Emergency and Disaster Management in Hospital

Emergency and Disaster Management in Hospital

1. Introduction
Disasters in the communities occur in all shapes and sizes. Some impact a small number of people and put intense demands on the health system for a short period. Others may involve a large number of casualties but reach a plateau only after a latent period, placing heavy continuing demands on the health system. For some natural disasters like hurricanes, floods and volcanoes-hospitals ace likely to receive advance warning and be able to activate their disaster plan before the event. For other natural disasters, such as earthquakes and tsunami, there is no advance warning, as of now. Many man-made disasters also provide no advance warning; these include chemical plant explosions, industrial accidents, building collapses and acts of terrorism

The emergence of slate-sponsored terrorism, proliferation of chemical and biological agents, availability of materials and scientific weapons expertise all point toward a growing threat of a mass casualty incident (MCI). Preparing for MCIs is a daunting task, as unique issues must be considered with each type of event.

For example, the systemic stress of a bio-threat is entirely different from that of a chemical disaster. These differences hold challenging implications for the hospital preparedness and training. The hospital disaster preparedness has therefore assumed on an increased importance at local, state and national levels.

Disaster plan is a must for every hospital as a disaster can occur anywhere, any lime. The drill of the plan should be practiced periodically. No master plan can be evolved to fit every emergency. But, if executed in a coordinated and disciplined fashion, a general plan of emergency activity could prove extremely helpful in times of stress.

2. Definition
Hospitals would be among the first institutions to he affected after a disaster, natural or man-made. Because of the heavy demand placed on their services at the time of a disaster, hospitals need to be prepared to handle such an unusual workload. This necessitates a well documented and tested disaster management plan (DMP) to be in place in every hospital. To increase their preparedness for mass casualties, hospitals have to expand their focus to include both internal and community-level planning. The disaster management plan of a hospital should incorporate various issues that address natural disasters; biological, chemical, nuclear-radiological and explosive-incendiary terrorism incidents; collaboration with outside organizations for planning; establishment of alternate care sites; clinician training in the management of exposures to weaponizable infectious diseases, chemicals and nuclear materials; drills on aspects of the response plans; and equipment and bed capacity available at the hospital. The most important external agencies for collaboration would be stale and local public health departments, emergency medical services, fire departments and law enforcing agencies. The key hospital personnel should be trained to implement a formal incident command system, which is an organized procedure for managing resources and personnel during an emergency. The hospitals should also have adequate availability of personal protective hazardous materials suits, negative pressure isolation rooms and decontamination showers. A hospital’s emergency response plan has to be evaluated whether that plan addresses these issues. The hospitals in USA are required to have disaster response plans to be accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). In India and probably in many other countries, there is no statutory body to regulate and accredit this requirement.

A disaster is defined as ‘a serious disruption to community life which threatens or causes death or injury in that community, and damage to property which is beyond the day-to-day capacity of the prescribed statutory authorities and which requires special mobilizations and organization of resources other than those normally available to those authorities’.

3. Disaster management concepts

• All Agencies (or integrated) approach
• Comprehensive approach embracing strategies in prevention, preparedness, response and recovery
• All Hazards
• Prepared Community

A range of disaster management concepts and the Hospital Incident Control System (HICS) have been adopted and implemented to assist in ensuring the Hospital’s preparedness in the particular area.

HICS provides a predictable chain of management, a flexible response as required for the event, accountability of position functions, and a common language to promote communication and facilitate outside assistance.

4. Aims and Objectives
To save as many lives as possible by providing best possible medical care under prevailing circumstances.

5. Types of Disaster
Disasters can be of various types as follow:
5.1 Vehicular train accident
5.2 Air crash
5.3 Fire in a big multi-storeyed building
5.4 Floods
5.5 Building collapse
5.6 Food poising, liquor poisoning and toxic gas poisoning
5.7 Earthquake
5.8 Explosions, blasts or ballet injuries
5.9 Mine accidents
5.10 Air raids
5.11 Storms and tornadoes
5.12 Atomic explosions

6. Training
A wide range of training of hospital staff is needed so ensure an effective health and medical response to a mass casualty event. Training should include, but not limited to,
6.1 General disaster response, including an. introduction to altered standards of care;
6.2 Legal and ethical basis for allocating scarce resources in a MCI;
6.3 Orientation to how an incident commands system would work in a mass casualty event;
6.4 How to recognize the signs and symptoms of specific hazards and treat specific conditions;
6.5 Basic and advanced life support; hazardous materials (HAZMAT) life support;
6.6 Decontamination and isolation protocols, triage protocols; personal protection gears; and
6.7 Use and maintenance of emergency equipment.

7. Disaster Management Preparedness
Preparedness for disasters is a dynamic process. In addition to having a well documented DMP in place, it is prudent to have regular drills to test the hospital’s DMP. The drills may be hospital disaster drills, computer simulations and tabletop or other exercises. In Bangladesh and India, hospitals rarely have a documented DMP and even rarely conduct disaster drills or publish the reports of such drills. The JCAHO actually requires hospitals to test their emergency plan twice a year, including at least one community-wide drill.

8. Purpose of Hospital Disaster Drill
The purpose of the hospital disaster drills is to train hospital staff to respond to an MCI, to validate the readiness and effectiveness of the hospital’s DMP. to make new hospital staff to become aware of procedures in disaster response, to incorporate advancements in knowledge and technology into the DMP and to use the reports from the drill to reinforce the DMP. Hospital disaster drills should test various components viz incident command, communications, triage, patient flow, drugs and consumables stock, reporting, security and other issues.

9. Procedure for Hospital disaster Preparedness
Survey of some published articles on disaster drills have highlighted that internal and external communications were the key to effective disaster response; a well-defined incident command center reduce confusion; conference calls were an inefficient way to manage disaster response; accurate phone numbers for key players were vital and regular updating was necessary; disaster drills appeared to be an effective way to improve clinicians’ knowledge of hospital disaster procedures;
9.1 Computer simulation is an economical method to educate key hospital decision makers and improve hospital disaster preparedness before implementation of a full-scale drill;
9.2 A tabletop exercise can help to motivate hospital staff to team more about disaster preparedness and can help to teach staff about aspects of disaster-related patient care in a way that simulates the practice setting;
9.3 A regional exercise involving top government officials can help to increase awareness of the need for better disaster response planning; and
9.4 Video demonstrations may be an inexpensive, Convenient way to educate a large number of staff about disaster procedures and equipment use in a short time.

10. Problems to be handled
10.1 Transportations of victims to the hospital
10.2 Provision of prompt medical attention
10.3 Advice on prevention of outbreak of epidemics.

11. Organization and Operation
Disaster Committee: There will be a standing committee of the Hospital Management Board. It consists of:

• Head of the Dept. of Orthopedics
• In-charge, Accident and Emergency Services
• Head of the Dept. of Surgery
• Head of the Dept. of Medicine
• Head of the Dept. of Forensic Medicine
• Head of the Dept. of Anesthesiology
• Head of the Dept. of Radio-Diagnosis
• Head of the Dept. of Gastroenterology

The Nursing Superintendent
It also consists of the Head of the Department of Hospital Administration if available to co-ordinate all the hospital supportive services DD/Deputy Medical Superintendent acts as the Officer-in-charge. The Director/ Medical Superintendent acts as the Chief Co-ordinator.

12. The Actual Operation Plan
12.1 Control Center: A control center for disaster operation is set up in open location (Room no-1) Ground Floor, of the Hospital, which functions with the Director/ MS as its chief organizer. The telephone numbers are: 0000000 / Ext. 000 and internal 000. The Director/ MS clearly identify the duties of his assistants and depute a standby for himself as well as for his assistants.
12.2 Alert: The moment information regarding a disaster reaches the Director/ MS, he alerts all those who are involved in the operation of the plan through a well-defined channel. The Mobile phone sod intercom play an important role at this stage. The operator, as informed by the Director/ MS informs all these persons shoot the disaster.

13. Reception Center

a. For moderate load:

The present casualty O.P.D / Emergency will function as the reception area.

b. For heavy load:

Main Hall of Ground floor O.P.D will be converted into reception center.

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Police and Security personnel of the Hospital will act as Traffic Controllers directing the patient and relatives to the respective reception centers on the orders of the co-ordinator.

14. First-Aid and Sorting

a. For moderate load:

Existing casualty medical team will function for first aid and sorting.

b. For heavy load:

The center will be manned by 4 teams, each consisting of:

1. One General Surgeon
2. One Orthopaedic Surgeon
3. One Physician
4. One Anesthetist
5. Two Sisters
6. Two Nursing Orderlies
7. One Sweeper/Cleaner
8. Two Teams of stretcher — bearers each having one stretcher and two Stretcher Bearers.

The responsibilities of First-Aid Center will be:

a. Quickly sorting out casualties into
i. Priority one: Needing immediate resuscitation
ii. Priority two: Immediate surgery
iii. Priority three: Needing first-aid and possibly surgery
iv. Priority four: Needing only First-Aid

b. Action
i. Priority one will be attended to in the Casualty Department and if need arises will be sent to intensive care.
ii. Priority two will be transferred immediately to casualty O.T. or Main O.T.
iii. Priority three will be given first aid and admitted if bed is available or transferred to other hospital.
iv. Priority four patients will be given first aid and discharged home.

The area marked for conversion into ward: Corridors of Ground and first floor
Brought in dead or those who stay die while receiving resuscitation will be segregated. Temporary morgue for keeping dead bodies will be created in the long verandah of Ground Floor. Necessary identification and handing over of bodies to the relatives after medico legal clearance will be done in this area. This will function under care of the Department of Forensic Medicine.

Additional Bed Space
In Addition to the area marked on first floor, extra bed will be created as follows:
1. Any vacant beds will be requisitioned by the Director / M.S. for this purpose.
2. By discharging following categories of patients:
a. Convalescing patients needing only nursing care
b. Elective surgical cases
c. Patients who can have domiciliary care or OPD advice
3. Ward side-rooms and Seminar rooms of the wards may have to be used temporarily.

15. Linen Stores
A room of second floor is earmarked for this purpose. Following stores will be transferred to that room.

• Mattresses — 40
• Bed Sheets — 120
• Blankets — 80
• Pillows & Covers — 60
• Patient clothing (female) — 30
• Patient clothing (male) — 30
• I.V. stand — 60
• O₂ Cylinder — 20

16. Drugs and Equipments
The Medical Store Keeper and the Surgical Store Keeper will be called at once to open the store. As an immediate measure the buffer stock earmarked in the Casualty will be utilized. All essential drugs will be stocked in the medical stores and will he issued on order of the Director/ M.S/ DMS/ Duty Officer.

Dressing material and items of surgical stores are similarly kept in reserve. A dozen emergency trays containing life saving drugs will be kept ready in medical stores. For the first few hours the drugs will be requisitioned from emergency stock lying with Sister-in-charge at the Casualty. Approximately 400 bottles of different types of saline/crystalloids are kept available at the saline/crystalloids stores for use in such emergencies.

17. Emergency Blood bank
Efforts shall be made for blood of all the available groups to he stocked in plenty. Volunteers and voluntary organizations will be approached to donate as much blood as possible. The responsibility for this will be that of the B.T.O. / the Asst. B.T.O.

18. Staff
Medical Staff: In addition to members of regular clinical units the faculty members of para and pre-clinical disciplines will be asked to render help to assist the clinical staff in managing the causalities. The duty roster of regular consultants and stand-by doctors is to be made available in control room.

Nursing Staff: A pool of nurses will be created by the Nursing Superintendent. So that nursing staff is available at short notice. This pool should consist of nurses staying in the hostel for operational reasons. Duty roster will be sent to Duty Officer by the Nursing Superintendent. One sister will be detailed to take charge of personal belongings of the patients.

Class IV Staff: All the available class IV staff will be utilized except for those who are already on duty in emergency areas. DD/DMS/Sanitary Superintendent will create a pool from amongst the staff residing in the campus. Duty roster will be sent to Duty Officer by DD/DMS /Sanitary Superintendent.

Volunteers: Volunteers will be invited by coordinated effort of the DD/ Deputy Medical Superintendent.

19. Documentation Center
a. For small load of casualty: Documentation shall be done at the casualty OPD itself.

b. For large load of casualty: It is to be established in Ground Floor OPD at the Central Registration Office of OPD. The staff working at registration counters and Nursing staff will be utilized for documentation and identification. Volunteers may also be engaged for this purpose.

20. Hospital Security
Security of staff, patients and hospital building and equipment being of paramount importance. Daring such disasters, Security Officer is required to tune up and organize the security arrangements for this purpose.

21. Food Service
Supply of nourishment to the patients and emergency duty staff will start immediately by the staff of the Dietary Services under direct supervision of the Head of Dietary-in-Charge of Kitchen. Most of she patients for first 24 — 48 hours will be using only liquid or semi-solids. During this time arrangement can be made for supply of proper meals.

22. Ambulances
All the available ambulances will be kept in first rate operational condition and shall be available at casualty department along with drivers as soon as the state of emergency/Disaster is declared.

23. Information Services
The Public Relation Officer (PRO) of the Hospital will function as Information Officer. All information to Press, Radio and other media, to individuals and organizations, Governmental or otherwise, will be issued by him. He will get prior clearance from component authorities before issuing such information.

24. Engineering and Maintenance Services
The engineering section will make sure that water and electricity is made available without interruption. All the standby electric power generators will he regularly checked, inspected and maintained in excellent serviceable condition.

25. Discharge Procedure
After appropriate treatment the patients fit to be discharged shall be discharged to go home or to other hospital for convalescence. For all cases discharged the destination will be noted by the hospital and police informed.

26. Success of Plan
Disaster in an emergency situation. Timely help of every individual is needed to make this plan a success to reduce the Mortality and Morbidity. In such state of affairs the individual and personal consideration take low priority in the face of duty to the profession for the sake of amelioration of human suffering.