negative blood results have been
obtained, the patient can be discharged back into the community. To allow preparation for
discharge to take place, the DERC should be informed of potential for discharge after obtaining
the first negative blood result.
The DERC holds the responsibility for returning the patient to their home. This is to be done in a
safe and timely manner.
The patient should return home with their survivors pack.
The patients name should be given to the Surveillance Desk to allow for 21 days follow up
arrangements to be put in place.
If the patient is to be discharged and the family still remain in quarantine the survivor can join
them as it will motivate them.
If the patient is to return home and the family have been relocated to quarantine elsewhere the
family should be consulted on where to take the survivor.
The discharge should be coordinated by the COS DERC, with input from all parties..
Discharge of non-EVD Patients
In the circumstance where a patient is admitted to the ETC and found to be negative for EVD,
(negative test 72hours after onset of symptoms) discharge must be arranged to an appropriate
facility. This includes the PHU’s or the Kambia District Hospital. It is understood that this is a
difficult area as often these patients remain quite unwell and the level of care required may not
be available; this places clinicians in a difficult situation. Each of these cases where concern
exists should be referred to the DERC COS/Case Management Pillar. They will be assessed on a
Case by Case basis and all efforts will be made to ensure the patient receives the best care
possible. Sent with triage form and info transfer form from ETC.
Deaths in the ETC/CCC
Should a death occur in a CCC, alert desk is notified. Coordinated by the DERC, the District
Burials Supervisor dispatches burial team and swabber. The patient will be managed and buried
in line with the Dead Body Management SOP. Swab results will be acted upon appropriately.
Should a death occur in the ETC, an alert will be notified through the DERC. A burial team will
be dispatched by the District Burials Supervisor and take over management of the body,
following its arrival in the mortuary. The ETC will conduct their own swabs; the burial team is
not to swab ETC patients a second time.
The Burial team members may NOT enter the red zone in the ETC under any circumstance.
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Patient Transport
The role of patient transport is to provide safe, assured and swift transport for suspect patients
(meeting case definition) and confirmed EVD positive cases to designated treatment centres. They also
provide transport for transfer between facilities, and discharge from facilities. The DERC remains
responsible for providing transport for all cases. Please contact the Case Management desk at the DERC
in the event transport is required.
1. The requirement for patient transport may arise from one of three situations; (1) upon
notification of a suspect case by a DSO (2) Transfer of a suspect/confirmed case between
healthcare facilities (3) Upon a patient being discharged from CCC or ETC EVD –ve or EVD +ve
Survivor.
2. All transport is coordinated through the Case Management Desk at the DERC. Any issues or
requirements should be raised here in the first instance. The DERC will dispatch ambulances
and communicate with health facilities about the imminent arrival of patients.
3. Ambulances should drive defensively and exercise extreme caution at all times. This is in order
to avoid injury to and person, animals or damage to property. Speed limits are clearly defined
by the fleet site and should be adhered to. Any person with concerns about the manner in
which ambulances are being driven should report these to the COS DERC.
4. Ambulance sirens SHALL NOT be used during collection of patients; siren use during transit
should be reserved for high-traffic areas only, and only if absolutely necessary. The safety and
comfort of patients should be considered at all times.
5. Normal daytime operating hours for ambulance are 0700hrs-1900hrs.
6. One EVD and one Non-EVD ambulance will be on standby every evening 1900hrs-0700hrs on a
rotating basis in order to support urgent transport of either patients or laboratory samples to
Kambia Laboratory.
7. For calls occurring near shift changes the preceding shift will take the call, even if it means
finishing after the end of shift. The only exception to this is calls within 30mins of the shift end,
where the new team will take the case, unless directed by the DERC in exceptional
circumstances.
8. Suspected EVD patients from different households should not be transported in the same
ambulance.
9. Dry and wet suspect patients should not be transported together in the ambulance.
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Laboratory Testing
2 Laboratories are available for use, both the African Union Mission Lab,
stationed in Kambia and the Public Health England Laboratory, stationed in
Port Loko. The AU Lab is to be used in the first instance however PHE lab may
be used if required.
Labs will receive samples from patients in the ETC Treatment Centres, (blood or swabs) and swabs taken
from dead bodies by burial teams prior to their safe and dignified burial. Samples will be processed
with the minimum delay and positives will be immediately followed up with notification to the DERC in
order to ensure patients are processed and treated appropriately. All results are collated with the DERC
at the end of the day. Samples from the community/CCC’s should all be processed through DHMT to
allow for chain of custody and accountability.
Kambia Lab Samples Flow SOP
Objective: Timely and safe testing of case/swab samples
Roles
DHMT: The DHMT is responsible for collecting samples from the Community Care Centres, packaging
and transportation of samples to the Kambia laboratory
WHO: Alert the clinical management pillar to a suspect case based on surveillance activities and follow
up with confirmed Ebola Virus Disease (EVD) cases through case investigation, contact tracing, and
other surveillance activities.
IMC: Collecting Sample of patients at the Kambia Ebola Treat Centre and dispatching them to the DHMT
for batching and dispatching to the Kambia EVD Laboratory
Kambia EVD Lab: The testing of samples and reporting of results
DERC staff:
1. Dispatching DSOs and ambulances to investigate and transport live cases to either a CCC or ETU
where Samples will be collected for testing.
2. Alerting the Burial teams and Surveillance so that the Swabber(embedded in the Surveillance
team) can collect the swab from all dead alerts and deliver them to them
3. Receiving Laboratory results from the Kambia EVD laboratory and sharing with Surveillance and
Social Mobilization pillars.
Responsibilities:
1. Sample Collection
1.1 IMC ETC – collect blood sample as per Guidelines(WHO)
-Completion of Clinical Specimens and Laboratory Testing Form
1.2 CCC – DHMT collects blood samples
Trained phlebotomists will be dispatched from the DMHT by the Case management
desk to go collect Blood samples from patients at the CCCs.
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They will collect blood under strict IPC protocols and in line with line with the
Guidelines(appendix: Procedures Collection of Clinical Specimens Ebola(blood))
for blood Sample Collection from a VHF suspect.
These samples shall be appropriately packaged (triple packaged) and safely
transported to the DHMT for processing and dispatch to the laboratory.
1.3 Dead swabs
- Joint swabbers and DSO teams will collect sample (see surveillance SOP)
The Swab will be collected under IPC protocol as per the guidelines (see appendix: Procedures
Collection of Clinical Swab FIELD ENGLISH 16Oct2014)
-DSO completes CIF and Lab Form The case investigator takes KAM stickers from the CIF and places one on each of the following:
a. Sample tube (being careful not to cover the existing sticker)
b. Primary biohazard bag
c. Secondary biohazard bag
Case investigator writes the name, age, and gender of the corpse on the label on the lab tube
2. Packaging and Transportation
2.1 Packaging - DHMT laboratory will ensure triple packaging as per the guidelines (add appendix: Ship human blood samples Ebola)
2.2 Samples will be transported to DHMT lab (to batch) Blood:
Swabs: Swab is returned to laboratory with original CIF and lab slips.
2.3 DHMT batch samples and transport to Kambia EVD Laboratory
- DHMT will complete Chain of Custody form and send with sample
- Case management Desk will receive copy of chain of custody form
- Timing of transport: Considering an average of 10 samples is received a day and the close
distance between the DHMT and the laboratory it is feasible for samples to be picked up
when packaged or batched every two hours
2.4 Sample lab drop off
- If samples arrive
o Between 8 amto 4pm – they will be tested the same today
o 4pm -7pm – accepted but process by 9AM the following day
3. Testing
3.1 Testing completed Kambia EVD Laboratory as per there SOP
4. Results
4.1 Reporting
Kambia EVD Laboratory will:
- report all positive cases immediately by phone to the Case Management Desk at the DERC
(088458015)
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-Daily email reporting to DERC (see list of recipients in Appendix B)
-send consolidate national reporting by 8pm
4.2 Lab result communication - DERC morning briefing (Live case management Desk will report any results)
- Communicating with patients/Family
o (Live case management Desk will communicate positive to Family Liaison and DSO
who will in turn communicate result to family
- Data management: data managers in consultation with Epidemiologists will share results (positive and Negative) with the surveillance teams
5. Regular Meetings:
Meetings with partners will be held once a week Tuesday at 1000hrs co-chaired by DHMT and WHO
case management lead to review issues and challenges.
The Care of Pregnant and Lactating Women
Pregnant and lactating women who meet case definition present unique challenges.
Women who are pregnant, and suspected to be suffering from
EVD, should be referred to PCMH in Freetown (a PIH facility) at the
earliest opportunity.
The only time this is not the case is if the lady is found to be in
“Second Stage” of labour In these cases, the risk of transporting a
patient whilst actively labouring, with the chance of delivery
unsupported in the back of an ambulance and risks involved for
mother, baby and transmission with exceptionally high viral loads, are thought to outweigh the
benefits. If CONFIRMED, the mother should be transported to the ETC as soon as possible.
The Clinical management of the EVD positive pregnant and lactating mother will be as per the
Guidelines. (Clinical Management of patient in the Ebola treatment Centres and other centres in
Sierra Leone 2014)
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Supporting Information
Social Mobilisation Team. The Soc Mob team will engage with the community to
address the issue and to bolster community support in the fight to get to zero
cases.
Nutritionalist. Will ensure any quarantined contacts are provided with sufficient
nutrition supplies for the quarantine period to discourage breaking of quarantine regulations.
Decontamination Team. Will conduct decontamination of the patient’s room and sanitation and burn
or decontaminate clothes and mattress.
Surveillance Team. Will immediately initiate contact tracing, placing quarantine restrictions on high risk
contacts and recording all low and high risk contact details for follow up action if required. If quarantine
is placed on a residence then DERC Ops will ensure that security is present to maintain the cordon for
the duration of Quarantine.
Quarantine. Upon notification of a positive EVD case the DERC Quarantine Officer will co-ordinate with
DERC Ops to ensure that a quarantine is imposed on the property and high risk contacts of the +ve case.
See Quarantine SOP.
Burials. A burial will be required upon receipt of a Death Alert (117 or 306) or following the death of a
patient at a health care facility. See Dead Body Management SOP.
Operating Times.
a. DERC Manning: 7.30am to 8pm daily
b. Ambulances: 7am to 6.00pm daily
c. Burial teams: 7am to 6.30pm daily
d. Lab Testing (Nigeria): 8.30am to 4pm daily (20 samples / day)
e. PHE Lab @ PL: 8am to 8pm and runs PCRs overnight
f. DHMT Labs: 24/7 (8am-4pm)
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Appendix A: Guidelines (click on Icon to open)
Procedures Collection of Clinical Swab FIELD ENGLISH 16Oct2014
Procedures Collection of Clinical Swab FIELD ENGLISH 16Oct2014
Ship human blood samples_Ebola
Ship human blood samples Ebola
Procedures Collection of Clinical Specimens_Ebola (1)
Procedures Collection of Clinical Specimens Ebola (blood)
Clinical Managment of patient in the Ebola treatment Centres and other centres in Sierra Leone 2014
Clinical Management of patient in the Ebola treatment Centres and other centres in Sierra Leone 2014
Appendix B – Results Recipient List and contact information
Name/Org Email Phone number Collette, IMC [email protected] 079 157 889
Lt. Hamid Bangura [email protected]
Major Tham [email protected]
Dr. Sesay, DMO [email protected]
WHO team [email protected]
CDC Epi Lead [email protected]
Victor Eboh, ? [email protected] Hassan Lab Liaison, MoH [email protected]
Kambia DHMT data manager [email protected] KAMBIA DERC [email protected] kambia derclo [email protected]
