2. Workshop on CHEMICAL EMERGENCY PLANNING, PREPAREDNESS AND RESPONSE-BEST PRACTICES AND INTERNATIONAL EXPERIENCES. (21 st Oct. 2010) Dept. of Factories, GoAP and National Safety Council Chemical Off-Site Emergencies- Ambulance Services ’ Dr G V Ramana Rao MD,DPH, PGDGM Executive Partner & Head Emergency Medicine Learning Centre and Research GVK EMRI

3. Agenda ‘108’ GVK EMRI emergency response services Chemical emergencies and pre-hospital care

4. Innovative Pro-Poor PPP (Public Private not for Profit Partnership) Service Delivery Model to provide free Emergency Response Services at one / Citizen / Month Serving 1 Emergency every 8 seconds and Saving 1 Life every 8 minutes

5. GVK Emergency Management and Research Institute A Non-profit organization

6. Why this Innovation ? 75,000 emergencies occur per day 80% are at the bottom of the pyramid 80% deaths occur in hospitals in the first hour 4 M deaths p.a. (Cardiac, Road Accidents, Maternal, Suicidal attempts, Neonatal / Infant / Pediatric, Diabetic related, etc) due to absence of 4As : Access to a universal toll-free number Availability of Life Saving Ambulance to reach quickly nearest and appropriate health facility Affectionate Care by trained paramedics (Compassion, Ability, Resourcefulness & Energy) Affordability by every citizen independent of income, religion and community Hence, GVK EMRI was born in April 2005

7. To respond to 30 million emergencies and save 1 million lives annually by 2011 To deliver services at global standards through Leadership, Innovation, Technology and Research & Training To become One Of Eight Wonders of the World Vision of GVK EMRI LeadershipR & TInnovation Technology

8. What is Unique in this Innovation ? Integrated Emergency Response Services for Medical, Police and Fire emergencies with single universal toll- free number ‘108’ Free services (no cost to citizen) PPP framework Government provides funds for OPEX & CAPEX Private Partner brings leadership, innovation, execution and technological capabilities Conducting Research and building capability in Emergency Medicine and Management

9. Launched on 15 th Aug, ‘05 in Hyderabad and expanded to 10 other States Andhra Pradesh Gujarat Sikkim Karnataka Orissa Haryana Punjab Himachal Pradesh Uttar Pradesh Chattisgarh Jharkhand West Bengal Bihar Arunachal Pradesh Meghalaya Tripura Manipur Nagaland Mizoram Uttarakhand Madhya Pradesh Tamil Nadu Kerala Jammu & Kashmir Maharashtra Rajasthan Assam Goa Delhi

10. Successfully Implemented by GVK EMRI in PPP Framework Political will, Public Servants’ commitment and Public Support 100% of Capital expenditure and Operational expenses by Government (Public) GVK funds Leadership, Innovation (Infrastructure, Process), Collaborations, Research and Training, Knowledge transfer and Quality assurance Mahindra Satyam provides free IT solutions as technology partner GVK EMRI manages and leverages government resources for better outcomes to serve poor Partnership involving Pain and Pleasure

11. Building Blocks of GVK EMRI’s Innovation Three digit toll-free No. Accessible from Land lines and Mobile phones Cost effective ambulances to provide quality care for Indian emergencies with facilities for rescuing and balancing patient care with public safety and patients relatives comfort Trained personnel for providing PHC Modern, spacious and open ERC GIS / GPS to locate victim / ambulance and hospital

12. Innovative Process Sense Reach Care Follow up after 48 hrs Developed detailed process understanding and well defined responsibilities through out the organization Maintained all information related to emergency in Patient Care Records (PCRs) Patient information is shared with the hospital on arrival 48 hour follow up with the patients admitted to hospital

13. Conference CCT: Communication Control Toolkit; SCCS: Symposium Call Centre Server; ERCP: Emergency Response Center Physician; EMT: Emergency Medical Technician SCCS, CCT & Voice Logger Telephone DB ERS DB Nortel Switch Public Switching Telephone Network (PSTN) Dial 108 Caller in distress GIS DB ERCP DO Supervisor CO Supervisor Transfer Dispatch Officers (DO) Communication Officers (CO) EMT in Ambulance Victim Shifted to Hospital COMPUTER SERVER ROOM E R C FIELD Base Location Victim Location (Scene) Ambulance Innovative use of Technology

14. Innovative Pre-Hospital Care Emergency Medical Technician (EMT) in the ambulance is trained not only to provide pre-hospital care but also to handle emergency situations EMT gets support over phone from qualified medical practitioner called ERCP (Emergency Response Centre Physician) located at the ERC ERCPs are in the ERC round the clock to provide support to EMT and to people at emergency scene until ambulance arrives

15. Singapore Health Services American Assoc of Physicians Of Indian Origin (AAPI) Shock Trauma Center, USA Stanford University, USA American Academy for Emergency Medicine in India Carnegie Mellon University, USA Geomed Research Public Health Foundation of India Collaboration for transfer of Knowledge and Technology know-how, Best practices, Research & Training

16. Impact.. Size One Center for 40 M population against one for every 0.05 M population in USA 372 M population covered in 9 States (increased reach of health care in rural, hilly and tribal areas) Trained 35,650 people (11,500 - EMTs, 10,000 – Pilots, 3,100 - Doctors, 2,100 - Nurses, 6,800 - First Responders and AHA/ ITLS Certification for - 2,150) 12,170 + emergencies handled per day (9.3 Million cumulative) 2,600 Ambulances - 4.5 trips a day 15,900 + GVK EMRI Associates SpeedWent live in less than 4 months from signing MoU 91% calls taken in first ring < 15 minutes (urban) and < 25 minutes (rural) Ambulances reached Govt. of A.P. Govt. of Gujarat Govt. of MP Govt. of Uttarakhand Govt. of Tamilnadu Govt. of Goa Govt. of Assam Govt. of Karnataka Govt. of Meghalaya Govt. of Chhattisgarh Govt. of HP

17. Impact Type of Emergencies and Lives saved Pregnancy related - 29%, Vehicular Trauma – 18%, Acute Abdomen – 13% Cardiac – 4%, Respiratory – 4%, Suicidal – 2%, Animal Bites 1% 300+ lives were saved per day (247,021 + till now) and 11,870 victims per day received timely, high- quality pre-hospital care CostsCost per ambulance trip Rs. 600 to Rs. 700 against $ 600 to $700 in USA Qualitative Outcomes Angel of Mercy – 108 Ambulance Successful PPP Well documented systems, impressive EMT training, high order management competence A historic landmark in health care delivery system Built more trust in the health system as a whole Increased institutional deliveries and reduced maternal mortalities by 20 – 25% A model for replication across the Country in any state

18. Impact - Doing More with Less for More Bomb Blasts Ahmedabad

19. A Gandhian Innovation July-Aug 2010

20. PRE-HOSPITAL CARE – AMBULANCE SERVICES

21. An injured patient needs (i) Treatment for life threatening injuries to maximize the likelihood of survival, (ii) Treatment for potentially disabling injuries to minimize disabilities and promote return to optimal functioning, and (iii) Reduction in pain and suffering (Mock et al. 2004).

22. Chemical Industrial Emergencies Evacuation of Casualties Decontamination Triage Resuscitation Treatment Transport

23. Ambulance

24. Advanced Life Saving Ambulance

25. S T R E T C H E R S E X T R I C A T I O N T O O L S AUTOLOADER WHEEL CHAIR SCOOP SPIINE BOARD AIR LIFTING AMBULANCE EQUIPMENT

26. MEDICAL EQUIPMENT SUCTION APPARATUSAUTOMATED EXTERNAL DEFIBRILLATOR VENTILATOR VACUUM SPLINTS

27. Rescue and evacuation

28. Four common triage categories (IDME) T4 Expectant T3 Minimal T2 Delayed T1 Immediate

29. T3 DEAD BREATHING WALKING OPEN AIRWAY YES NO RESPIRATORY RATE T1 PULSE RATE T2 NO less than 10 30 or more 10 - 29 radial pulse <120/min or >120/min INJURED NOT INJURED SURVIVOR RECEPTION CENTRE radial pulse absent

30. Key Message 1 Do Triage based on Airway, Breathing and Circulation when more than 3 patients are involved.

31. Triage and onsite treatment techniques

33. Andhra Pradesh: Mock Drill at GVK EMRI, Secunderabad on 5 th September ‘07 32

34. Andhra Pradesh: Mock Drill at Secunderabad Rly Station on 17 th October ‘08 33

35. Uttarakhand: Mock Drill at Parade Grounds, Dehradun on 20 th November’09 34

37. MCI- Important Roles – On site and Transportation Ambulance Incidence Officer (AIO) Triage Officer(TO) Treatment Area Supervisor (TAS) Treatment Area Officer (TAO) Logistic Officer (LO) Equipment Officer (EO) Ambulance Parking Officer (APO) Ambulance Loading Officer (ALO) Safety Officer (SO) Public Information Officer (PIO)

38. Evacuation of Casualties – NDMA- MP-MPE- Major Recommendations – Ambulances ReferenceNDMAEMRI Response time -Maintain minimum ( Golden hour) Urban 14mts; Rural – 21mts <10mts – 2/3 of RTA & cardiac. Medical Equipment For resuscitation, Essential drugs, Stretchers 2-way communication Spine board/ CPR skills; 106 drugs under medical directions; Collapsible / Scoop /Pediatric / Chair stretchers; Cell phones. Support Staff Well versed with equipment usage Quality checks Yes (training) Yes (OE wkly visits; Qrtly. Checks by quality teams) SOPsMaintenance of vehiclesYes including preventive maintenance, repair/accident processes etc. (Fleet managers)

39. Evacuation of Casualties – NDMA- CIDM- Medical Emergency Plans ReferenceCIDMEMRI District Off-site Plan Mock drills Yes Dedicated institutes for CDM To be identified / establishedCan be seriously considered for training and research. Community awareness Develop mechanism –kits. VoiCE program SOPsTo be laid out – Decontamination; risk and resource inventory, proper casualty chemical treatment kits, can cascade and provide

40. Integrated EoC Services - EMRI and NDMA Computer – Cellphone Integration (CTI) Ambulance network Community Awareness (VoiCE) Preparedness &Mock Drills (Medical/Police/Fire/ Railways) First Responders (> 3000 trained and handbook) Emergency Medical Technicians and Paramedics (PGPEC) Standard Operating Protocols (SO,MD,CCPs,MCI) Hospital Network (>6000 MoUs) Documentation (Pre-hospital Care Record PCR)

41. Essential elements for IAN Strategy partnerships Strategic support – technology, training and research Size and scale SOP Skills set Surface ambulances Site experiences Simulation SLA

42. Our legacy Like so many other things that are Indian, Mahatma worked as volunteer in South African war in 1899 and served injured people.

43. Thank you www.emri.in Ramanarao_gv@emri.in