Bheri zonal hospital disaster response plan

HOSPITAL PREPAREDNESSAND

RESPONSE PLAN FOR BHERI ZONAL HOSPITAL

Copyright. All rights reserved.

ActionAid NepalLazimpat, Kathmandu, Nepal

Publication Year 2010.

This Bheri Zonal Hospital Disaster Response Plan has been prepared by the planning committee formed as per the MOU signed among Bheri Zonal Hospital (VZH), Action-Aid Nepal (AAN), Handicap International (HI), National Society for Earthquake Technology-Nepal (NSET) and Bheri Environmental Excellence Group (BEE-Group). This plan was prepared with technical support from NSET and financial support from AAN under DIPECHO V project. The project is financed by European Commission Humanitarian Aid and Civil Protection department, and co-financed by Australian Agency for International Development, AusAID.

ABBREVIATIONS

AFP Armed Police Force

BZH Bheri Zonal Hospital

CCU Coronary Care Unit

CDO Central District Officer

CEO Chief Executive Officer

EOC Emergency Operations Center

HCC Hospital Control/Command Centre

HDPP Hospital Disaster Preparedness Plan

HICS Hospital Incident Command System

HoD Head of Department

IAP Incident Action Plan

ICS Incident Command System

ICU Intensive Care Unit

IOC Incident Operations Chief

JAS Job Action Sheet

MLC Medico Legal Case

NA Nepal Army

NP Nepal Police

NRC Nepal Red Cross

OPD Out Patient Department

OT Operation Theatre

PSTD Post Stress Traumatic Disorder

RPM Respiration, Perfusion, Mental Status

START Simple Triage and Rapid Treatment

Preface

The Himalayan region lies in an active seismic zone. History of the region is full of devastating earthquakes. Large earthquakes in Nepal are also expected in the future.

With possibility and expectation of large earthquakes in Nepal, we may witness unacceptable levels of damage anytime and such damage would greatly impact the functionality of hospitals in Nepal in terms of number of deaths and injuries as well as irreparable damage to the hospital buildings. On the other hand, the large number of casualties coming to hospitals during an earthquake will overwhelm remaining capacity of the hospitals. The preparedness of hospitals to handle mass casualty situations will greatly influence the emergency response of the hospitals. The better the preparedness in hospitals the better the response. However, very little has been done in Nepal in terms of disaster emergency preparedness in hospitals and health facilities; only a few hospitals have system of emergency preparedness planning and periodic drills. The efforts of Bheri Zonal Hospital, Nepalganj is a cornerstone in this direction. Current publication has tried to document and publicize such efforts of the hospital.

This publication “Hospital Disaster Preparedness and Response Plan” is an outcome of the program “Developing and Implementing Disaster Preparedness Plan in Bheri Zonal Hospital” implemented by the hospital with technical support from the National Society for Earthquake Technology – Nepal (NSET) under DIPECHO V program of Action Aid Nepal. This publication will not only help Bheri Zonal Hospital to respond to the disasters effectively, but will also help other similar hospitals in planning and preparing for hospital disaster response plan. We believe this publication would greatly assist concerned authorities and professionals to safeguard critical facilities and lifelines during unexpected disasters.

We are thankful to Action Aid and concerned health sector authorities for their support in Disaster Risk Reduction initiatives and trusting NSET for providing technical support in preparing Disaster Response Plan of Bheri Zonal Hospital.

We extend our gratitude to all professionals from NSET who were involved in developing this plan and Action Aid professionals for reviewing and finalizing to publish the plan. We strongly believe that publication of this plan will hold very significant value to bring health sector professionals and concerned authorities to work together for disaster risk reduction initiatives.

Amod Mani Dixit Executive Director National Society for Earthquake Technology-Nepal (NSET) December 2010

TABLE OF CONTENT

1 Disaster in The Context of Bheri Zonal Hospital _______________________________11.1 Disaster Definition ______________________________________________________ 31.2 Disaster Declaration _____________________________________________________ 41.3 Hospital Incident Command System (HICS) _________________________________ 51.4 Roles and Responsibilities of different Sections of HICS _______________________ 81.5 Incident Management Structure of BZH _____________________________________ 9

2 Incident Management Structure _________________________________________________ 112.1 Triaging ______________________________________________________________ 132.2 Flow of Patient Care ____________________________________________________ 162.3 Arrangement of Patient Care Flow during OPD Working Hours

(8:00am – 2:00pm) _____________________________________________________ 182.4 Arrangement of Patient Care Flow during OPD Closed Hours

(after 2pm and on holidays) _____________________________________________ 192.5 On-site/Field Medical Care ______________________________________________ 192.6 Everyone Must Know Their Job __________________________________________ 212.7 Team Work, Team Captains and Team Clipboards ___________________________ 212.8 Key Personnel _________________________________________________________ 222.9 Admission and Discharges _______________________________________________ 262.10 Logistics and Supply ____________________________________________________ 272.11 Disaster Risk Communication ____________________________________________ 272.12 Inter-Agency Coordination ______________________________________________ 322.13 The Aftermath and Return to the Normal Health Operation ___________________ 34

3 Psychological Consequences _____________________________________________________ 35

4 Job Lists for Personnel ___________________________________________________________ 40

ANNEXES 41

ANNEX I Guideline for Triage ______________________________________________ 43ANNEX II Map of Spatial Planning of Triage & Treatment Areas, Patients Flow ______ 47ANNEX III Checklist for Disaster Patient _______________________________________ 49ANNEX IV Job Action Sheets ________________________________________________ 51ANNEX V List of Activities and Logistics to Support Plan Implementation ___________ 57ANNEX VI Examples of Reactions of People who Experience Stress ________________ 61ANNEX VII Photographs _____________________________________________________ 63

1Hospital Preparedness and Response Plan for Bheri Zonal Hospital

DISASTER IN THE CONTEXT OF BHERI ZONAL HOSPITAL

1

2 Hospital Preparedness and Response Plan for Bheri Zonal Hospital


DISASTER IN THE CONTEXT OF BHERI ZONAL HOSPITAL

1.1 Disaster DefinitionA ‘Disaster’ is defined as “any event that overwhelms the available resources.”

The decision to define an incident as “disaster” is made when resources at disposal at normal times cannot cope. This may occur with a multi-casualty incident involving people in mass and, requiring immediate medical care or even with a less number of casualties if there are many cases in critical condition needing surgery simultaneously. However, a large multi-casualty incident with mostly trivial injuries is not defined as disaster if resources normally at disposal in at the time of day can cope without having to interrupt the normal running of the hospital. Disaster is a relative term depending upon the capacity of the individual hospital. Hence, disaster needs to be defined quantitatively for every hospital.

Considering Bheri Zonal Hospital (BZH) on the basis of this definition, it was found that multi-casualty incidents are a common occurrence in the Emergency Department of BZH, Nepalgunj, like in any other general hospitals. BZH has the history of operating up to 20 to 30 patients during Maoist insurgency and in bus accident cases. However, the BZH has only 12 bed capacity in the emergency department, which is quite low. Even more than 10 serious patients at a time absorb its full human and other resources. Moreover, the incident to be defined as disaster may not only depend on the number of patients of multi-casualties in mass or smaller number with critical cases, but also on time of the day, i.e. whether it is day time or night or during OPD hours. The availability of human resources really fluctuates during these times. Considering all these factors, the disaster response plan is anticipating the following two types of disaster scenarios:

Ü The first scenario might be when there are 30 or more than 30 patients of all categories, including serious and non-serious or when there are more than 10 all-serious patients, both in odd timing hours where the situation is serious enough to warrant additional arrangement in the hospital.

Ü The other disaster scenario might be when the situation is anticipating a large number of patients, say, more than 30 serious enough to warrant special arrangements across the hospital.

Any single incident of these types is a disaster and it is always effective to treat all such incidents simply as disaster from incident-response perspective. Hence, both scenarios are considered as disaster without differentiating the scenarios. This document is a hospital


The decision to declare “Disaster State” is to be made by on-duty Medical Officer or on-duty Paramedical in consultation with the Medical Superintendent, the chief of the hospital or HOD Surgery or HOD Medicine who is in the hospital at the time and assumes the responsibility of Incident Commander during a disaster.

The on-duty Medical Officer or on-duty Paramedical must be instructed to put on the siren bell for declaring “Disaster State” from the Hospital Control Centre (HCC) located in emergency store room at present, which is to be developed as HCC with necessary arrangements such as telephone line, electricity supply and loudspeaker. There is no landline telephone in all doctors’ and staff quarter and no intercom system in the hospital at present. The four sirens are to be located in four positions in the BZH premises to inform about the incident to the majority (90%) of the hospital personnel residing in the area. The four locations for siren are at hospital block, near Quarter No 3, near Post Mortem area, and near Four Family doctors’ Quarter and are maintained by maintenance in charge.

The Incident Commander alerts the Information Officer to inform rest of the staff living outside the complex in their mobiles phones and/ or using phone tree system, which is yet to be developed.The entrance to Emergency, Gate Number 1 and 2 is closed immediately by the on-duty Gate Keeper and patients are only allowed to enter through Gate Number 3 to the drive way area located between two large garden areas in front of the Emergency when the Triage Officers are ready. “One patient at a time per triage officer” concept needs to be followed as far as practical.

disaster response plan and refers to the management of disaster, according to the definition given below.

Ü The plan is capable of managing 30 to 100 casualties or more than 10 to 15 all-serious patients by defining it disaster.

Ü Multiple casualty incidents, generally less than 30 cases or less than 10 all-serious patients is within the capacity of Emergency Department to handle without calling it disaster.

1.2 Disaster DeclarationThe decision to define an incident as disaster must be taken carefully and quickly and then plan must be implemented. The decision is usually made by the chief or the most senior medical personnel of the hospital who is in the hospital at the time and assumes the responsibility of Incident Commander during disaster..

Based on the existing organizational system of the BZH, disaster declaration is to be made as described in the box below:


INCIDENT MANAGEMENT STRUCTURE There are various factors that make a hospital unable to provide the required services in a disaster. They include the structural damage of the hospital buildings and non-structural damage of lifeline facilities, equipment and contents and architectural components. A hospital can still lose its ability to function in a disaster even without structural, operational and functional components damage if the hospital staff are not organized in a system required for handling such situation.

How hospital personnel are organized to respond in disaster situations is central to functionality of the hospital during and after a disaster. Organization of the hospital staff refers the general organization of hospital management, implementation of disaster plans and programs, resources for disaster preparedness and response, level of training and disaster preparedness of the staff, and the safety of the priority services that allow the hospital to function. Organizational structure with clear roles and responsibilities is one of the most crucial elements for managing an incident.

Many organizational structures have been developed over the years in response to disaster management. A system known as Incident Command System (ICS) developed in the late 1980s is the most effective incident management structure for organizing response more effectively to major disasters. Since then ICS is being applied by various institutions involved in emergency response, including hospitals in their efforts to prepare for and respond to various types of disasters. When the system is used in a hospital, it is called Hospital Incident Command System (HICS).

1.3 Hospital Incident Command System (HICS) HICS is being increasingly utilized by the hospitals across the globe. It is necessary to understand HICS concepts, terminology, advantages, components and organization before it is adopted for implementing the hospital disaster preparedness plan.

CONCEPTThroughout the world, a major disaster, natural or human made, such as earthquake, fire, landslide, flooding, hazardous material release or terrorist activity may cause conditions that vary widely in scope, urgency and degree of devastation requiring various types of response, including medical care under hostile and austere conditions. The magnitude of damage to structures and lifelines rapidly overwhelms the capacity of the hospital to respond effectively to basic and emergency human needs.

Disaster planning and response after disasters is primarily a local event. Communities, local government and institutions like hospitals have to take the initiative and lead before, during


and after a disaster. Dependence on external assistance can become a false hope. It is best to anticipate “You’re on Your Own for the first 48 hours after a disaster”. This is informally known as the “YO-YO-48 Rule in the disaster management community.

Based on this theory and other experiences of the past disasters, a system called Incident Command System (ICS) was developed in the late 1980s to organize an effective response to major disasters. The Hospital Incident Command System (HICS) is ICS applied to the hospitals in their efforts to prepare for and respond to various types of disasters.

ADVANTAGESAdopting HICS has the following benefits:Standard - HICS is a standard emergency response management system that promotes greater standardization in terminology, response concepts, and procedures. By embracing the concepts and incident command design outlined in HICS, a hospital will be in position to be consistent with the International and National Incident Management System.

Flexible - HICS is flexible. Since the response management functions that have to be carried out are the same, HICS can be used by all hospitals, regardless of size or patient care capacities, and also be used to assist with emergency planning and response efforts for all hazards.

Only positions or functions that are needed can be activated. HICS allows for positions to be added or deactivated at any time during the lifecycle of the incident. This will promote efficiency and cost effectiveness.

If a position is not activated, the position above it on the organizational chart will assume responsibility of that function. For example, if the Incident Commander (IC) does not activate the Liaison Officer, the IC will take responsibility of the Liaison Officer.. Or, if the Operations Section Chief does not appoint a Staging Manager, the Operations Section Chief will take responsibility of the Staging Manager..

HICS has a clear span of control, which limits the span of control of each manager/supervisor to three to four staff/subordinates (1:3-4) in the attempt for effective supervision of the distributed work. It is hoped that this will lessen liability and promote the recovery of financial expenditures.

Clear Span of Control - The Span of Control means a designated number of staff/subordinates to whom every manager/supervisor delegates tasks at the scene of the incident.


Chain of Command/reporting - Chain of Command refers to the orderly line of authority within the ranks of the incident management organization. HICS recommends that that every individual has one designated supervisor to whom s/he reports at the scene of the incident.

COMPONENTSThe ICS structure includes five basic functional components of command, operations, logistics, planning and finance.

These four sections will provide the Incident Commander with all the information and advice that s/he needs to be able to make operational decisions and to establish priorities of action. Depending upon the nature and the scope of response demands, and personnel available, the sections may be further subdivided into units. The number of persons comprising each of the sections and its sub-units will, once again, be determined by the needs of the disaster and the extent of the hospital response being mounted. So, the system expands to meet needs, and then decreases as those needs diminish. What does not change, however, are the functions of response management. They still have to be carried out, regardless of scale of disaster or numbers of personnel involved. In fact, all four functions may be successfully carried out by one person is a small-scale incident.

Figure 1 below represents how authority and responsibility are distributed in each section of the HICS System.

The system expands to

meet needs, and then decreases as those needs diminish. What does not change, however, are the functions of response vmanagement. They still have to be carried out, regardless of scale of disaster or numbers of personnel involved.

Incident Commander

Liaison Officer

Medical Care Resources Service

Security Situation Support

Infrastructures

Staging

Operation Section Chief Planning section Chief Logistics Section Chief Finance/Admin Section Chief

Information Officer Safety & Security Officer

Medical Specialist

Figure 1 HICS Conceptual Structure


1.4 Roles and Responsibilities of Different Sections of HICS

Operations Section

The Operations Section manages tactical objectives outlined by the Incident Commander. It is responsible for monitoring and managing all response operations (Red, Yellow, Green and Black areas).

The essential positions of the Operations Section include the Operations Section Chief with Staging, Medical Care, Infrastructure and Security Manager. Position descriptions for the Operations Section are provided in the Job Action Sheets (JAS) (Annex IV).

Medical Care Manager - Inpatient, Outpatient, Casualty Care, Mental Heath, Patient Registration, Clinical support, Morgue.

Staging Manager - Personnel, Vehicle, Equipment and Supply, Medication Staging.Infrastructure Manager - Power/Electricity, Water Supply, Building and Ground Damages,

Medical-gases and Devices, Sewer, Environmental Services, Food Services

Security Manager - Access Control, Crowd Control, Traffic Control, Search, Law Enforcement Interface.

Planning Section

It is responsible for ensuring the development of strategic and tactical plans. Strategic plans address broader, longer-range issues of the response, tactical plans and short-term operational activities. So the Planning Section collects, evaluates, and disseminates incident situation information and intelligence to Incident Command. It also prepares status reports and develops the Incident Action Plan (IAP), including demobilization. The Planning Section also coordinates documentation efforts of the incident. It is also responsible for maintaining a file on all incident management information, including all forms submitted at the HCC.

The essential positions of the Planning Section include Planning Chief with Resources and Situation Manager. Positions descriptions are provided in the Job Action Sheets (JAS) (Annex IV).

Resources Manager - Personnel and Material TrackingSituation Manager - Patient and Bed Tracking

Logistics Section

It is responsible for the procurement and provision of personnel, equipment, and support services needed to sustain the hospital’s response, including food, drink, linen, and supplies that are critical. The Logistics Section, thus, coordinates support requirements of disaster response and recovery, including acquiring resources from internal and external sources.


The essential positions of the Logistics Section include Logistics Chief with Service and Support Manager. Position descriptions for the Logistics Section are found in the Job Action Sheets (Annex IV).

Service Manager - Communications, IT/IS, Staff Food and Water

Support Manager - Employee Health and Well Being, Family Care, Supply, Facilities, Transportation

Finance/Administration Section

This Section is responsible for maintaining financial and administrative records of the response activities. The Finance/Administration Section tracks personnel time, ordering items, initiating contracts, arranging personnel-related payments/Claims and Workers’ Compensation, and tracking response and recovery costs and invoice payments.

The Finance/Administration Section Chief is the only essential position for the section looking after time, procurement, compensations/claims and cost. Position descriptions for the Finance/Administration Section are provided in the Job Action Sheets (Annex IV).

So, most disaster plans have similar organizational structures with few modifications depending on the normal operations of a particular hospital departments concerned.

1.5 Incident Management Structure of BZH

Emergencies can occur at any time. Emergencies differ in type, size, scope, and duration. Nepalgunj area is threatened by many hazards that may cause a significant number of injuries to the local population and disrupt health care services. These hazards include:

Ü Natural disasters, such as floods, earthquakes fires.

Ü Technological incidents and others, such as bus accidents.

Ü Disease outbreaks.

The essential positions of

the Operations Section include the Operations Section Chief with Staging, Medical Care, Infrastructure and Security Manager.

The BZH will utilize Incident

Command System as incident management structure to manage emergency operations in response to events affecting the facility and/or surrounding community.


Ü Human-caused hazards, such as social conflicts.

The BZH will utilize Incident Command System as incident management structure to manage emergency operations in response to events affecting the facility and/or surrounding community.

In Nepal, ICS is also used by other national institutions such as Nepal Army (NA), Nepal Police (NP), Armed Police Force (APF) and Nepal Red Cross (NRC). Hence, organizations involved in disaster response can speak the same language as they have the same level of understanding.

Details on personnel for different responsibilities of HICS in case of BZH will be discussed in Section 3.8


PRINCIPLES & COMPONENTS OF DISASTER RESPONSE PLAN

2


2.1 TriagingÜ Triage officers: On-duty Medical Officer, on-duty

Paramedical and Emergency in charge are assigned to triage area to start the triage and return to emergency once the allocated Triage Officers arrive.

Ü Patients MUST be assessed and triaged (sorted) on arrival at the Triage Area, and directed to the correct Treatment Area.

Ü It is essential that the Triage is set up and manned near Emergency building on drive way located between two garden areas BEFORE patients are allowed to enter the Emergency building to prevent the Emergency Room from being swamped by people, which could result in total chaos.

Ü At the Triage Area, Triage Officers assess the patients and put around their neck a colored disaster card. The cards are in RED, GREEN, YELLOW and BLACK colors that symbolize the four categories listed below.

Ü The Triage Officers will hand over patients to waiting Transfer Staff who are assigned to transfer disaster patients to the appropriate treatment area according to seniority and severity of the patient’s condition, where doctors assigned are waiting. These Transfer Staffs are the following:

Ø On-duty non medical staff such as Peon and others (at present, minimum of 10 such staff are always present all the time)

Ø Nursing students who are always in the Hostel in the hospital premises except in long holidays. The Transfer Staff take the patients to the right area, according to the color of the tag for patient care

Ø Volunteers.

Ü Patients already in the Emergency at the time of the Disaster need”triaging backwards” in order to make as

PRINCIPLES & COMPONENTS OF DISASTER RESPONSE PLAN

It is essential that the Triage is

set up and manned near Emergency building on drive way located between two garden areas BEFORE patients are allowed to enter the Emergency building to prevent the Emergency Room from being swamped by people, which could result in total chaos.


much space as possible in the Emergency for new critical patients. They should be sent to the Treatment Area that best fits their condition, or else be admitted or discharged.

TRIAGE AREATriage area will be in front of existing Emergency area and also in under-construction emergency building on the drive way located between two garden areas (Exact location is given in the map in Annex II). This Triage Area will remain same even after the emergency is shifted in the new building after its construction is completed. It is better to start triaging in emergency regularly in multiple casualties incidents on normal situation and practice continuously to be more responsive during disaster.

TRIAGE CARDÜ Triage cards are to be kept ready in a box in the designated

Disaster Store and maintained by Store In-charge. There are 100 triage cards are in stock and 100 more has to be added to maintain the number as 200.

Ü The Triage card is colored (Red, Yellow, Green or Black) and has room for recording initial assessment and treatment. This has to be attached to patients e.g. tied to arm or put around neck.

Ü Each card will have a capital letter that is placed in front of the card number. The letters are R, Y and G, which stand for Red, Yellow and Green respectively. This, if a patient’s is category Red and the triage card has number 57, he will be R57. This will make it easy for the X-ray and lab staff to prioritize the investigation and also help in identifying the area where their reports have to be sent.

Ü Cards are numbered in advance and kept ready at all times for multi-casualty and disaster situations. They must be pre-numbered so that number duplication is avoided. The cards in stock at BZH also need pre-numbering.

Guideline of Triage is given in Annex I

Each card will have a capital

letter that is placed in front of the card number. The letters are R, Y and G, which stand for Red, Yellow and Green respectively.


Changing Category

Patients may need to be upgraded in their category of care.

Ü They will retain their old card and receive a new card of appropriate color.

Ü Requests and reports will carry the old number with a cancel line through it, as well as the new number.

TRIAGE CATEGORIES AND TREATMENT AREASTwo types of scenarios are anticipated on the availability of the treatment areas, the areas within the old buildings in particular. This requires two types of scenario-based spatial planning. Both types are given in Annex I.

SCENARIO ONE This is the situation when the casualty is caused by the disasters other than a big earthquake and all existing building area is available for the treatment purpose.

TRIAGE CATEGORIES

Category Classification Treatment Areas

Red IMMEDIATE CARE (life in danger)

Disaster Emergency RoomCapacity - 15 Mattresses Emergency Capacity - 12 Beds, 2 Oxygen, Suction

Yellow PROMPT CARE(serious, but life not in danger)

Newly-constructed OPD Waiting Area, extension to OPD Corridor if available or drive way in front of the Waiting Area

Green MINIMAL CARE(“Walking Wondered” – cuts and bruises)

Garden area in front of the new emergency under-construction, new under-construction emergency ground floor, garden area of quarter number 3 and 4 and beyond

Black DEAD ON ARRIVAL(death confirmed by two doctors)

Post-mortem block and its outside area

SCENARIO TWO Situation may arise when the old emergency and OPD buildings are damaged as the buildings are quite old and not available, particularly in big earthquake disaster. The newly


TRIAGE CATEGORIES

Category Classification Treatment Areas

RedIMMEDIATE CARE (life in danger)

Ground floor of new Emergency Block under construction or Maternity Block

YellowPROMPT CARE(serious, but life not in danger)

Newly-constructed OPD Waiting Area and driveway in front of the Waiting Area

GreenMINIMAL CARE(“Walking Wondered” – cuts and bruises)

Same as scenario one

BlackDEAD ON ARRIVAL(death confirmed by two doctors)

Same as scenario one

2.2 Flow of Patient Care

PATIENT FLOWÜ Disaster patients will be present in the Triage Area near the Emergency building on the

drive way between the two garden areas.

Ü Triage is done, and a colored and numbered treatment card attached to patients.

Ü Patients are handed over to a waiting Transfer Staff and accompanied to the treatment area, according to their triage color.

Ø RED will go straight to the Disaster Emergency Room and Emergency Area and then to the corridor of in patient Ward.

Ø YELLOW go to newly constructed OPD waiting area and OPD corridor.

Ø GREEN will go directly to the garden area in front of the new under-constructionEmergency Building garden area of Quarter no 2 and 3.

Ø Patients who are re-triaged from Yellow to Green will go through driveway in front of the Emergency Building

Ø Patients who are re-triaged from Red to Yellow will go through the corridor of the Emergency Building.

Ü Patients who are re-triaged from Yellow to Green will go through driveway in front of the emergency building

Ü Patients who are re-triaged from Red to Yellow or visa versa will go through the corridor of the Emergency Building.

constructed OPD waiting and the emergency block under construction are less likely to be damaged as they are new and constructed by incorporating earthquake resistant elements.


Ü Patients from the Green Area will follow the newly-constructed road leading to the gate near Post-mortem Block and eventually to the outside road

Ü Patients from the Yellow Area will go through the two exit gates of the OPD patients

Ü Patients from the black area will be taken out from the gate near Post-mortem Block.

PATIENT CARE Ü The doctor assigned will continue patient’s care with

other staff posted to the treatment area.

Ü Blood taking and X rays will be done in the Treatment Area and results brought back to the requesting doctor.

Ü Decisions to move a patient to OT or admit must be done through the senior doctor present in the respective treatment area in consultation with the Incident Operation Chief.

Ü Patients will have a file created if they are admitted.

Ü Patients may be admitted from the treatment area, admitted from OT or discharged with or without follow up in OPD.

Ü Patients well enough to be discharged are to be brought back the next day for non-urgent investigations. Admitted patients also wait until the disaster is over for non-urgent investigations.

PATIENT REGISTRATIONÜ Separate Disaster Registration Books for Red, Yellow,

Green and Black should to be kept in Disaster Store. This is maintained by the Sister in charge of each area for Red, Yellow, Green and by Mortuary in charge for Black. At present, Emergency has a separate register for emergency patient and has also maintained a separate register for Medico Legal Case (MLC).

Ü Normal registration and Medico Legal Case (MLC) registration system will be followed if the patients are admitted to stay overnight once disaster is over. Patients discharged the same day may be discharged without converting to normal registration, but their MLC must be registered.

Separate Disaster Registration

Books for Red, Yellow, Green and Black should to be kept in Disaster Store. This is maintained by the Sister in charge of each area for Red, Yellow, Green and by Mortuary in charge for Black.


BILL PAYMENTÜ There will be no bill payment counter for disaster patients because it is not practiced

even in normal disaster cases at the moment. However, payment of bill is subject to the policy and the decision of BZH Development Committee, which is responsible for the overall development of this governmental hospital. This again is subject to the National Policy. The following system exists:

» Some of the medicines and treatments such as iv canula, iv fluid etc are being distributed free of cost.

» There is only one bill counter where both OPD and in patients pay their bills. OPD patients pay their bills on the day of examination and in-patient pay during discharge, if they pay at all.

» At present, bill payment is done manually and there is no computerized system.

MEDICAL STAFF FLOWÜ Doctors, nurse and other staff residing in the quarters at the rear must enter the hospital

via corridors of Maternity Block. Those residing in Quarter No. 1, 2, 3, 4 including doctors must enter from the emergency entrance road of the newly-constructed block.

Spatial Planning map of Triage Area with disaster patient flow and medical staff flow is given in Annex 2.

2.3 Arrangement of Patient Care Flow during OPD Working Hours (8:00am – 2:00pm)

Ü The OPD must be cleared off patients immediately. On an average, there are 500 OPD patients per day in BZH.

Ü Patients should be told to come for the next clinic day and should not be charged if they are done.

Ü Patients with request papers for investigations must return the next day.

Ü All patients must leave via the special two OPD back doors, one at the end near 19 number OPD leading to NSARC building and road, the other through store leading to wide gate and eventually to the road. Patients must be directed by closing the entry gate to the OPD, waiting and in-patient block. (Refer map in Annex II)

Ü OPD patients must be guided to exit the building by on-duty Gate Keeper by opening the two gates and closing the channel gate to in-patient Block and entry gate of OPD waiting hall.

Ü Keys of the gate of NSARC building must be made available to the on-duty Gate Keeper24 hours a day in disaster store.


2.4 Arrangement of Patient Care Flow during OPD Closed Hours (after 2 pm and on holidays)

Ü Keys for OPD waiting and its corridor must be available with on-duty Gate Keeper 24 hours a day in disaster store.

Ü On-duty Gate Keeper will open OPD waiting and its corridor on instruction from Operation Chief to use it as a Yellow Treatment area

Ü The OPD staff and OPD doctors will need to be called in. The contact numbers of staff will be listed up-to-date and available at all times, particularly of those living outside the hospital complex.

2.5 On-Site /Field Medical CareOn-site medical care means providing medical care at the site of emergency itself. There are situations when a medical team is required to be sent in the disaster-stricken area to provide pre-hospital medical care or medical care either by themselves or to supplement other medical personnel. A medical team in a bus accident site and international medical teams in countries that are stricken by disasters are few of such examples.

Like Hospital Disaster Preparedness Plan, on-site medical care is also very important from disaster preparedness perspective though the situation is little different. The objective of medical response is to provide medical care in the shortest possible time. This is accomplished at the site of the major emergency and with a chain of medical care. The links in the chain of medical care are:

Ü Medical teams

Ü On-site medical facilities

Ü Effective transportation for medical evacuation

Ü Hospitals

It also requires an incident management structure as a command organization at the incident scene for medical response activities. Below is a basic diagram of the command organization at an incident scene.

There are situations

when a medical team is required to be sent in the disaster-stricken area to provide pre-hospital medical care or medical care either by themselves or to supplement other medical personnel.


It is important to realize that the first action at the scene should be not to initiate patient care. The following actions need to be carried out in on-site medical care:

Ü Identify the need for assessment of a major emergency scene.

Ü Explain the tasks to be performed before medical treatment of casualties can commence.

Ü Identify the zones of field management of major emergencies.

Ü Identify the basic requirements of an on-site medical facility.

On-site medical care requires careful assessment, and consideration for the medical response to be both safe and effective. It is important to adequately understand the situation, assess the availability of resources, and implement mechanisms to ensure the overall safety of workers and victims. All major incidents are unique and will demand specific type of responses. Team members must be aware of these requirements and of the reasons for these actions to be taken before any patient care.

Figure 2. On-site medical care management structure

It is important to realize that

the first action at the scene should be not to initiate patient care.

Incident Commander

Operations Chief

Medical CareDirector

Treatment GroupSupervisor

Transportation Group Supervisor

Triage GroupTreatment


BZH has not been involved in any Field Medical Care till now. So the doctors and other hospital staff do not have any experience on this aspect. Generally, Nepal Army, Nepal Police, Armed Police Force, Nepal Red Cross or Rescue officers are closely involved in disaster situation to provide pre-hospital medical care. Doctors and other medical staff have only been providing the medical care at the hospital premises on the arrival of the disaster patients.

Since the situation is likely to be continued for some years in the near future, preparation of the plan on on-site medical care is postponed for the time being. However, BZH being a zonal hospital, a medical team may be required for sending to the nearby areas such as in diarrhea outbreak. In such situation, members of the team will be decided by the Medical Superintendent of the hospital.

2.6 Everyone Must Know Their Job Ü Regular education of whole Hospital is necessary so that

people know what to do.

Ü Like actors in a play, everyone must know their part, and start doing it without being told. However, they should be ready to follow directions according to needs.

Ü When called in no questions must be asked and there should be no delaying.

Ü When Department Heads/other Senior Staff are called for Disaster, before moving from their residence, they should call key staff of their department, if they are living outside. Lists of telephone numbers of such department members should be maintained and kept near home phone at all times.

Ü Doctors should bring in their white coats, stethoscopes and pens. Doctors in BZH, however, do not use white coat and so they do not have any.

2.7 Team Work, Team Captains and Team Clipboards

Ü There are many “teams” of people taking part in the Disaster Response Plan. Follow HICS such as Incident Commander with Operation, Planning, Logistics and Finance divisions.

Like actors in a play, everyone

must know their part, and start doing it without being told. However, they should be ready to follow directions according to needs.

A deputy (or anybody) from

that team should assume the team captain’s role immediately, and pass the job over to more senior person, if available, later.


Ü Each division needs a “Chief” to ensure all the jobs on his team’s checklist get done. Ideally, the Chief should be a Department Head, but s/he may not be immediately available. Therefore, a deputy (or anybody) from that team should assume the team captain’s role immediately, and pass the job over to more senior person, if available, later.

Ü Each division has a “division clipboard” which defines the roles and tasks of that division. There are boxes to be ticked when tasks have been done. These division clipboards are located in the Disaster Store. When one arrives in the hospital, s/he has to go to Disaster Store and first see if her/his division’s clipboard has been taken. If not, one must take the clipboard, and assume the chief’s role until a more senior colleague arrives.

Ü If all clipboards are taken, one should move straight to his/her area of responsibility.

2.8 Key Personnel While everyone is important in the Disaster Response Plan, certain people have key roles. The following personnel will assume the following key roles.

1. Incident Commander – Medical Superintendent or HOD Surgery or HOD Medicine. S/he:

Ü Carries ultimate authority.

Ü Generally oversees the outworking of the Disaster Response Plan.

Ü Makes decision concerning major changes in the Disaster Response Plan.

Ü Liaises closely with Information Officer, Safety and Security officer, Liaison Officer and Incident Operation Chief and is available to give assistance to senior personnel as needed.

Ü Checks that all the teams have collected their clipboards from the Disaster Store.

2. The Information Officer – Health Assistant or Assistant Medical Recorder

Ü Makes the list of names of victims and their outcomes, and posts this on the inside of the OPD doors and outside the hospital gates. This keeps enquirers satisfied, and out of the way. One copy of the list should also be given to the Liaison Officer and the Information Desk for telephone inquiries. .

Ü Communicates with the Incident Operation Chief regarding number of victims.

Ü Communicates with Department Heads as needed.

Ü Communicates with transport and security.

Ü Is responsible for giving information to relatives of deceased regarding post-mortems, contact points, etc. and should delegate his/her staff to this job as necessary.

Ü Sets up the information desk next to OPD Inquiry, including an outside telephone line.


Ü Assigns staff to make patient records and collect information in RED, YELLOW and GREEN areas.

Ü Communicates with Officer inside Emergency and with in charge of GOPD area.

Ü Updates the list at regular intervals throughout the disaster by liaising with Incident Operation Chief.

3. The Liaison Officer – Administration Assistants

Ü Maintains communication with outside agencies to keep the public informed.

Ü Communicates to arrange transfers to other centres.

Ü Communicates with the other hospitals (after liaising with the Incident Operation Chief concerning hospital’s resources and the numbers of victims) regarding necessary transfers, available beds and medical personnel who might be called to help.

Ü Communicates with the Police.

Ü Communicates with the Press.

4. The Safety and Security Officer – On-duty Chief of Hospital Police Bit

Ü Controls traffic and crowds.

Ü Maintains peace and order

Ü Keeps traffic moving in one direction from Gate No. 3 to Gate No. 1

Ü Facilitates clearing OPD patients ensuring patients get to the right exit if OPD is opened.

Ü Guides disaster patients, ensuring they get to the right areas according to color.

Ü Guides the flow of disaster patients to follow the right exit according to the exit route.

Ü Controls number of patients according to how fast doctors are seeing the patients, particularly in the Triage Area.

Ü Makes sure the keys of all gates are kept in a fixed place to have them available in disaster for closing and opening doors when needed.

Ü Checks that on-duty Gate Keepers are in their correct locations.

Ü Liaises with Incident Operation Chief.

Ü Posts staff as necessary to direct ambulances, control crowds, direct traffic or collect patients.

5. Incident Operation Chief – HOD Orthopedic or HOD Surgery

Ü Oversees all aspects of medical work.

Ü Liaises with the wards (renumbers discharges and admissions)


Ü Liaises with the Surgeon in Charge and Operating Theatres

Ü Liaises with all treatment areas.

Ü Redistributes doctors where needed.

Ü Allocates patients beds and helps in coordinating admissions in consultation with treating doctors and patient needs.

6. Planning Chief – Head of House Keeping or Supervisor of House Keeping

Ü Ensures the development of strategic and tactical plans. Strategic plans address broader, longer-range issues of response, tactical plans and short-term operational activities.

Ü Collects, evaluates, and disseminates incident situation information and intelligence to Incident Command.

Ü Prepares status reports and develops Incident Action Plan (IAP), including demobilization.

Ü Coordinates documentation efforts of the incident.

Ü Maintains a file on all incident management information, including all forms submitted at the HCC.

7. The Logistics Chief – Store in charge or Assistant Store Keeper

Ü Keeps a separate Disaster Store up-to-date with disaster supplies.

Ü Reviews supplies in all areas every three months and after every disaster.

Ü Keeps supply cupboards ready in each treatment area with staff responsible for their upkeep.

Ü Prepares for increased food supply for patients, staff and volunteers.

Ü Provides free food to staff working for prolonged periods of overtime – and records details.

Ü Provides food to OT and RED area as requested.

Ü Orders more supplies from outside, if necessary.

8. Finance and Administration Chief – Finance Officer or Store Keeper

The Transport Officer –

ÜKeeps vehicles and drivers stand by for calls.

Ü Arranges transport for dead victims to the morgue.

ÜArranges transport for extra-supplies from General and Medical Stores.

ÜArranges transport for patients requiring transfer to other hospitals.

ÜLiaises closely with Incident Operation Chief who identifies victims requiring transfer.


The Finance Officer –

ÜMaintains records and creates accounts for people being admitted in the Disaster from all areas.

ÜCoordinates tracking of personnel time.

ÜCoordinates ordered items.

ÜInitiates contracts.

ÜArranges personnel-related payments/claims and workers’ compensation,

ÜCoordinates tracking response and recovery costs and invoice payments.

ÜCalculates bills for patients being discharged and collects money.

9. The Triage Officers - On-duty Medical Officer, On-duty Paramedical and Emergency In-charge in the beginning and Doctors assigned and decided by Incident Operation Chief afterwards.

There will be up to three Triage Officers at a time.

Ü Reports and remains in the Triage Area

Ü Rapidly assess all patients, determines the triage category for all patients, allocates triage category and tag by attaching the card to the patients with the string (to the arm or around the neck).

Ü Pass the patients on to the respective waiting Transfer Staff to take them in their respective Treatment Areas according to the seriousness.

10. Treatment Area In Charge

On-duty staff are assigned in the treatment areas for the initial stage and are back to their respective duty once the staff assigned arrive and take on the following responsibilities:

Ü Reporting to the respective Treatment Areas.

Ü Assessing and managing patients in the respective Treatment Areas.

Ü Working with Incident Operation Chief, Orthopaedics and Anaesthetics to make OT lists.

Allocating/assigning staff to OT.

Ü Assessing, superviseing and carrying out resuscitation, treatment, and management of patients (plan for surgery, emergency investigations, admit, discharge) in the respective Treatment Areas.

Ü Liaising with the Incident Operation Chief for OT times.

Ü Keeping disaster cupboards in their areas in order.

Ü Reviewing supplies every three months and after every disaster.


Red Area: Doctors from Department of Surgery and Orthopaedics with the following nursing and paramedical staff:

Ü General Ward on duty Sister

Ü Gyaene Ward on duty Sister

Ü Four Family Nursing Quarter - First Floor

ÜNew Family Quarter - Ground Floor

- 6 No Quarter – all

Yellow Area: Doctors from Department of Gyaene and Paediatrics with the following nursing and paramedical staff:

Ü Paying Ward on-duty Sister

Ü Old Family Quarter - First Floor

Green Area: Doctors from Department of Medicine with the following nursing and paramedical staff:

ÜNew Family Quarter - First Floor

ÜNew Family Nursing Quarter - Ground Floor

Ü All staff outside

Black Area: Staff from Forensic Department /Unit

Ü Ensures that all dead bodies are covered with sheets and transported to the mortuary.

Ü Performs necessary post-mortem.

Liaises with the Safety and Security Officer and police.

2.9 Admission and DischargesÜ All Red, Yellow and Green patients, if they are to be admitted, have to follow the normal

procedure of admission i.e. Sister In charge in the respective wards will admit them with the recommendation of Treatment Area in charge or Incident Operation Chief.

Ü If there are no OPD clerks to fetch X-ray and lab reports, they should be brought to a common place as soon as they are ready and should be put with the patient’s notes or taken to the ward of admission.

Ü Sister in charge of each ward prepares the list of patients that can be discharged from his/her ward on the recommendation of on duty doctor, and gives it to the Incident Operation Chief.

Ü They will leave the hospital via the OPD back door as the OPD patients exit gates.


2.10 Logistics and SupplyÜ There will be separate Disaster Store for disaster response

apart from Medical and General Store.

Ü Each treatment area will have a disaster cupboard that can be wheeled out into the treatment area. It will be stocked with treatment materials and stationery needed for the area. It will have non-structural safety measures.

Ü Extra disaster supplies are to be kept in the Disaster Store in a designated section and will be brought out as needed to top up exhausted supplies in each area.

Ü Extra trolleys and mattresses are to be kept in Emergency/Disaster Store.

Ü The other supplies to be kept in the Disaster Store are mattresses, bandage, disposable dressing trays, drip facilities and splints.

Ü Minimum stockpile is to be maintained and the responsibility should be given to the Store in charge.

Ü Re-stocking from Medical and General Store may be necessary if the disaster is large.

List of activities and logistics to support the implementation of the plan is given in Annex V. Some of them have been already implemented. Others need to be implemented on priority basis.

2.11 Disaster Risk Communication

INTRODUCTIONRisk communication means the imparting and exchanging of information about the existence, nature, form, likelihood, severity, acceptability, treatment or other aspects of risk among individuals, groups and institutions. The information includes risk types, risk levels and methods for managing the risks. This helps people understand facts in ways that are relevant to their own lives, feelings and values so they may put the risk in perspective and make more informed choices and decisions.

Risk communication is an important aspect of

disaster management, both in pre-disaster as well as in post-disaster situation.


Risk communication is an important aspect of disaster management, both in pre-disaster as well as in post-disaster situation. Pre-disaster risk communication is exchanging ideas with different stakeholders, primarily with the local institutions and the community, and consists of awareness program, early warning system, training and practice. The more prepared the community is before disaster, the less work hospitals will have after disaster.

Post-disaster communication is conveying information and updates about disaster. It is also about asking help in identifying patients, blood donations and other donations (blankets, food, funds, etc). Similarly, it is also about guiding patients and community for better disaster management. The communication and public relation officer and hospital disaster management team need to understand the various aspects of disaster risk communication.

TYPESThere are various types of disaster risk communication:

Ü Mass media: TV, radio, print and internet.

Ü New types of media: SMS messaging, blogging, email, etc

Ü Traditional media: street theatre, radio, FM, puppet shows etc

Ü Alternative media: signage, parades, concert, etc

METHODS OF MAKING RISKS COMMUNICATION EFFECTIVEDisaster risk communication consists of the following elements and understanding those elements makes it more effective.

Information processing

There are innumerable sources of information, including on-site teams, emergency services, operational personnel, other organizations, agencies and the general public. Yet it is likely that the available information is incomplete, inaccurate or out-of-date due to the rapidly-changing nature of disaster response operations.

Lack of information is rarely a big problem. It is usually the case that the available information is not been adequately assessed or the consequences not identified. Hence, it is important to evaluate the information and make good and timely decisions concerning it.

Information processing is sorting of information just as Triage is sorting of casualties.

The important steps for effective information processing are:

Ü Collecting Information – It is important to know the types of information the hospital needs to know, the reliable source of information, measures the hospital needs to


take during preparedness to assure information collection capability during disaster operations.

Ü Collating and Evaluating – The collected information needs to be checked and weighed to establish its relevance and reliability, gaps have to be detected and additional information has to be sought to make the information complete and useful for decision-making purposes.

Ü Decision making – Based on the information collected and evaluated, an overview has to be developed so that decisions can be taken in context and priorities can be identified. Invariably, a hospital’s decision makers have to contend with some or all of the complications such as insufficient information, limited time, competing priorities, limited resources and media attention when making a plethora of decisions that disaster demand of them.

Ü Disseminate – Decisions need to be distributed to all those who have a reason to know. This dissemination can be accomplished through the media channels during controlled media briefings.

Ü Monitor – Importantly, while some information may be ‘for information only’ purposes, most of the information and decisions distributed will require an action or reaction as a result. These actions can be from hospital departments and personnel, response teams in the field, the media and general public or from other agencies or organizations.

Documentation

Collected information is useless unless it is properly documented. Documentation is often overshadowed by other response activities in disaster and generally do not get due importance. However, careful documentation is imperative. Accurate documentation is required for patient management systems and for providing information on the hospital’s response activities and level of preparedness. Hence, a variety of documentation is essential in a hospital’s response to a disaster, including documentation of processes as well as actions taken during the response. Hence, the hospital disaster management team needs to consider the following while documenting:.

Ü Patient records – There has to be standard medical documentation with accuracy.

Ü Logs – Decision-makers and the personnel in the hospital’s command centre need to keep logs to account for the actions and decisions they make, including shift changes and changes of command and timings.

Following an emergency or disaster, particularly when deaths are involved, there may be an investigation into the cause and effects of the disaster and the actions and reactions of disaster workers. Accurate documentation at all stages of the hospital’s response and procedures is necessary so that personnel can account for decisions, action taken and priorities. The information may also be of use when identifying improvements to the systems, procedures, plans and training in the hospital’s preparedness.


Management of the Media

With the advancement of modern technology, the media has become an inescapable aspect with regard to disasters. It plays an important part in the disaster management community. It has a legitimate role to play during disasters. Planning and understanding are the keys to effective management of the media. Understanding what the media wants, how they operate, and how you can best meet their needs ensures that you can manage the relationship and benefit from the media’s participation. Hence, hospital disaster management team, including the communication officer should always consider working with them and not trying working against them. Some general rules to follow are:

ÜThe media should be managed, rather than controlled.

ÜCooperation is preferable to confrontation.

ÜThe media is a communication medium to and between the community.

The hospital disaster management team needs to be aware of the following aspects of the media to make the disaster risk communication more effective.

Knowing media issues

The common media issues in disasters are as follows:

Ü Security Issues – In major disaster situations the media can easily overwhelm a hospital with requests for interviews or the latest facts. This may result in attacking the media members by the family members of disaster patients and attempting to thwart hospital security measures by the media personnel. It is important for any hospital working in a disaster situation to have a security system and ensure that it is understood by members of the media. Security should be trained to specifically handle the media in disaster situations.

Ü Communication Issues – The frequency of phone calls can crash hospital switchboards or distract hospital workers from their main roles. Sometimes misinformation distributed by the media can cause uproar in the community and influence crowds to descend upon an already overwhelmed healthcare system.

Ü Psychosocial Issues – The media can cause problems with the grieving families of the deceased. The reporting of gruesome details can worsen the grief of already distraught survivors and families. The mediacan be be unfairly critical of relief workers or efforts, contributing to a worsening of morale.

Assembling of information that the media seeks

The media generally seeks certain information that can be predicted. Assembling such information is very useful in managing the media.

Ü Casualty Information - Number of dead and injured, percentage of seriously injured, umber of uninjured, a whether there is any VIP’s in the incident How the injured were managed? Where were they were taken? What happened to the dead?


Ü Health Risks – Shelter arrangements, food, water, sanitation, and infectious diseases.

Ü Damage to Health Facilities – Which health facilities have been damaged and how badly ? what affects the disaster will have on patients.? How the disaster will affect the operating capacity of facility ? Staff injuries.

Ü Response and Relief Activities – Who activated hospital response? Who is in charge? What are hospital personnel doing?

Releasing Information

The hospital disaster management team also needs to know some tips on releasing information that are vital in handling the disaster situation.

Ü Information should not be released or comments should not be provided on matter that is not strictly a medical responsibility.

Ü Information should be released in on pre-formatted media release forms with accurate information clearly printed with date and time. This saves time and also avoids misunderstanding or misinterpretation of what they see and hear individually.

Ü Information should be released regularly even if there has been no change in the situation. Reporting “no change” still constitutes the “latest information” for the event.

Ü Information should be provided immediately regardless of how inadequate the information is, or how marginal the source is as immediacy is a canon of journalism. Any delay makes them suspect that authorities are hiding information from them.

Response to the media is as an integral part of hospital preparedness and planning process. Hospitals should have staff previously trained in media relations and they should be called in when the disaster response is initiated. Having a defined media area will help the hospital with internal security measures and provide a separation between the media and grieving family members. Senior administration officials can use the media area to conduct interviews and give information. An official hospital spokesperson should be appointed to help facilitate communication.

Handling of VIPs and the Relatives

A huge number of visitors seek to gain entrance in the hospital during disaster. This includes relatives and friends of the injured and VIPs wishing to visit the hospital to view its response operation, meet victims, and greet the staff. The hospital needs to make arrangements for waiting areas separate from casualty area, information and public relations, matching of potential visitors to actual patient, escorts for VIPs, and identification for visitors. Hospital disaster management team, including Public Relation Officer in particular, needs to look into the following factors:

Ü Making arrangements for counseling support to patient’s families and basic facilities (tea, coffee, access to toilets). The influx of relatives and friends can cause chaos if not handled well.


ÜUsing outside agencies, such as the Red Cross, for counseling to avoid unnecessary political pressure on level of care and access to patients.

ÜMaking best of VIPs visit by briefing on arrival by senior hospital personnel and escorting during their visit.

ÜEnsuring necessary supplies or resources to the hospital and to boost staff morale.

Relatives are important to the emotional and physical wellbeing of the patients of disaster. VIPs are influential in providing support to the hospital. Both families and dignitaries should be handled in a sensitive manner.

2.12 Inter-Agency Coordination

INTRODUCTIONAssistance from other organizations is a must in disasters, as by definition itself, it overwhelms the capacity of the hospital. Much of the burden for disaster response falls on hospitals and health facilities. It is imperative that the hospital be prepared to respond and coordinate relief efforts. It is, therefore, crucial that the hospital be aware of the types of emergency assistance available in the local as well as national agencies, including the government agencies and understands the way these organizations work so that they may better coordinate and integrate emergency response.

The Liaison Officer as per the HICS of BZH of hospital disaster preparedness plan, needs to be aware of the principles of inter-agency coordination to facilitate the hospital recovery process. This includes sources of available assistance, proper place for coordination based on disaster preparedness plan and coordination structure with outside agencies.

SOURCES OF ASSISTANCE TO THE HOSPITALThere are multiple sources of assistance in the immediate disaster and post disaster setting at local, regional and national level. All of these need to be identified and listed.

VIPs are influential

in providing support to the hospital. Both families and dignitaries should be handled in a sensitive manner.

The Liaison Officer as

per the HICS of BZH of hospital disaster preparedness plan, needs to be aware of the principles of inter-agency coordination to facilitate the hospital recovery process.


National and international

organizations may seek to provide relief and reconstruction aid. But these organizations can also greatly complicate the relief process.

Ü Local Agencies – Local agencies such as district administration, district police, hospital networks, pre-hospital care providers and volunteers are important to meet the initial needs, since they are available at the scene and likely to assist. It takes time for regional, national and international resources to be mobilized in the event of disaster.

Ü Surrounding Health Facilities – Nearby facilities may assist by accepting patients from the most affected hospital, providing back up medical and surgical equipment and human resources. It is important to establish a local network of health facilities to be mobilized in the event of a disaster and the network must be developed in the pre-disaster phase.

Ü National Agencies – The hospital may require national assistance for logistical support, financial support, international coordination mechanism and a body of policies, procedures and legal documents, depending on the type and complexity of the disaster, the number of people affected and the overall scope of the disaster. The national agencies include Ministry of Home Affairs, Ministry of Health and Population, National Hospital Association, National Medical Associations and National disaster Medical Officer as designated in the National Disaster Preparedness Plan.

COORDINATING DISASTER RESPONSE WITH OUTSIDE AGENCIESNational and international organizations may seek to provide relief and reconstruction aid. But these organizations can also greatly complicate the relief process. Thus, the Liaison Officer also needs to set up a proper place within the Hospital Command Centre and needs to know coordination structure to coordinate all incoming assistance, personnel, and resources. This office also serves the function of on-going networking with agencies as well as coordinating reconstruction and media relations separately or combined to coordinate the response efforts by serving the following functions:

Ü Provide a forum for coordination meetings and constant communication.


Ü Serve as a central repository of information relating to the disaster.

Ü Provide informational updates for stakeholders in a disaster.

Ü Provide an updated list of needs and issues.

2.13 The Aftermath and return to the Normal Health OperationOnce the acute phase of disaster is over, a lot of work still needs to be done. Staff should check with their Heads of Department to make sure that there is nothing more to do before leaving.

The disaster state should be considered over when:

Ü No further victims are likely to be brought in. (This should be clarified by the Incident Commander with the Police and other relevant institutions.)

Ü All patients in Red and Yellow Areas have been stabilized, admitted or transferred.

Ü All patients in Green Area have been stabilized, discharged or admitted.

Ü Decision to reopen Emergency for normal function is made by Incident Operation Chief in consultation with Incident Commander.

SUBSEQUENTLYÜ X-ray and Lab will perform other necessary X-rays/investigations on disaster victims.

Ü The whole of Surgical and Orthopaedics teams will stay behind and do a detailed ward round of the admitted victims. Heads of each department will be responsible for seeing that this is done. (The mop up activity should not be lift only for the on call team.)

Ü If the number of patients is big, Surgical and Orthopaedics consultants in charge will divide the patients between the two teams for continuing management.

Ü The Nursing Supervisor will delegate more nurse to Surgical and Orthopaedics wards depending on the number of victims admitted.


PSyCHOLOgICAL CONSEquENCES

3


PSyCHOLOgICAL CONSEquENCESINTRODUCTIONThe loss of property and lives in the family caused by the disaster also has psychological effects following a disaster. The emotional effects may manifest immediately or may appear later. The more severe the disaster, the more negative is the outcome and it affects both, the disaster patients as well as the workers, including medical staff. Hence, these psychological consequences also need to be considered in the hospital disaster preparedness plan. The medical personnel, particularly those responsible for dealing with it, should be aware of the probable after-effects on psychological aspects, special needs groups and measures to be taken. It is also important for all the medical staff to know the self-help and professional techniques to come out from the event for themselves.

PEOPLE AFFECTED BY DISASTERS Apart from the primary victims from the affected area, there are a number of other people who are affected. Among them are the unaffected community members, and the rescue and recovery personnel.

VULNERABLE GROUPSAlthough every individual is susceptible, there are groups, which are vulnerable to the psychological consequences of disasters. They are: the elderly, children and adolescents, pregnant or lactating woman, single parent families, the bereaved, and rescue and relief workers.

PSYCHOLOGICAL AFTER-EFFECTS It is important for emergency medical personnel to recognize the after-effects. This would help them to take care of survivors and in recognizing these changes in themselves. The common psychological after-effects to a disaster are mainly divided into changes experienced in thinking, feelings and behaviour as given in the table below.

List of activities and logistics to support the implementation plan is given in Annex V. Some of them have been already implemented. Others need to be implemented on priority basis.

Severe reactions such as post-traumatic stress disorder and depression are seen in a smaller number of people than reactions such as sleeplessness, worrying, and anxiety.


MEASURESÜ Provide simple, accurate, brief and to the point, readily understandable information in

local language repeatedly at regular intervals. Many affected people can respond to the situation and make good decisions based upon the information they receive. Survivors must take the necessary steps in putting themselves and their communities back together.

Ü Handle bereaved, special needs group very carefully by supporting their specific needs including:

» Information about what happened.

» The option to see the body of their loved ones.

» Help to avoid unceremonious disposal of bodies of the deceased.

» Protection from media intrusion.

Ü Prepare for an extreme psychological trauma such as post traumatic stress disorder (PTSD) with its diagnostic criteria and treatment as it can develop on some people though they will be few in numbers. The usual psychological defenses are incapable of coping.

Ü Provide training to disaster worker for emotional and cognitive preparedness prior to the disaster. This reduces the risk of psychological effects of disaster for disaster workers. The training should include:

» Simulation of possible scenarios prior to going to the field.

» Education on the potential psychological effects seen in survivors.

» Awareness on likely psychological reactions in self and other relief personnel.

» Education on simple self-care techniques.

Ü Learn coping skills. There are numerous methods people use when under stress. Active or ‘action’ oriented coping is an adaptive response often utilized following a disaster. People cope by engaging in activities such as assisting others, engaging in practical tasks and setting up support groups.

Ü Be aware of possible symptoms of burnout. This can occur after a prolonged period of time on the job. Some of the symptoms observed are cynicism, feeling unappreciated or betrayed by the organization, loss of spirit, heroic but reckless behavior, neglecting one’s own safety and physical needs (not wanting/needing breaks and sleep), excessive tiredness, inability to concentrate, mistrusting colleagues and supervisors, sleep difficulties, inefficiency, and excessive use of alcohol, tobacco or drugs.

Ü Create a supportive environment in the hospital, which is one of the many crucial factors in minimizing stress by arranging regular and frequent meetings, adopting peer support system, developing a culture of openly talking and sharing, accessible guidance and support from managers and peers.

Ü Learn self-help techniques as shown in the table.


Remember that your reactions are normal and unavoidable.

It is helpful to express even frightening and strange feelings.

Be aware of your tension and consciously try to relax.

Slow your breathing and relax your muscles.

Talk to someone with whom you feel at ease. Describe to him/her what you were thinking or feeling during the critical event.

You process the unpleasant experiences when you talk about them.

Draw, paint, write, play music or exercise. Look for a healthy outlet.

Sometimes it is easier to express your feelings by doing rather than talking.

Listen to what people close to you say and think about the event.

It has affected them too, and they may share insight that will benefit you.

Take special care of yourself. Try to keep eating well and limit alcohol and tobacco. Physical exercise is good for you because it relieves tension.

Continue to work on routine tasks if it is difficult to concentrate on demanding duties.

Tell your peers and team leader/supervisor about how the distressing event has affected you, so that they can understand.

If you cannot sleep or feel too anxious, discuss this with someone you can trust.

Do not self-medicine. Get medical advice.

Get easy on yourself. It takes time to evaluate how you will view things after a distressing event has occurred.

Avoid inflated or perfectionist expectations, either about yourself or others.

These can only lead to disappointment and conflict.

After a few weeks, if you still feel uneasy about your reactions, you should seek professional advice.

Everyone who has ever experienced a disaster is affected psychologically in some way or the other sooner or later. Being aware of psychological consequences, including psychological after-effects, emotional and cognitive preparedness prior to disaster, burnout and using self- help techniques can help reduce stress that disasters cause.


4. JOB LISTS FOR PERSONNELLists of job descriptions and Job Action Sheets (JAS) of all the positions are provided in Appendix 4. Individual Job Descriptions should be printed, and attached to a clipboard. These should be kept in the cupboard of Disaster Emergency Store/HCC for collection at the time of Disaster.


ANNEXES

ANNEXES


ANNEX I Guideline for Triage

TriageTriage is a medical decision-making process of prioritizing patients based on the severity of their condition so as to treat as many patients as possible when resources are insufficient for all to be treated immediately.

ASSESSMENT OF TRIAGE:Ü Assess victims’ vital signs and their conditions.

Ü Assess their likely medical needs.

Ü Assess their probability of survival.

Ü Assess medical care needed at the site.

Ü Prioritize management of casualties.

Ü Colour tag patients by priority.

SIMPLE TRIAGE AND RAPID TREATMENT (START)START is a well-acclaimed triage system and has been field-proven in MCI, such as train wrecks and bus accidents though it was developed for use after earthquakes. The START plan aims to correct the main threats to life, blocked airways and severe arterial bleeding and it allows personnel to triage a patient in 60 seconds or less by quickly making an assessment of a patient’s:

Ü Respiration

Ü Perfusion

Ü Mental Status

Respiration – Every patient is assessed for their respiratory rate. If a patient is not breathing, check for obstruction in the mouth and reposition the head. If the above procedures do not initiate respiratory efforts, tag the patient BLACK. If the victim’s respiratory rate is greater than 30 per minute, tag the patient RED. If respirations are less than 30 per minute, do not tag at this time. Assess for perfusion.

Perfusion – The most reliable method to assess perfusion is the pulse.


Mental Status – The mental status evaluation is used for patients whose respirations and perfusion are adequate. To test, simple command such as ‘open and close your eyes’ or ‘squeeze my hands’ can be used.

The three assessment components of START are:

Ü Respiration

Ü Perfusion

Ü Mental Status

The initial step in START is to separate out those victims that are awake and ambulatory. They are asked to move to a safe, designated area before triage of the other victims takes place. These people are the “walking wounded” and are tagged as GREEN. They will be reassessed after triage of the more critical patients is completed. The remaining victims undergo a quick assessment of respiration, perfusion and mental status that will divide them into the three remaining categories identified below:

RED or Immediate: Ventilation is present only after repositioning the airway. They are also placed into this category if the respiratory rate is greater than 30 per minute, if there is delayed capillary refill (greater than two seconds), or the patient is unable to follow simple commands.

YELLOW or Delayed: Any patient who does not fit into either the immediate or minor categories.

BLACK or Deceased: No ventilation is present even after clearing the airway.

HOW TO EVALUATE PATIENTS USING RPMThe START system is based on three observations: RPM--Respiration, Perfusion and Mental Status. Each patient must be evaluated quickly, in a systematic manner, starting with respiration. If the patient is breathing, the breathing rate must be determined.

Ü Patients with breathing rates greater than 30 per minute are tagged Red.

Ü If the patient is breathing and the breathing rate is less than 30 per minute, move on to the assessment of circulation and mental status.

Ü If the patient is not breathing, quickly clear the mouth of foreign matter. Use a head-tilt manoeuvre to open the airway. In this type of multiple or mass-casualty situation, one might have to ignore the usual cervical spine guidelines when s/he is opening airways during the Triage process.

Special Note: The treatment of cervical spine injuries in multiple or mass casualty situations is different from what is normally taught. This is the only time in emergency care when there may not be time to properly stabilize every injured patient’s spine.


Ü Open the airway, position the patient to maintain the airway and -- if the patient breathes -- tag the patient Red.

Ü If the patient is not breathing and does not start to breathe with simple airway manoeuvres, the patient should be tagged Black.

Perfusion: The best field method for checking perfusion (circulation) is to check the radial pulse. If the radial pulse is absent or irregular the patient is tagged Red. If the radial pulse is present, move to the final observation of the RPM series: mental status.

Mental Status: The last part of the RPM series of Triage tests is the mental status of the patient. This observation is done on patients who have adequate breathing and adequate circulation.

Ü Test the patient’s mental status by having the patient follow a simple command: “Open your eyes.” “Close your eyes,” “Squeeze my hand.”

Ü A patient who is unresponsive or cannot follow this type of simple command is tagged Red.

Patients who can follow these simple commands and have adequate breathing and adequate circulation are tagged Yellow.


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ANNEX III Checklist for Disaster Patient

Ü The priority order for lab work, X-rays, admission, Operating Theatre (OT) etc is: Category “Red” patients over “Yellow” and “Yellow” over “Green”

Ü The Incident Operation Chief makes the priority list for the OT (in conjunction with the Surgeon on duty in the Red and Yellow areas), and for transfers.

Ü Patients with Disaster Card do not pay for registration, tests or treatment.

Ü Green patients needing investigation will have it done in Main Lab and Main X-ray, not in Emergency, until disaster is over when Emergency facilities may be used again.

Ü Depending on the type of disaster, the “walking wounded” (Category “Green”) should normally outnumber the seriously ill by a factor of two or three. It is important that they are assessed, treated and discharged reasonably quickly.

Ü Re-triage may be necessary and will be decided by the treating doctor as to whether it is necessary.

Ü It is important to clear Treatment Areas as soon as possible for possible further inflow of victims. Patients should be transferred to wards as soon as possible and should not wait for X-rays or investigations to be done. These can be done in the ward.

Ü ICU and CCU beds, if are available, will be allocated to critically injured disaster patients. Decisions about ventilator allocation will be made by the ICU in charge in discussion with the treating doctors.

Ü The Observation Ward (Emergency) will be developed as a High Dependency Unit by the anaesthetists if the number of serious patients warrants .

Ü Patient details, history examination, orders and treatment should be written directly in the patient card until admission notes are created.

Ü Only three x-rays are allowed during disaster in the Emergency Department: C-spine, chest and pelvis. Other x-rays will be sent to main X-ray and managed on priority basis. Non-urgent x-rays e.g. obvious or suspected limb fractures will be performed after disaster is over. Patients will have to be fetched from the ward for these x-rays later.

Ü However, if a patient requires an urgent CT of the head, then imaging of the cervical spine, chest and abdomen will done by CT at the same time (if injuries indicate the need).

Ü The only blood investigations allowed in Emergency Lab during disaster are Hb, grouping and cross-matching and blood glucose. Other investigations must wait untill later.

Ü Results will be collected by the treating team, not by patient party.


ANNEX IV Job Action Sheets

INCIDENT COMMANDERMission: Organize and direct the Hospital Command Center (HCC). Give overall strategic direction for hospital incident management and support activities, including emergency response and recovery. Authorize total facility evacuation if warranted.

Date:__________ Start:_______ End:_______ Position Assigned to:_______________

Signature: ___________________________________________ Initial:_____________

Hospital Command Center (HCC) Location:__________ Telephone:_____________

Fax:__________ Other Contact Info:__________ Radio Title:_____________________

Immediate (Operational Period 0-2 Hours) Time Initial

Assume role of Incident Commander and activate the Hospital Incident Command System (HICS).

1.1.1 1.1.2

Read this entire Job Action Sheet and put on position identification. 1.1.3 1.1.4

Notify your usual supervisor and the hospital CEO, or designee, of the incident, activation of HICS and your HICS assignment.

1.1.5 1.1.6

Initiate the Incident Briefing Form (HICS Form 201) and include the following information:

Ü Nature of the problem (incident type, victim count, injury/illness type, etc.)

Ü Safety of staff, patients and visitors.Ü Risks to personnel and need for protective equipment.Ü Risks to the facility.Ü Need for decontamination.Ü Estimated duration of incident.


Ü Need for modifying daily operations.Ü HICS team required to manage the incident.Ü Need to open up the HCC.Ü Overall community response actions being taken.Ü Status of local, county, and state Emergency Operations Centers

(EOC).

Contact hospital operator and initiate hospital’s emergency operations plan.

1.1.7 1.1.8

Determine the need for and appropriately appoint Command Staff and Section Chiefs, or Branch/Unit/Team Leaders and Medical/Technical Specialists as needed; distribute corresponding Job Action Sheets and position identification. Assign or complete the Branch Assignment List (HICS Form 204), as appropriate.

1.1.9 1.1.10

Brief all appointed staff of the nature of the problem, immediate critical issues and initial plan of action. Designate time for next briefing.

1.1.11 1.1.12

Assign one or more clerical personnel from current staffing or make request for staff to the Labor Pool and Credentialing Unit Leader, if activated, to function as the HCC recorder(s).

1.1.13 1.1.14

Distribute the Section Personnel Time Sheet (HICS Form 252) to Command Staff and Medical/Technical Specialist assigned to Command, and ensure time is recorded appropriately. Submit the Section Personnel Time Sheet to the Finance/Administration Section’s Time Unit Leader at the completion of a shift or at the end of each operational period.

1.1.15 1.1.16

Initiate the Incident Action Plan Safety Analysis (HICS Form 261) to document hazards and define mitigation.

1.1.17 1.1.18

Receive status reports from and develop an Incident Action Plan with Section Chiefs and Command Staff to determine appropriate response and recovery levels. During initial briefing/status reports, find out the following:

Ü If applicable, receive initial facility damage survey report from Logistics Section Chief and evaluate the need for evacuation.

Ü If applicable, obtain patient census and status from Planning Section Chief, and request a hospital-wide projection report for 4, 8, 12, 24 & 48 hours from time of incident onset. Adjust projections as necessary.

Ü Identify the operational period and HCC shift change.Ü If additional beds are needed, authorize a patient prioritization

assessment for the purposes of designating appropriate early discharge.


Ü Ensure that appropriate contact with outside agencies has been established, and facility status and resource information is provided through Liaison Officer.

Ü Seek information from Section Chiefs regarding current “on-hand” resources of medical equipment, supplies, medications, food and water as indicated by the incident.

Ü Review security and facility surge capacity and capability plans as appropriate.

Document all key activities, actions, and decisions in an Operational Log (HICS Form 214) on a continual basis.

1.1.19 1.1.20

Document all communications (internal and external) on an Incident Message Form (HICS Form 213). Provide a copy of the Incident Message Form to the Documentation Unit.

1.1.21 1.1.22

Intermediate (Operational Period 2-12 Hours) Time Initial

Authorize resources as needed or requested by Command Staff. 1.1.1 1.1.2

Designate regular briefings with Command Staff/Section Chiefs to identify and plan for:

Ü Update of current situation/response and status of other area hospitals, emergency management/local emergency operation centres, and public health officials and other community response agencies.

Ü Deploying a Liaison Officer to local EOC. Ü Deploying a PIO to the local Joint Information Centre.Ü Critical facility and patient care issues.Ü Hospital operational support issues.Ü Risk communication and situation updates to staff.Ü Implementation of hospital surge capacity and capability plans.Ü Ensure patient tracking system established and linked with

appropriate outside agencies and/or local EOC.Ü Family Support Centre operations.Ü Public information, risk communication and education needs.Ü Appropriate use and activation of safety practices and procedures.Ü Enhanced staff protection measures as appropriate.Ü Public information and education needs.Ü Media relations and briefings.Ü Staff and family support.Ü Development, review and/or revision of the Incident Action

Plan or elements of the Incident Action Plan.

Oversee and approve revision of the Incident Action Plan developed by the Planning Section Chief. Ensure that the approved plan is communicated to all Command Staff and Section Chiefs.

1.1.3 1.1.4


Communicate facility and incident status and the Incident Action

Plan to CEO or designee, or to other executives and/or Board of Directors members on a need-to-know basis.

1.1.5 1.1.6

Extended (Operational Period Beyond 12 Hours) Time Initial

Ensure staff, patient and media briefings are being conducted regularly.

1.1.1 1.1.2

Review and revise the Incident Action Plan Safety Analysis (HICS Form 261) and implement correction or mitigation strategies.

1.1.3 1.1.4

Evaluate/re-evaluate need for deploying a Liaison Officer to the local EOC.

1.1.5 1.1.6

Evaluate/re-evaluate need for deploying a PIO to the local Joint Information Centre.

1.1.7 1.1.8

Ensure incident action planning for each operational period and a reporting of the Incident Action Plan at each shift change and briefing.

1.1.9 1.1.10

Evaluate overall hospital operational status and ensure critical issues are addressed.

1.1.11 1.1.12

Review /revise the Incident Action Plan with the Planning Section Chief for each operational period.

1.1.13 1.1.14

Ensure continued communications with local, regional and state response coordination centres, and other HCCs through the Liaison Officer and others.

1.1.15 1.1.16

Ensure your physical readiness and that of the Command Staff and Section Chiefs through proper nutrition, water intake, rest periods and relief, and stress management techniques.

1.1.17 1.1.18

Observe all staff and volunteers for signs of stress and inappropriate behaviour. Report concerns to the Employee Health and Well-Being Unit Leader.

1.1.19 1.1.20

Upon shift change, brief your replacement on the status of all ongoing operations, critical issues, relevant incident information and Incident Action Plan for the next operational period.

1.1.21 1.1.22

Demobilization/System Recovery Time Initial

Assess the plan developed by the Demobilization Unit Leader and approved by the Planning Section Chief for the gradual demobilization of the HCC and emergency operations according to the progression of the incident and facility/hospital status. Demobilize positions in the HCC and return personnel to their normal jobs as appropriate until the incident is resolved and until operation returns to normal.


Ü Briefing staff, administration, and Board of Directors.Ü Approve announcement of “ALL CLEAR“ when incident is no

longer a critical safety threat or can be managed using normal hospital operations.

Ü Ensure outside agencies are aware of status change.Ü Declare hospital/facility safety.

Ensure demobilization of the HCC and restocking of supplies as appropriate including:

Ü Return of borrowed equipment to appropriate location.Ü Replacement of broken or lost items.Ü Cleaning of HCC and facility.Ü Restock of HCC supplies and equipment.Ü Environmental clean-up as warranted.

Ensure that after-action activities are coordinated and completed, including:

Ü Collection of all HCC documentation by the Planning Section Chief.Ü Coordination and submission of response and recovery

costs, and reimbursement documentation by the Finance/Administration and Planning Section Chiefs.

Ü Conduct staff debriefings to identify accomplishments, response and improvement issues.

Ü Identify needed revisions to the Emergency Management Plan, Emergency Operations Plan, Job Action Sheets, operational procedures, records and/or other related items.

Ü Writing the facility/hospital After Action Report and Improvement Plan.

Ü Participation in external (community and governmental) meetings and other post-incident discussion and after-action activities.

Ü Post-incident media briefings and facility/hospital status updates.Ü Post-incident public education and information.Ü Stress management activities and services for staff.


Ü Incident Action Plan

Ü HICS Form 201 – Incident Briefing Form

Ü HICS Form 204 – Branch Assignment List

Ü HICS Form 207 – Incident Management Team Chart

Ü HICS Form 213 – Incident Message Form

Ü HICS Form 214 – Operational Log

Ü HICS Form 252 – Section Personnel Time Sheet

Ü HICS Form 261 – Incident Action Plan Safety Analysis

Ü Hospital emergency operations plan and other plans as cited in the JAS

Ü Hospital organization chart

Ü Hospital telephone directory

Ü Radio/satellite phone

DOCUMENTS/TOOLS


ANNEX V List of Activities and Logistics to support Plan Implementation

RECOMMENDED WORKS TO BE DONE TO MAKE HDPP EFFECTIVE(HDPP – Hospital Disaster Preparedness Plan)1. Establishment of Hospital Command Center (HCC) in doctors rest room or emergency

store with necessary arrangements:

a. Telephone line with telephone set.

b. Electricity supply to connect siren at four places and loud speaker.

c. Sign board as HCC.

d. Clip board.

e. Copy of Hospital Disaster Response Plan with map of spatial planning.

2. Maintain contact numbers of all hospital staff with particular focus on staff living outside and update regularly. Appoint a personnel for doing this task.

3. Entry gates to the hospital should be named properly as Gate No 1, 2 and 3.

4. All the gatekeepers should know the which gates are to be opened and closed and when during disaster.

5. Stockpiling of disaster supply, such as 15 mattresses for disaster emergency room.

6. Clip boards also for Red, Yellow, Green and Black treatment areas. There are no clipboards with the hospital.

7. Oxygen cylinders or concentrator oxygen cylinders to be added to keep them on stand by as there are only two at the moment.

8. Screening arrangements at post mortem area to mark as Black area.

9. Start triaging in normal situation at emergency.

10. There are 100 triage cards at present. At least 100 more has to be added and pre-numbered as they are not numbered at present..

11. Separate disaster store has to be maintained and a staff has to be assigned for undertaking this task.


12. Hospital staff quarters also to be named as 1, 2, 3 …. with proper signboard.

13. Disaster registration book for four treatment areas to be purchased and kept in disaster store and maintained.

14. Wheeled cupboards for three treatment areas with their respective disaster supplies to be maintained with non-structural mitigation measures.

15. Portable x-ray has to be added to carry out x-ray in the treatment area during disaster.

16. Number of trolleys has to be increased. There are only two trolleys at the moment.

17. Garden areas in front of the emergency block has to be cleared in the middle part and maintained as a lawn to accommodate Green disaster patients.

18. Garden areas in front of the two medical staff quarters adjacent to the roadside has to be maintained as a lawn to accommodate more Green disaster patients, if required.

19. All disaster flow area, such as disaster patient flow, vehicle flow, OPD patient flow, hospital staff flow, including triage and treatment area are to be kept unobstructed all the time. Care should be taken particularly while dumping construction materials for the new construction. There is a need to talk to DUDBC to discuss with the contractor for necessary arrangements.

20. Hospital has to coordinate and make MOU with the Nursing Hostel in charge for involving nursing students as Transfer staffs.

21. Ramps at three places to provide easy accessibility for disable people and to have smooth flow for trolleys: inn the exiting emergency area, in the new OPD waiting area, in between the OPD waiting and in patient ward. All in ground floor.

22. Two channel gates to be put to direct the OPD patient to exit, one in-between the OPD waiting and in patient ward, and the other near OPD enquiry.

23. Two gates has to be constructed, one near post mortem block to make exit for the Green patient and the other near the store to make exit for the OPD patients.

24. One movable stair of five ft width and with five steps has to be constructed to meet the height difference of 2’-6” to keep on the OPD patient exit. This to be kept near store at visible and fixed location.

25. Framing or flex print of Spatial plan showing triage and treatment area and other flow should be made for display at various places.

26. Two pump houses should be strengthened to ensure its function in supplying water during disaster.

27. One new pump house for newly bored water pump at quarter no. 2 should be built with pipe lines connecting the hospital water tank and central water tank.

28. Existing generator house should be strengthened with stand-by maintained fuel supply for the generator.

29. A new generator house should be built for new generator resting on 8’x 15’ platform located near gate no 3.


30. Keys of the gates at NSARC building should be shared to make exit for the OPD patients.

31. All necessary infrastructures, such as generator supply, water supply, electricity supply, suction etc should be arranged in treatment areas.

32. Orientation /training should be provided to every hospital staff from Peon to Hospital Director.

33. Orientation on Hospital Disaster Response Plan should be done other stakeholders also, particularly Nepal Police, Armed Police Force and CDO office.

34. Regular drill for the evaluation of the Plan.


ANNEX VI Examples of Reactions of People who Experience Stress

EXAMPLES OF REACTIONS OF PEOPLE WHO EXPERIENCE STRESS

Thoughts

Common

Ü Recurring dreams or nightmares.

Ü Reconstructingthe events surrounding the disaster in your mind in an effort to make it come out differently.

Ü Difficulty in concentrating or remembering.

Ü Recurring and compulsive thoughts or memories of the disaster or of loved ones who died in the disaster

Less Common

Ü Questioning one’s relgions or spiritual beliefs.

Feelings

Common

Ü Experiencing fear and anxiety when reminded of the disaster, particularly sounds and smells.

Ü Lack of involvement or enjoyment in everyday activities.

Ü Feeling depressed, blue or down for periods of time.

Ü Feeling of anger or intense irritability.

Ü Feeling of emptiness or hopelessness about the future.

Less Common

Ü Feeling numb, withdrawn or disconnected.


Behaviours

Common

Ü Being overprotective ofoneself and ones family’s safety.

ÜBecoming very alert at times and startling easily.

ÜUnable to sleep or remain asleep.

ÜIncrease in conflict with family members

ÜCrying for no apparent reason.

Less Common

ÜIsolating oneself from others.

ÜAvoiding activities that remind ones of the disaster, avoiding places or people that bring back memories.

ÜKeeping excessively busy to avoid thinking about the disaster and what has happened to him/her.


ANNEX VII Photographs

Bheri zonal hospital disaster response plan

Documents

Transcript of Bheri zonal hospital disaster response plan