3. CTU-CTC evaluation form_GTFCC.xlsx

	B	C	D	E	F	G	J	K	L	M	N	O
1
2	Evaluation of CTC / CTU										DATE	/ /
3
4	Facility Information				Evaluation information						Notes
5
6	Structure name	------------------------------------------			Name of evaluators
7	Address	------------------------------------------			-------------------------------------------------------------------------------------
8	District/Region	------------------------------------------			Catchment population (est.): __________________________________
9		------------------------------------------			Date of first case:
10	Type:	Hospital	Health facility		Number of patients to date			Facility bed capacity		__________________
11
12		Tent	Other/none		Number of deaths to date			Current bed occupancy		__________________
13
14					CFR to date
15					CFR for last week
16	Facility manager	Government	NGO	_________________________________			Community			Top priority: within 24-48 hrs
17										High priority: within a week
18				Yes	No	date most recent				Priority: as soon as available/possible
19	Has at least one case been confirmed by culture?									Good practice: plan resources and implement
20										Useful but not essential
21	IPC						Yes	No		Comments
22	Clearly marked handwashing stations are available at point of entry and exit, at all latrines, in all patients’ areas, in the kitchen, the laundry area, the waste management area and the morgue with soap and safe water. Where soap and safe water are not available, an alcohol-based hand rub (ABHR) should be used. When neither is available, water treated with a 0.05% chlorine solution is used.
23	A staff is posted at the entry and exit to ensure washing of hands and control movement
24	Foot spraying or maintained footbath is available at to those entering and exiting the structure (maintained = muddy solution is replaced regularly). If installed, footbaths should use trays with cloth or sponge soaked in a 0.2% chlorine solution and changed twice per day
25	Floors, latrines and beds in CTC are cleaned when dirty with 0.2% chlorine solution (recommended is at least 4 times per day)
26	Handwashing stations with soap and safe water are available in each ward. Where soap and safe water are not available, an alcohol-based hand rub (ABHR) should be used. When neither is available, water treated with a 0.05% chlorine solution can be used.
27	Health staff and relatives wash hands before and after each contact with the patient
28	Gloves are worn when IV catheter or NG tube is inserted/removed
29
30	Facility layout/organization						Fully	Partially	Absent		Comments
31	A triage area is available for registration, evaluation and immediate treatment of severe cases
32	The layout and access to different spaces is organized to facilitate patient flow from triage to exit that isolates infectious patients from other wards or clean areas
33	The neutral area is clearly demarcated and access is restricted to staff only
34
35	Screening/admission and observation areas (mild to moderate)						Always	Partially	Absent		Comments
36	Cholera register is correctly filled in with patient name and address noted. Patient discharge should also be noted.
37	The age range < 5 years and >5 years and sex is clearly noted
38	Patients are evaluated and their level of severity defined according to protocol
39	Severe cases are immediately given IV fluids and transferred to the hospitalisation area
40
42	Hospitalisation area						Always	Partially	Absent		Comments
43	The patient's file is correctly filled in and the admission time is registered
44	Cholera beds (with a hole in the middle) are sufficiently available and use with all severe cases
45	Each cholera beds has two buckets available filled with around 2 cm of 2% chlorine solution for collection of stool and vomit
46	Each patient has not more than one family member to assist care
47	Treatment protocols are available and in use
48	Each patient has ORS available and is encouraged to drink regularly
49	IV fluid bags are changed rapidly when empty
50	Antibiotics are used according to national protocol
51
52	Kitchen and meals						Yes	No			Comments
53	Food is provided at the center and there is designated area for food preparation. Food handlers practice hand hygiene at critical times using soap and safe water (which should be made available in the kitchen) or ABHR
54	Food is provided by restaurant
55	Food is provided by family/friend (and arrangements made for people without a caregiver
56	No food is available
57	Left over food is disposed off in centre and not take home with family/friend
58	Eating and cooking utensils should be washed regularly (between each use) with detergent and a 0.2% chlorine solution
59
60	Water						Always	Partially	Absent		Comments
61	The quantity of water available is enough for at least 60 litres per patient per day and 15 litres of water per caregiver per day
62	Water for consumption (including ORS preparation) should be chlorinated, and have a free residual chlorine (FRC) level of at least 0.5 mg/L at pH < 8.0 after 30 minutes of contact time										Water source___________________
63	Free Residual chlorine for drinking water and water used for ORS preparation is tested daily
64	Water is available at all times (for preparation of ORS, handwashing,and cleaning purposes) and dose adjustment occurs as needed
65	Water storage available to cover water needs for 3 days
66
67	Latrines and showers						Yes	No		Comments
68	The center has 1 useable latrine per 50 patients in the hospitalization area (min. 2 latrines, male/female)
69	The centre has 1 useable latrine per 20 patients in the observation and recovery area (min. 2 latrines, male/female)
70	The center has at least 2 useable latrines for staff in the neutral area and visitors outside of the hospitalization area (2 latrines, male/female)
71	Handwashing stations are provided at all latrines with soap and safe water. Where soap and safe water are not available, an alcohol-based hand rub (ABHR) should be used. When neither is available, water treated with a 0.05% chlorine solution is used
72	Showers are available in each area, observation and recovery,hospitalization, and neutral (Min 2 showers, male/female)
73
74	Waste Management						Yes	No		Comments
75	The center has an designated pit to dispose the faeces and vomit of the severe cases (or another safe disposal method such as pit latrine)
76	Waste generated in the centre is treated and disposed of safely in the centre
77	A fenced waste zone is in the centre, scavengers have no access to the waste zone
78
79	Dead body management						Yes	No		Comments
80	The center has a designated isolated area for the deceased
81	Designated staff are trained and equiped to prepare and disinfect dead bodies
82	Dead bodies are disinfected with chlorine solution 2%
83	Funerals are conducted in a safe manner and supervised and supported by trained staff
84
85	Procedures/Protocols						Yes	No		Comments
86	Protocol for preparing ORS is in use
87	ORS is prepared daily with safe water (treated with chlorinated). ORS should not be stored for more than 12 hours at room temperature (or up to 24 hours if kept refrigerated)
88	ORS is available in all treatment areas in closed containers with a cover and accessible by spigot or tap
89	Protocol for preparing chlorine solutions is in use and stock solutions are clearly labelled - protocol on different stock solutions are available where solutions are prepared
90	Chlorine solutions 2%, 0.2% and 0.05% are prepared daily
91	2% chlorine solution is used for disinfection of dead bodies, stool and vomit
92	0.2% chlorine solution is used for disinfection of the entire cholera ward(s), toilets and showers/bathing units; laundry; kitchen and morgue. This solution should be used on all cholera beds or cots, bedding and linens; clothing; PPE (i.e. gloves, apron, goggles); waste containers and covers; food utensils, containers and dishes; and vehicles used for transporting patients
93	0.05% chlorine solution is used for disinfection of hands (when neither soap and safe water nor ABHR is available)
94
95	Stocks						Yes	No	estimated days of supply left
96	HTH or NADCC chlorine, properly stored (no direct sunlight, no humidity but ventilation)								<7 7-14 >14
97	DPD 1 tablets for testing free residual chlorine								<7 7-14 >14
98	Gloves, approns, and other PPE								<7 7-14 >14
99	ORS								<7 7-14 >14
100	Buckets								<7 7-14 >14
101	Soap								<7 7-14 >14