Keeping NCD care going in an emergency

Key messages to land

1. Find insulin users first; they can die within days without insulin.
2. In the first phase, NCD care is about treating emergencies and restarting essential medicines.
3. Do not delay treatment for tests; restart from a standard protocol.
4. Food insecurity raises the risk of hypoglycaemia on gliclazide and insulin.
5. The IEHK alone is not enough: order the NCD kit or procure locally, with cold chain for insulin.
6. A register and a patient-held card keep care going when people move.

Running the tabletop exercise

• Give each group a role: clinic lead, nurse, pharmacist, community health worker supervisor. Ask them to decide as a team.
• Release information in stages (part 1, then 2, then 3) to mimic a real response.
• Keep time strictly; the debrief matters more than finishing every question.

Common misunderstandings

"NCDs can wait until the emergency is over"

Insulin users, epilepsy and severe asthma cannot wait, and NCD emergencies are common in the first weeks.

"We need a laboratory before treating"

Most decisions can be made with BP, capillary glucose, history and examination.

"Give everyone a new regimen"

If a working regimen is available, keep it; frequent changes confuse people.

"The emergency health kit covers NCDs"

The IEHK has only a few NCD medicines; the NCD kit is designed for 10,000 people for 3 months.

Adapting the session

For a longer session, add the diabetes or hypertension trainer packs' skills stations. For coordinators, spend more time on case 3 and on handover to national services.

Case 1: Part 1: a new displacement site

About 9,000 people have arrived over two weeks after fighting. Your team runs the only clinic, with an IEHK. Registration records names and family size only. On day 3 a 14-year-old girl is brought in drowsy, vomiting and breathing deeply; her mother says she 'had injections for sugar' at home.

1. What is the girl's likely problem and what do you do?
   Answer: Diabetic ketoacidosis in type 1 diabetes after losing insulin. ABCDE, check glucose and ketones, start 0.9% saline per protocol, and refer urgently.
2. What should change at the site straight away?
   Answer: Add a question at registration and in every consultation ("Does anyone in the family take a medicine every day?"), list all insulin users by name, secure an insulin supply, and set up triage for NCD emergencies at the clinic.

Case 2: Part 2: three patients with lost medicines

(a) Mr Z, 60, hypertension, tablets lost, BP 168/102 on two careful readings, no symptoms. (b) Mrs A, 55, type 2 diabetes on metformin and glibenclamide, eats once a day now, glucose 9 mmol/L. (c) Mr B, 25, epilepsy, ran out of carbamazepine 5 days ago, had two seizures yesterday.

1. How do you manage each?
   Answer: (a) Restart from the protocol, for example amlodipine without waiting for tests; review in a month. (b) High hypoglycaemia risk with one meal a day: restart metformin, switch glibenclamide to gliclazide at a low dose or hold it, teach about lows and carrying sugar. (c) Restart one antiepileptic that will be reliably available; check for injury; advise not to stop suddenly; review soon.
2. What do all three need before they leave?
   Answer: A patient-held card with diagnosis, medicines and doses, enough medicine until the next visit, a return date, and their details in the register.

Case 3: Part 3: supplies and records

Three months on, the site is stable with 10,000 people. Your register lists 420 adults with hypertension, 160 with diabetes (12 on insulin), 70 with asthma or COPD and 30 with epilepsy. Stock-outs happen monthly.

1. What supply plan do you propose?
   Answer: Order the WHO NCD Kit 2022 (with its cold chain module for insulin) or procure locally from a short list based on the WHO Model List and the national list; keep a buffer stock; check stock weekly; coordinate cold chain with the immunisation team.
2. How will you know care is working?
   Answer: Use the register to count, each month, how many attended, how many missed visits and were followed up, and how many had BP and glucose at goal.

Read the questions aloud or print them. Participants choose one answer each. The answer key with reasons follows.

1. Who should be found first in a new crisis?
   1. People on insulin
   2. People with mild hypertension
   3. People with arthritis
2. What question should be asked at registration and in every consultation?
   1. Do you take any medicine every day?
   2. Do you smoke?
   3. What is your blood group?
3. Which is an NCD emergency to detect at triage?
   1. Stable osteoarthritis
   2. Diabetic ketoacidosis
   3. Mild acne
4. Suspected DKA: fluid before transfer?
   1. 0.9% saline 1 litre over 2 hours, then 1 litre every 4 hours
   2. No fluids
   3. 50% glucose
5. Can hypertension treatment be restarted without blood tests?
   1. No, never
   2. Yes; amlodipine is suitable to start without tests
   3. Only in hospital
6. Meals are irregular. Which medicines carry the main risk of hypoglycaemia?
   1. Metformin
   2. Gliclazide and insulin
   3. Amlodipine
7. The WHO NCD Kit 2022 is designed for:
   1. 1,000 people for 1 month
   2. 10,000 people for 3 months
   3. Hospitals only
8. Why order an NCD kit if you already have an IEHK?
   1. The IEHK has only a few NCD medicines
   2. The IEHK is out of date
   3. It is not needed
9. A patient is well controlled on an affordable medicine you can still obtain. You should:
   1. Switch to the protocol medicine
   2. Keep the current medicine
   3. Stop it
10. What best keeps care going when patients move?
    1. A patient-held card with diagnosis and medicines
    2. Memory
    3. A new diagnosis each time

Answer key

1. A. Insulin users can die within days without insulin.
2. A. It finds people on long-term treatment quickly.
3. B. DKA, hypoglycaemia, heart attack, stroke, heart failure, hypertensive emergency, severe asthma or COPD and status epilepticus.
4. A. HEARTS-D pre-referral fluids.
5. B. Do not delay treatment for tests.
6. B. Sulfonylureas and insulin; ask about meals and adjust doses.
7. B. An outreach population of 10,000 people for 3 months.
8. A. The IEHK is a general kit; long-term NCD care needs the NCD kit or local procurement.
9. B. Keep a working regimen; avoid confusing changes.
10. A. Patient-held records, a register and one shared protocol.