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Three Phase ExpansionI.Establish quality clinical training sitesat 3 referral hospitalsII. Establish quality clinical training sitesat 9 Provincial HospitalsIII. Establish quality PAC services atdistrict hospitals55I. Establish quality clinical trainingsites at 3 referral hospitals Advocate and develop support at national level(completed) Identify national training sites (completed) Orient hospital management and staff (completed) Prepare hospital (PAC organization within the facility,supply of necessary drugs, supplies, equipment, etc.)(completed) Strengthen underlying skills and services (infectionprevention, FP counseling & method provision, etc.)(completed)5628

I. (continued) Provide follow-up Support (completed) PAC Standardization (completed) Provide follow-up support to help establishmodel PAC services (completed) Train trainers in Clinical Training Skills(completed) Co-teach first PAC courses (See Below –training of provincial hospital teams)57II. Establish quality clinical trainingsites at 9 Provincial Hospitals Orient and secure support of PMO andDHMT Orient hospital management and staffand identify key staff Prepare hospital (PAC organizationwithin the facility, supply of necessarydrugs, supplies, equipment, etc.)5829

II. (continued) Strengthen underlying skills andservices (infection prevention, FPcounseling & method provision, etc.) Train PAC teams at one of the threeestablished training sites Follow-up support to help establishmodel PAC services Train PAC teams in clinical training skillsCo-teach first PAC courses (See Below –training of district hospital teams)59III. Establish quality PAC services atdistrict hospitals Orient and secure support of DHMT andhospital management teams Identify appropriate and interested hospitalsOrient hospital management and staff andidentify key staff Prepare hospital (PAC organization within thefacility, supply of necessary drugs, supplies,equipment, etc.)6030

III. (continued) Strengthen underlying skills andservices (infection prevention, FPcounseling & method provision, etc.) Train PAC teams at one of the 12established training sites Follow-up support to help establishquality PAC services61II. Establish quality clinical trainingsites at 9 Provincial Hospitals6231

Activity 2.01 Orient and secure support of PMO,DHMT, hospital management Conduct a one-week orientation andskills building workshops for PMO,DHMT and hospital management teammembers632.01 Outputs: 9 PMOs, DHMTs, and hospitalmanagement teams oriented to PAC Strengthened capacity developed tosupport the PAC expansion Support and coordination mechanismsestablished6432

Activity 2.02 Visit provincial hospitals to orient themanagement and staff Outputs:– 9 Provincial Hospitals supportive ofproviding quality PAC services– Plans developed for preliminarystrengthening prior to PAC training– Hospital staff to implement PAC servicesand training identified65Activity 2.03 Ensure that the necessary steps aretaken to prepare the hospital Outputs:– 9 Provincial Hospitals with adequateequipment, commitment to providenecessary medicines and supplies, andorganized to provide quality PAC services6633

Activity 2.04 Strengthen underlying skills andservices at the selected hospitals Outputs:– 9 Provincial Hospitals prepared to initiatequality PAC services, using quality infectionprevention practices, able to provide PAC,FP counseling and services, and integratedRH counseling with linkages to other RHservices on the ward as part of PAC serviceprovision67Activity 2.05 Train PAC teams in PAC services at oneof the three established training sites Outputs:– PAC teams from 9 provincial hospitalstrained in PAC services6834

Activity 2.06 Provide follow-up support to helpestablish model PAC services Outputs:– 9 provincial hospitals providing quality PACservices69Activity 2.07 Train PAC teams in clinical training skills Outputs:– Training teams from 9 sites prepared tooffer quality clinical training– 27 candidate PAC clinical trainers7035

Activity 2.08 Co-teach first PAC courses at ProvincialHospitals Outputs:– Training teams from 9 provincial hospitalscompetent in PAC clinical training– 27 qualified PAC clinical trainers71III. Establish quality PAC services atdistrict hospitals7236

Summary Expansion to the provincial level:– Establish quality PAC services– Develop training capacity Thorough preparation, orientation, andcollaboration with local management isa significant investment of the program73Roles and Responsibilitiesat National, Provincial, &District Levels in PACExpansion37

ObjectivesBy the end of this session, we will be ableto: Describe the role of National, Provincialand District level partners and theirinteraction List the key responsibilities for each ofour own institutions75National Level Guidelines and protocols for PAC Development of training system (materials,training sites, trainers) Coordinate expansion programs Advocate among stakeholders at the Nationallevel for funding and support Support Provincial and District level Overall monitoring / supervision / evaluation Feedback7638

Provincial Level Prepare expansion plans on Provincial level(coordinating among Districts) Ensure logistics – equipment & supplies (ensuredistricts are planning & budgeting appropriately) Collaborate with stakeholders for funds andlogistic support at the Provincial level Ensure Quality of Care – incorporate PAC intoquality assessment visits to all districts Monitoring, supervision & evaluation at theProvincial level (coordinating among districts)77District Level Plan for introduction of PAC within theDistrict Site assessment and preparation Support for site strengthening Ensure appropriate, adequate manpower Provision of quality, emergency PACservices on demand Outreach and linkages throughout thedistrict to improve access and referrals7839

District Level (cont.) Assure preventive services (immediateFP counseling and services on-site) Integration of other RH services withPAC (HIV/AIDS, STI, cervical cancerscreening, infertility, etc.) Ensure sustainability: budget forequipment and supplies, manpower Monitoring, supervision & evaluationwithin the District Reporting to the Provincial level and theNational Task Force79Conclusion National, Provincial & District levelseach have responsibilities These areas overlap, so there is needfor coordination and communication Through teamwork we can develop andsustain good quality PAC services8040

PAC Training & Supervision–––––––––Orientation to theIndividualized TrainingApproach and MaterialsObjectivesBy the end of this session, we will be ableto: Explain the training & supervisionapproach Describe the training and supervisionmaterials Discuss the realities from the field8241

Individualized Training On-The-Job-Training (OJT) Training small groups Competency-based & Performanceoriented83Why an Individualized Approach? Case load constraints Flexible, efficient, effective Practical8442

Learning Package Development Initiated in Nairobi in November 1999 Regional– Zambia, Kenya, South Africa, and Uganda Representative Cooperating Partners– JHPIEGO, INTRAH, IPAS, AVSC,REDSO/ESA, and USAID/Kenya85Learning Package Materials PAC Supervisor’s GuidePAC Trainer’s GuidePAC Trainee’s GuidePAC Reference ManualVideosAnatomical models8643

Key Players TraineesTrainersSupervisorsCentral level (PAC Task Force)Training site managementPAC service site management87Approach to Expansion Decentralize– Establish provincial training sites andcapacity Emphasize quality of care– IP, Counselling, Prompt & ComprehensiveCare Progressive Expansion Teamwork8844

Supervisor’s Role Establish, support & monitor trainingsites Identify potential PAC service sites– Orient administration and staff– Ensure basic quality services– Organize / coordinate training89Supervisor’s Role(cont.) Facilitate and Supervise Training– Supervise training & ensure competency Provide supportive supervision– To establish PAC Services– Continual support and monitoring of quality9045

Summary The decentralized, individualized approachdepends on:– Teamwork– Individual commitment to quality Supplies & equipment Manpower: skilled, consistent Basics: IP, interpersonal communication, etc. Comprehensive services: emergency care,counselling, FP, linkages to other RH91Integrating Family Planning& Reproductive HealthServices into PAC46

What is integration?Integration is the provision of two ormore types of services, which werepreviously provided separately, as asingle, coordinated and combined service93ObjectivesBy the end of this session, we will be ableto: Justify the need for providing FPservices on the ward Explain the value of integrating andlinking other RH services to PACservices9447

Why integrate? Ability to prevent future healthproblems (e.g., FP for PAC patients) Improvement of quality of service More efficient and cost-effective service No missed opportunity to meet clients’RH needs Convenient for the client Components of RH are interrelated95Importance of Starting PostabortionFP ImmediatelyFP is a preventive service for PAC clientsIncreased risk of repeat pregnancy:– Ovulation may occur by day 11 postabortion– 75% of women will have ovulated within 6weeks postabortionSource: L#hteenm#ki 1993; L#hteenm#ki et al 1980.9648

Which FP Methods to Use PostabortionAll modern methods are acceptable if:– Thorough counseling is given to ensurevoluntary acceptance and choice– Clients are screened for precautions97FP Methods for PAC Oral Contraceptive PillsInjectablesCondomsIntrauterine DevicesImplantsFemale Sterilization / VasectomyPeriodic Abstinence( )( )( )( )( )( )(– –) can be provided immediately at any PAC service site can be provided immediately, but require trained staff appropriate only if the woman / couple is sure of their choice, but may not be available immediately– – not appropriate until menstrual cycle regularizes9849

Integration of FP with PAC – what doesit take? Training ward staff in FP counselling andmethod provision Ensuring that FP counselling and methodsare always available, in the emergencycare setting (i.e., on the ward) Establishing clear protocols for FP followup after initial supply (e.g., an effectivereferral system to a FP clinic)99To ensure correct and continueduse:Systematic follow-up and information,education and communication arenecessary whenever a family planningmethod is supplied.10050

Examples of Other Linked RH Services HIV counseling, referral for VCT Treatment of sexually transmitted diseases(STDs) Cervical cancer screening for women over age30B35 Infertility services Pre-pregnancy advice (e.g., nutrition,immunization, management of existingmedical conditions)101Summary Quality services are comprehensive FP is a preventive service for many PACclients to prevent repeat abortions Some PAC clients want to get pregnant,and have suffered a miscarriage and mayneed help or guidance Some patients may only come in contactwith the health care system during anemergency, so it is a rare opportunity forthem and the health provider10251

Infection Prevention (IP)ObjectivesBy the end of this session, we will be ableto: Explain proper IP practices andprocedures Justify and support the need to improveIP practices to protect staff and clients10452

Objectives of Infection Prevention: To prevent major postoperativeinfections when providing surgicalcontraceptive methods To minimize the risk of transmittingserious infections (e.g., HBV, HCV,HIV/AIDS) from or to:– clients– service providers– other staff, including cleaning andhousekeeping personnel105IP PrinciplesStandard Precautions: Consider every person (client or staff) infectious Wash hands C the most practical procedure forpreventing person to person transmission Wear gloves before touching anything wet C brokenskin, mucous membranes, blood, body fluids,secretions or excretions C or soiled instruments andother items Use other physical barriers including personalprotective equipment (PPE) – such as protectivegoggles, face masks and aprons – if splashes andspills of blood, body fluids, secretions or excretionsare anticipated10653

IP Principles(cont.) Use safe work practices:– Not recapping or bending needles– Safely passing sharp instruments– Properly disposing of medical waste Process instruments and other items(decontaminate, clean, high-leveldisinfect or sterilize) using recommendedinfection prevention (IP) practices107IP Principles(cont.) In addition to the standard precautions,use transmission based precautions onlyfor patients known or suspected to beinfected with highly transmissible diseasespread by:– Airborne transmission (e.g., tuberculosis,measles, varicella)– Droplet transmission (e.g., influenza,mumps, rubella)– Contact transmission (e.g., hepatitis A,Staphylococal furunculosis, herpes simplex)10854

Risk of Disease TransmissionSource ofexposureSkin puncture(broken skin)MucocutaneousHBV(%)27S37HIV(%)0.3S0.4S 0.1As little as 10-8 ml (.00000001 ml) of HBVinfected blood can transmit HBV to asusceptible hostSource: Gerberding 1995; Seelf 1978; Bond et al 1982.109Reducing the Risks of DiseaseTransmissionBetween clients and staff:– Hand hygiene– Personal Protective Equipment (PPE) suchas gloves and clothing (worn by serviceproviders and cleaning staff)– Proper handling and disposal of sharps11055

Reducing Risks(cont.)From contaminated objects:– Processing instruments and other items Decontamination (staff) Cleaning (clients and staff) Sterilization (clients and staff) High-level disinfection (clients and staff)– Proper waste disposal (staff and community)– Encouraging appropriate IP practices in thecommunity (not reusing cutting implements orneedles, properly disposing of wastes, etc.)111Hand Hygiene Techniques Handwashing Hand antisepsis Waterless handrub Surgical scrub11256

HandwashingPurpose: Mechanically remove soil anddebris from the skin and reduce number oftransient microorganismsHandwashing may be the single mostimportant procedure in preventinginfection113HandwashingSteps:– Thoroughly wet hands– Apply a handwashing agent– Vigorously rub all areas of hands and fingers for10B15 seconds, paying close attention to fingernailsand between fingers– Rinse hands thoroughly with clean running waterfrom a tap or bucket– Dry hands with a dry clean towel or air dry them– Use a paper towel when turning off water if there isno foot control or automatic shut offSource: Larson 1999.11457

HandwashingWhen:– Before and after examining any client (directcontact)– After removing gloves, because gloves mayhave holes in them– After exposure to blood, body fluids,secretions and excretions – even if gloveswere worn115Hand AntisepsisPurpose: Remove soil and debris and reduceboth transient and resident flora on the handsSteps:– Similar to plain handwashing except that it involvesuse of an antimicrobial agent instead of plain soap ordetergentWhen:– Before performance of invasive procedures (e.g.,placement of an intravascular catheter)Source: Larson 1999.11658

Waterless HandrubPurpose: Inhibit or kill transient & resident floraIf hands are not visibly dirty, use an alcohol-basedwaterless preparationSteps:– Apply enough alcohol-based rinse or foam to coverthe entire surface of hands and fingers– Rub the preparation vigorously into hands until dry(approximately 30 seconds)When:– Same as handwashing– Following surgical scrub117Surgical HandscrubPurpose: Mechanically remove soil, debris, & transientorganisms & to reduce resident flora during surgical procedureSteps:– Remove rings, watches and bracelets– Thoroughly cleanse hands and forearms to the elbows– Clean nails with a nail cleaner– Rinse thoroughly– Apply 3 to 5 ml of antimicrobial agent– Vigorously scrub all surfaces of hands, fingers & forearms for at least2 minutes– If a sponge or a soft brush is used it should be discarded after useor processed before reuse– Rinse hands and arms thoroughly, holding hands higher than theelbows– Keep hands up and away from the body, do not touch anycontaminated surface or article, and dry with a sterile towel11859

Surgical Handscrub with WaterlessAlcohol-Based PreparationSteps:– Wash hands and arms with soap/detergentand water– Clean fingernails thoroughly– Dry hands thoroughly– Follow manufacturers’ instructions regardingapplication of alcohol preparation– Use enough alcohol for fingers, hands, andforearms, and rub for at least 20 seconds119Alcohol-Based Waterless Preparationfor Handrub and Surgical Handscrub Add 2 ml glycerine to 100 ml 60-90% alcoholsolution Apply 3 to 5 ml and continue rubbing thesolution over the hands, covering all surfaces,until dry Repeat the application a second time12060

Skin Preparation Prior to SurgicalProceduresPurpose – To minimize the number ofmicroorganisms on the skin or mucousmembranes by:– Washing with soap and water– Applying an antiseptic121Skin and Mucous MembranePreparation Do not shave hair at the operative site (ifnecessary, trim hair close to skin surfaceimmediately before surgery) Ask the client about allergic reactions beforeselecting an antiseptic solution Wash first with soap and water if visiblysoiled Apply antiseptic starting from the operativesite and working outward in a circular motionfor several inches12261

Cervical and Vaginal Preparations Apply antiseptic solution liberally to thecervix (2 or 3 times) and then to vagina– It is not necessary to prep the externalgenital area if it appears clean.– If heavily soiled, it is better to have theclient wash her genital area thoroughlywith soap and water before starting theprocedure123Personal Protective Equipment

Legal environment for abortion Zambia's Termination of Pregnancy Act of 1972: - abortion is permitted if continuation of pregnancy involves risk to the life, or injury to the physical or mental health of the woman, unborn child or the woman's existing children Legal abortion requires: - consent of three physicians, one of whom is a