Disaster Management

Concepts, Principles and Challenges

Prof. T.S.Ravi Kumar .R.N. M.Sc N , PhD ( Disaster Management)

Former Trauma Center Coordinator CMC Vellore
 FOCUS
• Objectives

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 Content
1. Crisis
2. Safety Culture
3. Disaster Management –Competency
4. Disaster Management Cycle
5. Disaster –Hospital
1. System
2. People
3. Training
4. Evaluation
6. Incident Command System

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 EM-DAT Classification
Disaster Cause Events
Subgroup

I. Geophysical Originating from solid earth Earthquake, Volcano, Mass

Movement (dry)

Short‐lived/small to meso scale

II. Meteorological atmospheric processes Storm
Natural
Deviations in the normal water cycle
III. Hydrological Flood, Mass Movement (wet)

Long‐lived/meso to macro scale Extreme Temperature, Drought,

IV. Climatological processes Wildfire

Exposure of living organisms Epidemic, Insect Infestation,

V. Biological to germs and toxic substances Animal Stampede

VI. Industrial, Human errors Motor vehicle crash, Building

Transportation (Air, collapse, Bhopal gas tragedy, etc.
Technological Water, Road),
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 Man Made Disaster

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 ”The Quadruple Human growth
Squeeze” 20/80 dilemma

Climate Ecosystems
550/450/350 dilemma 60 % loss dilemma

Surprise
99/1 dilemma
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CoVid 19
 Climate Change Risk Increasing

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Source: International Panel on Climate Change, 2014.
 Average Yearly Economic Losses from Natural
Disasters

Source: ESCAP Technical Paper Information and Communications Technology and

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Disaster Risk Reduction Division
 ELEMENTS OF RISK

HAZARDS EXPOSURE

RISK

VULNERABILITY LOCATION

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 Characteristic of Disaster

Predictability ?

Controllability ?

Speed of onset

Length of forewarning

Duration of impact

Scope and intensity of impact

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 Hazard, exposure and vulnerability

Disaster Risk Management Analysis

Hazard Exposure Vulnerability

Direct Risk Indirect Risk

Disaster Disaster
Risk Reducing Risk & Increasing Resil Risk
ience
Exposure Exposure
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Source: Adapted and expanded from IIASA CATSIM model (Mechler et al., 2006)
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 DISASTER
“… A serious disruption of the functioning of a society, causing widespread hu
man, material, or environmental losses which exceed the ability of the affecte
d society to cope using its own resources.”

According to WHO

“Disaster as any occurrence that causes damage, economic destruction, loss of

human life, and deterioration in health & health services on a scale sufficient

to warrant an extraordinary response from outside the affect

ed community or area”.

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 Disaster
• The disaster events concerns every community and
no community is immune from it.

• The term “DISASTER” is from French word.

• “DISASTER” is combination of 2 terms – DES + ASTER

• The expression of term “DISASTER” is ‘Bad or Evil Star’

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 Classification

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 DISASTER MANAGEMENT

A planned approach for the

• Prevention of disaster,
• Preparedness and
• Response to Disasters, and
• Recovery following disasters.
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 WHY DISASTER MANAGEMENT ?

 To minimize deaths and losses.

 Without identification of risk & vulnerability, only knowledge of

hazards is of no use.

 Normal procedures are insufficient to handle grave situations.

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 Definitions

• Risk is defined as the frequency of an event happening

and its impact
• Hazard Is a physical or human-made event that can
potentially trigger a disaster.
• Vulnerability is ‘Susceptibility to harm’ of those at risk
• Capacities are the qualities & resources of community
( or individual) to … anticipate, cope with, resist &
recover from the impact of hazards
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 Hazard
Phenomenon or situation which has the pot
ential to cause disruption or damage to
people, their property, their services and
the environment

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 Vulnerability
Is a condition or sets of conditions that reduces people’s
ability to prepare for, withstand or respond to a hazard

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 Capacity
“Those positive condition or abilities which incr
ease a community’s ability to deal with
hazards”.

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 Prevention

“ Measures taken to avert a disaster from

occurring, if possible (to impede a hazard so that it does
not have any harmful effects).”

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 Mitigation
Measures taken prior to the impact of a disaster
to minimize its effects (sometimes referred
to as structural and non-structural measures).

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 Preparedness
Measures taken in anticipation of a disaster
to ensure that appropriate and effective
actions are taken in the aftermath.

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 Response
“Actions taken immediately following the impact
of a disaster when exceptional measures are req
uired to meet the basic needs of the survivors.”

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 Relief
“ Measures that are taken for search and rescue
of survivors, as well to meet the basic needs
for shelter, water, food and health care”.

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 Recovery
“ The process undertaken by a disaster
affected community to fully restore itself
to pre-disaster level of functioning.”

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 Rehabilitation
Actions taken in the aftermath of a disaster to:
– assist victims to repair their dwellings;
– re-establish essential services;
– revive key economic and social activities

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 Reconstruction
“Permanent measures to repair or replace
damaged dwellings and infrastructure and to
set the economy back on course ”.

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 Development
“ Sustained efforts intended to improve or
maintain the social and economic well-being \
of a community. ”

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 Disaster Risk Reduction
A broad range of activities designed to:
 Minimize human suffering

 Prevent the loss of lives

 Inform the public and authorities of risk

 Minimize property damage and economic loss

 Speed up the recovery process

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 THE DISASTER MANAGEMENT CYCLE

DISASTER

PREPAREDNESS RESPONSE/RELIEF

MITIGATION REHABILITATION

PREVENTION RECONSTRUCTION

DEVELOPMENT
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 Terminology

• HEICS

• HERP

• ICS

• TRIAGE

• HAZMAT

• SURGE CAPACITY

• NDMA

• NDRF

• NIDM

• CAPACITY
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 Levels?
Or
different competencies?
• Aware: Basic level of mastery of the competency.
• Individuals may be able to identify the concept or skill but have limited ability to per
form the skill.

• Knowledgeable: Intermediate level of mastery of the competency.

• Individuals are able to apply and describe the skill.

• Proficient: Advanced level of mastery of the competency.

• Individuals are able to synthesize, critique or teach the skill.

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 Bhopal gas tragedy
(Man made disaster)

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 Riots
(Man made Disaster)

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 Mumbai bomb blast

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 Terms Key
• Hazard •Prevention
• Risk •Disaster Risk
• Disaster Reduction (DRR)
• Elements At Risk •Response
• Vulnerability •Recovery
• Capacity •Relief
• Mitigation •Rehabilitation
• Preparedness •Reconstruction
•Response
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22-07-2023 Thank You 47
 BITS Pilani–WILPMBA –Hospital and Health System Management
Course :Epidemic and Disaster Management
Disaster Management Cycle

Ronald Simon. R
GM Officer
Christian Medical College Vellore

Session Objective

At the end of the session you will be able to understand:

•Disaster
•Disaster Management
•Disaster Management Cycle
•Disaster Management Cycle –Phases
•National Disaster Management Plan
Disaster
A disaster happens when a hazard impacts on the vulnerable population and causes
damage, casualties and disruption.
Disaster Classification

•Slow –Famine/Drought/ HIV/ SARS/ Covid

•Sudden/ Rapid –Earthquakes, flood, Fire,
•Internal –Structural collapse/ Function collapse
•External -Floods/ Mass casualty

Disaster Management
The range of activities designed to maintain control over disaster and emergency situations
and to provide a framework for helping at risk persons avoid or recover from the impact of a
disaster” (Cuny)

Goals of Disaster Management:

•Reduce, or avoid, losses from hazards;

•Assure prompt assistance to victims;
•Achieve rapid and effective recovery.

Disaster Management Components

•Hazard analysis
•Vulnerability Analysis
•Prevention and Mitigation
•Preparedness
•Prediction & Warning
•Response
•Recovery

Stages in Disaster Management

There are three key stages of activities in disaster management:

•Before a disaster: to reduce the potential for human, material, or environmental losses
caused by hazards and to ensure that these losses are minimized when disaster strikes
•During a disaster: to ensure that the needs and provisions of victims are met to alleviate
and minimize suffering
•After a disaster: to achieve rapid and durable recovery

Disaster management cycle

•The Disaster management cycle illustrates the ongoing process to reduce the impact of
disasters, react during and immediately following a disaster, and take steps to recover after a
disaster has occurred.
•Appropriate actions at all points in the cycle lead to greater preparedness, better warnings,
reduced vulnerability or the prevention of disasters during the next iteration of the cycle.

Phases of Disaster Management cycle:

•The four disaster management phases illustrated Below:

–Mitigation: Minimizing the effects of disaster
–Preparedness: Planning how to respond
–Response: Efforts to minimizes the hazards created by a disaster
–Recovery: Return the community to normal

Disaster Management Cycle

Mitigation

•Mitigation-Minimizing the effects of disaster includes any activities that prevents an

emergency, reduces the chance of an emergency happening or lessens the damaging effects
of unavoidable emergences.
•Examples: building codes and zoning; vulnerability analyses; public education.

Preparedness

•Preparedness-Planning how to respond. It includes a variety of measures aimed at insuring

the community is prepared to reacts to any hazard that threatens the country.
•Examples: preparedness plans; emergency exercises/training; warning systems.

Risk Reduction: Mitigation and Preparedness

•Risk reduction strategy

–Legal and institutional framework

–Vulnerability Analysis and Risk Awareness
–Planning
–Implementation of Plan and Community Resilience
–Knowledge Creation and Dissemination

Response

•Response-Efforts to minimize the hazards created by a disaster.

•It includes action taken immediately before, during and just after a disaster or major
emergency. The goal of the responder is to save lives, minimize property damage and
enhance the beginning of recovery from the incident.
•Examples: search and rescue; emergency relief .
Disaster is the ultimate test of administrative efficiency, in the sense of positive impact on
the environment, preparedness, procedural simplicity, logistics, speed and expertise.
There are inherent important lessons to be learnt with regard to administrative reforms by
way of policy interventions to ensure:
•Better institutional preparedness
•Sense of self-help and ‘communitarianism’

Recovery

•Recovery-Returning the community to normal.

•It is the activity that returns infrastructural systems to minimum operating standards and
guides long term efforts designed to return life to normal or improved levels after a disaster.
This is a very daunting phases of Emergency Management because it requires personal and
community motivation.
•Examples: temporary housing; grants; medical care.

Recent trends in Disaster Management Cycle

•Risk based Planning and Resourcing

•Focused social media use
•Building and Rebuilding for Sustainability
•Education
•Comprehensive Disaster Management

Disaster Mitigation in Hospitals

•Improved design of new healthcare facilities

•Retrofitting of old healthcare facilities
•National policy & guidelines
•Hospital Disaster Preparedness Plan
•Testing the plan
•Revising & updating the plan
•Vulnerability Analysis
Process of disaster preparedness planning

Plan

The planning process is the production of written plan, But it is the process that is critical

•Step 1: Authority to develop –Leadership

•Step 2: Establish planning committee
•Step 3: Conduct hazard risk assessment
•Step 4: Set planning objective
•Step 5: Determine responsibilities
•Step 6: Analyze resources
•Step 7: Develop systems and procedures
•Step 8: Write the plan
•Step 9: Train personnel
•Step 10: Mock drill -Test plans, personnel and procedures
•Step 11: Review and amend the plan
•Step 12: Planning is dynamic/ continuous

Key elements of emergency response in Hospitals

•Communication
•Evacuation
•Mass Medical Care
•Search and Rescue
•Emergency Medical care
•Emergency Transportation -Ambulance
•Local, Regional, and International Assistance
•ER team

Disaster Management Cycle in India

National Disaster Management Plan

•National Disaster Management Plan (NDMP). This is the first ever National Disaster
Management Plan (NDMP) prepared in the country and was released on June 1st, 2016
•The NDMP has been aligned broadly with the goals and priorities set out in the Sendai
Framework for Disaster Risk Reduction.
•The National Disaster Management Plan (NDMP) provides a framework and direction to
the government agencies for all phases of disaster management cycle.
•The NDMP is a dynamic document in the sense that it will be periodically improved
keeping up with the emerging global best practices and knowledge bases in disaster
management.
•The approach used in this national plan incorporates the four priorities enunciated in the
Sendai Framework into the planning framework for Disaster Risk Reduction (DRR) under
the five Thematic Areas for Actions:

–Understanding Risk
–Inter-Agency Coordination
–Investing in DRR –Structural Measures
–Investing in DRR –Non-Structural Measures
–Capacity Development

•The Response part of the Plan has identified eighteen broad activities which have been
arranged into a matrix to be served as a ready reckoned:
–Early Warning, Maps, Satellite inputs, Information Dissemination,
–Evacuation of People and Animals
–Search and Rescue of People and Animals
–Medical Care
 –Drinking Water/ Dewatering Pumps/ Sanitation Facilities/ Public Health
–Food & Essential Supplies
–Communication
–Housing and Temporary Shelters
–Power
–Fuel
–Transportation
–Relief Logistics and Supply Chain Management
–Disposal of Animal Carcasses
–Fodder for livestock in scarcity-hit areas
–Rehabilitation and Ensuring Safety of Livestock and other Animals, Veterinary
Care
–Data Collection and Management
–Relief Employment
–Media Relations
•State government is primarily responsible for disaster
•In situation where the resources of the state are inadequate to cope it can get assistance
from the central government

National Disaster Management Plan-NDMP

•NDMP provides a framework covering all aspects of the disaster management cycle.
•It covers:
–Disaster risk reduction
–Mitigation
–Preparedness
–Response
–Recovery and
–Better reconstruction

Highlights of NDMP

•It is a comprehensive framework encompassing multiple hazards.

•Its an integrated approach that ensures the involvement of government and other numerous
relevant organisation
•Legal mandate: NDMP for whole of India

Scope of NDMP
•Prevention of disasters
•Integration of mitigation measures
•Preparedness and capacity building
•Setting roles and responsibilities

Disaster Management is Everyone's Responsibility

 BITS Pilani–WILPMBA –Hospital and Health System Management
Course :Epidemic and Disaster Management
Hospital Disaster Plan
Emergency Preparedness, Response and Recovery

T.S.Ravi Kumar. M.Sc. N, PhD ( Disaster Management)

Trauma Center Coordinator
Christian Medical college, Vellore
DISASTER

•Actual occurrence of an incident with negative consequences in which the hospital is

overwhelmed in coping (inability -that outside help is needed)
•Overwhelmed -in terms of manpower, supplies, equipment, other logistics for services to
manage incident

IN PATIENT DEPARTMENT (IPD) (OPD)

EMERGENCY

Renders services right from the elementary first aid to sophisticated management of surgical
and medical emergencies and full-scale trauma care.
ROLE OF HOSPITALS IN DISASTER MANAGEMENT
Hospital shares the goal:

“To Promote health emergency preparedness among general public and to strengthen the
health sector’s capability to respond to emergencies, disasters or calamities”
“To lead in the formulation of comprehensive, integrated, and coordinated health sector
response to emergencies and disasters”

SIGNIFICANT ROLES OF A HOSPITAL IN DISASTER

1.Receiving end of victims

2.Responders to emergencies/disasters
3.Direct life saving roles
4.Symbol of social progress
5.Prerequisite for social stability and economic development

Role of Hospital in Management of Emergencies

To protect public safety and public health, a hospital and its emergency services need:
•Capacity to reduce vulnerabilities
•Capacity to respond
•Capacity to recover
Preparedness

•Measures to build capacities to respond to, and recover from emergencies

Capacity

•Ability to manage risks by:

•Reducing hazards
•Reducing vulnerabilities
•Reducing consequences by responding to, and
•Recovering from emergencies

In terms of:

•Organization; Systems; Resources And Partnership

DISASTERT MANAGEMENT PLAN

An agreed set of arrangements for:
•responding to, and
•recovering from emergencies
A plan containing description of:

•Responsibilities
•Command & coordination mechanism
•Management structures
•Resource management
•Information management and communication
•Training and exercises

RISK MANAGEMENT

•Is a comprehensive strategy for reducing threats and consequences to public health and
safety of communities by:

•Preventing exposure to hazards (target = hazards)

•Reducing vulnerabilities (target group = community)
•Developing response and recovery capacities (target group = response agencies)

Risk Management in Hospital Planning

ALL HAZARD\TOP HAZARD

APPROACH

Phases of Emergency Management

Incident Command System

Emergency Management Committee

Emergency Operations Plan

Health Emergency Preparedness

EXAMPLE OF HOSPITAL HAZARD MAP

HOSPITAL EMERGENCY PREPAREDNESS, RESPONSE AND RECOVERY PLAN

1. Emergency Preparedness Plan or A risk reduction plan includes:

1. A hazard prevention plan

2. A vulnerability reduction plan
3. An emergency preparedness plan (or capacity development plan)
HAZARD PREVENTION PLAN

•Plan to prevent exposure to hazards

•Not all hazards are predictable or preventable
•Strategies/activities to prevent exposure to hazard

VULNERABILITY REDUCTION PLAN

•Plan to reduce consequences of exposure to hazards

•Identify vulnerabilities specific to the five elements of the community
•Strategies/activities to reduce the vulnerabilities
•Building resilience of the hospital to withstand impact and consequences of hazard

DISASTER PREPAREDNESS PLAN

Plan to build response capacity of the hospital

•Policies, Protocols, Guidelines and Procedures

•Plans
•People
•Promotion and Advocacy
•Partnership Building
•Physical (Facility Enhancement)
•Program Development
•Practices
•Logistics
•Package of Services

2. DISASTERRESPONSE PLAN

•To use existing response capacity, includes:

•Policies for direction and plans to be activated

•Systems and Procedures to be activated / implemented
•Organized team to respond to emergencies
•Available logistics and funds for the operation
•Established networks for emergency management

•Use existing capacities to deliver relief or response

•Mobilization of resources
•Use of developed systems for emergency management
•Actual implementation of guidelines/procedures for the developed systems

3. RECOVERY AND RECONSTRUCTION PLAN

•A plan to restore services and replace damaged elements of hospital for the better

Emergency Planning Process

ELEMENTS OF HOSPITAL PREPAREDNESS, RESPONSE AND RECOVERY

PLAN

I. Background
II. Plan description
III. Goals and objectives
IV. Planning Group
V. Emergency Preparedness Plan
Hazards prevention
Vulnerabilities reduction
Risk reduction
VI. Management Structures
VII. Roles and responsibilities
VIII. Hospital Response Plan
Policies, guidelines, protocols for the developed systems

IX. Recovery and Reconstruction Plan

X. Annexes
•Glossary
•Abbreviations
•Directory of contact persons
•Inventory of resources of hospital and partner agencies
•Hospital policies, guidelines, protocols, and other issuances relevant to emergency
or disaster management

HOSPITAL DISASTER PLANNING PROCESS

I. Background

1 .Name of the Hospital and address (narrative)

2. Geographic description (location: Low lying area? Etc.)

3. Hospital Profile

4. Health facilities found in the municipality/city

5. Health services areas/departments of the hospital

6. Manpower complementation of the hospital

7. Disasters responded/managed

8. Legal issuances establishing its authority

9. Partner agencies around the hospital

10. Anticipated hazards as basis for hospitals’ capacity and capability building

Aim, objectives, and scope

Tasks to be performed
Resources to be needed
Framework which emergencies will be managed

II. PLAN

•Brief description of the content of the plan

•Specific intentions relevant to set goals and objectives.

•Include the coverage, scope and limitations.

•Include the legal basis whereby the hospital is authorized to act in disaster situations

•Legal issuances detailing the roles and functions of hospitals in managing all phases of
emergencies or disasters

SCOPE OF THE PLAN

Significance:

Who will implement the plan

Extent of implementation including limitations

II. GOALS AND OBJECTIVES

•Gives the purpose of the plan from a broader to more specific perspectives.

Goal:To build the hospital capacity for effective and efficient response to and recovery from
emergency

Objectives:

•To strengthen the hospital HERP

•To develop systems and guidelines for emergencies
•To develop human resource competencies
•To upgrade hospital facility for better services
•To ensure availability of funds and logistics in times of emergency or disaster

III. PLANNING COMMITTEE

•Hospital Planning Committee include major stakeholders

•Permanent or “AD HOC Group” which convenes only for hospital emergency planning
purposes.
•This group shall be created through a hospital order.
•Roles and functions of the planning group/committee
•Develops, reviews and updates the HEPRRP
•Gathers required information and gain commitment of key people and
organizations
•Initiates testing of the plan for its functionality and adaptability to current situation

PLANNING COMMITTEE STRUCTURE

•Hospital Director/HEMS Coordinator

•Representative from Planning Division
•Representative from Administrative Division (especially finance and logistics officers)
•Representative from clinical areas of hospital operation
•Representative from the community

HOSPITAL PLANNING COMMITTEE STRUCTURE

IV. DISASTER PREPAREDNESS PLAN DEVELOPMENT

1. Hazard assessment ALL HAZARD\TOP HAZARD

•Identifying all the possible hazards that have the potential to affect the hospital

•Identify the possible areas to be affected

Translate into a Hospital Hazard Map

RECOVERY/REHABILITATION PLAN

HAZARD REDUCTION / PREVENTION PLAN

Risk Analysis
RISK ASSESSMENT

PREPAREDNESS PLAN

•List down all the weaknesses based on the expected hospital capacities.
•List down all the strategies and activities to be done for capacity development.

ACTIVITIES DURING RESPONSE PHASE

•Utilization of capacities built

•Activation of plans and systems developed
•Activation of HERP
•Mobilization of resources
•Management of emergency cases
•Validation and constant monitoring of the event

Available procedures, protocols, for emergency management

a. Security system
b. Public Information System
c. Incident Command System
d. Information Management System
e. Blood and blood products mobilization
g. Code Alert System

h. Infection Control

i. System to expand services, spaces and beds in case of surge of patients

j. System on drills/simulation exercises

k. Stockpiling of emergency medicines and supplies

l. SOP on Operation Center

m. Referral System Procedures

n. Logistics management system

o. Decontamination procedures

2. Manual for the operation, preventive maintenance, and restoration of critical services

a. Electrical supply and back-up generators

b. Drinking water supply and alternate sources

c. Fuel reserves

d. Medical gases

e. Back-up communication system

f. Wastewater and solid waste water treatment

g. Fire suppression

3. Hospital policies on emergency/disaster management

a. Hospital policies related to disaster management

b. Policy on managing volunteers during emergency

VI. RESPONSE PLAN

A. Management Structures

RESPONSE PLAN

a. Activation of Code Alert System

b. Activation of the Plan
c. Activation of the ICS
d. Activation of the Operation Center
e. Implementation of the RESPONSE Standard
Operating Procedures/ Protocols Emergencies
f. Implementation of existing Standard Operating
Procedures/Guidelines for systems developed
g. Initiation and Maintenance of Coordination and networking for referrals of cases
h. Initiation and Maintenance of Mental Health and Psychosocial Support Services for
casualties, patients, hospital staff and other responders, bereaved
i Management of Information
j. Activation of plan in the event of complete isolation of
hospital/CHD/community for auxiliary power, water and food rationing, medication/
dressing rationing, waste and garbage disposal, staff and patient morale
k. Provision of the Public Health Services
l. Management of the Dead
RECOVERY/REHABILITATION PLAN

DIRECTION

1. Write the Plan and have it approved by the head of the agency. The Plan is not a plan
until written and approved by the head of agency

2. Disseminate the plan to all the stakeholders and staff. Everyone needs to know the plan
so that in emergency no one would ever say, “he does nothing cause he knows nothing”.

3. Test the plan. The plan is believed to be effective only when it is tested, be able to know
its functionality, acceptability, and doability in the hands of the implementers. Update the
plan

4.Implement the plan.

5. Monitor and evaluate the implementation of the plan

6. Review and update the plan regularly.

What we can with what we have

BITS Pilani–WILPMBA –Hospital and Health System Management
Course : Epidemic and Disaster Management
Disaster Triage
Objectives

• To introduce the various types of triaging in Disaster

• Process and the practice of Triage

• To enlighten the simple and effective method triage based on the available resources

Goal of Disaster Triage

Do the greatest possible for the greater number of casualties

Why Disaster Triage

• Multiple victims

• Multiple presentations

–Trauma

–Medical

• Normal endpoint not available

• Austere conditions

• Limited resources

History
 TRIAGE: French word–‘trier’ meaning to separate, shift or select.
• The term triage may have originated during the Napoleonic Wars
• The French military surgeon Baron Dominique-Jean Larrey is generally credited with
developing the first battlefield triage system
• In his 1812 memoirs, Larrey explained his then- novel method of immediately treating the
most severely wounded first without waiting for the battle to end, as was previously
customary.

•French for “sorting” or “to sort”

•A process for determining who to treat and transport first in the case of a Mass casualty
incident (MCI)
•Refined during the Vietnam conflict by military medics

Types of Triage
 Simple Triage
 Advanced Triage
 Integrated Triage
 Over Triage
 Under Triage
 Reverse Triage

Simple Triage

• Done by Emergency Medical Technicians (Paramedics)

• Simple triage is usually used in a scene of an "mass-casualty incident" (MCI), in order to
sort patients into those who need critical attention and immediate transport to the hospital
and those with less serious injuries. This step can be started before transportation becomes
available.
• After triaging, each patient may be labeled which may identify the patient, display
assessment findings, and identify the priority of the patient's need for medical treatment and
transport from the emergency scene.
• Patients may be simply marked with coloured flagging tape or with marker pens. Pre-
printed cards for this purpose are known as a triage tag.

Advanced Triage
 In advanced triage, Doctors and specially trained nurses may decide that some
seriously injured people should not receive advanced care because they are unlikely
to survive.
 Used to divert scarce resources away from patients with little chance of survival in
order to increase the chances of survival of others who are more likely to survive.
  The use of advanced triage may become necessary when medical professionals
decide that the medical resources available are not sufficient to treat all the people
who need help.

Over Triage
 Over triage is the overestimating of the severity of an illness or injury
 Example: Categorizing a Priority 3 (Minimal) patient as a Priority 2 (Delayed) or
Priority 1 (Immediate)
 Acceptable over triage rates – up to 50% in an effort to avoid under triage.

Under Triage

 Under-triage is the underestimating the severity of an illness or injury.

 Example -categorizing a Priority 1 (Immediate) patient as a Priority 2 (Delayed) or
Priority 3 (Minimal).
 Acceptable under-triage rates have been deemed 5% or less.

Integrated Triage

• Continuous integrated triage is an approach to triage in mass casualty situations which is

both efficient and sensitive to psychosocial and disaster behavioral health issues that affect
the number of patients seeking care (surge), the manner in which a hospital or health care
facility deals with that surge (surge capacity) and the over arching medical needs of the
event.

• Continuous integrated triage combines three forms of triage with progressive specificity to
most rapidly identify those patients in greatest need of care while balancing the needs of the
individual patients against the available resources and the needs of other patients.

Integrated Triage – Types

1. MASS Triage
2. START Triage
3. SALT Triage
1. MASS Triage

• Doing the most good for the most victims

• MASS triage stands for Move, Assess, Sort, & Send
• Performed in the hot zone
• Offensive responders wearing appropriate PPE
• Based on the patient’s ability to move and respond
 Move: “Everyone who can hear me and needs medical attention, please move to a
designated area now!” – Green – Minimal or ambulatory
 “Everyone who can raise an arm or leg” – Non ambulatory
 Assess
 Sort: Proceed immediately to remaining victims. Reassess! Triage is an ongoing
process done many times. Mass Triage just starts the process – Utilize Triage
Ribbons (colored – coded strips) first. Tie the triage ribbon to a upper extremity, in a
visible location (wrist)
o Green – Minimal
 Ambulatory patients (No impaired function, can self-treat or be cared
for by non-professional)
 Walking wounded
 Abrasions, Contusions, minor lacerations etc
 Routine treatment within 24 hours.

o Yellow - Delayed
 Can wait for care after simple first aid (wound dressed, splints applied)
 Clearly need medical attention, but should not decompensate rapidly if
care is delayed

o Red – Immediate
 Critical (seriously injured, but have a reasonable chance of survival)
 Obvious threat to life or limb
 Complications in their ABC’s
 Urgent treatment within 2 hours.
 o Black - Deceased or Expectant
 Expectant; This patient shows obvious signs of death
 Included: Unresponsiveness patients with no pulse; with catastrophic
head injuries and / or chest injuries
 Send: Victims are sent (evacuated) both safely & promptly to the decongested area /
or treatment area. Victims are treated and released at the scene. Send to hospitals or
secondary treatment facilities. Send to morgue facilities.

2. START (Simple Triage and Rapid Transport)

 START was developed in the 1980s in Orange County, California as one of the first
civilian triage systems.
 Adopted as the defacto disaster triage standard by the Domestic Preparedness
Program of the Department of Defense.
 There is some evidence that START can lead to the over-triage of patients in a real-
time mass casualty setting.
 Why START?
o Easily learned
o Easily remembered
o Clear-cut decision process
o Relies only on BLS skills
 If you can walk, go stand over there!
 The Next Step
o Take a DEEP Breath
o Ensure that your scene is safe
o Start to triage all patients that were unable to move
o Spend about 60 seconds/patient
o Put triage tag on and note group
o Move to the next patient
START Algorithm (Airway/Breathing)

START Algorithm (Circulation)

START Algorithm (Disability)

Mnemonic: RPM 30 2 Can do

A simple Approach
Start: Potential Problems With Children

 An apneic child is more likely to have a primary respiratory problem than an adult.
Perfusion may be maintained for a short time and the child may be salvageable.

 RR +/-30 may either over-triage or under-triage a child, depending on age .

 Capillary refill may not adequately reflect peripheral hemodynamic status in a cool
environment.
 Obeying commands may not be an appropriate gauge of mental status for younger
children.

Why do we need a pediatric tool?

Pediatric multi-casualty triage may be affected by the emotional state of triage officers.
To optimize triage effectiveness to benefit all victims, not just children.

JumpSTART Pediatric MCI Triage

• Developed by Lou RomigMD, a pediatric emergency/EMS physician

• Now in widespread use throughout the US and Canada

• Being taught in numerous countries around the world

• Incorporated into national-level courses and EMS/disaster textbooks

• www.jumpstarttriage.com–all materials available for download at no charge

JumpSTART: Age

•Initially ages 1-8 years chosen

•Less than one year of age is less likely to be ambulatory.

•The pertinent pediatric physiology (specifically, the airway) approaches that of adults by
approximately eight years of age.

The ages of “tweens and teens” can be hard to determine so the current recommendation is:
If a victim appears to be a child, use JumpSTART.
If a victim appears to be a young adult, use START.
JumpSTART: Ambulatory
Identify and direct all ambulatory patients to designated Green area for secondary triage
and treatment. Begin assessment of non-ambulatory patients as you come to them.
Modification for non-ambulatory children
All children carried to the GREEN area by other ambulatory victims must be the first
assessed by medical personnel in that area.

JumpSTART: Breathing?
• If breathing spontaneously, go on to the next step, assessing respiratory rate.
•If apneic or with very irregular breathing, open the airway using standard positioning
techniques.
•If positioning results in resumption of spontaneous respirations, tag the patient immediate
and move on.

The “Jumpstart” Part

If no breathing after airway opening, check for peripheral pulse. If no pulse, tag patient
deceased / nonsalvageable and move on.

If there is a peripheral pulse, give 5 mouth to barrier ventilations. If apnea persists, tag
patient deceased / nonsalvageable and move on.

•If breathing resumes after the “jumpstart”, tag patient immediate and move on.

JumpSTART: Respiratory Rate

•If respiratory rate is 15-45/min, proceed to assess perfusion.

•If respiratory rate is <15 or >45/min or irregular, tag patient as immediate and move on.

JumpSTART: Perfusion

If peripheral pulse is palpable, proceed to assess mental status.

•If no peripheral pulse is present (in the least injured limb), tag patient immediate and move
on.
JumpSTART: Mental Status

 Use AVPU scale to assess mental status.

• If Alert, responsive to Verbal, or appropriately responsive to Pain, tag as delayed and

move on.

• If inappropriately responsive to Pain or Unresponsive, tag as immediate and move on.

Modification for non-ambulatory children

• Infants who normally can’t walk yet

• Children with developmental delay
• Children with acute injuries preventing them from walking before the incident
• Children with chronic disabilities

• Evaluate using the JS algorithm

•If any RED criteria, tag as RED.
•If pt satisfies YELLOW criteria:
–YELLOW if significant external signs of injury are found (ie. deep penetrating
wounds, severe bleeding, severe burns, amputations, distended tender abdomen)
–GREEN if no significant external injury

Individuals with special health care needs may also be MCI victims!

Patients’ limitations in ambulation and communication and differentiation between acute

and chronic neurologic conditions are the main challenges in the triage of children with
special needs and disabilities.
Note for Black Category Victims
Unless clearly suffering from injuries incompatible with life, victims tagged in the BLACK
category should be reassessed once critical interventions have been completed for RED and
YELLOW patients.

SALT (Sort-Assess-Lifesaving Interventions-Treatment/Transport)

• More recently, in response to the lack of scientific data regarding the efficacy of mass
casualty triage systems, the Centers for Disease Control and Prevention (CDC) formed
an advisory committee to analyze the existing systems and recommend a national
standard for disaster triage
• Because the literature did not conclusively identify any existing triage system as optimal,
the expert panel developed SALT by combining the best features of the existing systems.

• SALT is endorsed by several national organizations, including the American College of

Emergency Physicians, the American College of Surgeons Committee on Trauma, the
American Trauma Society, and the National Association of EMS Physicians
START Vs SALT
• Both have potential for over-triage
• The SALT triage system seems to combine a lot of other disaster triage protocols in its
development, and the applications takes a more scientific and data-driven approach.
• The global sorting method, triage officer can quickly establish 3 zones and potential use
the “walking wounded” to help other individuals at the scene.
• With all these advantages stated, SALT is by no means the perfect triage system.

Putting into Practice

Scenario 1
Scenario 2

Scenario 3
Scenario 4

Scenario 5
This patient is lying quietly on the floor
He is not breathing
His capillary refill is more than 2 seconds
He is unconscious.
What is the first thing you would do?
REPOSITION THE AIRWAY!
He is still unconscious

How would you triage this patient?

DECEASED (BLACK)

Key Points

The physiology of adults and children differ; therefore different primary triage
systems should be used

 Use JUMPSTART for infants through older children

 Use START for young adults and older
 Primary triage is just the first look at an MCI victim, similar to the primary / initial
survey / assessment.
Fire Management

Major reasons for hospital fire disaster:

No fire fighting equipment in the hospital and not adequately trained in fire fighting
Ronald Simon. R
Christian Medical College Vellore

At the end of the session, the participants will be able:

•To gain an understanding of what fire is and it’s consequences

•To establish the minimum requirements for a reasonable degree of safety from fire
emergencies in hospitals.
•To designed, construct, maintain and operate structures and mechanism to minimize
the possibility of a Fire emergency
•To limit the development and spread of a fire by providing appropriate arrangements
within the hospital
•To understand how to fight a fire (if it is safe to do so)

Increasing trend of fire incidents in India

The recent fire incidents in a hospital in eastern India has added another dangerous
possibility and dimensions to fire accident.
In 2017, India saw 16 lakh incidents of fire (around 18 per cent of the world-wide tally) with over
27,000 deaths, 2.5 times that of China.

From Rajasthan Hospital to AMRI Kolkata

Rajasthan Hospital
Safdurjung Hospital Delhi
Cygnus hospital Delhi
ESIC Kamgar Hospital in Mumbai
Calcutta Medical College and Hospital
Metro Hospital and Cancer Institute Delhi
Gem Hospital Coimbatore
SMU Bhuabaneswar
Murshidabad Medical College and Hospital in West Bengal
Shishu Bhawan hospital in Cuttack
PBM Hospital, Bikaner
AMRI Hospital, Kolkata –2011 –(Still fresh in mind and a major Learning curve to safety
in hospitals)

Many old hospitals, mostly government hospitals, do not have fire safety equipment like
sprinklers.
Even the roads inside big hospitals, which should be 6 metre wide, are blocked with
parked vehicles.

Fire safety and protection in hospital

Fire safety & protection is matter of vital importance concerning everyone in the hospital
industry.
For fire safety and protection in hospital an intelligent building design is neededto cater
to various potential emergency situations to avoid further incidence
The main objective of fire safety design of buildings should be assurance of life safety,
property protection and continuity of operations or functioning.
The designer must recognize the type of danger posed by each component and
incorporate effective counter-measures in hospital.

Fire safety Measures have 4 Parameters namely

•Means of access through approach roads,

•Open spaces,
•Means of escapes like external Staircases &
•Fire-fighting equipment.
An effective fire program calls for an understanding of the hospital fire plan & the active
participation of every employee at all times.
Laws related to fire safety in hospital

National Building Code 2005/2016: Part 4 –Fire & Life Safety

Indian boilers Act 1923
Prohibition of Smoking in Public place Rules 2008
Petroleum Act & Storage rules
PESO
NOC from Chief Fire Officer

What is Fire?

How Fire Start

Accidental
By-product of an unintended action
Deliberate
Arson or diminished responsibilities
Negligence
Putting the three sides of the triangle in the same
place at the same time without considering the consequences

Did you know?

53% of all Hospital Fires are either: PREDICTABLE or PREVENTABLE

How quickly does fire spread?

FIRE -takes hold in under3 minutes

How quickly does fire spread?
Remember –Fire Safety is Paramount!!

Alarm Signals
We have two types of alarm signals, what are they?

Full Alarm:
However the alarm was activated it is in your immediate area
Intermittent Alarm:
However the alarm was activated it is in a neighbouring Area

Control of Fire

Measures taken to limit the development and spread of a fire is by providing appropriate
arrangements within the hospital through adequate staffing & careful development of
operative and maintenance procedures consisting of:
•Design and Construction;

•Provision of Detection, Alarm and Fire Extinguishment;

•Fire Prevention

•Planning and Training programs for Isolation of Fire; and,

•Transfer of occupants to a place of comparative safety or evacuation of the occupants to

achieve ultimate safety.

Expected Levels Of Fire Safety In Hospitals

Hospitals shall provision for two levels of safety within their premises
•Comparative Safety
•Ultimate Safety
Comparative Safety:

Which is protection against heat and smoke within the hospital premises, where removal
of the occupants outside the premises is not feasible and/or possible.
Comparative Safety may be achieved through:
•Compartmentation
•Fire Resistant wall integrated in the Flooring
•Fire Resistant Door of approved rating
•Pressurized Lobby, Corridor, Staircase
•Pressurized Shaft (All vertical openings)
•Refuge Area
•Independent Ventilation system
•Fire Dampers
•Automatic Sprinkler System
•Automatic Detection System
•Manual Call Point
•First Aid (m) Fire Fighting Appliances
•Fire Alarm System
•Alternate Power Supply
•Public Address System
•Signage
•Fire Exit Drills and orders

Ultimate Safety:

Which is the complete removal of the occupants from the affected area to an assembly
point outside the hospital building. Ultimate Safety may be achieved through:
•Compartmentation
•Fire Resistant Door of approved rating
•Protected Lobby, Corridor, Staircase and Shaft
•Public Address System
•Signage
•Fire Drills and orders
Structural Elements of Fire Safety

 Open Spaces
 Basements
 Means of Escape/Egress
 Internal Staircases
 Protected Staircases
 External Staircases
 Horizontal Exits
 Exit Doors
 Corridors and Passage ways
 Compartmentation
 Ramps
 Service Shafts/Ducts
 Openings in Separation Walls and Floors
 Fire Stop or Enclosure of Openings

Non-Structural Elements of Fire Safety

 Underground Static Water Tank for Fire Fighting

 Fire Pump Room
 Yard Hydrant
 Wet Rising Mains
 Hose Box
 Automatic Sprinkler System
 Emergency and Escape Lighting

Fire Hazard Response and Mitigation Plan

Background of the city

City overview –population, density, land use, type of buildings, roads and accessibility;
Infrastructure, health care system, business and industrial locations, schools, educational
institutions, and other land use, etc. Classify the vulnerable assets, people, housing and
critical infrastructure; and
Resource and institutions –public and private that can help and support the fire hazard
response system.

Planning Process, Response And Mitigation Strategy

Goals, objectives and potential actions should be clearly spelt out in the plan;
Identify hazards by collecting historical hazard information (both natural and man
made);
Risk and vulnerability assessment –identification of city specific hazards and assessment
of risks involved (vulnerability analysis); and
Assess own assets and capabilities –(administrative, financial, technical, regulatory,
legal) and determine how the District / fire services need to address the requirements.

Identification of Resource

Identify role of the government departments, existing institutions, expert agencies,

NGOs, etc. along with their capacity assessment;
Identify key stakeholders in the community and surrounding areas;
Organize resources –identify hazard mitigation teams, agencies, community members;
Decide stages / steps for implementation of plan –key stages, actors, public participation
-training and capacity building, Public outreach & sensitization plan, involvement and
participation of the community and role of ward committee and area
Sabhas/Panchayats etc.;
Review and incorporation of future developmental plans of the city and other
information;
Preventive actions –property and natural resource protection techniques and strategies,
appropriate equipment and facilities of their own at large colonies and high rise
buildings, like water, fire extinguishers, escape routes, etc., public information and
awareness plans and actions required;
Potential impact and damages –social, economical and environmental; and
Use of GIS for planning.
Evaluation and Monitoring
For making the plan dynamic, integration of the community, continuous evaluation and
monitoring is necessary. In towns interaction with the municipal council and in villages.

The plans should be discussed with them and suggestions obtained should be
incorporated from time to time. Surprise mock exercises for fire emergencies will greatly
help in evaluating and monitoring of the plan.

Classification of Fuel

•Class A: Wood, paper, cloth, trash, plastics—solids that are not metals.
Trash, Wood ORDINARY COMBUSTIBLES
Class B: Flammable liquids—gasoline, oil, grease, acetone.
Class C: Flammable Gases & Electrical Fire –LPG, H2S, CH4
Class D: Metals—potassium, sodium, aluminum, magnesium. Requires and other
special extinguishing agents.

Danger of applying water on Metal Fire.

Water has a decomposition temperature of 1650C and hence when used on metal fire
may cause adverse effect as water breaks into Hydrogen and Oxygen Hydrogen itself is
an explosive gas and oxygen is a supporter of combustion. Hence, application of water
and foam also may lead to explosion.

Classification of Fire & its Extinguishing Media

Class Materials Involved Extinguishing Media/

Extinguisher
A Common material like wood, paper, cloths, Water, Foam, DCP, ABC
lignite and rubber etc., extinguisher
B Flammable liquids like oils, solvents, Mechanical Foam, DCP,
petroleum products, varnish and paints etc., CO2, BC Extinguisher
C Gaseous substances like LPG, Hydrogen, DCP, CO2, BC Extinguisher
etc.
D Combustible metals like Sodium, Titanium, Special Dry Chemical
Magnesium, Potassium and Zinc. Powder
Fire Management in Hospital

Evacuation -Planning evacuation:

 Emergency Preparedness Committees and integration with region or

operational area plans
 Identification of alternative locations
 Communications
 Transport options
 Cache of supplies or resources
 Employee safety and well-being
 Intense focus on facilities’ ability to respond
 Evacuation must be done in partnership
 Personnel were sent with NICU, ICU, and psychiatric patients, stable
patients were not accompanied
 Patients moved using backboards, walking, wheelchairs, blankets, sheets.
 Stairs only to be used
 No special equipment used
  Increased need for wheelchairs, walkers, adult diapers, colostomy supplies
and personal hygiene items, soft foods, clothing changes, portable oxygen
and medicines
 Evacuation requires a command structure to best manage the situation
 Safety of the patients, visitors and staff -All are at risk!
 Coordination and tracking are needed
 Staff health and safety while meeting the hospital’s medical mission are
the highest priorities in responding to any type of incident.
 Evacuation can be coordinated by a central Emergency Operations Center
(EOC) or independently by the affected facility and had equal success
 Should have a secondary evacuation plan in the absence of area EOC
 Evacuation from any cause requires accountability for patients and for
staff
 Family members who are with patients or staff in a crisis situation
 Priority for relocation will depend on the stability of the patients and the
resources available

Options in Evacuations
 Shelter in place
 Horizontal or lateral movement
 Vertical evacuation
 Complete facility evacuation
 The situation may require all methods

Shelter-in-Place

Stay in the facility but minimize the hazardous impact

Example: distance from a hazardous spill, isolated fires, security breach Fire location

Horizontal or Lateral Evacuations

Moving to other wings in the facility, beyond fire doors, into a safety zone
Easier movement of beds and equipment
Faster in initial phases
Further evacuation may not be necessary or shelter-in-place option may be ordered
Vertical Evacuations

Complex
Cumbersome
Increased physical risks
Depending on cause for the evacuation, elevators and escalators may be prohibited or
out of operation

Complete Facility Evacuation

Most evacuations can be controlled

In a controlled evacuation, exit at direction of Incident Command Center, Fire or Police
or authority in charge
Lateral / horizontal first
Vertical second
Evacuees can be staged in outside areas to facilitate transport

Facility and Utility Considerations

Evacuations may require rapid shut down of ventilation systems, power, water, gas and
other infrastructure controls for the protection of everyone
Risks include: explosion, flooding, electrocution, toxic gases

Who is Evacuated First?

Green –Walking
Yellow -Chair assist
Red -Full assist in stretcher and accompany
The basic concept of triage in a disaster circumstance is
to do the greatest good for the greatest number

Communication and Transportation of Patients

Private cars
Public buses
Hospital vans
Ambulances
Communications intermittent but all evacuations relied on functioning communications
Pay phones, cell phones, intermittent landlines, ham radios, ambulance radios, hand-
held radios

Evacuation: Challenges, Principles and Safe Methods

Risk Reality

All hazards approach

Evacuation can be from multiple causes
Intense focus on facilities’ ability to respond
Evacuation must be done in partnership

Importance of Planning

Planning should include:

Emergency Preparedness/ Safety Committees and integration operational floor plans
Identification of alternative locations
Communications
Transport options
Supplies or resources
Employee safety and well-being

Testing of Plans

Mock drills
Participation in Mock drills
Evaluations of Mock drills
Consideration of lessons learned from actual events
Adaptation of plans and equipment to modify plans

Command Structure

Evacuation requires a command structure to best manage the situation

Safety of the patients, visitors and staff -All are at risk!
Coordination and tracking are needed
Command systems vary by regions, country and experiences
A command structure model commonly used all around the world is Incident Command
System (ICS).

HICS - Hospital Incident Command System (HICS)

Staff Safety in Evacuations

“Staff health and safety while meeting the hospital’s medical mission are the highest
priorities in responding to any type of incident.”

When Facilities Impacted in the Emergency Event

Mass casualty events with incoming patients may occur concurrently with the need to
evacuate

Human Chain -Ambulatory Patients

Evacuation Devices or Hand Carries

Use of evacuation devices is an option to decrease the physical strain on employees and
provide a safer means of transport for the patient
Devices require training
Devices have weight limitations
Manual carries may still be required

Evacuation Devices & Employee Safety

Evacuation Chairs and Hand Lifts

Areas often Need a Specific Plan

The nature of the patients or residents of the facility may require more specific plans and
techniques
Examples:
•Sensory impaired (sight, hearing)
•Specialty units: dialysis, operating rooms, ICUs, psychiatric care, hyperbaric
oxygen chambers
•Pediatrics facilities, NICU
•Extended care units

Special Considerations

 Dialysis patients to dialysis centers

 Transplant cases
 Fresh post-surgical patients
 Requirements for oxygen
 Chemotherapy needs
 Psychiatric hospitalized patients

Accountability & Movement

Evacuation from any cause requires accountability for patients and for staff
Family members who are with patients or staff in a crisis situation
Priority for relocation will depend on the stability of the patients and the resources
available

Thousands to Evacuate

Complex problems
Shortages of supplies, equipment and resources
Minimal hospital staff were available to accompany the evacuated patients
It was necessary to triage evacuees based on the clinical situation, urgency of evacuation
and methods of available transportation
Security Challenges in Evacuations

Security staff in most hospitals are:

•Private guards (hospital or contract)
•Unarmed and have no powers of arrest
•Expected to restrain violent patients or visitors or act as deterrents
Facilities may need to make do with on site security
Training must include exercises and realistic planning and models

Benchmarking for Hospitals Evacuations

Largest number of hospitals evacuated after a single event and used to develop a
standardized tool to gain information about evacuations

Fire Safety & Fire Extinguisher Use

Fire Protection SystemCentral system

Central system Local system

Fire water hydrant system Fire extinguishers
Fire protection system Fire fighting equipment
Fire detection system
FIRE FIGHTING EQUIPMENT

Emergency Evacuation
P.A.S.S. Method
Fire Emergency Response Plan
Fire Officer & Team

Rush to the spot

Fire office staff inform Electrical, Medical Gas, AC section & other support services
based on the area of event

Levels of Fire

Level 1 Fire
-Contained fire
-No evacuation

Level 2 Fire
-Partially controlled fire
-Partial evacuation of building
-Full area evacuation

Level 3 Fire
-Uncontrolled fire
-Full evacuation

IF LEVEL 1 FIRE

CONTAINED FIRE-NO EVACUATION

IF LEVEL 2 FIRE

FULL EVACUATION AREA

Fire Officer

Surge area Planning needs

Evacuation route
Evacuation route if the fire is blocking the main entrance

It is a Statutory requirement for staff to attend Fire training on a regular intervals

What if we don’t comply?

If you, with your knowledge, allow contraventions of any Acts or Regulations then you
are deemed as the responsible person and as such, if an incident occurs, then you may be
held personally liable and subject to heavy personal fines and/or a custodial sentence

Ignorance is no defence!!

Reference:

Fire safety and protection in hospital, Tarun Katiyar, Principal Consultant, Hospaccx
India Systems
National Disaster Management Guidelines—Hospital Safety

There is no better protection against fire than constant vigil to detect fire hazards, prompt
action to eliminate in safe conditions & a high degree of preparedness to fight fire.
 BITS Pilani–WILPMBA –Hospital and Health System Management
Course : Epidemic and Disaster Management
Mass Casualty / Incident Response

Prof.T.Samuel Ravi Kumar. R.N.M.SC.N , PhD (Disaster Management)

Former Head Emergency Nursing
Trauma Center Coordinator
Christian Medical College
Vellore India
Overview
What is 15‘til 50?

•Handling of 50 or more patients within 15 minutes of notification of a Mass Casualty

Incident (MCI)
•Rapid deployment of staff, supplies, and equipment
•Process initiated using existing supplies and equipment

Mass Casualty / Trauma – Challenges

Standard Precautions
Ambulance
TRIAGE
Incident Commander
Protocol

1
MCM Scenario

1. Terrorist Acts:

2. Explosions:

3. Natural Disasters:

4. Multi-Vehicle Accidents: Mass Transit Mishaps:

5. Riot \Active Shooter Situations \Mob Violence:

6. HAZMAT:

7. Radioactive exposure:

8. CBRN

Mass Casualty Management Response

1. Field / On site Response
2. Hospital Emergency Department Response

2
Mass Casualty Management – Sequence

1. TRIAGE – (Pre Hospital)

2. Extrication and Evacuation

3. In Hospital ER Triage

4. Trauma Level response

5. Resuscitation

6. Definitive care

7. Disposition –Admission/Operating Room/Discharge/ Death

Mass Casualty Management Plan – Zones

I. Triage
II. Advanced Medical Post
III. Decontamination zone
IV. Ambulance bay
IV. Hospitals to receive patients from the disaster site

TERMINOLOGY

1. Mass Casualty Incident (MCI)

2. Mass Casualty Management
3. Impact phase (Initial Period is very crucial)
4. Impact site
5. Advanced Medical Post (AMP)
6. Conventional vs. MCM Triage Model
7. Surge capacity &
8. Incident Command System (ICS)

3
Scene Size-Up METHANE Scene Assessment Tool

• Mass Incident Declared

• Exact Location

• Type of Incident

• Hazards Present

• Access & Egress

• Number of Casualties & Severity*

• Emergency Services Required

Zero Preventable Deaths

1. Non Preventable death

2. Possible preventable death
3. Preventable death

Tactical Combat Casualty Care

Three Goals

1. Treat the Victim

2. Prevent additional Victims
3. Complete the Transportation

Pre-hospital care continues to be critically important

•Up to 90% of all combat deaths occur before a casualty reaches a Medical Treatment
Facility (MTF)
•Penetrating vs. Blunt trauma
•Factors influencing combat casualty care
•Medical Equipment Limitations
•Widely Variable Evacuation Time

4
STAGES OF CARE

1. Care Under danger zone

2. Tactical Field Care
3. Combat Casualty Evacuation Care

CBRN FIELD

5
Mass Casualty Management

1. Systems based approach

2. Tested Protocols Simulate, simulate, simulate

3. Trained Human resources

4. Customized approach

5. Resource Management

6. ATLS to MTLS to ADLS –

7. SMART Scene safety, Massive Hemorrhage, Airway, Respiration, Trauma Call, Temp,
Transport MARCH –PAWS Etc

6
SIMULATION

Overview

Disaster response failures

1. Disaster Plan?
2. Unknown roles & tasks
3. Poor communications
4. Unclear patient pathways
5. Lack of relevant supplies
6. “That’s what it says, but that’s not what we do.”

DisasterResponseSolution“15‘til50…”

•Rapid deployment
•Designated response
•Test it through simulation and Drills
•Plug and play model

7
Initiation Activities

Incident Occurs

Initiation

Notification

Verification

Activation

Job Action Sheet / Checklist

1. Alert ERT (Emergency Response Team

2. Turn on hand held radio and conduct radio check(s)

3. Update MAC (Multi Agency Coordination) and incident command as new info is
received

4. Team roles: Human Deployment, Resource Management

5. Roles assigned

6. Triage (Internal) closed

The facility receives notification that there has been an MCI, or worse, people begin
showing up without any warning.
Activation of (EOP) ICS and 15-50 protocol.
Establish a triage area to the handle the sudden surge in patients (20%-50% increase in
patient volume).
These protocols are a way of keeping control of the situation and allocating resources.
Patient center care on Priority Centered approach
SED“Do the mos tgood with what you have available”

8
Set Up

9
Set – Up

10-20 gurneys in place

10-20 wheel chairs in place

Set up cots

10
Set up canopies

Signs posted

Supply carts out

20 IV lines ready

20 oxygen tanks ready

PPE donned

Treatment area teams ready

Radio checks

11
Roles
Roles Incident Command Center

•Incident Command Center activated and coordinates

•Equipment
•Personnel and labor pool
•Ancillary support services
•Patient flow
•Communicates with Disaster Lead

Roles Treatment Areas

•Emergency Department\ERT
•Disaster lead (external)–

•Charge (internal)–RN

•Set up & decon–Tech’s

12
•Triage–RN

•Minor treatment area team ( As per patient load)

•2RNs+MD+ registrar + EMT
•Immediate treatment area team
•2RNs+MD+reg+EMT
•Delayed treatment area team
•2RNs+MD+reg

Roles Clinic Setting

Facilities and clinic staff work together to get the triage area and equipment setup-this
include stents, cots, generators, etc.
Once the area is functional the facilities team steps back and clinic staff take the lead, with
facilities to continue in a supporting role as needed.
Know who is in charge on the clinical side, where does direction come from?
Know where emergency medical supplies are located and how to access them!
Follow direction as given.

Roles Inpatient Units

•Patient transfer \ Hospital \ ED \ ICU
•Safe patient hand-off
•Facilitate patient flow

Roles Case Managers

•Increase bed surge capacity in the Hospital to accommodate an influx of patients resulting
from MCI

•Coordinate discharge of patients

•Establish a patient discharge area

•Coordinate activities to expedite discharge including transportation

•Assist the family information center

13
Roles Public Safety

•Facility lock down

•Access control
•Traffic control
•Crowd control
•Ongoing/PD assist

Roles Facilities / Plant Operations

Immediate facilities structure evaluation

Immediate systems check (True assessment=1.5-2hours)
Check structural integrity
Deputize on-site construction personnel to assist
Assist with decontamination
Assist with infection control
Assist with patient transport
Assist as runners
Ensure utilities are viable

Roles Supply Chain

• Resource management
•Tracking supplies and usage

•Warehouse maintains additional disaster supplies (two pallets of ED supplies)

• Supply cache
•Identical supply carts kept at warehouse
• Logistics
•Warehouse is 200 yards from main hospital
• Identified gaps/limitations
• Organization uses a lowest unit of measure system (LUMS)

14
Patient Care

Triage and treat patients as they arrive

15
 BITS Pilani–WILPMBA –Hospital and Health System Management
Course : Epidemic and Disaster Management
Hazard Identification and Risk Analysis (HIRA)

Prof.T.Samuel Ravi Kumar. R.N.M.SC.N , PhD (Disaster Management)

Former Head Emergency Nursing
Trauma Center Coordinator
Christian Medical College
Vellore India
Definition of Hazard and Risk

Hazard:the property of a substance or situation with the potential for creating damage

•Hazard:
A phenomenon, substance, human activity or condition that may cause loss of life, injury or
other health impacts, property damage, loss of livelihoods and services, social and economic
disruption, or environmental damage. These may include natural, technological or human-
caused incidents or some combination of these

•Hazard Identification:

A structured process for identifying those hazards which exist within a selected area and
defining their causes and characteristics

•Risk:
The likelihood of a specific effect within a specified period complex function of probability,
consequences and vulnerability

TERMS
•Acceptable Risk:The level of potential losses that a society or community considers
acceptable given existing social, economic, political, cultural, technical and environmental
conditions.

•Changing Risk:
A variable in the HIRA methodology that allows for the inclusion of information on
changes in the likelihood and vulnerability of the hazard.

Risk Assessment:

A methodology to determine the nature and extent of risk by analyzing potential hazards
and the evaluation of vulnerabilities and consequences

1
•Risk Analysis:

The process by which hazards are prioritized for emergency management programs at that
particular point in time based on their frequency and potential consequences.

•Comprehensive Emergency Management:

It is an all-encompassing risk-based approach to emergency management that includes

prevention, mitigation, preparedness, response and recovery measures.

•Building Code:

A set of ordinances or regulations and associated standards intended to control aspects of

the design, construction, materials, alteration and occupancy of structures that are necessary
to ensure human safety and welfare, including resistance to collapse and damage

Human-Caused Hazard:

•Human-caused hazards are hazards which result from direct human action or inaction,
either intentional or unintentional. This includes hazards that arise from problems within
organizational structure of a company, government

•Monitor and Review:

The part of the HIRA process in which the HIRA is reviewed and changes in the likelihood
and consequences of the hazards is updated.

Natural Hazards & Human-Caused Hazards

•Natural …………
•Human ………………………
•Civil Disorder
•Cyber Attack
•Sabotage
•Special Event
•Terrorism/CBRNE
•War and International Emergency

2
Technological Hazards

•Critical Infrastructure Failure

•Dam Failure
•Energy Emergency (Supply)
•Explosion/Fire
•Hazardous Materials Incident
•-Fixed Site Incident
•-Transportation Incident
•Space Object Crash
•Oil/Natural Gas Emergency
•Nuclear Facility Emergency
Radiological Emergency (Hospital)
•Transportation Emergency
Air
Marine
Road
Rail
•Building/Structural Collapse
•Mine Emergency

Hazard in Hospital

•What hazards exist in the Hospital?

•How frequently do they occur?

•How severe can their impact be on the community, infrastructure, property, and the
environment?

•Which hazards pose the greatest threat to the community\ Hospital?

Risk = [Likelihood] x [Sum of Consequences]

3
•Likelihood: Likelihood provides a standardized view of how often a given hazard event
may occur, either in the hospital or its community.

•The ranking scale is from 1‐5, with 1 being the lowest possible rank and 5 being the highest.

•Likelihood is based on a combination of history and best estimates of future frequency of

events.

Consequence:

•Consequence: For the purpose of this document, consequence is defined as the anticipated
impact from a given event in a worst‐case scenario.

•This measure is based upon the logic that it is always preferable to over‐respond to an
emergency. Consequence can be broken down into four components, each of which is of
critical concern to a hospital.

•These four aspects are human impact, physical/infrastructure impact, financial impact,
and damage to reputation.

LIKELIHOOD

1 –Unlikely (but not impossible) to occur within a 100 year period in the hospital or
Community,
2 –May occur every 100 years in the hospital or community,
3 –May occur every 10 years in the hospital or community
4 –May occur every year in the hospital or community, or a rating of
5 –Multiple occurrences per year in the hospital or community

Human Impact:

Human Impact: The cost of a given event in human terms; lives lost and people injured.
This impact is ranked for each event on a scale of 1 to 5, with 1 being the lowest possible
score and 5 being the highest.
1 –Injury or illness unlikely
2 –Low probability of injuries or illness
3 –High probability of injuries or illness
4 –High probability of injuries or illness and low probability of death
5 –High probability of injuries or illness and high probability of death

4
Physical Impact:

•The cost of a given event in terms of loss of the use of hospital property or equipment,
whether destroyed, damaged, or requiring clean‐up.

1–Property damage or loss of access unlikely

2–Minor clean-up or recovery time
3–Minor damage, temporary loss of access
4–Major damage, prolonged loss of access
5–Indefinite loss of access to the affected area; complete rebuild

Financial Impact:

•The cost of the impact of a given event in terms of Rupees cost, whether for repair /
replacement or for unbudgeted incident response costs. This also includes insurance claims,
where appropriate.

1–Negligible

2-Generates expenditures or an insurance claim under (determined by the Institution)

3–Generates expenditures or an insurance claim of under

4–Generates expenditures or an insurance claim of under

5–Generates expenditures or an insurance claim over

Reputation Damage:

•The cost of the impact of a given event in terms of damage to corporate or facility
reputation. While often overlooked in such exercises, the impacts can affect patient census,
staff recruitment, funding, and fundraising efforts.

•1–Reputation unlikely to be affected

•2–Limited negative local media coverage and / or public stigma

•3–Negative regional media coverage and strong public stigma

•4–Negative national media coverage, fundraising and / or recruitment affected

•5–Permanent association of adverse event with hospital, large affect on fundraising and /or
recruitment

5
 The basic steps in developing and maintaining a HIRA.

Matrix Model

6
Risk Assessment
Risk assessment and risk analysis of technical systems can be defined as a set of systematic
methods to:
1. Identify hazards
2. Quantify risks
3. Determine components, safety measures and/or human interventions important for plant
safety

Risk analysis is teamwork

Ideally risk analysis should be done by bringing together experts with different backgrounds:

–Hospital
–Human error
–Process equipment

Risk assessment is an on-going process!

7
Risk Analysis –Main Steps

8
Preliminary hazard identification

Identification of safety relevant sections of the establishment, considering

•Raw Materials And Products
•Hospital Equipment’s And Facility Layout
•Operation Environment
•Operational Activities
•Interfaces Among System Components

Important to secure Completeness, Consistency and Correctness

Methods for hazard identification

1.”What if”
2.Checklists
3.HAZOP (HAZARD OPERABILITY)
4.Task analysis
5.Index (Dow, Mond)
6.Failure mode and effects analysis (FMEA)

The HAZOP Method (Hazard and Operability)

•HAZOP analysis is a systematic technique for identifying hazards and operability

problems throughout an entire facility.
•It is particularly useful to identify unwanted hazards designed into facilities due to lack of
information, or introduced into existing facilities due to changes in process conditions or
operating procedures.

9
HAZOP Criticality analysis
Criticality : combination of severity of an effect and the probability or expected frequency
of occurrence.
Example formula for Criticality:
Cr = P X B X S
Cr: Criticality number
P: Probability of occurrence in a year
B: Conditional probability that the severest consequence will occur
S: Severity of the severest consequence

Substance and process indexes

Dow Fire and Explosion Index (F&EI): Evaluates fire and explosion hazards associated
with discrete process units.

Mond Fire and Explosion Index: Developed by ICI’s Mond Division, an extension of the
Dow F&EI.
These indices focus on fire and explosion hazards, e.g. Butane has a Dow Material Index
of 21, and Ammonia 4.

Fault Tree Analysis

•Graphical representation of the logical structure displaying the relationship between an

undesired potential event (top event) and all its probable causes

–Top-down approach to failure analysis

–Starting with a potential undesirable event -top event
–Determining all the ways in which it can occur
–Mitigation measures can be developed to minimize the probability of the
undesired event

Fault Tree can help to:

Quantifying probability of top event occurrence

Evaluating proposed system architecture attributes
Assessing design modifications and identify areas requiring attention
Complying with qualitative and quantitative safety/reliability objectives
Qualitatively illustrate failure condition classification of a top-level event
Establishing maintenance tasks and intervals from safety/reliability assessments

10
Event Tree Analysis

•Graphical representation of a logic model

–Identifies and quantifies the possible outcomes following an initiating event

–Provides an inductive approach to reliability assessment as they are constructed

using forward logic.

BOW –TIE

Example Bowtie Tree

11
Human response as a Asset\barrier
Responses can be skill-, rule-, and/or knowledge based
–Skill based: routine, highly practiced tasks and responses
•I.e. steering a car
–Rule based: responses covered by procedures and training
•I.e. obeying traffic rules
–Knowledge based: responses to novel situations
•I.e. finding the way to a new destination
Skill-and rule based responses can be relatively fast and reliable, knowledge based
responses are slow and not so reliable

Functions of Safety Management :

1.Training and education.
1.Provides the competence to respond properly
2.Procedures
1.Paperwork is not a barrier, only the response itself
3.Maintenance and inspection
1.Necessary to ensure functioning of primary barriers over time
4.Communications and instructions

They influence barrier reliability a lot!

Qualitative analysis –results: risk matrix

12
Risk acceptance
•For society’s acceptance the following factors play a role:

–Risk aversion
–“Cost/benefit” and ALARA principle
–(ALARA stands for “as low as reasonably achievable)
–The source of the risk: fatality risk in apartments is a factor 150 less acceptable than in
traffic (Swedish study)

•Kaiser Permanente Hazard Vulnerability Analysis

–Process to help Clinics evaluate their vulnerability to specific hazards;

–Puts each hazard in perspective by using categories:

•Probability of the Hazard Occurring;

•Impact of the Hazard;
–Human Impact; Property Impact; Business Impact.
•Preparedness of your organization;
•Ability to Response to the Hazard:
–Internal Response;
–External Response.

Purpose
•Purpose of HVA is to Make Risk-Based Choices:

1.Address your Vulnerabilities;

2.Mitigate Hazards;
3.Respond to Events;
4.Recover from Events;
5.Create an Emergency Operations Plans to address greatest Risks.

13
Hazard Vulnerability Analysis (HVA)Planning Resource Tool -Kaiser Permanente

Hazard Vulnerability Analysis (HVA) Planning Resource Tool -Kaiser Permanente

WHAT NEXT

14
Keys to a successful Emergency operations plan (EOP)
•Hazard Vulnerability Assessment (HVA)
•Policies and Procedures (Annexes, Quick Reaction Checklists)
•Emergency Communications Plan (ECP)
•Training and Testing

Emergency Operations Plan (EOP)

•Must develop and maintain an all hazard plan based upon the risks and vulnerabilities
raised in the HIRA
–Emergency Operations Plan (EOP) and Business Continuity Plan (BCP) that can guide
your organization’s response to both Medical and Non-medical disasters
–Update EOP and BCP annually

EOP must include elements such as:

Incident Command System (ICS) to reflect who is in charge
Supplies and equipment to support effective disaster response and recovery
Making provisions for patient tracking and vulnerable populations health needs

HIRA -TOOLS
•https://www.calhospitalprepare.org/sites/main/files/file
attachments/kp_hva_template_2014.xls
•https://www.calhospitalprepare.org/hazard-vulnerability-analysis

15
BITS Pilani–WILPMBA –Hospital and Health System Management
Course : Epidemic and Disaster Management

MAN MADE DISASTERS

BIOLOGICAL DISASTER

Reginald G Alex DNB (Med)., MPH (OH)., Dip. Toxicology

Disaster Management – CMC Vellore

BIODISASTER / BIOTERRORISM

•What is Bioterrorism?
•Bioterrorism Agents by categories
•Bioterrorism Agents by name
•Bioterrorism preparedness

INTRODUCTION
•A deliberate release of viruses, bacteria or
other germs used to cause illness or death in
people, animals or plants.

•Natural agents, but possible to cause disease, make them resistant to current medicines,
or to increase their ability to be spread into the environment

•Can be spread through the air, through water or in food

•Terrorists may use biological agents because they can be extremely difficult to detect
and cause extensive damage lives and environment

Source : CDC

1
ADVANTAGES OF BIOLOGICS AS WEAPONS
•High morbidity and mortality
•Potential for person-to-person spread
•Low infective dose and highly infectious by aerosol
•Lack of rapid diagnostic capability
•Lack of universally available effective vaccine
•Potential to cause anxiety
•Availability of pathogen and feasibility of production
•Environmental stability
•Database of prior research and development
•Potential to be “weaponized”
•Perpetrators escape easily

Is bioterrorism something new?

Battle of Tortona-Italy 1155

•Barbarossa (Roman Emperor) put human corpses in his enemy’s water supply,
successfully contaminating it

Mongol Army -1346

•Mongols catapult bodies of plague victims over walls of Caffa, Crimean Peninsula

Naples -1485

•The Spanish supplied their French enemies with wine laced with leprosy patients’
blood.

Pizarro’s Conquest of South America 15th Century

•Improved his chances of victory by presenting to the natives, as gifts, clothing laden
with the smallpox virus.

Biological Warfare US Civil War -1865

•W.T. Sherman’s memoirs contain accounts of invading

forces often slaughtering animals and dumped the rotting

2
carcasses on water wells as they passed through enemy territory

•They obtained the idea from the Romans, who used dead animals to foul the water
supply of their enemies.

World War I –1914 to 1918

•During WWI, as the field of microbiology developed, the

causative organisms for many diseases were identified, and
many were capable of growth in laboratories.
•During the war, most biological attacks were directed at
animals using anthrax and glanders.

Biological Warfare WWI

•Germany aims an ambitious biological weapons

project at its enemies’ livestock (Romania, Italy,
France, Russia, Mesopotamia).

•Anthrax is used to infect food animals and

Glanders to infect horses used by the Calvary.

Gas Mask on Soldier and His Horse / WWI

Anthrax is often considered a good biological agent because of its stability for decades in
spore form and ease of production.

Biological Warfare, Japan -1930

Ishii Shiro (Surgeon General)
Sino-Japanese war

3
“If we can stop the effects of disease from killing our own troops, why can’t we harness
disease to kill our enemies.”

Biological Warfare -1842

•Great Britain 1942

-Anthrax / Animal Diseases

-Gruinard Island

Biological Warfare 1984

•Rajneeshee-Religious Cult intentionally

contaminated salad bars in Oregon restaurants
with Sallmonella causing 751 cases of enteritis.
Forty-five of these people need hospitalization.

•The Rajneesheused a home made brew of

poisonous salmonella typhimuriumand sprinkled it secretly on the fruits and vegetables in
salad bars, poured it in the blue cheese dressing and on table-top coffee creamers in ten
restaurants in the Dalles in Oregon.
•They purchased the seed stock of salmonella from a medical supply company

Biological Warfare 2001

•Washington DC 2001
•9/11 Anthrax Scare
•22 Cases of Anthrax / 11 Inhalation / 5 Deaths

4
•This is the letter that was sent to NBC anchor Tom Brokaw with cutaneous anthrax

Future
Currently working on “super bug” of cancer genes and cold viruses. Catching a cold
would give you rapidly fatal cancer.

WHY BIOLOGICAL WEAPONS?

Effective and Cheap

•1 gram Botulism can kill 1 million people – 0.7 to 0.9 micro gm is enough to kill a
person
•Purified Botulism is 3 times more potent than our best chemical weapon

•SCUB Missile filled with Bolulism Toxin would affect an area 16 times greater than our
best chemical weapon

NOT EASILY DETECTABLE

•They cannot be detected by x-rays, dogs, and most devices, making them easy to
transport.
•Infected humans can serve as transport devices

DELAYED ONSET

•Onset can be from a few hours to a few weeks after exposure.

•Perpetrators can have escaped by then and have protected themselves with vaccines

CATEGORIES

Category A :

•These high priority agents include organisms or toxins that pose the highest risk to the
public and national security.
•They can be easily spread or transmitted from person to person, mostly airborne

•High death rates and have the potential for major public health impact

5
CATEGORY A

CATEGORIES B

•These agents are the second highest priority

•They are moderately easy to spread

•They result in moderate illness rates and low death rates

•Require CDC’s diagnostic capacity and enhanced disease surveillance

CATEGORY B –WATERBORNE

•Salmonella species
•Shigella dysenteriae
•Escherichia coli O157:H7
•vibrio cholera
•cryptosporidium
•Noroviruses

CATEGORY C

•These third highest priority agents include emerging pathogens that could be engineered
for mass spread in the future
•They are easily available
•They are easily produced and spread
•They have potential for high morbidity and mortality rates and major health impact

6
•Nipah virus
•Hantaviruses
•Tick borne hemorrhagic fever viruses
•Tick borne encephalitis viruses
•Yellow fever
•Multidrug-resistant tuberculosis

AGENTS OF HIGHEST CONCERN

•Bacillus anthracis(Anthrax)
•Variolamajor (Smallpox)
•Yersinia pestis (Plague)
•Francisella tularensis (Tularemia)
•Botulinum toxin (Botulism)
•Filo viruses and Arena viruses (Viral hemorrhagic fevers)

Anthrax

•Anthrax rarely spread from person to person

•Biologic weapon beginning at the time of World War II
•Soviet Union in the late 1980s stored hundreds of tons of anthrax spores for potential
use as a bioweapon
•At present there is suspicion that research on anthrax is ongoing by several nations and
extremist groups
•Example -release of anthrax spores by the Aum Shrinrikyo cult in Tokyo in 1993.

•1979: the accidental release of spores into the atmosphere from a Soviet Union
bioweapons facility in Sverdlosk:
–at least 77 cases of anthrax were diagnosed with certainty, of which 66 were fatal
–victims have been exposed in an area within 4 km downwind of the facility
–deaths due to anthrax were also noted in livestock up to 50 km away from the facility
–interval between probable exposure and development of clinical illness ranged from 2 to
43 days (the majority of cases were within the first 2 weeks)
–death typically occurred within 1 to 4 days following the onset of symptoms
–the anthrax spores can lie dormant in the respiratory tract for at least 4 to 6 weeks

•September 2001: anthrax spores delivered through the U.S. Postal System.
–CDC identified 22 confirmed or suspected cases of anthrax (11 patients with
inhalational anthrax, of whom 5 died, and 11 patients with cutaneous anthrax -7
confirmed -all of whom survived)
–cases occurred in individuals who opened contaminated letters as well as in
postal workers involved in the processing of mail

7
 –one letter contained 2 g of material, equivalent to 100 billion to 1 trillion spores
(inoculum with a theoretical potential of infecting up to 50 million individuals)
–The strain used in this attack was the Ames strain -was susceptible to all
antibiotics

•Caused by the bacterium Bacillus anthracis

•Developed as a biological weapon during
the Second World War
•Route of entry –Ingestion, Inhalation and Skin
•Start with flu like syndrome progressing to
respiratory collapse
•Skin –Necrotic ulcer and eschar

Cutaneous Anthrax: Early lesions

(CDC Public Health Image Library)

(courtesy AB Christie, Liverpool)

http://www.vaccines.mil/default.aspx?cnt=resource/viewImage&imgID=36

8
Progression of chest x-ray findings in a patient with inhalational anthrax.Findings
evolved from subtle hilar prominence and right perihilar infiltrate to a progressively
widened mediastinum, marked perihilar infiltrates, peribronchial cuffing, and air
bronchograms.

Vaccination and Prevention

•The first successful vaccine for anthrax was developed for animals by Louis Pasteur in
1881

•The efficacy of AV in a post exposure setting in humans has not been established.

PLAGUE

9
PLAGUE –EPIDEMIOLOGY
Since 1965: approximately 1500 cases/year
25 countries reported cases
1980-1994: 18,739 cases reported from 20 countries to WHO
2000 –2005: Zambia, Algeria, Malawi, DR Congo
Endemic in U.S.1947-96: 390 cases/y

•Caused by a bacterium Yersinia pestis

•Transmitted to humans from infected rats by the
oriental rat flea
•Three types
–Bubonic plague
–Septicemic plague
–Pneumonic plague
•“Black Death” –Subcutaneous heamorrhage,
gangrene of fingers, toes and nose
•local lymph node -Bubo

10
SMALLPOX

11
Smallpox vaccination and Prevention

BOTULISM

Botulinum toxin was the primary focus of the pre-1991 Iraqi bioweapons program
(19000 : l conc. toxin.)
AumShrinrikyocult unsuccessfully attempted on a least three occasions to disperse
botulism toxin into the civilian population of Tokyo.
•1990 -Outfitted a car to disperse botulinum toxin through an exhaust system and drove
the car around Parliament.
•1993 -Attempted to disrupt the wedding of Prince Naruhito by spreading botulinum in
Tokyo via car.
•1995 -Planted 3 briefcases designed to release botulinum in a Tokyo subway.

12
WEAPONISATION
It is the process of converting the biological agent into a usable weapon.

Delivery device-
Bombs
Missiles
Spray systems – Aerial, Aerosol based
Non traditional– food, water supplies, animals

ADVANTAGES

1. Multiple Methods For Delivery

2. Wide Utility-non-discriminating, cause sickness, death, panic, may disseminate
widely, may be persistent
3. Good Logistics-cheap to make and store
4. Versatile-can be in small or large quantities
5. Defence May Be Difficult
6. Cause No Damage To Infrastructure
7. Easy To Conceal
8.‘Status’ WMD-‘poorman’s nuclear weapon’

DISADVANTAGES

1. Slow onset (except toxins)

2. Indiscriminate
3. Difficult to control distribution (IF contagious)

13
 4. Preventive and / or Treatment measures available for some.
5. Level of technical sophistication required for effective delivery.
6. International taboo (deterrent to state / nations)

TREATIES & CONVENTIONS

Before the 20th century, biological agents were clubbed with chemicals as ‘poisons’.
Various treaties have tried to restrict or ban the use of such ‘poisons’ and asphyxiants.
The Brussels convention on laws and customs of war, 1874.
The Hague Declaration concerning asphyxiating gases, 1899
The Treaty of Versailles, 1919

Geneva Protocol,1925
League of Nations, the “Conference for the Supervision of the International
Trade in Arms and Ammunition and in Implements of War”-May1925.
Appeal by International Red Cross & Poland.
“Protocol for the Prohibition of the Use of Asphyxiating, Poisonous or Other Gases, and
of Bacteriological Methods of Warfare” was adopted by the International community
in Geneva on 17th June1925.
Customary international law
A no-first-use agreement only.

Biological Weapons Convention(BWC),1972

Eighteen-Nation Disarmament Committee in 1969.

Convention on the Prohibition of the Development, Production and Stock piling of
Bacteriological (Biological) and Toxin Weapons and on Their Destruction was signed
on 10th April,1972.
Entered into force on 26 March, 1975.
First treaty to ban an entire class of weapons.
Prohibits development, production, stockpiling and acquisition of biological
weapons.

PUBLIC HEALTH SURVEILANCE

USA’s Bio Watch:

Network of detectors across US to detect bio-agents.

Also stock piles vaccines & medicines for biological threats.

WHO’s Global Out break Alert and Response Network (GOARN):
Works for both biological warfare agents as well as other communicable
diseases.

14
World Health Assembly (2001):
Mandated the Director General to “provide technical support to Member
States for developing or strengthening preparedness and response activities
against

INDIAN SCENARIO

Geneva protocol,1925:
Signed –17th June,1925
Ratified –9th April,1930

BWC,1972:
Signed –15th January,1973
Ratified –15th July,1974

Nodal agencies –DRDO (MoD), NDMA, MoHA, MoHFW.

Indian Biodefence Program – started in 1973

National Disaster Management Authority:

Coordinating & mandating government policies for disaster reduction / mitigation
Devising plans to counter the threat of biological disaster, both natural and man-made
(bioterrorism).
Ensuring preparedness at all levels
Coordination of response to disaster and post disaster relief & rehabilitation.
Conducts civilian bio defence and disaster management activities and drills.

15
Ministry of Defence:

 Evacuation,Logistics, Control & Coordination, Clinical

 First responders

DRDO:
R&D
Equipment &Materials

AFMS:
Command and direction
Stockpiling of vaccines/medicines
Exercises and drills
Immunisation of 1st responders
25 hospitals for biological disaster management

Ministry of Health & Family Welfare:

Outbreaks & epidemics
Training & deployment of RRTs
EMR department:
Primary1st responder in case of human affliction
Formulation of policies & plans to handle medical problems

NCDC:
Investigation of outbreaks
Training
R &D

ICMR:
R &D
Training

Ministry of Home Affairs:

Nodal agency in bioterrorist attacks.

Threat perception &analysis
Threat mitigation
Policy development
Law enforcement
Technical support from MoHFW & MoD

16
Stock pile maintenance:
Vaccines –NIV
Medicines–Withstates, Pharmaceutical manufacturers
PPE –State RRTs, Central RRT, DMSRDE
Containment equipment –DMSRDE,DRDE

Consequences of Bio disaster / Pandemics

•Health Impacts
•Economic impacts
•Social and Political impacts

17
PANDEMIC MITIGATION: PREPAREDNESS AND RESPONSE
1.Situational Awareness
2.Preventing and Extinguishing Pandemic Sparks
3.Risk Communications
4.Reducing Pandemic Spread

Situational Awareness

•Situational awareness—in the context of pandemic preparedness—can be defined as

having an accurate, up-to-date view of potential or on going infectious disease threats
and the resources (human, financial, informational, and institutional) available to
manage those threats

Preventing and Extinguishing Pandemic Sparks

•After a pandemic has spread widely, certain activities may prevent and contain
pandemic sparks before they become a wider threat. At the core of pandemic prevention
is the concept of One Health, an approach that considers human health, animal health,
and the environment to be fundamentally interconnected

Risk Communication

•The dissemination of basic information (such as how the pathogen is transmitted,

guidance on managing patient care, high-risk practices, and protective behavioural
measures) can rapidly and significantly reduce the transmission of disease.

Reducing Pandemic Spread

•Curtailing interactions between infected and uninfected populations: for example,

through patient isolation, quarantine, social distancing practices, and school closures
•Reducing infectiousness of symptomatic patients: for example, through antiviral and
antibiotic treatment and infection control practices
•Reducing susceptibility of uninfected individuals: for example, through vaccines.

Prevention & Mitigation Measures

General Measures of Protection

•The general population should be educated and made aware of the threats and risk
associated with it.
•Only cooked food and boiled/chlorinated/filtered water should be consumed
•Insects and rodents control measures must be initiated immediately.

•Clinical isolation of suspected and confirmed cases is essential.

18
•An early accurate diagnosis is the key to manage casualties of biological warfare.
Therefore, a network of specialized laboratories should be established for a confirmatory
laboratory diagnosis.
•Existing disease surveillance system as well as vector control measures have be
pursued more rigorously.
•Mass immunization programme in the suspected area has be more vigorously followed
up.
•Enhancing the knowledge and skills of clinicians

Stages of Prevention

Inter-disaster stage:
•(a) Constitution of a Crisis Management Structure
–Identification of personal for Crisis Management
–Focal points for control of epidemic
–Constitution of advisory committees -Administrative and Technical
–Preparation of contingency plan including Standing Operating Procedure.
•(b)System of Surveillance. System of information, data analysis, flow of information
during crisis period.
–Establishment of control rooms.
•c) System of Epidemiological Investigation.

•(d) Confirmation of pathogens by laboratory set up

Pre impact stage of warning (Early Detection):

•Early identification of an outbreak of disease
–Sudden high mortality or morbidity following acute infection with short
incubation period
–Acute fever with hemorrhagic manifestations,
–Acute fever with altered sensorium and malaria and JE excluded in endemic
areas
–Even one case of suspected plague or anthrax.
–Occurrence of cases which are difficult to diagnose with available clinical and
laboratory support and their non-responsive to conventional therapies.
–Clustering of cases/deaths in time and space with high case fatality rate
–Unusual clinical or laboratory presentations

Disaster Stage:
Public Health Control Measures:

•Identification of all infected individuals based on an established case definition

19
•Eliminating or reducing source of infection (Isolation and treatment of
patients)identified by epidemiological and laboratory studies.

•Interrupting Transmission of disease: Spread of disease depend of mode of

transmission which could be prevented by:
–Possibility of reducing direct contacts with patients;
–Vector control: Rodents/Mosquitoes control.
–Food control
–Environmental control: Transmitted by water/air.
–Control through sewerage system.
•Protecting persons at risk (Community): Immunization and Health Education plays
major role in protecting person at risk.

Post disaster stage:

•Evaluation after disaster is most important step in disaster management in order to
rectify deficiencies in the management and to record the entire operation for future
guidance for which following measures are necessary:

•· Evaluation of control measures

•· Cost effectiveness
•· Post-epidemic measures
•· Sharing of experience
•· System for documentation of events.

Dos & Don’ts in a Biological War Attack

Before:

•Children and older adults are particularly vulnerable to biological agents.

•Ensure from a doctor/the nearest hospital that all the required or suggested
immunizations are up to date.

During:

•Close the doors and windows when a biological attack is imminent.

•Watch television, listen to radio, or check the Internet for official news and information
•The first evidence of an attack may be when you notice symptoms of the disease caused
by exposure to an agent.
•Be suspicious of any symptoms you notice, but do not assume that any illness is a result
of the attack.
•Use common sense and practice good hygiene.

After
•Pay close attention to all official warnings and instructions on how to proceed.

20
•It is important for you to pay attention to official instructions via radio, television, and
emergency alert systems

21
 MBA Hospital and Health Systems Management
BITS, Pilani

Dr Dheeraj Kattula
MBBS, [MMC,Chennai]
1
PGDHA, MPhil Hospital and Health Systems Management [BITS, Pilani],
DPM, MD Psychiatry[CMC, Vellore],
DM Addiction Psychiatry [AIIMS, New Delhi]
Christian Medical College
Vellore 632002

Introduction
What are disasters
Phases of disaster
Disaster impact
Mental health interventions
Role of mental health professionals
Issues in research
Summary
Take home message
2
 Origin of Word Greek Dis + aster
meaning
Why need to study & define disaster?
WHO definition
A disaster is an occurrence disrupting the
normal conditions of existence and causing
a level of suffering that exceeds the
capacity of adjustment of the affected
community

Who.int. [cited 2022 June 13]. Available from: https://apps.who.int/disasters/repo/7656.pdf

WHO estimates about 30 50% of the population suffer from diverse

psychological distresses in disaster

Prevalence of mental morbidity in disaster affected population varies from 8.6

to 57.3 percent

Mental health disorders noted during disasters classified

Acute phase (1-3 months)
Long term phase (>3 months)
1.Math SB, Nirmala MC, Moirangthem S, Kumar NC. Disaster management: mental health perspective. Indian journal of psychological medicine. 2015 Jul;37(3):261-71 4
2. Stoddard FJ, Pandya AA, Katz CL. Disaster psychiatry: readiness, evaluation, and treatment. American Psychiatric Pub; 2011
 India more vulnerable for disasters
Geographically
The economically and socially

According to tenth Five Year

Plan, natural disasters have affected
nearly 6% of the population and 24% of
deaths in Asia caused by disasters have
occurred in India

5
Krishnan S, Patnaik I. Health and disaster risk management in India. Public Health and Disasters. 2020:155-84.

Natural

Man made

Partridge RA, Proano L, Marcozzi D, Garza AG, Nemeth I, Brinsfield K, Weinstein ES, editors. Oxford American handbook of disaster medicine. Oxford University 6
Press; 2011 Jul 15.
Heroic Phase

Honeymoon Phase

Disillusionment Phase
* Anniversary reaction

Restorative Phase
7

Mental health
Impact depend

Protective Vulnerability Type of

factors factors disaster
8
 Relative mental health, absence of psychiatric
problems

-perception of ability to cope and control

outcomes

emotional, & financial

9
Makwana N. Disaster and its impact on mental health: A narrative review. Journal of family medicine and primary care. 2019 Oct;8(10):3090.

Pre-traumatic factors Peri-traumatic factors Post-traumatic factors

psychological reactions
traumas life (self or others)
supports
and sensory experiences
others (e.g. blame or
or economic) rejection of suffering)
trapped)
performance guilt

people)

10
Alexander DA. Early mental health intervention after disasters. Advances in Psychiatric Treatment. 2005 Jan;11(1):12-8.
 The number and intensity of disaster-
related events

The type of disaster, duration of exposure,

death toll, and proximity to the disaster

The greater or more intense exposure

consistently and strongly predicts higher
risk of psychopathology
11
Goldmann E, Galea S. Mental health consequences of disasters. Annu Rev Public Health. 2014 Mar 18;35(1):169-83.

a.
b. Fear of losing control on overwhelming
emotions
c.Becoming mentally ill
d. Substance use
e. Death wishes and suicidal ideas

12
Makwana N. Disaster and its impact on mental health: A narrative review. Journal of family medicine and primary care. 2019 Oct;8(10):3090.
 Acute stress reactions
Relapse of any pre-existing psychiatric
Insomnia and depression
disorders
Substance abuse & dependence
Adjustment disorders/Abnormal grief
Post traumatic stress disorders
Anxiety disorders like panic disorders,
phobic disorders NOS, Non specific Dissociative symptoms

anxiety symptoms and startle response Somatoform disorders

Math SB, Nirmala MC, Moirangthem S, Kumar NC. Disaster management: mental health perspective. Indian journal of psychological medicine. 2015
Jul;37(3):261-71. 13

Non-specific somatic symptoms

School refusal, school dropout and academic decline

Anxiety disorders like panic disorders, phobic disorders NOS, Non specific
anxiety symptoms

ODD symptoms, conduct symptoms, post traumatic stress disorders

Math SB, Nirmala MC, Moirangthem S, Kumar NC. Disaster management: mental health perspective. Indian journal of psychological medicine. 2015
Jul;37(3):261-71. 14
 The apex body for disaster management headed by
At national level : the Prime Minister
At the State level: the Chief Minister
At district level: DM

The role in disaster

Central government
Central Ministries and Departments
National Crisis Management Committee (NCMC)

Important components
National Disaster Relief Force (NDRF)
National Institute of Disaster Management
(NIDM)
National Executive committee (NEC)
Yadav DK, Prasad RN, Barve A. Investigating causal relationship of disaster risk reduction activities in the Indian context. Int J Emerg Manag [Internet]. 2020;16(1):1. 15

The first major paradigm shift involves a focus on health

rather than disease
In the acute phase, the psychiatrist primarily educates and
facilitates the natural recovery process rather than treating
pathology
The validation of their emotions needs to be done during the
therapy to address the issue
The identification of individuals in an essential
element of successful interventions

16
Morganstein JC, Ursano RJ. Ecological disasters and mental health: causes, consequences, and interventions. Frontiers in psychiatry. 2020 Feb 11;11:1.
 Psychological First Aid involves the following themes:

17
Feuer BS. First responder peer support: an evidence-informed approach. Journal of police and criminal psychology. 2021 Sep;36(3):365-71.

Minimize exposure to traumatic stressors; educate about normal

responses to trauma and disasters
Provide consultations to other health care professionals and
community leaders; advise people on when to seek
Professional treatment; assist in resolution of acute symptomatology;
reduce secondary morbidity; and identify those who are at risk
Higher risk for the development of psychiatric disorders and to treat
those who develop them.

18
Norwood AE, Ursano RJ, Fullerton CS. Disaster psychiatry: principles and practice. Psychiatric Quarterly. 2000 Sep;71(3):207-26.
 Public education activities and disaster response
network
Disaster response training of trainers in disaster mental
health first aid training (both medical and psychological)
The counseling skills stress management identifying
common mental disorders and referral life skills training
Community level support and community resilience
training and Communication (IEC) activities

Math SB, Nirmala MC, Moirangthem S, Kumar NC. Disaster management: mental health perspective. Indian journal of psychological medicine. 2015 19
Jul;37(3):261-71.

Rapid assessment (mental health surveillance)

Providing health care medical and psychological first aid
and establishing the referral system
Providing targeted disaster mental health interventions to
the needy
Promoting of resilience and coping and dealing with the
victims and volunteers stress (stress management)
Educating the administrative personnel, local leaders and
public and utilizing mass media to reach the survivors

Math SB, Nirmala MC, Moirangthem S, Kumar NC. Disaster management: mental health perspective. Indian journal of psychological medicine. 2015
Jul;37(3):261-71. 20
 During disillusionment phase

Providing care for the mental ill patients and

attending to the referrals
Continuing and expanding the capacity
building activities
Training of resourceful community members
and community outreach camps
Hand holding of the community health workers
Assessment of the interventions and feedback
mechanism
Math SB, Nirmala MC, Moirangthem S, Kumar NC. Disaster management: mental health perspective. Indian journal of psychological medicine. 2015 Jul;37(3):261-
71. 21

Short-term sedative-hypnotic medication for initiation

insomnia.
Prazosin demonstrated efficacy in treating insomnia
associated with posttraumatic
Individuals with co-morbid depression may benefit from
the sedating histamine properties of Trazodone
Psychiatric disorders; SSRIs and SNRIs as first-line
therapy.

Morganstein JC, Ursano RJ. Ecological disasters and mental health: causes, consequences, and interventions. Frontiers in psychiatry. 2020 Feb 11;11:1. 22
 Behavioral Techniques
Diaphragmatic breathing
Progressive muscle relaxation
Guided visual imagery
Trauma focus psychotherapy:
Cognitive Processing Therapy
Prolonged Exposure Therapy PTSD
Mindfulness

23
Morganstein JC, Ursano RJ. Ecological disasters and mental health: causes, consequences, and interventions. Frontiers in psychiatry. 2020 Feb 11;11:1.

Disaster research allows professionals in the field to advance existing

preparedness, response, and recovery practices
We can understand
Emergence of psychopathology
Interventions which prevent or mitigate effects

24
 Funding constraints
Timing constraints
Environmental concerns
Risk for disaster survivors
Public perception of conducting research during a time of distress
(Knack et al., 2006)
The primary dilemma faced by researchers is safely balancing the pursuit of answers to their
questions with the serious and immediate needs of survivors
(Benight et al., 2007)

25

1. Risk-benefit analysis 7. Participant tracking

2. Funding 8. Researcher safety and distress
3. Institutional Review Board approval 9. Cultural sensitivity
4. Participant recruitment 10. Environmental factors
5. Informed consent 11. Generalizability
6. Emotional distress of participants 12. Disaster Response and Recovery Funding
Opportunities Relevant to Behavioral Health

26
Risk benefit analysis
Vulnerable populations
Balance potential risks and benefits for participants
Novelty of research question and need on the field
Two principles: Utilitarianism and Social justice
Funding
Time sensitive
To design and seek funds before disaster strikes
IRB approval
Use info from previous studies
Obtain before disaster
Inform early about upcoming submission

27

Participant recruitment
Let them meet basic needs first
Compensation: monetary is considered unethical

Engage and persuade survivors and relief workers

Engage with government, NGOs and local bodies
Informed consent
MacArthur Competence Assessment Tool for Clinical Research (McCAT-CR)

Controlled setting
Emotional distress or participants
Research is less distressing than disaster
Interview/questionnaire is better than psychological assessment
No long term effect
Referral to service

28
 29

Researcher safety and distress

Work in teams
Training
Cultural sensitivity
Language
sensitivity to gender, culture, power dynamics, and other biases
Environmental factors
Infrastructure
New normal
Generalizability
Replication in different populations and different contexts

30
Definition of Disaster
Classification of Disasters: Man made and Natural
Phases of Disaster Mental Health Heroic, Honeymoon, Disillusionment, Restorative
Early intervention: Psychological debriefing and psychological first aid
Overall role of mental health professional
Role of Pharmacotherapy Minimal
Rehabilitation and psychotherapy
Issues in Research

31

Disaster Management Cyclical process of planning, organization, coordination and

implementation

Post Disaster centric approach: Holistic, Integrative and Preventive approach

Need for differentiate between distress and disorder
Conservative approach towards medication and aggressive approach towards
psychosocial measures in disaster mental health

32
33
Hospital Incident Command System

The Hospital Incident

Command System

Dr Srujan Sharma
Trauma Surgery
Division of Surgery
CMC, Vellore
 Objectives
Hospital Incident Command System

• Describe the role, responsibility and command

considerations for the following:
– Operations Section
– Planning Section
– Logistics Section
– Finance and Administration Section
• Discuss command staff identification
• Discuss the importance of building a command staff
• Describe function and design of the Job Action Sheet
• Describe the purpose and how to use the incident
response guide
• Discuss the importance of integration with unified
command, and the healthcare system
• Discuss issues related with managing simultaneous
events
 The Incident Management Team
Hospital Incident Command System

(IMT) Charts

Incident Commander

• Depict the hospital Public

Information
Officer
Safety
Officer

command functions that Liaison

Officer
Medical/
Technical
Specialist(s)

have been identified Operations

Section Chief
Planning
Section Chief
Logistics
Section Chief
Finance/
Administration
Section Chief

Staging Manager
Resources Service Time
Unit Leader Branch Director Unit Leader

• Represent how authority

Medical Care Situation Support Procurement
Branch Director Unit Leader Branch Director Unit Leader

and responsibility are

Compensation/
Infrastructure Documentation
Claims
Branch Director Unit Leader
Unit Leader

HazMat Demobilization Cost

distributed in the incident

Branch Director Unit Leader Unit Leader

Security

management team
Branch Director

Business
Continuity
Branch Director
 Incident Commander
Hospital Incident Command System

Public
Safety
Information
Officer
Officer

Medical/
Liaison
Technical
Officer
Specialist(s)

Finance/
Operations Planning Logistics
Administration
Section Chief Section Chief Section Chief
Section Chief

Staging Manager
Resources Service Time
Unit Leader Branch Director Unit Leader

Medical Care Situation Support Procurement

Branch Director Unit Leader Branch Director Unit Leader

Compensation/
Infrastructure Documentation
Claims
Branch Director Unit Leader
Unit Leader

HazMat Demobilization Cost

Branch Director Unit Leader Unit Leader

Security
Branch Director

Business
Continuity
Branch Director
Hospital Incident Command System
 The IMT Charts
Hospital Incident Command System

• Identify the critical functions that

have been pre-identified for each type
of incident

• Not intended that every position will

be activated for each incident or event

• HICS positions are assigned to

personnel only as indicated by an
assessment of the scope and
magnitude of the incident or event
 Command
Hospital Incident Command System

• The activities at the Hospital

Command Center (HCC) are directed
by the Incident Commander (IC)

• IC has overall responsibility for all

activities within the HCC

• The IC may appoint other Command

Staff personnel to assist as the
situation and resources warrant
 Sections
Hospital Incident Command System

Incident Commander

• Operations Public
Information
Officer
Safety
Officer

Medical/
Liaison
Technical
Officer
Specialist(s)

• Planning
Finance/
Operations Planning Logistics
Administration
Section Chief Section Chief Section Chief
Section Chief

Staging Manager
Resources Service Time
Unit Leader Branch Director Unit Leader

• Logistics
Medical Care Situation Support Procurement
Branch Director Unit Leader Branch Director Unit Leader

Compensation/
Infrastructure Documentation
Claims
Branch Director Unit Leader
Unit Leader

HazMat Demobilization Cost

Branch Director Unit Leader Unit Leader

• Finance/ Security
Branch Director

Administration Business
Continuity
Branch Director
 Department Level Command
Hospital Incident Command System

The following should be maintained

available for immediate access

– Job action sheet

– Identification vest
– Radio/phone
– Appropriate command forms
– Pre-designated resources
 Department Level Command
Hospital Incident Command System

Each floor should have ready access to

necessary equipment and supplies:

– Bottled water
– Flashlights and chemical light sticks
– “RESTROOM CLOSED” signs
– Chemical or standard portable toilets/toilet
paper
– Hand washing foam/disinfectant wipes
– Evacuation chairs/sleds
 Command staff
Hospital Incident Command System

• Till accomplishment of that mission,

commander typically has four “special
duty” direct reports:

– the safety officer,

– the public information officer,
– the liaison officer (who coordinates with
other response agencies),
– Medical/Technical Specialists
 Command staff
Hospital Incident Command System

• The Public Information Officer (PIO) will be

responsible for coordinating information sharing
inside and outside the facility.

• The Safety Officer will monitor hospital response

operations to identify and correct unsafe
practices.

• The Liaison Officer will be the hospital link to

outside agencies. In some cases one Liaison
Officer may be at the HCC while a second one is
assigned to represent the hospital at the local
EOC or field incident command post.
 Command staff
Hospital Incident Command System

• Medical/Technical Specialists are

persons with specialized expertise in
areas such as the infectious disease,
legal affairs, risk management, and
medical ethics who may be asked to
provide the Incident Command staff
with needed advice and coordination
assistance.
Hospital Incident Command System

Operations Section
 Operations Section
Hospital Incident Command System

• Responsible for managing the tactical

objectives outlined by the Incident
Commander
• The largest in terms of needed resources
• Branches, Divisions, and Units are
implemented as needed
• The degree to which command positions
are filled depends on the situational needs
and the availability of qualified command
officers
 Operations
Hospital Incident Command System Section Chief

Staging Manager

Personnel Staging Vehicle Staging Team

Team Leader Leader

Equipment/Supply Medication Staging

Staging Team Leader Team Leader

Medical Care Infrastructure HazMat Branch Security Branch Business Continuity

Branch Director Branch Director Director Director Branch Director

Power/Lighting Unit Detection and Access Control Unit Information Technology

Inpatient Unit Leader
Leader Monitoring Unit Leader Leader Unit Leader

Water/Sewer Unit Spill Response Unit Crowd Control Unit Service Continuity Unit
Outpatient Unit Leader
Leader Leader Leader Leader

Casualty Care Unit Victim Decontamination Traffic Control Unit Records Preservation
HVAC Unit Leader
Leader Unit Leader Leader Unit Leader

Facility/Equipment
Mental Health Unit Building/Grounds Business Function
Decontamination Unit Search Unit Leader
Leader Damage Unit Leader Relocation Unit Leader
Leader

Clinical Support Medical Gases Unit Law Enforcement

Services Unit Leader Leader Interface Unit Leader

Patient Registration Medical Devices Unit

Unit Leader Leader

Environmental Services
Unit Leader
Operations Section
Food Services Unit
Leader
 Medical Care Branch
Hospital Incident Command System

Responsible for the provision of acute and

continuous care of the incident victims as
well as those already in the hospital
• The Medical Care Branch Director
– Works with the Logistics Branch to
ensure needed personnel, equipment,
medication, and supplies are requested
– Works with the Staging Manager to
ensure their delivery to needed areas
– Directs the Casualty Care Unit Leader
(usually be located in the Emergency
Department)
 Medical Care Branch
Hospital Incident Command System

It will be important that patients

arriving at the hospital are quickly and
correctly triaged to a definitive
treatment location and medical care is
not delayed waiting in a treatment
area.
 Infrastructure Branch
Hospital Incident Command System

• Maintains the normal operational

capability of the facility including:
– Power and lighting, water and sewer,
HVAC, medical gases and medical
devices, building/grounds
• Increases capacity when patient surge
requirements dictate
• Identifies and restores utility service-
delivery failures
 Infrastructure Branch
Hospital Incident Command System

If an incident occurs with resulting

damage to the hospital, this branch
director will assign an assessment
strike team and remediating the
problem.
 HazMat Branch
Hospital Incident Command System

• Deals with internal or external hazmat

response issues including:
– Agent identification
– Spill response
– Victim decontamination
– Decontamination of equipment and the
facility
– Having decontamination area that can be
quickly established and suitable in size
and flow to accommodate patient
processing needs is vital.
 Security Branch
Hospital Incident Command System

• Responsible for security of facility and

staff
• May need assistance from local law
enforcement or contract security
• Planning needs to address:
– Lock-down vs. restricted visitation
– Supplemental security staffing
– Traffic control
– Personal belongings management
– Chain of custody
 Business Continuity Branch
Hospital Incident Command System

• Facilitates the acquisition and access

to essential recovery resources
• Supports the Infrastructure and
Security Branches
• Coordinates restoration of business
functions and technology
requirements
• Assists other branches and impacted
areas
 Additional Branch Options
Hospital Incident Command System

• Special Operations Branches might be

created to address the specific needs
of an incident that are not already
being met

• New Branch creation at discretion of

hospital unique operational needs
Hospital Incident Command System

Planning Section
Hospital Incident Command System

Planning Section
Chief

Resources Unit Situation Unit Documentation Demobilization

Leader Leader Unit Leader Unit Leader

Personnel
Patient Tracking
Tracking
Manager
Manager

Materiel Tracking Bed Tracking

Manager Manager

Planning Section
 Planning Section
Hospital Incident Command System

• Responsible for collecting evaluating,

and disseminating incident situation
information and intelligence to
Incident Command

• Prepares status reports

• Displays various types of information

• Develops the Incident Action Plan

 The Situation Unit
Hospital Incident Command System

• Responsible for writing and

maintaining incident updates including
those related to patient tracking

• A Patient Tracking Manager may be

appointed to assist
 The Situation Unit
Hospital Incident Command System

• A Patient Tracking Manager may be

appointed to assist with staying current
with patient location assignments and
making this information available to
HCC personnel as well as with the local
EOC and other appropriate external
agencies through the Liaison Officer.
 The Resource Unit
Hospital Incident Command System

• Tracks the status of personnel and

material resources that are being
utilized in various locations of the
hospital

• A Personnel Tracking and Materials

Tracking Manager may be appointed
to assist when needed
 The Documentation Unit
Hospital Incident Command System

• Completes action plans and other

support documents and archives them
 Demobilzation Unit
Hospital Incident Command System

• Responsible for developing and

revising the demobilization plan
 Archiving
Hospital Incident Command System

• At the termination of the incident, all of

the collated information will be used to
help outline the hospital’s response
activities and decision-making
processes.

• All other documentation materials will

be collected and archived as well
 Logistics Section
Hospital Incident Command System

• Responsibilities Logistics Section

include:
Chief

– acquiring resources Service Branch

Director
Support Branch
Director
from internal and
external sources
Employee Health
Communications Family Care Unit
IT/IS Unit Leader & Well-Being Unit
Unit Leader Leader
– use standard and
Leader

emergency acquisition
procedures to acquire
Staff Food &
Supply Unit Facilities Unit
Water Unit
Leader Leader
Leader

– Make requests to the Transportation

Labor Pool &

local EOC or the RHCC

Credentialing Unit
Unit Leader
Leader

for assistance when

needed
Hospital Incident Command System

Logistics Section
Chief

Service Branch Support Branch

Director Director

Employee Health
Communications Family Care Unit
IT/IS Unit Leader & Well-Being Unit
Unit Leader Leader
Leader

Staff Food &

Supply Unit Facilities Unit
Water Unit
Leader Leader
Leader

Labor Pool &

Transportation
Credentialing Unit
Unit Leader
Leader
 Logistics Subdivisions
Hospital Incident Command System

Service Branch Support Branch

Will be responsible for – Focuses on acquiring

supporting: needed supplies,
supporting infrastructure
- Communication operations
- Food services
- IT/IS resource needs
– Coordinating internal and
external transportation

– Acquiring additional
personnel
 Finance /Administration Section
Hospital Incident Command System

• The costs associated with the response must

be accounted for from the outset of the
incident
• Daily financial reporting requirements are
likely to be modified and in select situations
new requirements outlined by state officials

Finance/
Administration
Section Chief

Compensation/
Procurement Unit
Time Unit Leader Claims Unit Cost Unit Leader
Leader
Leader
Hospital Incident Command System

Finance/
Administration
Section Chief

Compensation/
Procurement Unit
Time Unit Leader Claims Unit Cost Unit Leader
Leader
Leader
 Finance Planning and Roles
Hospital Incident Command System

• The Finance/ Administration Section

coordinates:

– Personnel time
– Orders items
– Arranges personnel-related payments and
Workers’ Compensation
– Payment of invoices.
Hospital Incident Command System
Command Staff Identification
 Building Command Staff Depth
Hospital Incident Command System

• Three to five persons should be trained for

each command position in case a prolonged
response is required

• Training and exercises should be used as a

means of preparing personnel to competently
and confidently assume one or more roles
based on situational need and available
resources.

• Formal training is required – one should be

able to different roles
 Job Action Sheets
Hospital Incident Command System

• JAS need to be prepared for every hospital based

on their need and expected disasters

• Information tool provided on a JAS includes a radio

identification title, purpose, to whom they report,
and critical action considerations

• These tasks are intended to “prompt” the incident

management team members to take needed
actions related to their roles and responsibilities
Hospital Incident Command System
 Incident Response Guides
Hospital Incident Command System

• Incident Response Guides need to be devised for

common scenarios

• Each IRG should list fundamental decision

considerations specific to managing that situation
by timeframe

• The IRG’s are intended to complement the hospital

EOP and provide a primer that will provide some
directional assistance and a means of initially
documenting the actions undertaken.
Hospital Incident Command System
 Integration of HICS with
Hospital Incident Command System

Unified Command

• Unified command will be used when more

than one responding agency for the incident
is present or the situation crosses political
jurisdictions

• This command model does not change any

feature of HICS. It does allow for all agencies
with responsibility for the incident, including
the hospital, to participate in the decision-
making process
 Integration of HICS with
Hospital Incident Command System

Unified Command

• The hospital must be effectively integrated into

the community response, including the overall
incident command structure

• This integration actually starts before the

incident occurs through
– the hospital’s regular participation in community
preparedness meetings, training, and exercises
– mutual understanding of roles and responsibilities,
incident management principles, resource allocation, and
effective communication and information-sharing
practices.
 Managing Simultaneous Events
Hospital Incident Command System

• Normally hospitals confront one incident at a

time

• Sometimes problems come in multiples

– Earthquake w/gas leak in the facility
– Flooding and water loss in the facility

• This command model does not change any

feature of HICS. It does allow for all
agencies with responsibility for the incident,
including the hospital, to participate in the
decision-making process
 Review
Hospital Incident Command System

• It is important to understand the role, responsibility and

command considerations for the following:
– Operations Section
– Planning Section
– Logistics Section
– Finance and Administration Section
• It is important to quickly build a command staff
• Command staff should be assigned as needed to trained persons
• JAS should be designed for each command position
• Incident Response Guides should be developed to provide
response guidance
• The hospital must integrate with unified command, and the
healthcare system
• Issues related with managing simultaneous events will occur
and should be planned for
 Review: Key Points
Hospital Incident Command System

• Scenarios can be applied to emergency

operations planning.

• Scenario-specific Incident Planning Guides

(IPGs) and Incident Response Guides (IRGs)
contain elements that assist with planning
and training.

• Materials can be revised as needed based on

hospital assessment of their circumstances.
Hospital Incident Command System
Evacuation of Hospital During Disaster

T. Samuel Ravi M.Sc N PhD Disaster Management

Former Trauma Center Coordinator
Professor Head Emergency Nursing
1
Christian Medical College Vellore
 Disclaimer

• Need to listen to the lecture as the content is

too large to be given in a slide and also requires
discussion and clarification

2
HOSPITAL SAFETY OFFICER

3
 Major Elements of “Safe Hospital”
Safe Hospital

Structural Non-structural Functional

Component Component Component
Lifeline Medical Architectural
Facilities Facilities Elements

Emergency Exit System

Fire System
Electricity System
Critical Systems
Water Supply System
Medical Gas Supply System
4
Communication System
 Hospital Vulnerability
• Clinical
• Specialty
• Location
• Preparedness
• Response Level

5
 Hospital Components

1. Structural

2. Non Structural

3. Functional

6
 Hospital Evacuation

• Planned

• Emergent

• Urgent

7
 Hospital - People

I. Dependent
I. Critical , Non Critical

II. Inter-dependent
I. Patient can be moved with assistance even with
auxiliary support

III. Independent
8
I. Self Mobility
 Patient Handling

Patients in a hospital can be categorized as:

(1) Ambulatory (outpatients), and
(2) Admitted patients (inpatients).
The mobility of inpatients depends on the severity of their illness, such that:
 Seriously ill patients depending completely on life support systems, cannot move by
themselves and need support of the health care workers/hospital staff to move
 Not seriously ill patients but those restricted by IV lines, nebulizers etc. need
support from their attendants to move, and
 Not seriously ill patients, require no support and can move by themselves.

9
 Logistics

Transportation

A

B

C

D

10
 Evacuation

1. Pre Evacuation

2. Evacuation
1. Transportation

3. Receiving Area
1. Surge Capacity

2. ACS Alternate Care site

11
 1.Pre Evacuation

• Scenario Based
• Decision making ( Incident Commander ?)
• Empowerment
– Triage
– Preparing the patient
• Ready to Move

12
 2. Evacuation

1. Transportation
1. Transportation Coordinator

2. Continuity of Care

3. Space control and mobility

4. Safety norms

5. Involvement of the relatives

13
 Hospital Evacuation

 Ward
 Critical Care facilities (ICU, Nursery, Operating Room,
Labor Room, Radiotherapy patients, Rehabilitation all
immobilized patients, Dialysis Center etc.)

14
 Evacuation Process

1. Incident Commander
2. Triage
3. Team - Medical, Nursing, Technician, Fire & safety Officer,
House Keeping Staff, Security, Patient’s Relatives
1. ICU Evacuation Team,
2. Transportation Team,
3. Surge Receive Team
4. Return To Normalcy

15
Incident Commander & Triage

 Medical Personnel on Floor

 Empowerment

 Job Description ( Brief)

 Decision Making

16
Hospital Emergency Response Team
HERT

a. Medical,
b. Nursing,
c. Technician,
d. Fire & safety Officer,
e. House Keeping Staff,
f. Security,
g. Patient’s Relatives.

17
 Process

1. ICU Evacuation Team:

Post Triage, Prepare Life Saving Support system,
Evacuate
2. Transportation Team:
Safe Transportation with the life saving support system
3. Surge Receive Team :
Life saving, Functional service

18
 3. Receiving Area

1. Surge Capacity

2. ACS Alternate Care Site

1. In Charge Nurse at Surge Area

2. Surge Level

3. Continuity of care

19
Evac Protocol

20
 Challenges in ICU

1.Designate a Critical Care Team Leader (CCTL)

2.Prepare for Critical Care Evacuation
3.Prioritizing Critical Care Patients for Evacuation
4.Preparing the Critical Care Patient for Evacuation
5.Ensure Adequate Power and Transport Ventilation Equipment
6.Critical Care Patient Distribution
7.Sending Critical Care Patient Information With Patient
8.Transporting Critical Care Patients to Receiving ICU\Hospitals
9.Tracking Critical Care Patients and Equipment
10.Operating Room as temporary ICU
11.responding to any disaster, 3 resources are vital:
21
 Complexities–
Ward\Critical Care Facilities during
CoVid Pandemic

Compound Disaster Management

22
 WHERE ARE WE ?
• Since August last year,
– India -24 cases of hospital fires,, 93 people have died in such incidents
• Nagpur Chief Fire Officer Rajendra Uchake reports that in order to support more
COVID-19 patients, the hospitals are increasing beds, equipment as well as staff,
but they are not able to expand the electrical wiring system at such a short notice
• The electrical system is carrying current load more than it is capacity and has the
potential to overheat, which is causing these hospital fires, along with a fire audit,
hospitals should also undergo electrical audit.
• The report stated that of the 24 fires, 13 had begun in ICUs
• COVID-19 is leading to their being presence of more inflammable material in the
hospitals – including sanitiser vapour and spills, more oxygen content, as well
as synthetic material-made PPE kits.
• These aid in quicker spread of fire and leave lesser response time, the report said.
Financial Express Online | May 05, 2021

23
 ICU fire evacuation preparedness in London: a cross-sectional study.
G. R. F. Murphy* and C. Foot ,
Critical Care Unit, Royal Marsden Hospital, Fulham Road, London, UK

1. Weaknesses were reported in unit design, equipment, and planning.

2. Unit design was compromised by inadequate fire doors (20%),
ventilation cut-outs (17%), and escape routes (up to 60%).
3. The ability to evacuate multiple patients simultaneously may be
limited by a lack of portable monitoring equipment (49% of beds)
and emergency drug supplies (20% of beds).
4. Evacuation plans were often limited in their scope (96% expected to
remain on their floor; 14% had plans to obtain medications after
evacuation), and not rehearsed (60%).
5. Staff training, while well provided for permanent staff, is less so for
temporary staff (34%).

24
 Ward\ICU
1.Fire Resistance Rating
2. Means of Egress
3. Occupancy
4. Stack Pressure
5. Travel Distance
ICU FIRE SAFETY 6. Venting Fire
1. SEEN
2. UNSEEN

25
ICU PATIENT EVACUATION

26
1. SPACE
2. EGRESS
3. EQUIPMENT

27
FIRE

28
 Way out

1. Fulfill Statutory Requirements

2. National Building Code requirements

3. Safety Team

4. Safety Rounds (Vulnerable Locations & Types)

5. Fire and Safety Audits

6. Checklist approach

7. TTX\Simulation

29
 Challenges in ICU
1. Designate a Critical Care Team Leader (CCTL) Lead
2. Prepare for and Simulate Critical Care Evacuation
3. Prioritizing Critical Care Patients for Evacuation Triage
4. Preparing the Critical Care Patient for Evacuation PP
5. Ensure Adequate Power and Transport Ventilation Equipment
6. Critical Care Patient Distribution
7. Sending Critical Care Patient Information With Patient
8. Transporting Critical Care Patients to Receiving ICU\Hospitals
9. Tracking Critical Care Patients and Equipment
10.Operating Room as Temporary ICU
11.Responding to any disaster, 3 resources are vital:
Money, Time, and Resources.

30
Gist

31
 Challenges of Hospital Evacuation
1. Plan doesn’t work

2. Decision Making

3. Time

4. CBRNE

5. Logistics

6. Communication

7. Documentation

8. Budget
32
9. Community Preparedness
 Overcoming the Challenges

1. Capacity Building
2. Simulation
3. Drill
4. TTX\TTE Table Top Exercise
5. Alert Level ( White, Yellow, Red)

33
 What we can, with what we have.

• Thank You
34
EPIDEMIC AND DISASTER MANAGEMENT
Disaster Drill, Simulation, TTX / TTE
T. Samuel Ravi

1
Training and Exercises
•Training and exercises are invaluable tools for preparing staff and testing emergency
plans.
•Training and exercises should reinforce concepts in the organization’s emergency plan.
•Training should be conducted regularly
•(Reality: we do what we've practiced, not what is in the plan).

Mock drill
•Mock drillis a practice to save life/ lives in real time situation of any kind of danger or
calamity that occurs suddenly with no time or very little time to react.
•Mock drill is a exercise / scenario organized to assess the level of preparedness and
check the response procedure pertaining to any disaster is followed

TEAM
•Team leader
•Members
•Health care
•Dr, Nurse, Paramedic
•Specialist as per need (Infectious Disease, Radiation)
•Fire
•Security
•General Services
•Additional
Purpose of mock drill is to
1.Review the emergency preparedness plan of the organization.
2.Evaluate standard operating procedure.
3.Check the understanding of the staff on their roles and responsibilities.
4.Enhance coordination among the emergency support functions and various
departments.
5.Check the workability of the systems and installations for mitigating the risk
6.Understand gaps in the system to remove deficiencies and to execute further
improvement plan to avoid life and property loss.
7.Enhance the ability to respond faster.

2
Classification of Mock Drills
Pre-announced drills
•It is conducted after informing staff about the drill.
•It involves:
•Establishing new protocols.
•Performing a drill for the first time in the area/ department.
•Performing a drill in sensitive/ vulnerable areas.

Unannounced drills
•It is conducted after the staff are clear about the mock drills and have attained a
certain level of proficiency.

Focus
•Define the mock drill or exercise
•Need and importance of the mock drill
•Explain the phases to organize mock drill for earthquake
•Precaution need to taken in organizing mock drill
•Define requirements for managing evacuation and rescue operations
•Demonstrate the mock drill

3
Hospital Disaster Drills
•Drills as necessity
–Hospitals will be called upon to provide care to the ill, injured, exposed, and
concerned
–Accreditation Requirement
–May help train employees
–Tests aspects of hospital response
•Types
–Computer simulation
–Tabletop exercises
–Operationalized drills involving specific victim scenarios
•Evaluations
–Can help maximize the value of the drill
–Based on accurate observation
–Benefit of standardization

Guiding Principles in Developing Evaluation Modules

•Need for observing multiple hospital zones
–Evaluation of a disaster drill requires an understanding of drill activities in all areas of
the hospital
–Four zones identified include:
•Incident Command
•Decontamination
•Triage
•Treatment
–Addendum if Biological or Radiological Scenario
–Decontamination Zone Module needed for radiation & chemical drills; not
recommended in biological drill
•Need for documentation of time points
–Recording time points of drill activities is a widely accepted method of evaluation
–Labor-intensive if excessive number of time points and may detract from overall
evaluation
•Limited, specific time points thus predetermined

4
•Need for documenting clinical care outcomes
–Track the volume of victims in each zone and adequacy of provisions made for
them, including space, staff, supplies, etc.
–Modules are not intended to collect individual victim level data
–Modules monitor the zone and outcome for the zone as a whole, not for each
victim
•Need for debriefing (after-action review)
–Obtain feedback from participants, including organizers, staff, and victims
–Allows for discussion of issues that span more than one zone
–Evaluate and integrate cross-zone issues at a post-drill debriefing session
•Need for safety and security
–Consider planned drill activities; i.e., use of unfamiliar equipment
–Protect actual patients on the premises
–Safety of drill victims and healthcare workers
–Contingency plan to stop the drill in case of an actual emergency
–Consider designating a safety officer to monitor the drill and its participants

Internal Structure of Evaluation Modules

•Zone forms for Incident Command, Decontamination, Triage, and Treatment have
same structure and subject headers:
1.Time points
2.Zone description
3.Personnel

5
 4.Zone operations
5.Communications
6.Information flow
7.Security
8.Victim decontamination and tracking
9.Victim flow
10.Personal protective equipment (PPE) and Safety
11.Equipment and Supplies
12.Rotation of Staff
13.Zone disruption

Common Sample Questions from an Evaluation Module (Time Points)

1.Time the drill began:___AM/PM

2.Time the hospital disaster plan was initiated in this zone:___AM/PM/U/Not initiated
3.Time this zone was ready to accept victims:___AM/PM
4.Time when this zone was notified that incident command was operational:___
AM/PM/U/Not notified
5.Time the drill ended in this zone:___AM/PM

Common Sample Questions from an Evaluation Module (Zone Description)

Was the boundary for this zone defined? Y/N

If this zone had a defined boundary, how was it defined? Barricade
Security personnel
Sign
Tape
Vehicle
Wall (permanent or temporary)
No boundary
Other (specify): __________________

6
Common Sample Question from an Evaluation Module (Personnel)

•How was the person in charge of the zone identified? (Check all that apply)
–a. [ ] Arm band
–b. [ ] Hat
–c. [ ] Name tag
–d. [ ] Verbal statement
–e. [ ] Vest
–f.[ ] Not identified
–g. [ ] Other physical identification (specify):

Common Sample Questions from Evaluation Module (Zone Operations)

•Was the space allocated for the zone adequate?Y/N

•If not enough space for the zone, where did zone activities overflow to? (Check all that
apply)
–Adequate space allotted
–Conference room
–Hallways
–Outside hospital
–Treatment/victim care areas
–Waiting rooms
–No overflow
–NA
–Other (specify): ______________________________
•Was this zone used for the same functions during non-drill operations?Y/N
Common Sample Questions from Evaluation Module (Zone Operations)
•Did clinical staff interact directly with families of victims? Y/N/U/NA
•Were families of victims referred to specially designated staff? Y/N/U/NA
•How was victims’ privacy ensured? (Check all that apply)
–Curtains
–Individual areas
–Privacy screens

7
 –Not ensured
–Other (specify):

Description of Modules and Objectives

1.Pre-drill Module
2.Incident Command Center Zone Module
3.Decontamination Zone Module
4.Triage Zone Module
5.Treatment Zone Module
6.Group Debriefing Module

1. Pre-drill Module
•Should be used in all disaster drills during the planning stages
•Form is designed to collect the following:
–Goals and objectives for the scope of evaluation
–Background information
–Information on areas that hospital wishes to evaluate
–Resources required
–If multi-hospital or regional drill, each site must work closely with overall
coordinators

2. Incident Command Center Zone Module

•Designed to reliably collect information about operations of the incident command
system (ICS)
•Should be used in all disaster drills when evaluating the ICS
•Form is designed to assess the following:
–Command structure in the zone
–Adequacy of staffing in the ICS
–Communication and information flow from hospital areas to the ICS
–Communication with outside agencies
–Adequacy of security, safety provisions, and physical space

8
 3. Triage Zone Module
•Designed to collect information re: functioning of treatment areas
•Should be used whenever drill objectives include evaluation of patient care activities
beyond triage
•Appropriate for use in emergency department-based treatment areas or in other clinical
areas

4. Debriefing
•Debriefing is integral part of drill process
•Main objective of debriefing is to identify issues not captured by evaluation modules
•Facilitators should create an open, non-judgmental atmosphere
•Should occur in all drills to obtain feedback from participants and observers

Biological Incident Addendum

•Form is designed to assess the following:
–Awareness that biological agent cause of illness
–Whether appropriate personnel were contacted
–Whether health and safety needs of staff were met
–Whether health and safety needs of existing patients were met
–Whether health and safety needs of victims were met
–Availability of special medications and supplies

Radiation Incident Addendum

•Designed to gather information in response to radiation-related incident
•Should be added to end of each zone module
•Should be used in all drills that address radiation exposure

Observers
•Value and success of drill, depend on observers, who must be able to understand and
record events
•Observer selection is therefore critically important
•Observers must be trained to use evaluation modules

9
 –Documentation by observers provides information for evaluation
–Record the type and number of victims, as well as the care given or not given to
victims
–May record personal views but should note it as opinion

Table Top Exercises

-A tabletop exercise is a facilitated, scenario-based group discussion
-Typically 2 hours to 4 hours in duration
-Scenario should be chosen on likely hazards in the area
-There are many formats and methods

Why Table Top Exercises?

1.Are low-stress discussion of coordination and policy within the organization and/or
between the organization and other agencies.
2.USEFUL IN CRITICAL AREAS
3.Provide a good environment for problem solving.
4.Provide an opportunity for key agencies and stakeholders to become acquainted with
one another, their interrelated roles, and their respective responsibilities.
5.Provide good preparation for a functional exercise.
6.Cost Effective
7.Minimal Disruption
8.Validation of your Plan

10
Through Exercises, Organizations Can:
•Test the preparedness of critical care areas where Mock Drill cannot be conducted
•Test and evaluate plans, policies, and procedures.
•Reveal planning weaknesses, Reveal gaps in resources.
•Improve organizational coordination and communications.
•Clarify roles and responsibilities.
•Train personnel in roles and responsibilities.
•Improve individual performance.
•Gain program recognition and support of officials.
•Satisfy regulatory requirements

Getting Started: Steps for Success

Developing a tabletop exercise normally evolves over a 1-month to 2-month period if
conducted properly

Tabletop Exercise Preparation

•Flipchart and markers
•Scribe
•A/V equipment
•Attendance sheet
•Extra seats for observers
•Copies of the exercise scenario
•Clinical floor plans
•Emergency plans-Hospital
•Maps
•Additional pre-incident information
•Participant evaluation form

11
The After Action Process
1.Immediate Debriefing
2.Evaluator and Participant Comments
3.Written Comments from Evaluators
4.Comprehensive Report
5.After Action Meeting (Weeks Later)
6.Improvement Ideas and Implementation
7.Training

After-Action Review
•After-action reviews capture key lessons learned from emergency response and make
recommendations for improvements.

•Benefits of after-action reviews

•Supports proactive response management
•Provides documentation for any future litigation
•Identifies areas for improvement.
•After-action reviews must not be an after-thought!

After-Action Review
Consideration must be made for the best timefor this -not necessarily immediatelyafter!
A skilled facilitator is important. Tension must be constructive.

Identify components of after-action reviews:

–Exercise / emergency overview
–Exercise goals and objectives
–Analysis of outcomes
–Analysis of capacity to perform critical tasks
–Summary ,Recommendations
–Specific improvements for each partner
–Accountability plan.

12
Setting Up for a Simple Table top Exercise
Room Characteristics:
•Large conference table w/ chairs
•A/V Requirements:
•computer and LCD projector projection screen

Setting Up for an Enhanced Table top Exercise

Room Characteristics:
•Large, open space

•Moveable tables and chairs

•A/V Requirements:
•Computer and LCD projector

Exercise Room Setup (Simple)

•Print all exercise materials such as maps
•Place pre-exercise materials and maps on conference table
•Set up exercise slide presentation on computer w/ LCD
•Set up tables and chairs -follow table layout diagram
•Post double-sided table signs to identify tables
•Print and place pre-exercise role-specific materials and maps on tables
•Set up exercise slide presentation on laptop

13
Tabletop Exercise Agenda
•Introductions & Exercise Overview
•Module 1 –Incident Notification
•Module 2 –Incident Response
•Module 3 –Demobilization
•Wrap Up & Hot Wash

Welcome & Introductions

•Name
•Job Title & Your Assigned Role for the Exercise
•Agency
•What do you hope to gain from today’s exercise?
Logistics
•Restrooms
•Refreshments
•Assign a scribe & spokesperson for each table
•Follow along in your Situation Manual

14
Background

Purpose

Exercise Objectives
•Fire in Intensive Care Unit
Exercise Guidelines
Assumptions & Artificialities

INCIDENT NOTIFICATION

HOT WASH
Exercise Wrap Up

Hot Wash Guidelines

•Focus on plans, policies, & procedures; not an individual person or position
based on exercise discussions.
Example: Identify training needs or plan/ policy, revisions.
•Focus on exercise discussion.
oUse Participant Feedback Forms to evaluate the design of the exercise.

Hot Wash Topics

1.Identify top 3 strengths.
2.Identify top 3 areas of improvement.
3.What additional planning efforts or needs were identified?
4.What additional team should be involved in future planning for this type of event?
5.What additional training and/or equipment needs were identified?
Thank You for Participating!
•Turn in Participant Feedback Forms & notes from the Scribe to the facilitator.

15
TTX Process
1.Set Objective
2.Select Scenario
3.Select people
1.Facilitator
2.Participants
3.Observer
4.Create Conducive environment
5.Conduct the exercise
16
6.Conduct debriefing
7.Write an evaluation report
8.Meet to discuss follow up

Participant Roles and Responsibilities

•Groups of participants involved in the exercise, and their respective roles and
responsibilities, are as follows:

•Players.
–Players are personnel who have an active role in discussing or performing their regular
roles and responsibilities during the exercise. Players discuss or initiate actions in
response to the simulated emergency.

•Observers.
–Observers do not directly participate in the exercise. However, they may support the
development of player responses to the situation during the discussion by asking relevant
questions or providing subject matter expertise.

•Facilitators.
–Facilitators provide situation updates and moderate discussions. They also provide
additional information or resolve questions as required. Key Exercise Planning Team
members also may assist with facilitation as subject matter experts (SMEs) during the
exercise.

•Evaluators.
–Evaluators are assigned to observe and document certain objectives during the exercise.
Their primary role is to document player discussions, including how and if those
discussions conform to plans, polices, and procedures.

Question 1
A nurse from the medical service at the facility was informed of the accident and decided
to send the patient to your hospital. You are an Charge Nurse in ER responsible for
radiation emergencies at your hospital.
1) How do you receive the patient?

17
2) How do you prepare for this?
3) What is your plan for the patient’s care?
4) What plan is there in your hospital for a radiological emergency?
• Discussion
• Exercise
• Hot wash

18
 EPIDEMIC & DISASTER MANAGEMENT
Disaster Ethics
Arul Dhas T
Department of Bioethics
Christian Medical College, Vellore
11.11.2023
What is Ethics ?
 Study and evaluation of human conduct in the light of moral principles
 Moral principles – standard of conduct that individuals have constructed for
themselves or obligation and duties a society requires of its members

What Ethics is not

 Feelings
 Religion
 Law
 What the majority agrees

Life Boat – a thought Experiment

1. Retired professor of medicine
2. Eight month pregnant woman
3. Physically challenged man
4. An unemployed man who is a drug addict
5. A nun sister who is working among the poor
6. Unmarried woman suffering from cancer
7. A homeless man
8. A political leader who has amassed wealth by corrupt methods

Cardinal virtues of Disaster response

 Prudence
Courage
Justice
 Stewardship
Vigilance
Resilience
Self‐effacing charity
Communication
•Sara Kathleen Geale

Unethical aspects in Disaster

Examples... By participants
Recollect any two unethical acts during any disaster –witnessed/ heard about/ read about
(in small groups)

Theories
 Divine Command Theory
 Consequentialism /Utilitarianism – Consequences most good and least harm
 Deontology – duty based
 Virtue Ethics – Aristotle – neither excess nor shortage
 Ethics of Care

Four principles
 Beneficence (Do good)
 Non-Maleficence (Do not do harm)
 Autonomy (Give Respect)
 Justice (Be just and fair)

Ethical Decision Making

• Get the facts
• Most good and Least harm
• Rights of all at stake
• Dignity of others
• Treat people equally and proportionately (greatest good for largest number)
• Serve the community as a whole (common good)
 • The action is virtuous

Break
 Think of a disaster you have experienced or heard about.
 What are the unethical things that happened?

Case Study
 A major earthquake has struck a densely populated urban area, causing widespread
destruction and leaving thousands of people injured and homeless. Emergency
response teams from various organizations, including government agencies, NGOs,
and international aid groups, have mobilized to provide assistance. However, the
scale of the disaster overwhelms the available resources, leading to difficult ethical
decisions regarding resource allocation.
(Source: ChatGPT)

Questions
 As a Healthcare Team Leader, what are the ethical challenges you might face?
 As a Search and Rescue Team Leader, what are the ethical challenges you might
face?
 As a local Community Leader, what are the ethical challenges you might face?

Shift in Disaster
 Less emphasis to liberty and privacy & more emphasis to security and safety
 Clinical medicine protocol to Rescue medicine protocol

Before Disaster
 Preventive Measures, disaster preparedness, training, awareness – ignored
 Unthoughtful priorities
 Development of infrastructures – commitment to future generations
 Usage of resources – with sense of stewardship
 New technologies and inventions – responsibility towards the whole creation
  Training rationale with the revised protocols of disaster – ethical soundness

Triaging - Three groups

 Those who may not survive even with treatment
 Those who will recover without treatment
 Those who need treatment to survive

Egalitarian Model of Triage

No regard for rank or distinction
During Disaster
 Moral duty - do humanitarian assistance
 Dignity of the person – considered during compulsory evacuation
 Care for the vulnerable – reflecting justice and fairness
 Triaging systems – sharing of scarce resources
 Attention – Care for the Disaster caregivers
After Disaster
 Misuse of pictures taken
 Misleading advertisements
 Misdirection of humanitarian funds
 Paternalism of the donors
 Balance between resilience of the community and rights of the community

Disaster Management Act

 India, 2005
 11 Chapters and 79 sections
 National Disaster Management Authority
 5 year term
 National Executive committee
 State Disaster Management Authority
 District Disaster Management Authority
 National Disaster Response Force
 Ethical Decision Making

 Get the facts

 •Most good and Least harm
 •Rights of all at stake
 •Dignity of others
 •Treat people equally and proportionately (greatest good for largest number)
 •Serve the community as a whole (common good)
 •The action is virtuous
 Epidemic and Disaster Management

Top Hazard Approach Management

Dr. Vijayan Purushothaman,

MBBS, MS, DNB, MCH (Trauma and Critical Care), FACS, FMAS, FSHM, MBA
(Health Services Management)
Associate Professor,
Department of Trauma Surgery,
Christian Medical College, Vellore.

Introduction
•No one can predict time, location, or complexity of next disaster
•Management of contemporary disasters, whether natural or man-made is most
significant challenge facing medical providers
•Disaster medical care is not same as conventional
medical care
Disaster medical care requires a fundamental
change in approach(“crisis management care”)
Achieve objective of “greatest good for greatest
number of individuals”
Definition

•Disaster–origin from French word disaster (dis-meaning Bad and aster meaning star) –
Bad or Evil Star
•Any occurrence that causes damage, ecological disruption, loss of human life or
deterioration of health and health services on a scale sufficient to warrant an
extraordinary response from outside affected community
(definition by WHO)
•Also defined as occurrence either natural or manmade that causes human suffering and
creates human needs that victims cannot alleviate without assistance

Definition

•Multiple casualty incidents: Events in which medical resources are strained (prehospital
and/or hospital resources) but not overwhelmed
•Mass casualty incidents (MCI): Events causing numbers of casualties large enough to
disrupt health care services of affected region
•Resources of trauma centre as well as regional trauma system are overwhelmed
•Priority shifts from those with most urgent need to providing care to those with highest
probability of survival

(Demand for resources always exceeds the Supply of available resources in a disaster)

Disaster : When and where it occurs?

•Anytime and anywhere, not confined to any part of the world
•Some can be predicted and some cannot be predicted
•Warfare is a special category where it is well planned and damage is intended goal of
action
Epidemiology of disasters
•In the last 10 years :
Natural disasters have killed 760,000 people
Injured 2 million
Affected more than 2 billion people
Mortality and morbidity is likely to increase in coming years due to climate change
Earthquakes are the main killer of all natural disasters on an annual basis
Floods are most common natural disasters worldwide and drowning is m/c cause of
death following floods

Types of Disasters

•Natural Disaster
•Manmade Disaster
•Terrorist related Disaster
•Internal Disaster
•External Disaster
•Acute Disaster
•Non-acute Disaster
After effects of disaster
Characteristics
•Acute disaster : large number of casualties in a short time frame present to ED
Minimally injured patient without prehospital triage / evaluation
arrival of most affected people by prehospital transport
•Non-acute Disaster : ED volumes has a slower onset of surge
ED volumes remains elevated for extended period of time

Severity of impact:
Depends on many factors:
•Predictability: some disasters can be predicted and the degree of preparedness
will be high. (cyclones, floods)
•Type of disaster: in earthquakes the mortality is high due to collapsing buildings,
falling objects, density and population distribution warning opportunity condition
of environment

India’s vulnerability to disasters

•68% land vulnerable to drought
•57% land vulnerable to earthquakes
(12% is vulnerable to severe earthquakes)
•12% land vulnerable to floods
•8% land vulnerable to cyclones
•Some cities are vulnerable to chemical and industrial disasters (northern mountain
region –land slides, snow storm, earthquakes. Eastern coastal area –prone to floods,
cyclones) (western deserts prone to draughts)
Of 7,516 km long coastline, close to 5,700 km is prone to cyclones and
tsunamis

In India 58.6% of land mass is prone

to earthquakes of moderate to very high
intensity

68% land is vulnerable to drought

All hazard vs Top hazard approach
Hazard vs risk
•Hazard
•A hazard is something that can cause harm

•Risk
•A risk is the chance, high or low, that any hazard will actually cause somebody
harm.

All hazard Approach -pros

•Focuses on hazard
•Same plan of management for all disasters
•Pooling of resources
•Thought to be effective co ordination between the players

All hazard Approach -cons

•Not all hazards are same
•Not all needs all the departments
•Waste of resources
 •E.g. Heat wave does not require evacuation

Top hazard approach

•Focusses on risks
•High profitable
•High risk
•Risk specific
•Geographic and other
factor specific approach

Aims of disaster management

•Disaster cannot be taken away but extent of damage can be reduced considerably
•Handle in effective manner to limit and reduce the quantum of loss
•Develop important strategies to reduce and control the occurrence of disasters
•Minimise risk of disasters

•Train individuals and community to remain prepared for sudden disasters

•Reduce impact of disaster and quantum of loss
•Organize recovery and rescue mechanism
•Elicit action for management of disaster in time bound manner
•Draw attention of national and international agencies for disaster relief
•Develop systematic approach to management of disasters
Key Principles of disaster response*
•Principle 1
•All disasters are not same
•Disaster response includes basic concerns (similar to the ABCs of trauma care)
•Differences in disasters is degree of disruption of medical and public health
infrastructures and the amount of outside assistance

•Principle 2
•Medical providers cannot utilize traditional command and control structures when
participating in disaster response

•Principle 3
•Disaster responders must understand basic principles of disaster response to be effective
members of disaster teams
•All providers involved in disaster response must ensure their personal safety prior to
their roles in disaster response before a disaster occurs.

•Principle 4
•Disaster care of traumatic injuries requires a fundamental change in approach to care of
victims (“crisis management care”).
•The objective of disaster trauma care is the greatest good for the greatest number of victims.
Emergency operations planning
The Team

Hazard Risk Analysis

 Identify Hazards
 Profile Hazards
 Apply Risks
 Scenario creation
 Resource at hand
 Plan EOP
 Test EOP
 Maintain EOP
Assign responsibilities
•CEO –Assumes overall responsibility
•EOP manager –Over sees and reports to CEO
•Communications Co-ordinator
•Emergency manager
•All public health related departments
•Resource manager –to keep a tab on utilization
•Public information officer –Most important to prevent chaos
•Inter jurisdictional liaison officers
Approach to Disaster
Mitigation (Measures before Disaster)
•It involves taking sustained actions to prevent or reduce the long term causes, impact
and consequences (loss to life and property) of a disaster. These sustained actions are
also known as mitigation.
•It is initial phase of disaster management and should be considered before a disaster
occurs.
•It is long and continuing activity that is integrated with each of other phases (
preparedness, response and recovery) of disaster management

The goal of mitigation activities are to:

•Protect people and structure during disaster
•Reduce the cost of response and recovery

Mitigation measures includes the following activities like-

•To identify:
•What disaster can occur in and around the community?
•The likelihood of its occurrence.
•The consequences of the events in the terms of causalities, destruction and
disruption of services.
•The cost of response and recovery.
•Revised zoning and land use management
•Strengthening of public infrastructure.
•Efforts to make community more resilient to disastrous events.

Four ways to prepare and reduce vulnerability

•Strategy 1:
•EXAMINE past disasters
•Taking a look in past disasters –what went well and what went wrong before and
after disaster

•Strategy 2:
•Become familiar with emergency processes and policies
•Role of a leader , teaching and training of emergency management
•Strategy 3:
•Hands on practice

•Strategy 4:
•Plan and plan again

Preparedness (action before disaster)

means readiness to response.
•Because it is not possible to mitigate completely against any disaster so by taking certain
actions before, harmful consequences of a disaster can be reduced.
•Preparedness includes planning, training and educational activities
•Developing disaster preparedness plans for what to do, where to go and who to call
for help in a disaster.
•Exercise emergency plans through drills and full scale exercise.
•Early warning systems
•Community awareness and education
•Indentifying resources and creating supply list of items that are useful in a disaster.
•Identification of high risk areas and designating facilities for emergency use.

Response (during or immediately after disaster)

•This phase occurs in the immediate aftermath of the disaster as a immediate action or
relief like-
•Implementing of disaster response plans.
•Taking action to protect yourself, your family , your animalsand others.
•Conducting life saving missions like evacuation and search and rescue.
•Provisions of relocation and temporary shelter.
•Provisions of food and water and emergency healthcare.
•Providing emergency assistance and critical services to victims.
•To conduct a rapid situation assessment
•to priorities response activities.
•to allocate scare resources.
•to provide life saving and life sustaining needs to the affected.
Recovery (after disaster)
•This phase is to return the community’s system and activities by rebuilding or
restoration efforts beyond the provisions of immediate relief like-
•Rehabilitation
•Rebuilding damaged structure.
•Preventing or reducing stress related illness.
•Providing financial support to people.
•Development of practices and policies to reduce the vulnerability or mitigate
similar situations in future
Medical response to disasters

Search and rescue:

•Specialized search and rescue teams are integral part of national disaster plans
•Members of these teams receive specialized training in confined space environments
•Include the following:
•A cadre of trauma specialists
•Technical specialists in hazardous materials
•Structural engineering, heavy equipment operation and technical search and
rescue methodology
•Trained canines and their handlers

Triage : “sorting” of patients

• dynamic decision-making process of matching patient needs with available resources
• Most important and challenging aspect of disaster medical response
• Disaster triage is significantly different from conventional trauma triage
• Identify critically injured patients who require lifesaving treatments, including damage
control surgery, from the larger majority of noncritical casualties
• Critical patients having greatest chance of survival with least expenditure of time and
resources are prioritized to be treated first

Levels of triage
Three levels of disaster medical triage
•Field triage (level 1)
Rapid categorization of victims need immediate medical care
Victims are designated as “acute” or “non-acute”
Colour coding may be used.

•Medical triage (level 2)

•Rapid categorization of victims by experienced medical providers at casualty collection
site or fixed/mobile medical facility
•Victims are classified into the following categories:
•RED
•YELLOW
•GREEN
•BLACK

•Evacuation triage (level 3)

Neglected area of disaster preparedness.
Priorities for transfer to medical facilities are assigned to disaster victims using
same colour classification as a medical triage

Reverse triage
•In the event of disasters, hospital systems faces significant demands for health care
services .•Reverse triage is one tool that can allow judicious use of resources to provide
most beneficial care to a greater number of patients .
•Its is a way to create in patient surge capacity by identifying hospitalized patient who
don’t require major medical assistance for at least 96 hours and who have small risk for
serious complication resulting from early discharge .
Disaster triage Simple Triage and Rapid Treatment (START)
AIM -Triage large numbers of patients rapidly

•Focus of START-Evaluate four physiologic variables:

Patient’s ability to ambulate
Respiratory function (RR-</>30)
Systemic perfusion (CRT </> 2 Sec.)
Level of consciousness. (following commands)

•Victims are usually divided into four groups with colour codes according to timing of
care delivery
(1) green—minor injuries (walking wounded);
(2) red—immediate
(3) yellow—delayed
(4) black—unsalvageable or deceased.
Mass casualty triage principles are the same for children and adults

Disaster triage Simple Triage and Rapid Treatment (START)

 SALT (Sort-Assess-Lifesaving Interventions-Treatment/Transport)

Expectant category of triage victims

•Victims are classified as “expectant” if not expected to survive due to severity of

injuries or underlying diseases and/or limited resources
•Classified as “yellow or delayed” category
•Criteria utilized as guidelines for expectant category are:
Cardiac arrest on scene
Severity of comorbid diseases
Requirement for intubation and ventilation
Severe Head injuries
Massive burns (>80% total body surface area)

Evacuation
•Useful to decompress disaster area and provide specialized trauma care for specific
patients
•Special considerations during evacuation include
•Decrease in cabin pressure occurs as altitude increases. Tapped gas in any body
cavity can cause serious complications as it expands on ascent.
 •Partial pressure of oxygen decreases with increasing altitude. Monitoring with
pulse oximetry is important.
•Take offs and landings present unique challenges, especially with head injury
patients
•Children, burn and post-surgery patients are particularly susceptible to
temperature changes during evacuation

Definitive medical care

•Refers to Care that will improve, rather than simply stabilize patient’s condition
•Minimally acceptable trauma care to provide lifesaving interventions
•Damage control surgery is an important component of crisis management care

Hospital Emergency Operation Plan

1. Activation of Emergency Plan
2. Set Up ICS
3. Assess hospital Capacity
4. Create Surge Capacity
5. Establish Communication System
6. Provide Supplies & Equipment
7. Establish support area
8. Decontamination triage and Treatment areas
9. Terminate disaster response & amp; remediation
1. Activation of Emergency Plan

•Initial & vital stage

•Describe roles & responsibility of staffs in hospital
•Clarification regarding emergency operation plan activation
•Mobilization of supplies, equipment & personnel

2. Incident command system (ICS)

•ICS is modular/adaptable system for all incidents and facilities and accepted
standard for all disaster response
•Incident command (IC): Maintains overall responsibility for disaster response Sets
objectives and priorities for disaster response
•Operations Section: Directs activities of all organizations responding to disaster
•Logistics section: Provides resources and logistical support to meet disaster needs
•Planning section: collects, evaluates and disseminates information about incident
operations and the status of resources. This section also develops incident action
plans and conduct planning meetings.
•Finance/administration section: Monitors costs, manages legal affairs and
maintains personnel records

3. Assess Hospital Capacity

•Before receiving casualties assess own damage and capability

•Once hospital is safe determine its capacity to manage disaster
•Account for :
•Beds
•Medications
•Staff
•Operating Room
•Doctors
•Supplies
 4. Create Surge Capacity

Surge capacity for medical response

•Surge capacity: rapid development of space for the casualties

•Ability of health services to expand beyond normal capacity to meet increased demand
for clinical care
•Surge capability: rapid mobilization of resources such as stretchers, medical supplies
and equipment, and medical and nursing personnel to care for casualties

Surge capacity priority

•Three most needed and utilized hospital units

1.Emergency department (ED), where all casualties are initially evaluated
2.Operation Theatres
3.ICU.

How to increase existing bed capacity?

1. Early discharge of patients

2. Streamlined discharge processes
3. Transfer to other facilities
4. Cancellation of elective admissions
5. Cancellation of elective procedures
6. Conversion of outpatient service areas to inpatient care units.
7. Changing single-patient rooms into double-patient rooms
8. Utilizing portion of post-anaesthesia recovery units or similar type units as inpatient
bed space
9. Conversion of large rooms/spaces (such as physical therapy space, hallways, etc.) into
multiple-patient rooms/wards

Surge capacity of hospital

•Hospital Treatment Capacity (HTC): number of casualties that can be treated in

hospital in an hour and is usually calculated as 3%of the total number of beds

•Hospital Surgical Capacity (HSC): Number of seriously injured patients that can be
operated upon within a 12-hour period i.e.

HSC = No. of operation rooms x 7 x 0.25 operations / 12 hrs

5. Establish Communication System

•Good communication is critical in disaster

•Cellular phone often overwhelmed in disaster
•Satellite telephones, two way radio, messenger/ runners

6. Supplies & Equipment

•Necessary supplies & equipment must be ready for
immediate distribution
•Quantity must be calculated according to local disaster
plan
•Equipment must be sufficient & appropriate enough to
combat situations

7. Establish Support Areas

•Family Information Centre
•Volunteer Co-ordination Centre
•Media Centre
8. Decontamination

•Perform decontamination in an area that is outside of the clinical care area of the ED.
•This area is located external to the ED but may be in internal locations.
•Use the decontamination facility to remove clothing and cleanse the skin and hair of
patients exposed to a chemical or radioisotope .
•Provide patient coverage and protection from the environment.
•Make sufficient personal protective equipment available for hospital staff assisting with
decontamination.

Mental Health

•Depression
•Anxiety
•Exacerbation of psychiatric disorder
•Target population
Victims
Visitors
staffs
Morgue facilities

•Need to be expanded to other areas of the hospital

•Viewing of deceased patients should take place here, not in treatment areas.

9. Terminating disaster response

•In appropriate time; efforts are directed to bring hospital activity in regular terms
• Address post disaster stress experienced by hospital staffs
• Critical Incident Stress Debriefing (to reduce the psychological impact of these events
on medical responders)
• Careful record & review of deficiencies in disaster plan

Hospital Disaster response scenarios

Chain of incident command at trauma centre in case of multiple/mass casualty

incident
Information Flow Chart in Disaster

All the members of the respective teams to wear respective color coded jackets to be
provided by nursing superintendent from disaster cupboard
Disaster plan activation for a Trauma center
Plan A
Plan B

Plan C

Patient flow during disaster at trauma center

“Plan B and C”
Job cards in order of their appearance in flow of information
•Telephone operator/ counter nurse

•Ask the information about which agency he is calling from: in case of MCI/MCE.
•Inform to the TNC immediately
•Proper recording of everybody’s response time and handing over phone to TNC where
response comes from staff members.
•Participate in post disaster briefing.
•Trauma nurse coordinator
•Confirmation of incident from police from first caller & (100) collect all
information.
•Type of incident

•Place of incident

•Approx. number of victims

•Mode of transportation (ambulance / Private Vehicle)

•Time of arrival.

1. Inform ED SR ( Trauma Surgery, EM, Ortho, Neurosurgery)

2. Call Nodal Officer (As Per Schedule) Take Approval Of Type Of Disaster Plan
Activation.

3. Inform Call Centre As Per Plan Activation.

4. Call Nursing Supervisor On Duty.

5. Inform Nursing Superintendent And All ED Nurses.

6. Inform (Computer Facility)

7. Inform ( Media Coordinator)

8. Inform (Registration Counter)

9. Inform (Security Supervisor)

10. Inform (Sulabh Supervisor)

11. Check All Areas Of Emergency And Ask Of Evacuation.

12. Pass Information To Following And Tell Them To Prepare for MCI.
i. Computer facility
ii. Blood bank
iii. Radiology
iv. Laboratory
v. Manifold
vi. ICU
vii. Public relation officer
viii. Mortuary

Senior residents in Emergency Department

(Trauma Surgery, Emergency Medicine, Orthopedics, Neurosurgery)
1. Report to nodal officer.
2. Senior most SR should take leadership role ( INCIDENT COMMANDER) till the
arrival of NODAL OFFICER.
3. Take stalk of manpower i.e. JR/SR.
4. Inform floor SRs, JRs on duty.
5. Evacuate and relocate the patients in ED.
6. Organize and give the treatment to the patients as per RED/YELLOW/GREEN
teams academic to executive plan.
7. Supervise and help in resuscitation and treatment of patients.
8. Assign the jobs to SRs/JRs/ Nurses as per the RED/YELLOW/GREEN teams
mentioned in the protocol.

Senior residents outside Emergency Department

1. Report to NODAL officer/ INCIDENT commander.
2. Take stalk of situation as to the number of patients requiring surgery/ admission.
3. One SR Anesthesia to assist in RED area resuscitation or as described by the Incident
Commander.
4. All SRs to report back to their respective work areas and arrange for following:
a.SR anesthesia to inform OT nurses and OTA’s and prepare OT’s for receiving
patients.
 b.SR’S of ward and ICU to go back and find patients which can be discharged
immediately i.e.
•Patients waiting for surgery
•Patients convulsing
•Patients waiting for discharge.
5. Call the consultant on call and inform him. Take stalk of manpower and call for more
hands as per duty roster.
6. Call additional SR’s depending upon daily duty roster.

Nodal officer / Operation chief

1. Report To duty As Soon As Possible And Take Charge As Incident Commander
From Senior most SR In Emergency department
2. Supervise the entire incident
3. Better to keep a Rota of doctors who are in hospital on that day to be operation chief

Take home message

•Disaster is Evil Star
•No one can predict time, location, or complexity of next disaster
•Disaster medical care is not same as conventional medical care
•Do crisis management care
•Achieve objective of greatest good for greatest number of individuals
•Taken actions before a disaster to reduce impact
•Triage and re triage when ever needed
•Damage control surgery is an important component of crisis management care

Pitfalls
•Common pitfalls in disaster medical response always the same :
Communication
Supplies
Security
Use of Volunteers

Drill Review Reconcile