anaesthesia.co anaesthesia.co@gmail

Disaster planning, evacuationtriage and organization of first response teammod:prof.ravi saxena m.d www.anaesthesia.co.inanaesthesia.co.in@gmail.com

Disaster Any emergency that disrupts normal community function causing concern for the safety of its citizens including their lives and property.

Types of disasters • External disasters • Mass Casualty Incident (MCI) • Any event that leads to the generation of a large number of casualties • Natural disasters • Manmade

Types of disasters • Internal disasters • Fire,explosion • Hazardous material spillage • Bomb threats • External disasters affecting the hospital itself

Disaster planning • Purpose • To provide policy for response to both internal and external disasters situations that may affect hospital staff,patients and the community • Identify responsibilities of individuals and departments in the event • Prime function is to minimize the resulting loss of property, injuries, suffering and death that accompanies a disaster

The disaster difference • Large number of people with different severity levels • Rapidly declining survival rates • Narrow window of opportunity for salvaged • Disorganised and haphazard delivery of health care if hospital itself is affected

Planning • At the site of disaster itself • At the hospital-managing victims • Disaster at the hospital itself

Mass medicine vs individual

Plans must be simple and flexible. They should be made by the people who are going to execute them.” george patton

Goals of planning • to control the large number of patients and the resulting problems as good as possible • by enhancing the capacities of admission and treatment, • by treating patients based on the rules of individual medicine

Goals of planning • by ensuring ongoing proper treatment for all patients who where already there • by a smooth handling of all additional tasks caused by such an event. • to give medical support the damage area

Phases to be planned for • activation phase • Implementation phase • Recovery phase

Phases to be planned for Activation phase • Notification and initial response • Organization of command and control

Implementation phase • Search and rescue • Triage, initial stabilization and transport • Definitive management of patients/hazards

Recovery phase • Scene withdrawal • Return to normal operations • Debriefing

Key components of a hospital disaster plan • The flow of patients into the hospital must be direct and open. • Patient flow must be quick and direct throughout the hospital. • Triage area near disembarkation point. • Treatment areas must be pre-determined and marked.

principles and requirements • simple and clear organization should be mobilized within short notice - • headquarters at predefined and prepared site with the required infra-structure • no re-organization but developing on the existing base • to ensure that the remaining routine hospital work continues

Alarm and mobilization • competence to set the alarm in motion has to be settled as low as possible in the hierarchy. • alarm has to be given early and generously • Alerting must never be a privilege of the director of administration or to the head of the physicians

Competencies and emergency rights • premature discharge of patients from hospital • transfer of patients • postponement of scheduled admissions and operations • release of beds and operations rooms • preparation and reservation of rooms

Competencies and emergency rights • mobilization of personnel • restrictions concerning visitors • instructions concerning right and duty to inform • cancellation of the alarm and state of emergency • instructions for evaluation of the emergency procedure

Admission and treatment capacities • Treatment capacity –only decisive criterion • Defined by available operating rooms and surgical teams as well as available intensive-care-unit places. This number can be increased by cancellation of operations, calling additional surgical teams and premature transfer of patients from the intensive-care units to the normal ward.

Predefined patient transportation routes • A colored guiding system • enlargement of suitable spots, if necessary even by changing their function. In addition, the careful marking of additional areas has to be prepared.

Communication • Wire and radio contacts as well as messengers have to be integrated into the communication concept

Protective measures • to secure the driveways for authorized parties, namely ambulances, • to restrict and strictly control the entry to the hospital • to direct the entry for authorized persons into appropriate areas, e.g. for relatives or media people, • to protect personnel and patients

Internal and external information • information of staff • information of neighboring hospitals and operation partners, such as ambulances, police, etc. • information of friends and relatives, • information of media (Media always get their information - the better way is the controlled one)

Substitute measures and redundancies • Technical systems such as communication systems, powerplant, and medical gas supply may fail, due to overcharge or other reasons.

Task-books and checklists • Simple and easy-to-use checklists

Phased Disaster Plans • Phased rather than “all or none”. • Typically in place at larger community hospitals or teaching hospitals. • Phase I: On-call staff • Phase II: On-call staff and select groups • Phase III: Total staff mobilization

Preparedness • Disaster manual • Exact protocols for various types of disaster • Contact number of authorities • Role of all departments clearly stated • Simulations • Mock disaster drills atleast once every year

Evacuation “Any organized withdrawal or removal (as of persons or things) from a place or area especially as a protective measure”

Types of evacuation • Total-partial • Vertical-horizontal • Permanent-temporary • Real-simulated

Impact of evacuation • Patients • Who can walk unassisted or with relative • Critical patients requiring complete assistance • Rapid triage of inpatients to determine patients benefit of transfer Vs staying

Impact to personnel • Major stress due to responsibility of their own evacuation and that of dependant patients • Responsibility towards family members • Unless already planned. Practised and evaluated, difficult to co ordinate

Impact to infrastructure • Equipments costlier than structure • Risk of damage, malfunction • May be needed for several patients • Trained personnel/technicians should be involved

Impact to public • Hospital services needed most in time of disasters • Very few possibilities for treatment in evacuated hospital and for referral

Impact to hospital • Losses in economic terms • Credibility of hospital at risk, difficult to salvage perception of hospitals safety in future • Loss of public confidence

Where to evacuate? • Can be supplemented by unevacuated hospitals or part of same hospital in partial evacuations • Usually to outside ‘safe’ areas- parks, green areas, covered passages, subways • Other public buildings-schools etc

Before evacuating…. • Proper space • Alternative water and energy sources • An ‘outside hospital is impossible

Is it necessary • Evacuate only if absolutely necessary • Risk of evacuation usually more than staying put • Some valid indications • Major fire, major structural damage making inadequate/impossible treatment • Severe flooding, terrorist events-Bomb threats • Biological, chemical radiologic contamination

Evacuation methods • Depends on hospital design and nature of patients • Evacuation protocol at hand • Decision to evacuate- usually with hospital director

Guidelines • Admitting office informed first • Other hospitals contacted, ambulance service requested • Copy of patients’ treatment record, charts,lab reports • Patients prepared-Intact airway,iv line,hemostasis, splinting of fractures • Competent accompaniment

Guidelines • First moved exits on the same floor, then to lower floors if unsafe • Systematic moving, all patients and personnel closest to danger moved first • If moved out of building, assembles at a common area • Transport facility arranged before hand

AIIMS evacuation protocol Protocol for evacuation during fire outbreak available, applies to other evacuations Duty officer and security control room informed Ambulant patients guided to go to other floor using staircase Fire escape routes opened with keys, if not lock broken

Lying cases rescued by staff immediately with guidance from doctors/sisters/senior worker • Disaster plan activated • Casualty staff,residents,consultants on call informed • Contact to other hospitals established

Evacuation from C wing • Through private ward stairs if D wing is unsafe • If private wards are affected evacuation through fire escape stairs or central stairs

Evacuation from D wing • Through escape stairs of D wing • Through C wing and then to private ward stairs if D wing is unsafe

Evacuation from AB wing • Through OPD stairs • If OPD block unsafe,through central stairs and through private ward stairs • Evacuation from private ward and OPD block through corresponding stairs • All available man power and resources mobilized by contacting MS/hospital administration/duty officer

Problems in evacuation • Resuming normal activity may take months • Exact circumstances? • How well prepared? • Where to evacuate staff and patients,who is first? • How long can evacuation last? • When to occupy? www.anaesthesia.co.inanaesthesia.co.in@gmail.com

anaesthesia.co anaesthesia.co@gmail