Disaster Sudden or great misfortune DISASTER MANAGEMENT Minakshi

Disaster - Sudden or great misfortune DISASTER MANAGEMENT Minakshi Gautam, Assistant Professor, IIHMR

Introduction • ‘Disaster – – Originated from a french word Combination of two terms Des and astre ‘Des’ meaning bad or evil and ‘astre’ meaning star – The expression of term disaster is bad or evil star.

Disaster is a……… • “A major incident arising with little or no warning” • Affecting in high magnitude • Calls for special mobilization and organization of services

Disaster is a calamity of sudden occurrence, a catastrophe causing injury and death to a large number of people during a short span of time.

Disaster – WHO definition “WHO defines a disaster as any occurrence that causes damage, economic disruption, loss of human life and deterioration of health and health services on a scale sufficient to warrant an extraordinary response from outside the effect community or area. ”

Disaster – UNISDR* Definition - 2004 “A serious disruption of the functioning of a community or a society causing widespread human, material, economic or environmental losses which exceed the ability of the affected community or society to cope using its own resources. ” *United Nations International Strategies for Disaster Reduction

Definition • Situation or event, which overwhelms local capacity, necessitating a request to national or international level for external assistance (CRED*). * Centre for Research on Environmental Decisions

Disaster Management • For centuries, examined and treated as an expression of supernatural • Scientific explanation and knowledge based on ‘Cause and Effect’ • This helped in disaster preparedness and mitigation

Disaster Management in India • Both central responsibility and state governments share • Basic responsibility of relief and rescue operations is of state government • Central government plays a supportive role in terms of financial and other resources • Many countries have detailed policy and legislations giving comprehensive direction to prevention, preparedness and response. • The focus of current contingency action plan is relief activities but modifications are being made

Disaster Management in India • 10 th Five Year Plan – a detailed chapter of Disaster Management • 12 th Finance Commission mandated to review financial arrangements for Disaster Management –abolished national fund for calamity relief and created national calamity contingency fund with initial corpus of 500 crores • Department of Agriculture and Cooperation of Ministry of Agriculture is nodal department in Disaster Management • Central Relief operations Commissioner coordinates relief

International relief* under the aegis of the League of Nations in 1927 Beginning in the late 1960’s and early 1970’s the international community became increasingly aware of inadequacies of international relief assistance One of the outgrowths of these debates in early 1970’s was creation of UNDRC** in 1971 by UN General Assembly Under this government of disaster stricken country bears primary responsibility In the federal Set up of India, both the central and State governments share the responsibility *United Nations Disaster Relief Organization. WHO, International Red Cross ** United Nations Disaster Relief Coordination

Contingency Action Plan for Natural Calamities issued by the Ministry of Agriculture, Go. I in 1990 High Power Committee 1999 Earthquake in Gujarat (26 Jan 2001) resulted in creation of Nation Disaster Commission and formulation of National Disaster Policy 2002 -2009 national initiative namely Disaster Risk Management Programme was implemented in collaboration with State Governments by Government of India and UNDP (reduce vulnerabilities of communities in some of the most hazard prone districts of India) 23 rd Dec 2005 Go. I envisaged NDMA*** headed by PM and SDMA^ headed by CM for holistic and integrated approach In India – Act is ministerial level document, not a comprehensive document which has functional, informational and operational linkages *United Nations Disaster Relief Organization. WHO, International Red Cross ** United Nations Disaster Relief Coordination ****national Disaster Management Authority ^ State Disaster Management Authority

Agencies in Disaster Management • Central and State Government • District Administration • Armed Forces • Paramilitary Forces (BSF, CRPF, Assam Rifles, national security guard, etc. • NGOs • International agencies including UN agencies • Media

Organizational Structure at National Level Apex level – Cabinet Committee under chairmanship of PM National Crisis Management Committee under the chairmanship of Cabinet Secretary Crisis Management Group CMG under chairmanship of Central Relief Commissioner and Additional Secretary, Ministry of Agriculture meet regularly *United Nations Disaster Relief Organization. WHO, International Red Cross ** United Nations Disaster Relief Coordination

Agencies in Disaster Management • At national level depending on type of disaster, nodal ministries are assigned the task • • Natural Disaster – Ministry of Agriculture Railway Disaster – Ministry of Railways Air Disaster – Ministry of Civil Aviation Biological Disaster – Ministry f Health

Transmission of Information Indian Meteorological Department and Central Water Commission informs Central Relief Commissioner about forecast of natural disasters CRC informs Secretary (Agriculture and Cooperation) Informs Cabinet Secretary CS informs Prime Minister, Agriculture Minister, National Crisis Management Committee CRC informs other concerned central and state government departments including Mohfw through Emergency Medical Relief Division (EMRD) of DGHS

Transmission of Information • Present state of warning system in country includes – 158 flood forecasting stations – 56 seismic stations – Disaster warning system – INSAT Satellite

Disaster Management at State Level • Each state has its own organization pattern, policies and plan • Broad pattern based on guidelines by Go. I • Each state has Relief Commissioner and Chief Secretary • Primary responsibility – relief operations, preparedness and rehabilitation instead of comprehensive plan encompassing prevention • District is the basic unit • District administration prepares contingency plans

Committees and various organizations • Cabinet Committee • National Crisis Management Committee • Commando Force – professional well equipped specialized in calamity specific operations • Disaster High Power Committee 1999 • Crisis management Group • State Crisis Management Group • District Administration • District Relief Committee • district collector has the authority for requisition to the Armed Forces

Committees and various organizations • National Centre for Disaster Management • International consortium known as Prevention Consortium (coalition of World Bank, Insurance companies, government, universities, NGOs)

Group Activity : 30 minutes • Activity 1: Classification of Disasters • Activity 2: Difference and relationship between risk, vulnerability and disaster • Activity 3: action to be taken at health centre when casualties reach there • Activity 4: health problems related to disasters • Activity 5: What is triage? Discuss • Activity 6: Public health measures to prevent vector borne and communicable diseases

Classification of Disasters • Natural Disasters – Earthquakes – Floods and famines – Cyclones, hurricane, typhoons (cyclones – Indian and pacific Oceans, Hurricane – Northeast Pacific, typhoons – northwest Pacific) – Tsunami, tidal waves – Landslides and Avalanches – Volcanic eruptions • Man-made Disasters – Nuclear, Biological, Chemical Disaster (NBC) – Accidents

Earthquakes • Earthquakes have caused huge damage to life and property worldwide • Significant threat to India also because of falling of almost 59% of its geographical area in earthquake vulnerable zones. • Impacts of an earthquake are the loss of human lives and property, economic & social losses and environmental degradation. • Over the last century, about 75% of fatalities attributed to earthquakes have been caused by the collapse of buildings.

Earthquakes • A great number of victims die in the collapse of nonengineered weak masonry buildings • absence of knowledge in earthquake resistant construction & retrofitting techniques at the grassroots and • non-compliance of appropriate building regulations and town planning legislations for earthquake safe guided physical development in towns.

Earthquakes • Besides, ignorance of basic tips of earthquake survivability • Further, least expertise by rescuers in search & rescue • Deaths almost more than 10% of population • The ratio of dead to injured approx 1: 3 resulting from primary shock • Use of thermal imaging, sniffer dogs, multiple sensors

Destructive Winds • Unless complicated by secondary disasters such as floods or sea surge cause relatively few deaths and injuries Flash Floods and Sea Surge • Deaths mainly due to drowning • Commonest amongstt weakest members of population

Floods • Slow flooding causes limited immediate morbidity and mortality • Slight increase in deaths from venomous snake bites • Traumatic injuries caused by flooding requires limited healthcare

Hurricane Earthquake Floods

Thunderstorm Indonesia

Landslides and Avalanches • Landslides & Avalanches are among the major hydrogeological hazards that affect large parts of India, especially the Himalayas, the Northeastern hill ranges, the Western Ghats, the Nilgiris, the Eastern Ghats and the Vindhyas, in that order. • Landslides in the Darjeeling district of West Bengal as also those in Sikkim, Tripura, Meghalaya, Assam, Nagaland Arunachal Pradesh pose chronic problems causing recurring losses.

Nuclear, Biological and Chemical Warfare • In 1995, the Japanese religious cult, Aum Shinrikyo, released the nerve gas, Sarin, in the Tokyo Subway. • 12 persons were killed and several thousands suffered illness • Investigation disclosed aerosols of anthrax attempts to disseminate • Unsuccessful as he used weakened strain of Anthrax

Salient features in medical management of NBC causalities • The lack of experience and skills of professionals will adversely affect the medical management • Healthcare workers may themselves suffer significant damage • Triage protocol during NBC scenario is different – difficult to save victims with burns of more than 30% total body surface area (TBSA) and exposure to more than 450 rads of ionising radiations

Salient features in medical management of NBC causalities • Nuclear Warfare – Segregated and monitored casualty evacuation, separately for radioactive, biologically contaminated and non contaminated cases. – Significant numbers are burn casualties which are caused due to ‘flash’, ‘fire’ or ‘beta’particles – Immediately after a nuclear explosion temperature may go upto 106 degree C and pressure 105 atmospheres – 50% energy due to blast, 35% heat and 15% nuclear radiation after detonation

Salient features in medical management of NBC causalities – All casualties of nuclear warfare must be regarded as radiation victims unless proven otherwise. – Use of dosimeters and PPE

Salient features in medical management of NBC causalities • Chemical Warfare – Potent means of mass destruction – Lethal agents like Sarin or incapacitating agents like Distilled Mustard – Blister agents, nerve agents, blood agents, choking agents, tear agents (riot control agents) – Blister agents were used by Germans against the British during 1 st world war – Phosgene (choking agent) accounted for 85% of deaths attributable to chemical weapons during the 1 st world war.

Bhopal Gas Tragedy memorial

Salient features in medical management of NBC causalities • Biological Warfare – Use of living organisms or their toxic products to cause disability, damage and death. – Recipes for making biological weapons are now available on internet. – 14 th century – targets besieging the Italian in a fortress in Cremea threw over walls bodies of plague victims – Red Indians in North America were given smallpox infected blankets – Use of mycotoxins in Afganisthan

Salient features in medical management of NBC causalities • Biological Warfare – In 1972, Biological and Toxic Weapons Convention attended by almost all the countries agreed to cease bio-weapons research programs – Also the agreed to destroy all stocks – Despite this reported fact is that during 1990 s countries had stockpiled tons of dried spores of Anthrax, smallpox, plague, etc – Indicators of biological attack – number of persons affected, time relationships, sharply defined geographical boundaries and clinical profile

Salient features in medical management of NBC causalities • Biological Warfare – Lab diagnosis by antigen-antibody detection – Application of fluorescent antibody technique (FAT) – PPE – Ultra high efficient filter masks which are capable of filtering more than 99% particles of 1 -5 microns – Isolation of cases- negative pressure isolation – Immunoprophylaxis – vaccines during Gulf War to protect from Anthrax – Chemoprophylaxis

Short term effects of major natural disaster Effect Earthquakes High Winds Tidal waves Floods Death Many Few Severe injuries requiring extensive care Overwhelming Moderate Few Increased risk of communicable diseases Food Scarcity Potential risk following all major disasters (Probability rising with overcrowding and deteriorating sanitation) Rare Common May occur due to factors other than food shortage Major Population Movements Rare May occur in heavily damaged urban areas

Health Problems related to Disasters • • Pre-existent level of disease Ecological changes Population displacement Sewage disposal, water and other public utilities may be interrupted • Interruption of basic public health services

Types of Diseases Disease A Water and Food Borne 1. Typhoid 2. Food Poisoning 3. Sewage Poisoning 4. Cholera 5. Leptospirosis B Public health measures Adequate disposal of faeces and urine Safe water for drinking and washing Sanitary food preparation Fly and pest control Disease Surveillance Isolation and treatment of early cases Immunisation (typhoid and cholera) Person to Person Spread Contact and respiratory diseases 1. Shigellosis 2. Streptococcal infections 3. Scabies 4. Small pox 5. Measles 6. Infectious hepatitis Reduce Crowding Adequate Washing Facilities Public Health Education Disease Surveillance in Clinics Treatment of clinical cases Immunisation (typhoid fever, cholera, smallpox, measles)

Types of Diseases Disease Public health measures 7. Whooping cough 8. Diptheria 9. Influenza 10. Tuberculosis Isolation of cases (chicken pox) Primary immunization of infants (diptheria, whooping cough, tetanus) C Vector Borne Diseases 1. Louse borne typhus 2. Plague 3. Relapsing fever 4. Malaria 5. Vital encephalitis Disinfection (except malaria and encephalitis) Vector control Disease surveillance Isolation and treatment D Wound Complications TT injection Post exposure tetanus antitoxin

Global Scenario • Second major human problem after war • In terms of monetary damage and number of people killed or effected. • Greatest economic and social impact in poorest countries

Global Scenario • An event that causes deaths of 125 people in a high income economy tends to cause 33, 000 deaths in low-income economy*. • Average per event mortality per 1000 population was 69 in low income, 28 in middle income and one in a high income economy* * Debrati, Guha, Sapir, Michal F Lechat. Disaster Management. Report of Workshop organised by Directorate General of Health Services, Mohfw, Go. I, 1986

Global Scenario • Estimated that disaster events globally cost about 50, 000 million US dollar each year* • Results in approx 2, 50, 000 deaths in a year* • Nearly 20 major disaster strike the world every year * Carter W Nick. Disaster Management. A disaster management handbook. Asian development bank, Manila, 1991

Global Scenario • Amongst the major disasters are floods, cyclones and earthquakes • World Disaster Report 1999 indicates 89, 546 people were killed in 542 disaster events with average estimates of 71. 9 million dollors. • Nearly 80% of deaths were due to Natural Disasters* * IFRC World disaster report 1999

Global Scenario • Asia-pacific region witnesses a large number of natural disasters due to geographical location • 60% of major natural disasters reported in the world occur in this region.

Global Scenario • World’s worst disaster occur in regions between Tropic of Cancer in north and Tropic of Capricon in south • It has approx 20 major disasters annually

Global Scenario • This region includes poorest nations of world • 90% of all deaths from disasters, therefore, occur in developing countries

Global Scenario • Asia is the continent hit hardest by disasters according to figures from Belgian WHO collaborating centre for Research on Epidemiology of Disasters (CRED)- (2007 database)

Global Scenario – natural disaster occurrence by continent Asia 74, 80% Africa 6, 10% Americas 12, 20% Europe Oceania 5, 10% 1, 40% 0, 00% 20, 00% Series 1 40, 00% 60, 00% 80, 00%

Total number of reported disasters Continent Droughts Earthquakes Floods Volcanic Eruptions windstorms Industria Accidents Africa 13 24 442 7 86 57 America 56 43 357 23 343 27 Asia 60 170 686 19 398 406 Europe 11 35 256 2 149 51 Source: EM-DAT, CRED, University of Lovain, Belgium

Global Scenario – floods and windstorms have maximum impact 250 206 200 150 103 100 in d an o lc Vo or m 6 W s id e nd sl Fl oo ds La Ea rt hq u ak e gh t ou dr 18 10 st 19 10 0 Fi re 50 Source International strategy for Disaster Reduction (UN/ ISDR – www. unisdr. org)

Indian Scenario • Frequency distribution of disasters in the Asian region between 1964 and 1986 showed that India is one of the most disaster prone country. • Natural disasters like floods, earthquakes, cyclone and drought are major causes

Indian Scenario • This is due to vast variation of geographical terrain and climatic conditions. • India with 2. 4 % of world land area, seventh largest country in the world, 15% of world population, and population density of 273 persons per square km makes disaster effects more serious.

Indian Scenario • Most flood prone countries in world • Area affected by flood annually on an average is 9 million hectares. • Accounts for one fifth of global death counts due to floods. • Out of 96 internationally recognized natural disasters country experienced between 1960 and 1981, 28 were due to floods*. * Jain PC. Flood Mitigation Practices in India, Disaster Management. IIPA. New Delhi, 1984

Indian Scenario • 56. 3% of its total area (amounting to 3. 3 million square kilometers) is vulnerable to seismic activities of different intensity*. • Entire northern part of India from Hindukush to Eastern Himalayas lies in earthquake prone belt. * Parischa UP. Natural Disaster Management in India. Disaster Management in Asia and Pacific. ADB, Manila, 1991

Indian Scenario • From Kashmir to North East the geological processes of rock formation and uplifts makes area earthquake prone. • These areas have witnessed over 31 major earthquakes in last century. • 5700 km long coastline of India is vulnerable to tropical cyclones arising in Bay of Bengal and Arabian Sea.

Indian Scenario • Havoc caused by cyclone is mostly due to strong winds, accompanied by rains, tidal waves • Every year 5 -6 cyclones occur out of which 2 -3 are severe • More cyclones in Bay of Bengal than Arabian Sea and the ratio is about 4: 1.

Indian Scenario • India has been witnessing increasing incidence of man made disasters. • Worst man made disaster so far – Bhopal Gas Tragedy on 3 rd Dec 1984 (Union Carbide India Limited (UCIL) pesticide plant. A leak of methyl isocyanate gas and other chemicals from the plant) • Resulted in the exposure of hundreds of thousands of people. 3000 died within a week and 8000 ever since the incidence • A government affidavit in 2006 stated 558, 125 injuries including approximately 3, 900 severely and permanently disabling injuries.

• Five fold increase in the frequency of disasters during last 30 years. • Some of the major disasters were; – Cyclones along the coast of Andhra Pradesh and Orissa at interval of every few years (claimed 25, 000 lives) – Earthquake in Uttarkashi in 1990 – Earthquake in Latur in Maharashtra in 1993 – Many train accidents off and on – Earthquake in Gujarat – Jan 2001 – Tsunami, Southern Indian Coastline – 26 Dec 2004. 10273 dead, 2, 39, 024 families homeless, 27, 22, 000 population affected.

Disaster Results from • Earthquakes, heavy rainfall, typhoons, storms, chemical accident, drought or armed conflict. (primary cases) • Flooding, fires, famine and multitude of refugees (secondary cases) • In general, primary cases of disasters are not preventable. • Secondary effects, however are amenable to prevention, or at least mitigation.

• Disaster have the tendency to; – Interrupt the normal functioning of community – Exceed the coping mechanisms of the community – Require external assistance to return to normal functioning of a community

Definitions • Hazard: A source of danger; an extreme event; possibility of incurring loss or misfortune. A potentially damaging physical event, phenomenon or human activity that may cause the loss of life or injury, property damage, social and economic disruption or environmental degradation. Hazards include latent conditions that may represent future threats

Modes of Hazard • Dormant – potential to be hazardous but no life harmed • Potential – hazard in position to affect persons • Active – certain to cause harm, as no intervention is possible or planned • Mitigated – potential hazard identified and reverted

Risk, Hazard, Vulnerability Risk: Probability that loss will occur as the result of an adverse event Risk = hazard x vulnerability Vulnerability: Extent to which a community’s structure, services, or environment is likely to be damaged or disrupted

Risk, Hazard, Vulnerability Resilience “The capacity of a system, community or society potentially exposed to hazards to adapt, by resisting or changing in order to reach and maintain an acceptable level of functioning and structure. This is determined by the degree to which social system is capable of organizing itself to increase this capacity for learning from past disasters for better future protection and to improve risk reduction measures.

Hazards vs. Disasters • Disaster = interaction between a hazard and a community • Potential for disaster is based on: • Hazards present in community • Vulnerabilities of the community • Disaster preparedness of the community

PICE* System in Mass Casualty Incidents A. Potential Casualties B. Resources C. Geographical Involvement D. PICE Stage Static Controlled Local 0 Dynamic Disruptive Regional I Dynamic Paralytic National II Dynamic Paralytic International III * Potential Illness Creating Event Column A : Potential for Additional Casualties Column B: describes whether resources are overwhelmed (augmentation or reconstitution needed) Column C: describes extent of geographical involvement Source: Koeing K, et al: Disaster Nomenclature – a functional impact approach: the PICE System: Acad Emeg Med, 1996, 3: 723 -727

PICE* System in Mass Casualty Incidents • It is a method for consistency in Disaster Classification based on the likelihood that outside medical assistance will be needed • Stage 0 means little or no chance • Stage I means there is small chance • Stage II means there is moderate chance • Stage III means local medical resources are clearly overwhelmed

Incident Command System Incident Commander Information Safety Liaison Operations Planning Logistics http: //www. emsa. ca. gov/HICS/default. asp Finance/ Administratio n

References • http: //ndma. gov. in/ndma/index. htm

Disaster Management • Spectrum of disaster management involves: – – – Prevention Mitigation Preparedness Response Reconstruction or Recovery • Each of these are interlinked and mutually dependent • Three important aspects of disaster management are – Prediction, Prevention and Planning • Similarly, three important operational aspects are rescue, relief and rehabilitation

Disaster Management • Prevention concerns – formulation and implementation of long-range policies and programs to prevent or eliminate the occurrence of disaster • Disaster Mitigation includes all those measures aimed at reducing the impact • It spans the broad spectrum of prevention and preparedness • Disaster preparedness aims at measures, which enables governments, organizations, communities and individuals to respond rapidly and effectively

Disaster Management • It is supported by necessary legislation, resource planning, training, etc • Disaster Response are measures that are taken immediately prior to and following disasters • These are directed towards saving property, lives • Disaster Recovery is the process by which communities and nations are assisted in returning to their proper level of functioning following a disaster

Hospital Disaster Management Plan • Preparedness is the central issue • It is based on risk assessment, hazard assessment and vulnerability analysis • All disasters inevitably have health consequences • A well-planned health delivery system is most important preparedness for a catastrophe • Planning, organizing and coordinating healthcare in advance

Hospital Disaster Management Plan • Aim – The aim of disaster management plan is to provide prompt and effective medical care to the maximum possible in order to minimize morbidity and mortality • Objectives – optimally prepare the staff – Optimally prepare institutional resources – Make community aware of sequential steps that should be taken

Hospital Disaster Management Plan • Principles of Disaster Management Plan – – – Simple Flexible Concise – specify roles and responsibilities Comprehensive – pre and post hospital components Adaptive and anticipatory- hospital provides aid and when itself the site of disaster – Part of regional plan – fire brigade, police and administrative components

Hospital Disaster Management Plan Phases of a Disaster • • • Pre-disaster phase Alert Phase Impact Phase Post-impact Phase Reconstruction and rehabilitation phase – Reconstruction and rehabilitation phase lasts the longest

Hospital Disaster Management Plan-Predisaster Phase • Risk assessment – Awareness about nature – Readiness to respond promptly – Meant to demonstrate the risk factors required to be addressed in order to mitigate the effects of disaster. – Local hospital has an active role to play both before and after disaster • Training – Key to successfully deal with disasters – Training for skills related to; • Effective personal protection from falling debris. • Prompt rescue of the wounded • Triage of the wounded • Resuscitation and first aid for injured victims • Pre-positioning of relief supplies needed for the post impact phase such as surgical equipment, essential medicines, blankets, tents • Establishment of temporary water supplies. • Allocation of responsibilities for different relief activities to avoid unnecessary chaos.

Hospital Disaster Management Plan - Alert Phase • Refers to period when a disaster is developing • Duration varies according to type of disaster – For e. g. nonexistent for earthquakes, short but crucial for typhoons and quite long in case of draught and famine.

Hospital Disaster Management Plan - Impact Phase Needs of community depends on characteristics of disaster and degree of preparedness. – Earthquakes are very unpredictable and highly lethal whereas cyclones are more predictable. – Priorities of a relief effort should reflect these realities. – The immediate response should not await a detailed assessment of impact. – The effectiveness of relief effort will depend entirely on local efforts and preparedness of community. – During this phase, planning includes activation of response mechanism, daily monitoring, updating of response measures and coordinating outside assistance.

Hospital Disaster Management Plan - Postimpact Phase • • • This phase may vary between few days and several months following the initial impact. Actions required; Evacuating the survivors to safe areas Provide shelters to homeless Providing food and water Continuing the triage and transportation of the injured to appropriate facilities. Re-establishing primary health care services. Re-establishing sanitary measures to prevent outbreak of epidemics. Health implications in such situations are manifested as food and water borne disease.

Hospital Disaster Management Plan – essential requisites • Situation Analysis – administrative and medical set up, topographical, demographical, disaster mapping, industries • Effective Networking • Unified Medical Command • Comprehensive Disaster Plan and Manual

Disaster Management in Hospitals

Types Of Disaster • External Disaster • Internal Disaster

CODES Blue: Individual disaster Grey: earthquakes Red: Fire Pink: Baby disaster (Abduction) Purple: Fight likely Orange : Hazardous material spill

HOSPITAL PREPAREDNESS PLANNING • Should address both External and Internal emergencies. • Resources may often be depleted quickly in both circumstances • Internal incident requires major adaptation from SOPs due to disruption in physical plant by events such as loss of structural integrity, utilities or hazard exposures.

HOSPITAL PREPAREDNESS PLANNING • Hospital plan should be integrated with other community preparedness plans • It is important that the hospital be able to maintain its basic functions

ROLES AND RESPONSIBILITIES OF PLANNING COMMITTEE • • • Steps in the planning Developing written preparedness and response plans Identifying training needs Organizing tests/exercises or drills at regular intervals Liaising with other emergency management agencies

The Elements of the plan • • • Incident Commander, who will take command of the entire hospital and its resources. Hospital Medical Operations Chief will be responsible for the hospital medical response Command centre staffing Lines of authority within the hospital and departments Roles and responsibilities of key personnel Information detailing responsibilities and tasks

The Planning Process • • Determine the authority to plan Establish the planning committee Conduct Risk Assessment Set Planning objectives – based on Ri. SK ANALYSIS Analyse Resources Develop systems and procedures –strategies for prevention, mitigation, preparedness, response and recovery Write the plan Train personnel

The Planning Process • • • Test the plan, personnel and procedures Review the plan Amend the plan – Hospital planning committee should include representatives of each department, representatives of community health system like public and mental health, as well as external emergency services like ambulance, police, fire services, etc.

The Planning Process • Significant part of planning process is “What if” Analysis • Ponders on Questions like what if such and such happened, what would we do, what would we need, what would be the implications, etc.

ACTIVATION OF PLAN • Activation should specify circumstances for which the plan can be activated Should identify those responsible for activation Activation stages; • • – – ALERT – possible hazard impact STAND BY- hazard impact probable (staff need to be ready for immediate action) IMPLEMENT – hazard impact has occurred (deployment has occurred) STAND DOWN- response operation has ended, situation contained

Internal Disaster is an emergency situation that occurs within the institution interrupting services, threatening lives of staff, patients, and visitors and sometimes necessitating mass evacuation. Fire, building collapse, an explosion, chemical spills, strikes etc. can cause Internal Disasters

Procedure in case of fire If smoke detector or the sprinkler system gets activated Alarm in fire command room gets activated with active zone flashed Parallel Alarm in LT panel in the engineering gets activated with active zone flashed Verifies the Zone Informs the Security Supervisor Security personnel to reach the site Informs engineering control room supervisor Engineering personnel to reach the site

Site checked In case of fire In case of false Alarm Contacts engineering and Security for additional help, if required Control room informs Chief Engineer/ CSO/ GM Assessing the gravity of fire, fire brigade is informed with approval from COO/MD/GM Engineering and Security control room is informed and entry is made

Types Of Internal Disaster 1 Fires: Implement the R-A-C-E plan. 2 Bomb Threat: Contact Security immediately. 3 Chemical Spills: Contain the spill if possible, contact HAZMAT team. This action shall be taken immediately without waiting for declaration of CODE for activation of Internal Disaster Plan.

Disaster due to fire The Principle of R. A. C. E. • When faced by a Fire Situation, always remember the principle of R. A. C. E. while taking any action in the matter: • R-escue - Remove everyone from the area. If a fire has occurred in a patient room the staff shall immediately remove the patient from the area. • A-larm – Activate the Fire Alarm by pulling down the nearest Manual Call Points (MCP) are located throughout the building, several on each floor. By activating the Fire Alarm a fire action plan is set into motion where Security receives the signal and initiates the emergency response. The Engineering department is also alerted to act immediately to cut off AHUs and Electrical Power wherever necessary to retard the spread of fire.

Disaster due to fire • C-onfine – Once the room or area has been cleared of patients the door shall be closed thus confining the fire, which enables the fire response team the time needed to arrive. • E-xtinguish or Evacuate - When practical and only when an employee has been properly trained in the safe and proper use of a fire extinguisher, extinguishing shall be attempted using one fire extinguisher. Evacuate if you are not comfortable using a fire extinguisher or if more than one extinguisher is needed.

CLASSES OF FIRE • • “A” “B” “C” “D” CLASS FIRE - GENERAL FIRE flammable liquids electric fire Metallic Fire

Know your fire extinguishers 1) Pressurized Water – 2 ½ gallons – – Range : 30 -35 feet To be used on class A fire (wood, paper, trash, bedding, etc. ) 2) Carbon-di-oxide – – – 5 -15 lbs Range: 4 -6 feet To be used on class B fires (flammable liquids) and on class C fires (Electrical)

Know your fire extinguishers 3) Dry chemical (ABC) – – Range : 5 -10 lbs Used in Class ABC all – – 4) Halon Type Bromochlorodiflouromethane (BCF Cylinder for sophisticated equipments etc. )

BCF Cylinders

Disaster due to fire • In deciding to fight a fire, you need to determine a few things: i) If there is a fire extinguisher with the proper fire rating and classification available ii) The size of the fire; anything more than a wastebasket is probably too large iii) The amount of firefighting ability needed to address the situation. If you are not completely confident, close the door to the fire area and evacuate. iv) Fourth, Remember the Acronym P. A. S. S. – – Pull the Pin. Aim the Extinguisher nozzle at the base of the Fire. Squeeze the handle while holding the Extinguisher upright. Sweep from side to side covering the fire with extinguishing agent.

Responsibilities Fire Fighting Team: • Trained Fire Fighting Guard on rolls of the Security staff and on duty shall head the Fire Fighting Team at the time of the incidence of Fire. • There shall be at least 4 trained Fire Fighting Guards on duty in each shift and shall be stationed at each floor at all times. • The Fire Fighting Guards shall take action as per Fire Fighting Manual of the hospital. • The Fire Fighting Guards shall reach the site of Fire on activation of the Fire Alarm, communication from the Fire Command Room or on telephonic or verbal intimation by any personnel of the hospital

Responsibilities • Rescue Team: • The Security Supervisor on duty shall head the Rescue Team. The Rescue Team shall be trained to handle rescue operations at the site of incident. • All Security Staff shall be trained in rescue operations in case of Fire, Chemical Spills, and Building Collapse etc. • The Rescue Team shall be activated by the Chief Security Officer immediately after assessing the need based on the nature of the incident

TRANSPORTING HANDICAPPED PERSONS • Backpack lift by one rescuer • Seat Carry by 2 rescuers • Mattress drag technique

Safety Manual • Defines steps and procedure (SOPs) • Policies for response to both internal or external disaster • Identifies responsibility of individuals & departments

Purpose of Manual • Identification of disaster • Policy and procedure in case of external and internal disaster • Policy for involving networked hospitals • Training procedures and mock drills

STRUCTURE OF THE MANUAL • Policy and procedures for internal and external disaster • Policies and procedures for hospital networking • Training techniques and guidelines • Roles and Responsibilities • Reporting Mechanism

Policies in Manual • • • Communication system in case of external/ internal disaster Responsibilities of administrative staff Responsibilities of clinical staff and departments Mandatory equipments and medicines Storage of dead bodies Components required for hospital Networking Procedure for hospital networking Allocation of staff Classification of casualties Policy on operations of lift in fire Policy on Smoking Control Policy on fire safety and fire doors

Contd…… • Manual should also have annexures – – – Telephone numbers List of ambulance services List of emergency services List of mortuary services List of network hospitals List of blood banks List of crash cart locations List of crash cart contents List of emergency kits content List of 24 hrs pharmacies List of blood groups of all hospital employees Sample assessment sheet for mock drills

Disaster Management Team ADMINSTRATION DAY TEAM • General Manager • Chief of Medical Services • Chief of Nursing • CMO • Customer Care Manager • Support Services Manager • Facilities Manager • Bio Medical Engineer CLINICAL DAY TEAM • • • Consultant ER Medical Officers ER Physicians on duty Nurses Technicians Blood Bank staff SUPPORT SERVICES DAY TEAM • Security Officer • Housekeeping Manager • Materials Manager • Pharmacy Manager • IT Team

Disaster Management Team ADMINSTRATION NIGHT TEAM 6 pm – 8 am CLINICAL NIGHT TEAM 6 pm – 8 am Manager on Duty Nursing Supervisor ER Duty Doctor Customer Care Assistant • Housekeeping Supervisor • Facilities Technician • ER Duty Doctor • All Duty Registrars • All Junior Consultants • Nursing staff • Technicians • • SUPPORT SERVICES NIGHT TEAM 6 pm – 8 am • Security supervisor on duty • Store assistant • Pharmacy assistant • IT support staff

ESCALATION MATRIX CUSTOMER CARE/ER General Manager Coordination with External Agencies Internal Communication and Coordination Chief of Medical Services Chief of Nursing Consultants Communication to CEO/ COO Communication with Media and Press Staff of ER

COMMAND NUCLEUS S. No. Designation Extensi on No. Mobile No. +91 ----- 1. Chief Operating Officer Head Of Command Nucleus 4120 2. Medical Director 4105 3. GM Administration 4943 4. Head Emergency 4086 5. Chief Engineer 4901 6. Chief Security Officer 4975 7. Support Services: - F& B H. K. 4959 4982 8. Nursing Superintendent 4013

Response of hospital personnel to internal emergencies • • Remove individuals from areas of risk. Remove equipment if appropriate. Ring up No. XX and report the incident. Contact your supervisor before leaving your work area if possible. The Command Nucleus, shall be established as per location of the incident. ( Board Room/ Gate No. 1) Security shall secure the Hospital exits & entrances as necessary and direct media to the Public Information Center established at Training room/Gate No 1. Report to your department heads for instructions. Assist in damage control if possible.

COMMAND NUCLEUS In the event a situation causes disruption to normal activities an Internal/External Disaster may be declared by any member of the Command Nucleus. The internal/External disaster shall be Communicated by announcement of code grey/red on the hospital public address system by the operator on duty. Contact number for declaration of code e. g. grey/red is: XX.

Contd. The first available member of the Command nucleus shall be authorized to declare CODE GREY/Red depending upon the enormity of the incident.

About Command Nucleus All members of Command Nucleus present in the hospital shall meet immediately in board room and in case of any emergency in that area, from Gate no. 1, at the security gate of the Hospital, on declaration of CODE for external disaster.

Activation of contingency plan for internal/external disasters Information for any Internal Disasters shall be received at the EPABX through Hospital internal phone no say extension 56 On receiving information of an Internal or external Emergency from any individual the operator on duty shall identify the person giving the information and inquire about the location, nature and magnitude of the emergency. THE OPERATOR ON DUTY will then immediately inform any of the members of the Command Nucleus in the following order: Chief Security Officer, Medical Director, COO, Chief Engineer, Head Administration, Nursing Superintendent, Director Emergency and Head Support Services Facilities.

COMMUNICATION OF CODE GREY The EPABX is the HUB for all communications Internal Contact Number for CODE for external disaster is e. g. XX Operator On Duty (OOD) after declaration of CODE will inform the security control room to announce CODE over the Public Address System (PA) of the hospital. The announcement shall be made 3 times at a time after every 30 seconds, at least thrice.

Contd. After announcement of CODE on the PA system, the Operator on Duty shall ring up each member of the Command Nucleus on extension as well as cell numbers. The Operator on Duty shall ring up Senior Medical Officer (Emergency) on duty after informing the members of the Command Nucleus. The following Department Heads shall then be informed so that they can perform the assigned duties in case of Internal Disasters. Blood Bank, Pharmacy, Biomedical, House Keeping, F&B, Marketing, Transport, Nursing, Lab Medicine, Radiology.

PUBLIC INFORMATION CENTER • Hospital shall set up a Public Information Center (PIC) headed by Senior Manager Media & Communications which shall be activated in case of any Internal Disaster. The PIC shall operate from (specify the room in the hospital) Training Room First Floor if that area is affected than from the Gate 1. The Center shall have the following telephone numbers: Internal Number: External Number: 5139 2547000

Responsibilities of administrative staff & Administrative Departments • General Manager – – Check with local authorities Obtain additional information Ask for help with local police, volunteer organizations Facilitate administrative support • Chief of Nursing – GM’s function in his/her absence – Inform all department heads – Ensure information reaches victim’s family

Responsibilities of administrative staff & Administrative Departments • Nursing Supervisor on duty – Identify extent of disaster – Set up Command Center – Adequate number of nurses • Admission Office • Public Relations

Responsibilities Chief Operating Officer: • The COO of the hospital is the overall Administrative Head for the implementation of plan Internal Disasters. He has the following broad responsibilities: • Clearance of information to be released to the Press, relations of effected and outside agencies. • Periodic review of arrangements. • Overall direction and leadership in the matter

Responsibilities • Chief Engineer: • The Chief Engineer shall be responsible for ensuring cutting off of power to the effected areas if required. • Ensuring that Fire Pump House is manned. Ensuring that water supply source remains intact. • Maintaining water and power supply to the areas that are not affected. • Maintaining proper ventilation of the Casualty Triage. • Cutting off medical gas supplies to the areas that are affected. • Maintaining interruptions free Medical Gas Supplies to the areas that are not affected. • Controlling CSSD operations.

Contd. • Ensuring sufficient stock of HSD for Boilers & DG Sets. • Overlooking Biomedical Equipment maintenance, availability and checks. • Recalling all off duty/ on leave staff. • Ensuring that lifts are not used in case of fire. • Ensuring that there is no unauthorized entry in the Utility, Medical Gases, and CSSD and Water Supply areas. • Providing support for Fire fighting, if required, on request from CSO. • Providing technical support for rescue and evacuation

Senior Manager Media & Communications/ Head Marketing: • The Senior Manager Media & Communications/ Head Marketing shall be responsible for: • Setting up Public Information Center on declaration of CODE GREY. • Taking care of all activities pertaining to the Public Information Center. • Establishing Information Services for attendants of the casualties. • Centralizing information about the casualties and updating Casualty List. • Deploying Marketing Team for Public Information activities. • Keeping a close communication with the Command Nucleus. • Liaising with the Press and outside agencies for releasing information and data after clearance by the Command Nucleus. • Organizing Press Conference, if required.

Responsibilities Medical Director: • The Medical Director (MD) shall be overall in charge of all Medical Operations in case of Internal Disasters. He shall: • Interface with medical staff, nursing and ancillary disciplines to ensure the appropriate level of medical response. • Take over all administrative duties in the absence of the COO. • Ask for help from local police and volunteer organizations as deemed necessary. • Liaise with government agencies and public hospitals for inter hospital transfer of patients if necessary. • Have the telephone numbers of nearby & other private & government hospitals to coordinate the efforts.

Responsibilities Nursing Superintendent: The Nursing Superintendent of hospital in case of Internal Disasters shall: • • Identify nursing needs. Help in Evacuating patients if required. Allocate extra nursing staff in essential areas. Re-deploy existing staff and Recall of off duty staff. Ensure assistance in providing Basic Life Support. Periodically review nursing arrangements. Ensure arrangement of drugs, medical oxygen cylinders, linen etc. in co-ordination with support departments.

Responsibilities of Support Service Department • • • Nursing personnel assigned to Disaster Victims Imaging Services Laboratory Blood Bank Maintenance Housekeeping & Laundry Materials department Pharmacy IT Infection Control CSSD Security

Responsibilities • Chief Security Officer: • The Chief Security Officer of hospital shall be responsible for Leading operations of Fire Fighting, Rescue & Evacuation Teams. • Cordoning off the Casualty/ Emergency area. • Regulating entry & exit of personnel to ensure smooth functioning of Emergency Services. • Ensuring Ambulance and other emergency services vehicles are allowed exit and entry freely. • Controlling of unwanted traffic and public gathering by Security till local police help available. • Ensuring that Security Guards deployed at Critical Areas have Walkie -Talkie sets.

Contd. • Ensuring regular communication between Security Guards stationed at Casualty Triage through Walkie –Talkie sets. • Ensuring regular testing of Walkie –Talkie sets so that they remain in good working order. • • Ensuring safeguarding of belongings of Disaster Victims. Calling in police if required. • Providing separate parking to attendants of the victims and regulating parking. • Earmarking area for transfer of dead bodies and safe & efficient transfer of dead bodies to the morgue.

Contd. • Maintenance of Morgue Register with proper identification, time of arrival, name & identification of the person taking the body, signatures of a witness to the release of the body, destination of the body, name of the security guard on duty and his signatures, and time of release of the body. • Ensuring that personal valuables are collected from the dead bodies & sealed. • • Ensuring that enough lady guards are deployed for handling ladies. Requisitioning of additional transport in consultation with MD/GM Admin & Engineer • • Identifying a vehicle marshalling area. Training two senior supervisors for coordinating the security operations in his absence. • Ensuring that press is directed to the Public Information Center.

Mandatory Medicines & Equipments • Define medicines and equipments • Can be stored or procured from other departments – define • Spell quantity in policy

• MEDICINES – Analgesics, antibiotics, antiseptics, bandages, cotton, suture material – Inj Ceftriaxone – Inj Metrogyl – Inj TTD – Inj Tramazac – Inj Diclofenac – Silverex burn ointment – IV fluids RL, NS, DNS, FFP

• EQUIPMENT – – – – • EQUIPMENT Splints- all sizes IV stands Ventilators Heart Monitors Crash Carts Dressing Sets Wheel Chairs Trolleys Pulse Oxymeter Defebrilators Syringe pumps Pacemakers Suction apparatus Incubators Invasive and non-invasive pressure monitors – Oximeters – Glucometers • Vacuum mattress fitted • Spine board • Stretcher • Aero medical stretchers

Procedure to be followed for hospital Networking • Effective and efficient communication system with network hospital. • Mobile Medical Assistance. • Mobile vehicle with life saving drugs. • Mobile blood bank. • Defined number of disaster victims. • GM, Head Emergency or Senior Manager Operations authorized to activate. • Maintained list of networked hospitals and their contact numbers.

Classification of Casualties • Care of Priority 1 - Immediate Care (approx 20%) – Major hemorrhages – Severe smoke inhalation – Thoracic and cervico-maxillo facial injuries – Cranial trauma with coma and rapidly progressive shock – Compound fractures – Burns (more than 30%) – Crush injuries – Any type of shock – Spinal cord injuries

Classification of Casualties • Care of Priority 2 – Delayed Care (Approx 40%) – – – Non-asphyxiating thoracic trauma Closed fractures of the extremities Limited burns (<30%) Cranial trauma without coma and shock Injuries to soft parts

Classification of Casualties • Care of Priority 3 - Minor Care Casualties (Approx 40%) • Dead on arrival and subsequent death Qualified medically trained person to start triaging. Victims moved from triage area to more appropriate holding area

Triage Tags Sections of triage tags • 4 colors of triage – Black – Red - – Yellow - – Green - Deceased Immediate care (Critical Patients- life threatening injuries) Delayed Care (Urgent Patients -non-life threatening injuries) Minor (entails minor injuries) • Patients demographics • Section with pictorial view of human body

Reception of Causalities • Reception or sorting area should be earmarked for receipt of causalities • Preliminary sorting out carried out by nature of injuries or illness • Existing Casualty and Emergency department would mostly be unsuitable because of size. • Area should allow for retention, segregation, and basic documentation of incoming casualities. • The sorting staff should be directed and supervised by an experienced physician or surgeon. • Sufficient equipment, supplies and apparatus should be made available in this area to permit prompt and efficient patient movement.

Task at Reception • Personnel: – Doctor I/C (1) – Nurses (2) – Clerical (1) – Attendants (2) • Tasks: – Check Priority – Check Documentation – Valuables of the patient – Reassurance – Medical Comforts (water, tea, coffee, etc) – Information to relatives – Directing the casualty

Minimum Documentation • General data like name, age, sex, etc. • Medical data: prepare inpatient card or outpatient card • Check general conditions, splints • Admission register : only preliminary diagnosis

References - DMP • Distributed text books • Emergency Medical Services and Disaster Management – A holistic Approach – P K Dave pg 266 -280 • Maharashtra Multi-hazard Disaster Management Plan

Activity In groups prepare the Disaster Management Plan for 200 bedded hospital – 15 marks

QUESTIONS