TABLE OF CONTENTS
Table of Contents
1. INTRODUCTION ...... 1 2. OBJECTIVES OF THE SIMULATION EXERCISE ...... 1 3. BACKGROUND AND PROCEEDINGS ...... 2 The first cross-border 4. EXERCISE EVALUATION AND RECOMMENDATIONS ...... joint 4 simulation 5. CONCLUSION ...... exercise 7 on public health emergency 6. CONTRIBUTORS ...... 8 preparedness 7. PHOTO GALLERY ...... between...... 9Perak State Health Department, Malaysia and Yala Provincial Health Office, Thailand.
Dr. Husna Maizura Ahmad Mahir
PERAK-YALA SimEx 2018 REPORT Public Health Medicine Specialist, CPRC Perak State 11 APRIL 2018 Health Department
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1. INTRODUCTION
Simulation exercises are identified as among key components in Public Health Emergency Preparedness in the validation of core capacities under the International Health Regulations (IHR) 2005, and especially for the international points of entry.
On 11th April 2018, the Perak State Health Department, Malaysia (JKN Perak) and the Yala Provincial Health Office, Thailand conducted a joint simulation exercise (Perak – Yala SimEx 2018) at the Bukit Berapit Pengkalan Hulu Immigration, Customs, Quarantine and Security Complex (ICQS) to field – test the draft Guidelines for Inter Facilities Patient Transfer across Perak – Yala Border (“The Guidelines”).
Planning of the Perak-Yala SimEx 2018 involved JKN Perak staff at various levels. The secretariat at the state level is from the Crisis Preparedness and Response Centre JKN Perak (CPRC Perak) with the cooperation of the state Inspectorate and Legislative Unit, the Hulu Perak District Health Office (PKD Hulu Perak), Gerik Hospital and Infectious Disease (ID) Consultant Physician, Emergency Physician (EP) and Medical Emergency Call Centre (MECC) Coordinator from Raja Permaisuri Bainun Hospital (HRPB). This event was supported by multiple agencies at the ICQS including Immigration Department, Royal Customs, Royal Malaysian Police, Road Transport Department and People’s Volunteer Corps (RELA).
This exercise is a follow up action to some of the recommendations of the 30th Border Health Goodwill Committee Meeting (BHGWCM) held in Sabah, Malaysia in August 2017.
2. OBJECTIVES OF THE SIMULATION EXERCISE
a. To engage both Perak and Yala authorities in preparing for the eventuality of Malaysian and Thai patients transfer across the border. b. To facilitate Inter Facilities Patient Transfer across Perak – Yala Border c. To test the draft Guidelines for Inter Facilities Patient Transfer across Perak – Yala Border d. To test intra and inter-agency communication systems involved in patient transfer across the Perak-Yala border. e. To test the logistical preparedness in transferring patient across the Perak-Yala border. f. To identify any shortcomings and make recommendations to the Guidelines. g. To foster greater camaraderie and cooperation between Malaysian (Perak) and Thai (Yala) authorities.
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3. BACKGROUND AND PROCEEDINGS
3.1 EXERCISE TYPE
A field exercise wherein all participants were expected to respond as in a real – life situation, per the protocol specified in the Guidelines.
3.2 EXERCISE MANAGEMENT TEAM
Exercise Coordinator:
Dr Asiah Ayob Public Health Medicine Specialist, Head of CDC Unit, JKN Perak
Exercise controllers:
Dr Husna Maizura Ahmad Mahir Public Health Medicine Specialist, Head of Surveillance Unit, JKN Perak
Dr Masliza Mustafa Medical Officer (Preparedness & Rapid Response), CDC Unit, JKN Perak
Exercise evaluators:
Dr Ker Hong Bee Consultant Physician (Infectious Diseases), HRPB
Dr Marina Kamaruddin Public Health Medicine Specialist, Hulu Perak District Health Officer
Dr Tan Wan Chuan Emergency Medicine Physician, HRPB
Mr Mohd Nazir Bin Isa Assistant Medical Officer, Emergency & Trauma Centre, HRPB
Mr Najib Bin Ramli Senior Assistant Medical Officer, Public Health Division, JKN Perak
Mr Mohd Azrul Azwan Bin Abdul Roni
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Assistant Environmental Health Officer, Enforcement & Legislative Unit, JKN Perak
Dr Sheela Mithra Family Medicine Specialist, Pengkalan Hulu Health Clinic
Matron Norzanria Jamalhuddri Nursing Supervisor, Gerik Hospital
Mr Khairul Anuar Mohamad Nasir Senior Assistant Medical Officer, Gerik Hospital
Ms Zainab Che Lah Staff Nurse, Gerik Hospital
Secretariat:
Teams from CPRC Perak led by Dr Asiah Ayob, Hulu Perak District Health Office led by Dr Marina Kamaruddin and Gerik Hospital led by Dr Khuzaini Abdul Karim.
3.3 EXERCISE SCOPE
A scenario wherein a Malaysian citizen warded in Betong Hospital, Yala Province, Thailand with the diagnosis of Avian Influenza, wished to return to his hometown in Gerik, Perak, Malaysia.
The premise involved were the Isolation Room at the ICQS and Pengkalan Hulu Health Clinic (KK Pengkalan Hulu). Domains tested included communications, logistics, transportation procedures, international cross – border procedures, infection prevention and control measures as well as decontamination of premises, equipment and personnel.
3.4 AGENDA
The exercise proper was conducted on 11th April 2018, preceded by a briefing session by the exercise coordinator to all personnel involved.
The simulation exercise commenced with communication between Yala and Perak focal points. This was followed by the planned scenario. A debriefing and panel discussion session was held immediately on completion of the exercise at 3.30pm.
This panel discussion was chaired by Dr Venugopalan A/L K Balan, the Perak State Deputy Director of Health (Public Health) and the other three panellists were Dr Banyong Luajareonsook, Betong Hospital Director, Dr
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Tubtim Chatwattanatum, Betong Hospital Deputy Director and Dr Asiah Ayob, Head of CDC Unit, JKN Perak.
3.5 EXERCISE PARTICIPANTS AND LOCATIONS
The following agencies and locations participated in the exercise:
1. Perak State Health Department 2. Yala Provincial Health Office 3. Hulu Perak District Health Office 4. Gerik Hospital 5. Raja Permaisuri Bainun Hospital, Ipoh 6. Pengkalan Hulu Health Clinic 7. Betong Hospital, Yala Province, Thailand 8. Royal Malaysian Customs Department 9. Malaysian Immigration Department 10. RELA of Pengkalan Hulu 11. Royal Malaysian Police
The participants are listed in the Annex.
4. EXERCISE EVALUATION AND RECOMMENDATIONS
4.1 Pre-transfer communication of patient
Observations:
1) The communication process between Yala Province Health Office and Perak State Health Department was fully functional. However, there was a delay in communication between
i) CPRC PKD and ICQS Health Office; and ii) CPRC PKD and Gerik Hospital. iii) ICQS Health Office & other agencies at ICQS.
2) No network coverage for Thais to communicate with Malaysian counterparts once they cross the Thai border.
3) Information provided to other agencies was limited to patients’ particulars only and not including accompanying persons such as family members or health staff.
4) Information on patient current health condition during transfer was not updated.
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Recommendations:
1) Alternative/backup liaison officer to be assigned at all times in case the first officer is not available.
2) Use of walkie-talkie among agencies in ICQS.
3) Suggest Thai counterpart to provide walkie talkie to their ambulance staff to communicate with ICQS Health Office.
4) Use of Government Integrated Radio Network (GIRN) between KK Pengkalan Hulu and hospitals.
5) CPRC PKD to inform HRPB Medical Emergency Coordination Centre (MECC) of the transfer date and time (to be included in the algorithm in the Guidelines).
6) CPRC PKD to provide liaison officers with additional information including number of health staff/family members accompanying patients and contact details of treating/referring clinicians. This is for the purpose of facilitating process of relevant agencies, especially the Immigration Department, at the border.
4.2 Process of receiving patient
Observations:
1) No designated area for referring and receiving ambulances at the ICQS.
2) No ramp at the entrance of the isolation room causing difficulty in pushing stretcher from and to the ambulances.
3) Patient was received by a team from Pengkalan Hulu Health Clinic. Clerking and examination of patient was done in the isolation room by a medical officer and a nurse. Nevertheless, as the patient was intubated on ambu bagging, more health personnels were needed to handle the situation.
4) The team from Hospital Gerik arrived with portable ventilator and was asked to wait outside isolation room until patient fully assessed by the Pengkalan Hulu team.
5) The transfer of patient to our ambulance could be smoother.
6) Inadequate basic medical equipment at the isolation room at ICQS, e.g. drip stand, suction.
7) No PPE kits, however loose PPE is available.
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8) Goggles used by staff in the isolation was outdated causing the goggles to fog up (not expiry issue but due to vapour during breathing).
9) Difficult to identify staff in full PPE e.g. cannot differentiate immigration officer from health staff.
Recommendations:
1) PKD Hulu Perak to initiate a memorandum of understanding with ICQS authority to designate an area for referring and receiving ambulances at the ICQS.
2) Ramp access should be available at the entrance of the isolation room – for wheelchair and stretcher.
3) It is recommended that the same team from Hospital Gerik to do the initial assessment, to communicate with the referral hospital and to transfer the patient, as transfer of such patients are pre-arranged.
4) The team in the isolation room should have a commander (to give instructions or get external help) to ensure process of transfer happens smoothly.
5) The team handling the patients should have regular training on the PPE and transfer policy.
6) The receiving ambulance must be equipped with HME (Heat moisturizer exhalation) filter for intubated patient on ventilator.
7) Basic medical equipment must be made available at the isolation room at ICQS at all times.
8) Have pre-packed PPE kits to facilitate gowning and avoid missing out on PPE item as well as reduce cluttering.
9) To equip isolation room with minimum numbers of updated goggles. Suggested use of anti-fog wipe or face shield to prevent goggles to foq up.
10) Staff in PPE to stick identification tag using micropore tape, stating names and job designations.
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4.3 Decontamination of ambulance
Observations:
1) Degowning process protocol was adhered to.
2) Ambulance driver was not aware of the proper dilution of disinfectant solution to be used during decontamination process.
3) Handling of spillage in ambulance was not done properly by the ambulance driver i.e. missed a step of mopping the area of the spillage prior to the decontamination process.
Recommendations:
1) To include a chapter on procedure for decontamination of ambulance in the existing Guidelines for Inter Facilities Patient Transfer across Perak – Yala Border.
2) Continuous and regular hands-on training on; a. gowning and degowning of PPE b. decontamination of ambulance including dilution of disinfectant solution, and c. handling of spillage.
5. CONCLUSION
The Crisis Preparedness and Response Centre, Public Health Division of Perak State Health Department with the cooperation of Hulu Perak District Health Office, Gerik Hospital and Raja Permaisuri Bainun Hospital has successfully conducted the first cross-border simulation exercise on public health emergency preparedness at an international point of entry as required under the International Health Regulations 2005.
Perak-Yala SimEx 2018 has highlighted enhanced cooperation between Public Health and Medical Divisions in Perak State Health Department. In addition, this event has strengthened networking between Perak State Health Department and Yala Provincial Health Office as well as other relevant authorities at the border.
The findings and recommendations from this simulation exercise serve as an opportunity to refine our existing Guidelines for Inter Facilities Patient Transfer across Perak – Yala Border. This activity also enhances our preparedness and response capacity in addressing public health emergencies.
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6. CONTRIBUTORS
Public Health Division, Perak State Health Department
Dr Asiah Ayob - Public Health Medicine Specialist, Head of CDC Unit
Dr Husna Maizura Ahmad Mahir - Public Health Medicine Specialist, Head of CDC (Surveillance) Unit
Dr Masliza Mustafa - Medical Officer (Preparedness & Rapid Response) CDC Unit
Dr Alvin Tan Lik Hooi - Postgraduate Medical Officer, CDC Unit
Mr Najib Bin Ramli - Senior Assistant Medical Officer
Mr Mohd Azrul Azwan Bin Abdul Roni - Assistant Environmental Health Officer, Enforcement and Legislative Unit
Hulu Perak District Health Office
Dr Marina Kamaruddin - Public Health Medicine Specialist, Hulu Perak District Health Officer
Dr Sheela Mithra - Family Medicine Specialist, Pengkalan Hulu Health Clinic
Raja Permaisuri Bainun Hospital, Ipoh
Dr Ker Hong Bee - Consultant Physician (Infectious Diseases)
Dr Tan Wan Chuan - Emergency Medicine Physician
Mr Mohd Nazir Bin Isa - Assistant Medical Officer, Emergency & Trauma Centre
Gerik Hospital
Matron Norzanria Jamalhuddri - Nursing Supervisor
Mr Khairul Anuar Mohamad Nasir - Senior Assistant Medical Officer
Zainab Che Lah - Staff Nurse
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7. PHOTO GALLERY
Briefing and discussion of the preparation for Perak- Briefing of the SimEx 2018 by Dr. Asiah Ayob to Dr. Yala SimEx 2018 on the day before the actual Banyong Luajareonsook, Head of Thai Delegates and simulation . Director of Betong Hospital, and Dr. B. Venugopalan, Perak State Health Deputy Director (Public Health).
The evaluators, secretariat, and players from multi- The morning briefing before the simulation exercise agencies at the ICQS Bukit Berapit attending the by Dr. Asiah Ayob, the Public Health Medicine morning briefing before the simulation exercise. Specialist (CDC) of CPRC Perak.
Brefing by the …. Summary of the briefing by Dr. Husna Maizura Ahmad Opening remarks by Mr Tajul Aripin Mohammed Mokhtar Mahir, Public Health Medicine Specialist Head of Immigration at the ICQS Bukit Berapit, Pengkalan (Surveillance) of CPRC Perak. Hulu.
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Dr. Ker Hong Bee, Consultant ID Physician of HRPB Dr. Banyong Luajareonsook, Head of Thai Delegates and Ipoh as the Perak Chief Evaluator looking at the logistic Director of Betong Hospital, and Dr. B. Venugopalan, Perak preparedness at the isolation/treatment room at the State Health Deputy Director (Public Health) visiting the ICQS. isolation/treatment room at the ICQS.
Commencement of the SimEx 2018, where the I.C.Q.S. Communication between the I.C.Q.S. Health Unit and Bukit Berapit Health Unit received the notification and RELA Officer. direction to prepare to receive the patient at the border.
Arrival of Betong Hospital ambulance at the I.C.Q.S., using the designated route to the transfer location. Both ambulances should be put side by side to ensure easy transfer of the patient.
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The Betong Hospital accompanying staff transferring the Passing over of the case by Betong accompanying patient to the treatment room at the transfer location. staff to Pengkalan Hulu Health Clinic staff who There was slight hindrance since there was no ramp received the case access over the drain at the entrance of the isolation room.
Staff preparing the mobile ventilator for the transfer of The Immigration officer in full PPE reviewing the patient patient’s documents and viewing the patient to confirm his identity.
The receiving staff moved the patient into the Preparing to transfer the patient to the receiving ambulance to be sent to ‘designated receiving receiving ambulance hospital’.
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The Health attendant removing used linens Decontamination process underway at the after the transfer of the case treatment room
Decontamination of spillage on the floor of the Decontamination of spillage on the floor of the isolation room receiving ambulance
The Health Attendant degowned at the degowing It was 2.00 p.m., and the temperature outside area. A poster on the degowning steps was was 33 degree Celsius. The protective goggles placed at the area for reference. worn by the Health attendant was fogged up.
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The Health Attendant was performing hand The container for tissue paper was placed on washing at the designated wash area. There was a the window sill of the bathroom at the wash ‘hand washing steps’ poster in front of the sink for area. It is recommended that a tissue dispenser reference. placed near the sink for easier access for the staff to dry their hands after hand washing.
Decontamination and disinfection process of the ambulance Decontamination process of Gerik Hospital Ambulance was done by the ambulance driver at the “designated receiving hospital”. All ambulance drivers are to be trained in decontamination procedures to ensure the proper procedures are followed.
Welcoming speech by Dr. B. Venugopalan, Speech by Dr. Banyong Luajareonsook, the Head Perak State Health Deputy Director (Public of Thai delegates and Betong Hospital Director Health) at the debriefing session of the Perak- Yala SimEx 2018
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Summary of the evaluation and Summary of the evaluation and recommendation recommendation of the simulation exercise of the simulation exercise done at Betong done at the Bukit Berapit I.C.Q.S by the Perak International Point of Entry by the Yala Chief Chief Evaluator, Dr. Ker Hong Bee Evaluator, Dr. Tubtim
Comments by Dr. Mazlan from Thanto Hospital, Comments by one of the Yala delegates, from Yala Emergency Department of Betong Hospital, Yala.
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Secretariat bidding bon voyage to the last batch The Health Inspectors of Perak State Health of Thai delegates Department, Hulu Perak District Health Office and point of entries at Bukit Berapit (Perak), Betong (Yala) and Sadao (Songkhla)
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