Disaster Preparedness in Hospitals

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Framework• Introduction• Disaster Management Cycle• Role of Hospitals in Disasters/Mass casualty incidents• What constitutes a disaster for a Hospital?• Need for Emergency plans for Hospitals• What is Hospital Networking?• Role of District Medical Authority • Hospital Disaster Management Plan• Model Emergency Plan for District Hospital

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Introduction Disasters can cause large scale damages to systems, structures, and health and well

being of the people,

They occur anywhere anytime – causing - displacement , injuries, deaths, leading to risk of epidemics, economic loss ,damage to water supply, food shortage, affects future sustainable development

Morbidity caused is due to - injuries, emotional stress, epidemics ,etc.

Vulnerability to hazards that lead to disasters is increasing – as population grows, resources become limited,

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Definition

Disaster - A disaster is defined as: “…….. a serious disruption of the functioning of the society, causing wide spread human, material, or environmental losses, which exceeds the ability of the affected society to cope, using its own resources.”

A disaster occurs when a hazard (natural or man made) strikes a vulnerable society.

Vulnerability - is defined as “the extent to which a community, structure, service, or geographical area is likely to be damaged or disrupted by the impact of a particular hazard, on account of their nature, construction, or proximity to a hazard prone area”

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Definition ....

• Risk is a measure of the expected losses (deaths, injuries, property, economic losses etc.) due to a hazard of a particular magnitude striking in a given area.

• “Peripheral emergencies” like road, rail and air accidents, fire, drowning and stampedes in mass gathering, industrial accidents, explosions and terrorist attacks that have an inherent potential to convert into a Mass Casualty Incident (MCI).

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Disasters in India• India is highly prone for disaster – 8 major disasters /year

Year Disaster Mortality

1999 Orissa – super cyclone 1000 people died

2004 Indian Ocean -Tsunami 10749 deaths

2008 Kashmir - Earthquake 1400 deaths

2013 Uttarakhand – Kedarnath- Cloudburst 5700 deaths, 70000 affected

2014 Kashmir – floods 300 died

2015 Chennai - foods 280 died

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Types of DisasterTypes of Disaster GOI classification - categories Nodal ministry /

Support ministryNatural Disasters Water & Climate related – floods,

cyclones, heat & cold waves, droughts, sea erosion

Geologically Related- Landslide, Earthquake, Dam bursts, Mine fires

Agriculture/ Health

Chemical Disasters Chemical , Industrial & Nuclear Realated Environment/ Health

Nuclear Disasters Atomic Energy /Health

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Types of DisasterTypes of Disaster GOI classification - categories Nodal ministry & Support

ministry

Biological Disasters

Biological related disasters –Biological disasters and epidemicPest attacks ,Cattle epidemic , food poisoning

Health/ Public Health Engg.

Accident Related Disasters

Forest Fires , Urban fires, Village fires, oil spill, mine food, Mojor building collapse, serial bomb Blast, Air , Road, Rail accidents,

Ministry of Environment and Forests /Ministry of Railways

Civil Strife --- Home/ Health

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Impact of disaster depends on :

• Types of disasters

• Density and distribution of population

• Condition of the environment

• Degree of preparedness

• Opportunity of warning

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Distribution of disaster prone areas in India

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Distribution of disaster prone areas in India

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How How to reduce the risk of Disaster?

Disaster

Response & Recovery

Rehabilitation &

Reconstruction

Prevention & Mitigation

Preparedness

Disaster Managmnt

Cycle

Preparedness - to reduce the loss & damage to human lives, propertyPrevention -completely avoid potential adverse impacts through action taken in advanceMitigation - limitation of the adverse impacts of hazards and related disasters Response: provision of emergency services and public assistance during or immediately after a disaster Recovery-to return life to normal levels after a disaster

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Role of Hospitals in Disasters/ MCI Ensures an effective healthcare response during disasters and the safety of the patients

Provide 24*7 emergency/critical care services , including laboratories, blood banks, ambulances, rehabilitation , aged care and pharmacies.

Its a vital resource for diagnosis , treatment and follow-up for physical and psychological care.

Collecting and analysing data on illness to detect and prevent potential outbreaks

Providing immunisation services to prevent outbreaks of diseases, such as measles Failure of hospitals and emergency services during a disaster can greatly affect public

morale and a community's social and health capital.

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What constitutes a Disaster/ MCI for a hospital?

“ A temporary lack of resources, which is caused due to sudden influx of unexpected patient load”- is a disaster for that hospital.

• That means a same event may have a disaster potential for a smaller hospital and not so for a bigger hospital.

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WHO – Categories for -The Mass Casualty Emergencies • To find out what constitutes a disaster for the hospital - the hospital needs

to calculate its normal capacity, beyond which it has to act according to the Disaster Plan

• Mass Casualty Emergencies can be categorized in one of the following ways

Based on the Number of Casualties - Cat 1/2/3

Based on type of casualties - Cat A/B/C

Classify by the contingency plan - Class A/B/C

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Need for Hospital Disaster Emergency plan• A Hospital Emergency Plan is unique to each hospital as it depends upon its bed strength, staff and other

resources.

Why have Emergency plans for hospitals? Helps to plan, prepare and respond in case of disasters to reduces morbidity and mortality

Disaster creates chaos ,confusion and inefficiency in hospital, due to burden on staff , resources, space, supplies- So a command structure and clear cut jobs is defined in plan

. There is reduced quality of medical care – planning will provide quality care to the serious / critical

patients with available manpower

Integration with other departments of the hospitals for better outcomes A proportional distribution of patients to other health care facilities is possible

Small hospitals need plan – for referral ,mobile emergency care, definitive care for not seriously injured

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Hospital Networking HN means a dynamic link between various health care facilities of a given geographical area

for augmentation or optimization of available resources. • Different state and district medical authorities have to plan for facility networking in their

areas along with various health care providers.• The health care facilities have to be networked for

Benefits :- Analysing the available resourcesAugment available resources if and when required.Optimally utilising available resources in the area

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TERLevels of hospital networking

Hospital networking can be done at various levels within the district as well as with intervening bigger hospitals where ever available.

District hospital

PHCPHC

Railways , Defence,

Private hospitals

Tertiary referral centres

District hospitalDistrict

hospital

CHC

CHC

PHCPHCPHC PHC

CHC

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Site of Disaster/ MCI

Nearest Hospital Small Facility/ CHC

STABLE UNSTABLE

FIRST AID RESUSITATE AND STABILIZE

DISCHARGED Refer to OPD of Networked

Hospitals where specialists are

present

Refer for treatment in networked

hospital

Facilities availableFacilities not present

DEFINITIVE TREATMENT

Suggested Flow of

Patients in a network

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Role of Emergency Health Services in Disasters• Disasters needs a coordinated response between curative and preventive health

services, including food supply, water and sanitation.

Role in Preventive Health - Three levels of preventive health measures:

Primary prevention is the ultimate goal of preventive health care and aims to prevent the transmission of disease to generally healthy populations

Secondary prevention identifies and treats diseased people to prevent progress of infection to serious complication or death.

Tertiary prevention reduces permanent damage from disease such as a patient being offered rehabilitative services

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Role of District Medical Authorities....• Roles in Pre disaster phase - Critically access the available medical resources within the district and share them with

other neighbouring districts i.e. networking of the various medical resources and hospitals

The networking of facilities, transport vehicles like ambulances, blood banks, CT scan and trained manpower like quick reaction medical teams (QRMT’s) specialists like neurosurgeons etc. is done

• Role in The disaster phase – leading role in medical treatment of victims

The District Health officer should set up a medical command structure working in co ordination with the district administrative authorities.

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Organization of Health Delivery System in Disaster• Health delivery system management plays an important role in reducing

morbidities and mortalities during disaster – casualty management at the district level should be planned in two stages: -

i) Pre-Hospital Management• a) First Aid Parties• b) First Aid Posts(static and mobile)• c) Ambulance service• d) Mobile Surgical Units.

ii) Emergency Hospital Organizationa) Emergency Hospital Services (including critical care facilities)b) Emergency Surgical Servicesc) Emergency Transfusion Servicesd) Emergency investigation facilities

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Hospital Disaster/Emergency Management Plan:

• The plan should include Disaster that has occurred away from the hospital, and also the situation where the hospital itself has been affected by a disaster – fire, explosion, flooding or earthquake

• Aim - to provide prompt and effective medical care to minimize morbidity and mortality resulting from any disaster.

• Objective – to optimally prepare the staff and institutional resources of the hospital for effective

performance in different disaster situations.

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Goals - Disaster : away from the hospital and not affecting the hospital

To control large number of patients coming and manage the resulting problems in an organized manner,

Enhancing the capacities of admission and treatment.

Treating the patients based on the rules of individual management, in spite of large casualties.

Ensuring proper treatment for all patients already in the hospital.

Smooth handling of all additional tasks caused by such an incident.

To provide medications, medical consultation, infusions, dressing material and any other necessary medical equipment.

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Goals – Disaster : Affecting the hospital To protect life, environment and property inside the hospital from any further

damage

Putting into effect the Preparedness plan measures.

Appropriate actions of the staff who have to know their tasks in such a situation.

Getting help from outside in an optimal way.

Re-establishing as quickly as possible, an orderly situation in the hospital, enabling a return to normal work conditions.

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Principles of a Hospital Disaster Plan• Predictable

• Simple

• Flexible

• Concise

• Comprehensive

• Adaptable

• Anticipatory

• Part of a Regional Health Plan in Disasters

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Phases of Hospital Emergency Planning• 1) Pre disaster phase a) Planning b) The disaster manual c) Staff education and training

• 2) Disaster Phase a) Phase of activation: b) Activation of the chain of command in the hospital. c) Operational phase: d) Phase of deactivation

• 3) Post Disaster Phase Here the activities of the disaster/ emergency phase are discussed and the inadequacies are noted for

future improvements.

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1) Pre Disaster Phase - Planning

• All hospitals providing emergency care to patients start planning for the worst at the earliest with following steps:-

• Hospital Disaster Management Committee• Central Command structure (Incident command system) for hospital• Job Cards• Plan activation of different areas of hospital• Disaster beds/ how to increase bed capacity in emergencies?• Planning of public information• Planning for security of hospitals in emergency situation• Logistics planning• Operations Planning• Phase of Staff Education and Training• Disaster Drills/Table Top drills/ Partial evacuation/Non-evacuation Drills

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The disaster manual should incorporate the following:

• Medical Command Authority (Unified Incident command)

• Control center location• Names and contact numbers of all

members of the staff and their position.• Disaster Alert Codes• Quick reaction teams formation,

responsibilities and movement details• Responsibilities of individuals and

departments• Job Action Cards• Chronological Action Plan• Details of resource mobilization for

logistics and manpower

• Details of Operational Areas (Patient Care Areas)

• Standing Orders and Protocols for patient management

• Hospital Triage Criteria• Documentation details• Communications (Intra and Inter Hospital)• Networking including capacities and

capabilities of health facilities• Pre-hospital transports• Security arrangements• Police networks• Evacuation details• Medico-legal responsibilities• Disposal of the Dead (Role of Mortuary

services and Forensic dept )

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2) Phase of Disaster• Disaster Activation - The Hospital Administration must appoint an Incident Commander/Incident Staff/The

operations chief/The Logistics chief/The planning chief/The public information officer/ Public Relations Officer/The Liaison Officer/The Security and Fire Officer/The Finance Officer

• Different types of hospital Responses- In-Hospital Response Phase (small multi-casualty incident, using only main Em. Dept. patient

Care) Additional Area/Out of Hospital Support Phase (Large multi casualty incident Damage to Hospital Phase Catastrophic Disaster in City Phase

• Disaster Deactivation (Demobilization phase) - The decision to deactivate the hospital emergency plan should be taken after proper assessment of the situation by the incident commander and other hospital administrator.

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3) Post Disaster Phase

• Debriefing –

The Disaster Committee after the Disaster has been deactivated does a critical self review of hospital’s own performance during a disaster.

What went right is taken cognizance of and what went wrong is further

incorporated into the disaster plans

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A Model Hospital Emergency Plan for District Hospital• a) Pre-Disaster Phase (Phase of Planning)• i) Formation of a Hospital Emergency/Disaster Committee:• The civil surgeon (CS) of the district hospital must constitute a disaster

preparedness committee with folowing members ,to prepare the hospital emergency plan and the emergency manual

- I/C Pediatrics- I/C Gynecology- I/C from any other clinical department - I/C Nursing Superintendent- Store Offices- Account Officer- Sanitation In-charge - Chief Medical

Superintendent- I/C Emergency Services- I/C Surgery- I/C Orthopedics- I/C Anesthesiology- I/C Medicine

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ii) The formation of the Hospital Incident Command:

• It is very important that the prominent members of the staff take up specific roles during an Emergency.

• This incident command structure should be written down so that there is no confusion and the persons are known by this position on the command structure e.g. Operations Chief, Logistics Chief etc.

• The committee might decide that one person holds more than one position or work of one person is divided amongst different people

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The model incident command structure for a District level Hospital.

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A Model HEP -District Hospital ...• iii) Control Room -The CS office should act as the control and should have good

communication network like landline, mobiles and if possible in-hospital CUG (Close User Group Mobile Connection).

• the control room should have all contact numbers of the hospitals, staff and district authorities , blood banks ,police ,which is mentioned in the incident command

• iv) Organization of Patient Treatment Area- Patient Reception Area Resuscitation, Observation , Minor Treatment Area, OT, Wards,mortuary

• v) Organization of Patient transfer Area after stabilization - area from where patients who cannot be treated at district hospital can be reffered . This area also will be under the Operations Chief.

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A Model HEP -District Hospital ...

• vi) The Medical Support Services -investigations (Radiology, Laboratory etc.)

• vii) The Nursing Services- provide adequately nursing staff where ever needed

• viii) Organization of the Logistics – Communication, Transport , Dietary Supply, Sanitation, Water & Electricity

• ix) Medical Supplies- medical supplies should be adequate

• x) Security – hospital security staff , police involved

• xi) Public Relations Officer (PRO) – should brief media, take help of media – to spread information,

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b) The Disaster Phase

• i) Notification and Activation of Plan:• Information regarding the mass casualty incidents is received by the operator at

district hospital from -• District authorities• Police• General Public

• The person on the board verifies the incident and gather information regarding• Nature and magnitude of event• Possible numbers of victims• Location• Time of Incident• Expected time of arrival of victims at district hospital

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The Disaster Phase...

• This person on the board passes the information to RMO Clinical , who after knowing number of expected casualties activates the hospital emergency plan.

All staff present in the hospital is asked to reach the patient receiving areas as described earlier.

All Chief of respective areas to be contacted and informed according to the incident command structure.

All the Chiefs of respective areas to reach the hospital and report to RMO clinical / ACS and carry out the requisite work of their areas.

• All the staff members report to the respective areas of work and take direct orders from their area Chief.

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Deactivation of the Emergency Plan

• Once the incident commander (Medical Superintendent) and the Chiefs of respective areas are convinced that there will be no more casualties who will come to the hospital they would take a decision to deactivate the plan and resume the normal functioning of the hospital.

Post Disaster Debriefing – • The Chief Medical Superintendent (CMS) of the district hospital should sit down

with his/her team after the disaster has been called off and prepare a report as to how things went during the disaster and what were the problem areas.

• This will help in developing a more robust plan for the next time.

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National Policy on Disaster Management 2009• Formulate policy guidelines to enhance capacity in emergency medical response and mass

casualty management

• Hospitals DMP will include developing and training of medical teams and paramedics for disaster managmnt.

• The casualty handling capacity of all hospitals at the time of disasters, will be worked out

• Formulate appropriate procedures for treatment of casualties by private hospitals during disasters

• Creation of mobile surgical teams, mobile hospitals and heli-ambulances for evacuation of patients and adequate mortuary facilities.

• Testing efficacy of plans and Standard Operating Procedures (SOPs) through training, seminars and mock drills.

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References• GOI , National Disaster Management Division Ministry Of Home Affairs,UNDP DRM Programme, Guidelines for Hospital

Emergency Preparedness Plannning, 2002-2008 www.undp.org/content/dam/india/.../guidelines_hospital_emergency.pdf

• National Disaster Management Authority, National Disaster Management Guidelines Hospital Safety ,December 2013 • www.ndma.gov.in/images/pdf/NDMAhospitalsafety.pdf

• NDMA , GOI http://www.ndma.gov.in/en/disaster.html

• NIDM .TOT Module for Preparation and Implementation of Hospital Disaster Management Plan Focus on Emergency Health Services , 11 July 2014

• nidm.gov.in/pdf/ncrmp/Deliverable%2012-2.pdf

• UNISDR terminology on disaster risk reduction. Geneva, United Nations International Strategy for Disaster Reduction, 2009 (http://www.unisdr.org/eng/library/lib-terminology-eng%20home.

• Mass casualty management systems. Strategies and guidelines for building health sector capacity. Geneva, World Health Organization, 2007 (http://www.who.int/hac/techguidance/MCM_guidelines_inside_final.pdf, ).

• K. Park. Park Textbook of preventive and Social medicine.23rd ed. Jabalpur (India ): M/S Banarsidas Bhanot; 2015.