Background

By August 2014 the Ebola Virus Disease (EVD) outbreak in West Africa was spiralling out of control with unprecedented transmission rates. Epidemiological modelling suggested alarming forecasts in the spread of the virus.1 This was the largest and most complex outbreak of EVD ever reported, caused by the Zaire strain, which is typically associated with mortality rates of 50–90%. National Governments and Non-Government Organisations (NGOs) operating in the region were overwhelmed with the numbers of patients arriving at the appointed treatment centres. This prevented the isolation and safe treatment of EVD cases that is essential to interrupt community transmission and reduce case fatality rates.

Despite a rapid scaling up of Ebola Treatment Centres (ETCs), focussed in Liberia and Sierra Leone, there was inadequate health care workers to staff these centres. As a result the deployment of Foreign Medical Teams (FMTs) to support host nations was requested by WHO and the Ministries of Health in the affected countries. Foreign medical teams are groups of health professionals and supporting staff operating outside their country of origin, aiming to provide health care specifically to affected populations. They include governmental (both civilian and military) and non-governmental teams.

Following sudden onset disasters, a large number of FMTs often arrive in-country, but experience has shown that in many cases the deployment of FMTs is not based on assessed needs and that there is wide variation in their capacities, competencies and adherence to professional ethics.2 Such teams are often unfamiliar with the national or international emergency response systems and standards, and may not integrate smoothly into the usual coordination mechanisms. For this epidemic it was specified that FMTs needed to be self-sufficient, not requiring logistic or financial support from the affected country's Government, and be responsible for their own travel arrangements, including evacuation and medical repatriation arrangements.

Despite this WHO effort, a wider world and military response was required to contain the epidemic. Medecins Sans Frontieres (MSF), a key NGO in the EVD response reported that the epidemic could only be abated through an increased international response,3 including military intervention within the region.4 Operation GRITROCK was the designated title given by the UK Ministry of Defence to the operation to provide support to The Department of International Development in their assistance to the Government of the Republic of Sierra Leone in the fight against the outbreak of EVD within the country. The UK Military were tasked with a number of roles including: provision of an ETC specifically for health care workers, training HCWs, building ETCs and co-ordination. Although experienced in providing medical care in austere environments the UK Defence Medical Service (DMS) had not previously operated in an Ebola outbreak. This article describes the training process undertaken by the UK DMS in order to independently manage an ETC, in line with WHO training guidance which can serve as a model for other FMTs in future outbreaks.

Army Medical Services Training Centre

Army Medical Services Training Centre (AMSTC) is a recognised centre of excellence for the collective training (CT) of military Deployed Hospital Care (DHC) that endeavours to deliver first-class healthcare regardless of the operational environment. It has evolved over many years to become the centre responsible for the training, assessment and validation of land-based Military Medical Treatment Facilities (MTFs) above the level of primary care. The methodology of assurance known as HOSPEX is internationally recognised as an examplar of best practice. The process is formulated to enable the assessment of a unit's deploying teams and systems, in a simulated healthcare environment, in order to confirm the adequacy of their preparation for Operations. For Operation GRITROCK the training process had to be reviewed, adjusted and abbreviated to meet deployment timelines without compromise and still assure the chain of command that the deploying force was equipped with robust safe systems of operation.

CT events at AMSTC are designed to be progressive and follow the philosophy of action centred leadership.5 which focuses on the requirement for the creation of competent individuals, successful teams6 and careful analysis of the task. Training then builds, immersing personnel into a mission specific environment, utilising macro simulation as a vehicle to develop the knowledge, skills, understanding and attitudes that are only possible to achieve as a collective, such as command, control, communication7 and medical logistics. It is assumed that this end to end process of training, assessment and validation improves the management of the care itself, as well as priming the organisational setting8 in which the care takes place with the aim of optimising outcomes.

Exercise process

The aim of Mission Specific Training (MST) and Mission Ready Training (MRT) is to enable the lead Field Hospital warned for operations to be introduced to, receive, and integrate their deploying personnel. This 12-month continuum then assists it in developing effective capabilities of care and clinical teams to create a fully functioning hospital unit able to conduct a relief in place on Operations at minimum risk to the integrity of patient care. This process adopts a CRAWL—WALK—RUN methodology to allow for the lead unit to conduct UNDERSTAND and LEARN whilst being provided with a peer review of areas of strength and those requiring further development which is articulated through a formal Military Judgement Panel (MJP) chaired by Commander 2nd Medical Brigade. This series of events concludes with a capstone CT event in the RUN phase which is classed as the unit's Mission Specific or Ready Validation. This event is delivered at pace and allows the Commanding Officer to display that the hospital is fully prepared to deploy on operations.

Using a unique blend of delivery that includes direct observation, hands-on learning, debriefing and testing, the training aims to tackle clinical and ethical issues as well as exploring hospital command and control, logistics, re-supply and the management of major incidents. Each HOSPEX training event is conducted in two parts; a Directed Training phase (DT) and CT Exercise (CTX). The CTX is conducted exclusively in a bespoke hospital trainer that is equipped to provide a faithful representation of the deployed hospital facility in theatre both in structure and function.

CT exercises delivered by AMSTC are founded on three underlying principles. Firstly, all events are based on the Mission Essential Task Lists (METLS) and CT Objectives (CTOs) Secondly, all exercises are delivered at the tactical level and include serials that test the engagement of the Field Hospital with its operational Headquarters and medical flanks, and finally exercise activity is created to reflect the challenges of delivering a joint, multi-agency (civil/military) and multidisciplinary effect.

Operation GRITROCK

In relation to this operation 2nd Medical Brigade were given the task to Force Generate and Force Prepare to deploy and operate a specialist ETC designated for healthcare workers. This task was unprecedented, highly complicated and multifaceted. The first task was to design, and assess for staff and patient safety, a 12 bedded (rapidly expanded to 20 bedded) ETC in AMSTC that would provide a safe working environment for our deploying medical personnel. Once completed this facility would be reproduced by British Military Engineers in Sierra Leone and be opened for patient treatment.

The initial component of training design was to appreciate that the intent was the provision of a high level of medical care, that could be safely delivered within the ETC (this being a tented facility within a jungle environment) underpinned by existing UK military medical capability. It was evident from the initial estimate that although high levels of patient intervention would be undertaken, they would not match that provided in a High Level Isolation Unit such as that at The Royal Free Hospital, London. Once this component of care provision was determined the training plan was formulated and there was an urgent requirement to draft a new and comprehensive set of Standard Operating Procedures (SOPs). The deploying unit supported by Defence Consultant Advisors, Public Health England and The National Ambulance Resilience Unit constructed a total of 57 new SOPs within 3 days for operating within the facility.

Composition of the Ebola medical team

The number and composition of the medical team was determined by the size of the planned facility, resources available and level of medical care to be provided. More staff is not automatically safer as it requires more training and quality assurance is more challenging. Key individual requirements apart from professional competence for FMTs generally include experience of working in resource-limited environments, good interpersonal skills and physical fitness due to physiological challenge of working in Personal Protective Equipment (PPE). A wide range of medical and nursing specialities could be utilised, but due to the nature of EVD, infectious diseases and critical care experience was advantageous. This must be supported by infection, prevention and control (IP&C) expertise that is considered integral to the delivery of safe Ebola clinical care and staff protection. WHO has recommended a staff ratio of 1:4 nurses to patients per shift and 1:12 doctors to patients9 that balances the required levels for patient care and allows adequate rest to prevent degradation. Equally important to clinical staff are the support staff providing leadership, water and sanitation and logistical expertise and they also require basic and mission specific skills training.

Training to operate in an ETC is unique in that it is dealing with a disease that most will never have seen before, and is underpinned by infection prevention and control practices. As the UNDERSTAND phase of operating an ETC developed, it was evident that in order to keep deploying personnel safe that a fundamental mindset and philosophical change to treatment protocols and training delivery had to occur. The patient outcome success developed through a DMS ‘Formula 1′ style trauma hospital, as required in Afghanistan or Iraq, with kinetic team activity around a patient was not fit for purpose for operating within an ETC and had to change. It was determined that in order to achieve clinical success within Op GRITROCK, treatment delivery and patient care had to be finely balanced against staff safety. To achieve this it was clear that all processes had to be highly methodical, understood by all and repeatedly rehearsed.10

Adjusting training delivery

To achieve the simulated layout of the ETU utilising the in-theatre materials, a rapid reformat of the training area from the Camp Bastion Role 3 Hospital had to be achieved. The developed simulated ETU environment constructed and provided through HOSPEX afforded a highly effective educational platform to achieve excellence through rehearsal and repetition (Figure 1). Although HOSPEX cannot achieve a full facsimile of the operational environment, many aspects of the training platform developed at AMSTC proved to be highly effective in understanding and developing the knowledge, skills and attitudes required to operate effectively within the ETU. This capability of developing a whole hospital system through training allows for an in-depth understanding of how to operate a MTF whilst providing standardised care processes and better inter-professional communications.7 Although the WHO training programme was utilised as a point of reference throughout, and was further utilised on deployment for aspects such as on-site training and mentoring, much of the training delivery format previously utilised within MST was entirely transferable into Op GRITROCK MRT such as periods of DT, cultural awareness, resilience training and departmental familiarisation process. EVD patient management also requires strong team-work and a relative breakdown of the traditional hierarchical nature and roles of doctors/nurses. This process of changing historic culture proved suited to the HOSPEX process. The utilisation of tested method allowed for risk to be identified and dealt with using the daily MJP risk management methodology of; TOLERATE, TREAT, TRANSFER and TERMINATE. This evolving process assisted greatly in educating and building individual and collective confidence.11

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Figure 1

The simulated training environment.

Personal protective equipment

ETU training required a significant focus on practical training related to operating in PPE. This required both individual and collective ‘team-based’ training and required adequate equipment, personnel and time allocation. This was particularly the case when training personnel in PPE removal, which was acknowledged as a high risk activity for HCWs. The collegiate effort, diligence and forensic attention to detail provided by the DMS, Public Health England, Department of Health, Health and Safety Executive and The National Ambulance Resilience Unit developed a bespoke PPE solution and a novel donning and doffing methodology that was clearly defined and rigidly enforced. The approach to doffing utilised a ‘buddy approach’ and involved direction by a third party (Doffing Monitor) that proved to be highly effective and mitigated fatigue-associated risk12 occurring from HCW who had completed clinical care within the stressful workplace environment of ETU. Staff internal validation on this component of training displayed a high level of confidence in the process.

Novel training adjuncts

As a deeper understanding of the risks and challenges this working environment accrued, additional innovation procurements were required to ensure staff safety was enhanced and never subject to compromise; procurements that were trialled and accepted included Bluetooth patient note transfer and two- way video and microphone systems which allowed for remote monitoring of staff and patients in all areas of the facility. Within the ETU, phlebotomy and cannulation were high risk procedures and training was focussed on ensuring safe individual skill levels together with a safe collective process of needle and blood handling from patient entry into the ETU though to the processing of the bloods in the laboratory. It was determined that in order to achieve the required levels of staff confidence in the venepuncture process that ‘live’ needles would be utilised throughout training activity. A suitable device for training did not exist commercially and so AMSTC developed a Safe Cannulation Sleeve to allow HCWs to practice this invasive procedure whilst wearing PPE with a human patient actor until a high standard of confidence and competence was evident.

The same training design and delivery process was performed to assist in developing confidence and the protocol for central venous catheter insertion into EVD patients. The utilisation of such novel training adjuncts proved effective in a high risk and challenging process. It was decided that systems to contain infectious body fluids such as catheterisation, and Flexi-Seal Faecal Management System (FMS) would provide comfort to the patient and protection against skin degradation and pressure sore development. In addition, containment of infectious waste would reduce the possible onward transmission of EVD to HCWs. The use of these systems along with training in areas such as palliative care and handling of the deceased within this environment were a new challenge for AMSTC. To be able to train and assess the competence of HCWs in performing tasks that could not be conducted on live actors, an anatomically correct palliative care doll was designed which provided the capability to conduct invasive procedures as well as provide an appropriate tool for handling of the deceased (Figure 2).

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Figure 2

Body mapping of ultra-violet dye contamination when exiting the simulated Ebola Training Centre.

Distance learning

As the training audience for AMSTC rapidly expanded to include international military medical services and NGOs, Director Training Army attached members of Educational and Training Services to develop an online learning package for pre-attendance learning. This package included professionally filmed, edited and narrated footage of the developed SOPs and mission specific reference material. This capability which could be monitored by AMSTC for individual training compliance proved to be a useful tool in developing understanding.

Assurance of capability

The aim of Mission Specific Assessment is to assess the developing hospital's teams and systems and assure it by comparing its collective performance against standards currently expected on operations or in the case of Op GRITROCK, against WHO policy and drafted MST SOPs, in order to confirm its suitability to deploy. As such, the conduct of CT can be intimidating to some and has the potential to expose professional frailties in its conduct. All those involved in the construct, delivery and conduct of training must be mindful of this and show consideration and professional courtesy at all times to those being trained. Training is best achieved when conducted in a supportive, collegiate and collaborative manner.13

The philosophy of AMSTC is to strive for this and create a safe and rewarding training environment that allows mentorship and mature learning to take place. These conditions are essential for the delivery of a seamless transition of medical capability from exercise to operations and must be strived for at all times. To achieve this, AMSTC endeavoured to attach personnel from both defence and civilian agencies who possessed not only an appropriate range of expertise and technical knowledge of EVD which was key but also CT, human factors in a health care environment and operational analyst skills. This team of permanent staff and assisting subject matter experts (SME) employed a system to structure departmental training as a framework to evaluate departments and the roles of key individuals.

Progress and contemporaneous observations are electronically captured and monitored through CCTV which offers an auditable trail of Unit performance. This performance was then assessed daily against more than 700 Key Performance Indicators (KPIs) drafted and tailored specifically for Operation GRITROCK. These KPIs were complemented by Decisive Conditions (DC), which considered fundamental end-to-end requirements that were considered to contribute to operational success. Together the KPIs and DCs were assessed using the Land Warfare Centre 7-colour grading system, which allowed each hospital department to be benchmarked against extant clinical policies, statutory healthcare requirements and evidence based treatment protocols. In addition, during the conduct of all capability assessments it was important to recognise that:

1. Training and learning was as important an end-point of the exercises as assessment.

2. Tempo was controlled by the Chief Instructor, AMSTC in order to achieve the best possible outcome; aiming to challenge the hospital but not overmatch it. To understand and mitigate risk, fracture lines within the capability have to be identified which on occasion can only be achieved by stressing the MTF.

3. Post-exercise feedback took place down to departmental level and included a whole system approach to the delivery of DHC. Although it did not explicitly consider the performance of individuals, an individual's influence on the functioning of the team or system would be apparent and may attract comment.

4. AMSTC Exercise Planning Staff and the external SMEs should offer guidance, support and value to the training audience by facilitation and mentoring but not direct intervention.

Understanding training success

When training and preparing a deploying force that will be in contact with a Category 4 pathogen14 such as EVD, understanding and articulating training success and therefore gaining staff and command confidence in the training methodology proved fundamental to operational success. For Operation GRITROCK a key facet of gaining such confidence was borne through the utilisation of Ultra-Violet dye and subsequent ‘body-mapping’ of the contaminant1 (Figure 3). Throughout CT, patients deemed to be EVD positive would be presented under SME supervision having been prepared by patient simulation experts (TraumaFx Ltd, Thirsk, UK) and provided with realistic simulated body fluids such as blood, diarrhoea, urine, and vomit. An ultraviolet (UV) tracer dye (Glo Germ_ Co., Moab, Utah, USA) was added to the simulated body fluids and titrated according to the expected viraemia of the simulated patients. This tracer was used to test the robustness of infection control and decontamination procedures employed by clinical staff in their dealings with patients. All participants on the exercises underwent formal assessment with ‘body mapping’ prior to and following removal of their PPE by passing a UV lamp over their body.15 Subjective causality could then be determined following any evidence of contamination. Through this process the rigour of doffing drills could be adjusted in correspondence with developing SOPs. As such in subjectively visualising the virus, staff confidence exponentially grew from viewing their grossly contaminated PPE having treated a simulated EVD positive patient to conducting a supervised doffing drill and being ‘body-mapped’ to show no evidence of florescence.

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Figure 3

HCW setting up a central line on an simulated patient.

After deployment it was essential that during the required period of in-country acclimatisation, staff underwent site-familiarisation and additional in-country training including revision of standard operating procedures/protocols. Training in the use of medical equipment unfamiliar to staff was also important as was team building. An essential component in the process of the commissioning of a new treatment facility or prior to deployment to an existing facility was the conduct of a short exercise during which the deployed team simulated the care of patients with EVD whilst wearing PPE. This exercise allowed all elements of the treatment facility and clinical team to be assessed including command and control, logistics, laboratory, communications and catering as well as clinical care. Issues identified during the simulation exercise could then be rapidly rectified before the Treatment Facility was declared fully operational. During a graduated opening of a facility a further period of SME mentorship was then required as the facility and clinical teams scaled up to full capacity.