1. Disaster Preparedness in Hospitals

2. 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

3. 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,

4. 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”

5. 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).

6. Disasters in India Year Disaster Mortality
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, affected
2014
Kashmir – floods
300 died
2015
Chennai - foods
280 died

7. Types of Disaster Types of Disaster GOI classification - categories
Nodal ministry / Support ministry
Natural 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

8. Types of Disaster Types of Disaster GOI classification - categories
Nodal ministry & Support ministry
Biological Disasters
Biological related disasters –
Biological disasters and epidemic
Pest 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

9. Impact of disaster depends on :
Types of disasters
Density and distribution of population
Condition of the environment
Degree of preparedness
Opportunity of warning

10. Distribution of disaster prone areas in India

11. Distribution of disaster prone areas in India

12. How How to reduce the risk of Disaster?
Preparedness - to reduce the loss & damage to human lives, property
Prevention -completely avoid potential adverse impacts through action taken in advance
Mitigation - 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
How How to reduce the risk of Disaster?
Disaster
Response & Recovery
Rehabilitation & Reconstruction
Prevention & Mitigation
Preparedness
Disaster Managmnt
Cycle

13. 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.

14. 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.

15. 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

16. 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

17. Hospital Networking Benefits :-
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 resources
Augment available resources if and when required.
Optimally utilising available resources in the area

18. Tertiary referral centres
Levels of hospital networking
Hospital networking can be done at various levels within the district as well as with intervening bigger hospitals where ever available.
PHC
PHC
Private hospitals
Railways , Defence,
District hospital
CHC
PHC
PHC
PHC
Tertiary referral centres
PHC
District hospital
District hospital
CHC
CHC

19. STABLE Suggested Flow of Patients in a network 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
Facilities not present
Facilities available
Refer for treatment in networked hospital
DEFINITIVE TREATMENT

20. 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

21. 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.

22. 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 Organization
a) Emergency Hospital Services
(including critical care facilities)
b) Emergency Surgical Services
c) Emergency Transfusion Services
d) Emergency investigation facilities

23. 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.

24. 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.

25. 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.

26. Principles of a Hospital Disaster Plan
Predictable
Simple
Flexible
Concise
Comprehensive
Adaptable
Anticipatory
Part of a Regional Health Plan in Disasters

27. 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.

28. 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

29. 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 )

30. 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.

31. 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

32. 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
Superintendent
- I/C Emergency Services
- I/C Surgery
- I/C Orthopedics
- I/C Anesthesiology
- I/C Medicine
- 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

33. 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

34. The model incident command structure for a District level Hospital.

35. 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.

36. 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,

37. 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

38. 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.

39. 1

40. 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.

41. 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.

42. References
GOI , National Disaster Management Division Ministry Of Home Affairs,UNDP DRM Programme, Guidelines for Hospital Emergency Preparedness Plannning,
National Disaster Management Authority, National Disaster Management Guidelines Hospital Safety ,December 2013
NDMA , GOI
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% pdf
UNISDR terminology on disaster risk reduction. Geneva, United Nations International Strategy for Disaster Reduction, 2009 (
Mass casualty management systems. Strategies and guidelines for building health sector capacity. Geneva, World Health Organization, 2007 ( ).
K. Park. Park Textbook of preventive and Social medicine.23rd ed. Jabalpur (India ): M/S Banarsidas Bhanot; 2015.