Disaster Management

Disaster Planning/Mass Casualty Incidents in Hospital

Introduction

The root of the word disaster ( comes from an astrological theme in which the
ancients used to refer to the destruction or deconstruction of a star as a disaster.
 

DISASTER alphabetically means:

D - Destructions
I - Incidents
S - Sufferings
A - Administrative, Financial Failures.
S - Sentiments
T - Tragedies
E - Eruption of Communicable diseases.
R - Research programme and its implementation
 

Definition of Disaster

Any event that abruptly throws off people's routines, leaving them in a state of perplexity and misery while necessitating their immediate need for food, clothes, housing, medical care, and psychological support.
Disasters are spontaneous occurrences or catastrophic situations that typically interrupt daily routines, necessitating the provision of people with shelter, food, clothes, medical treatment, and other basics of life. According to the Red Cross, a catastrophe is a significant disruption of a community or society's normal operations that results in widespread losses of people, property, money, or the environment that are greater than the capacity of the afflicted community or society to manage using its own resources (WHO). We speak of a disaster in a hospital when more than 15 injured/ casualties come at once needing medical help Incident.

The Global Scenario

Impact of natural disaster in the last 30 years.

• Death of 3 million people
• Economic loss increased due to disaster like flood
• In Indian scenario, 34 million people affected per year and 5116 death per year.
• In US, economic loss is 400 million dollar and 3 million people died.

Types of Disaster

Natural Disaster:

 ​​​Earthquakes, hurricanes, floods, volcanic eruptions, cyclone, fire, epidemic, famine, glacier lake outburst, drought, storm, landslides, thunderbolts, Tsunamis. E.g., Sandy hurricanes in New York in October 2012.
Asia and pacific is estimated to face 60% of the total disaster occurring in the worl

Manmade Disaster:

• Accidents: roadside, air crashes, etc.
• Fire
• Industrial hazards: chemical, gas radiation, explosion
• War: civil or international, armed insurgence
• Terrorism
• Pollution
• Social insecurity
• Epidemics
• Famine and ecological misbalance

According to WHO, a mass casualty occurrence is one that causes a significant enough number of victims to interfere with regular emergency and healthcare facility operations. With mass being a relative term that is interpreted depending on a region's response capabilities and available resources, a mass casualty occurrence is therefore a disaster that results in a mass number of fatalities and injuries.

Disaster Management Lifecycle

Mitigation

• Mitigation- long term strategy to reduce or eliminate risks to human life and property from incidents of damage. Mitigation planning is such a process that involves the following steps:
• Organizing resources- start using resources needed for a successful mitigation planning process, identifying technical expertise (E.g.- engineers or security officers)required during the planning process.
• Mass Casualty Incident
  • Assessing Risk- to define a specific hazard's features, possible effects, and effects on crucial community assets. For instance, a healthcare institution should prepare to have the tools and equipment necessary to decrease the effects of large storms if it is situated in a flood zone. Similar control is required in the event of an earthquake in isolated regions like the Jumla district.
• Implementation of mitigation strategies
  • Hard Mitigation- Structural and equipment improvement that can reduce the risk of a hazard. E.g. power generators, fire protection.
  • Soft Mitigation- relates mainly to the human aspects of lessening the severity of an incident.
  • Training, exercising and preparing staffs and continuing improvement.

Prevention
Some preventive activities include community education, investigation and operations, intelligence analysis and critical infrastructure protection.
Prevention has become an important aspect of incident management and is necessary for:

• Reducing the disease outbreak.
• Preparedness

Preparedness

Readiness in the public sector, in healthcare facilities, in business, and in volunteer organizing families (Red Cross). Key planning initiatives to reduce the risk of fatalities and other adverse effects during an occurrence containing the specified dangers. In order to be fully prepared for a mass casualty incident, the responding community (such as the fire department, police department, medical facilities, public health, and Red Cross) must communicate with one another. In order to manage a mass casualty incident, multi-agency planning, training, and exercises are required.

Response

The steps taken to save lives and stop more infrastructure damage from happening. example: rescuing those who were buried in a landslide. Giving vaccines during a pandemic, for instance, is regarded as a reaction.
Implementing the readiness plan is a part of an organized response effort. If the preparation efforts are thorough and successful, the reaction ought to function as efficiently as feasible given the incident conditions. Remember that managing a mass casualty disaster will involve significant coordination and communication between multiple reacting agencies in order to save the most lives as much as is practical.

Recovery

The community concentrates its efforts on reestablishing vital systems and services and bringing life back to normal or better conditions during the recovery function. After the reaction, recovery begins.
Government authorities and the agencies will coordinate the goals of the functions after people are no longer in danger of being hurt.

• In short term recovery activities, focus on restoring the communities medical and infrastructural system to minimum operating standards. Short term recovery activities may include restoring homes, foods, infrastructure.
• In long term recovery effort, focus on restoring a sense of community throughout the affected population and developing mitigation strategies for the future mass casualty incidents.

However, recovery is an extensive process and may continue over a long period depending upon the magnitude of the incident. Let us consider Haiti’s long term recovery efforts related to structure damage and loss of life from the 2010 earthquake.
 

Types of Disaster (In hospital setting)

• Minor Disaster

  • Under 20 victims ( or 15 if all serious)

  • Managed within ER in normal way

  • Instruct receptionist to call extra doctors/staff

  • May develop into Major disaster

• Major Disaster

  • Over 20 victims ( or 15 if all serious)

  • Decision to declare disaster state made by (or in consultation with) Consultant, Nursing Supervisor or senior administrator present in the Hospital at the time

  • Receptionist must be instructed to announce the disaster state over the loud speakers & put on siren

  • Disaster Plan activated

  • ER entrance must be closed.

  • Victims to enter via the main Hospital gate

Principles of disaster plan-Triage

Definition:

Triage in French for – “ sorting, selection and choice”. Triage is a system used by first responders and healthcare professionals to sort people based on their need for immediate medical treatment.
A process in which a large group of patients is sorted in order that care is concentrated on those who are likely to survive.
 

Purpose of Triage

• To determine the victims' evacuation priority
• Determining which victims are in imminent danger and require urgent therapeutic actions
• To hasten the treatment of less urgent situations
• To enhance the movement of patients through the emergency rooms
• Encourage efficient use of the employees and resources
• Reduce crowding and confusion
• By ensuring prompt intervention, you can lessen treatment delays and lessen the severity of your condition.

Patient triage evaluation:

Because mass casualty incident may affect hundreds to thousands of people, spending to most time evaluating anyone patients condition may lead to the death of other patients. Most triage system typically use the following evaluation methods to rapidly assess a patient condition:

• Respiration rate

• Effort to breath
• Pulse
• Ability to follow instruction or commands
• Skin color, capillary refill and ability to move
   

Triage Tools

• Triage tags
• Colored tape
• Writing on body,
• Clothing, and bandages

Triage Sieve Algorithm1

Method of triaging

• START (Simple triage and rapid treatment)
• Developed by the Hoag hospital and Newport Beach Fire department in USA
• Triage done in 60 seconds or less
• Done by assessing RPM (respiration, perfusion, and mental status) or
• ABCD (Airway, Breathing, Circulation, Disability)

STEPS of triaging
Check ventilation: No breathing, check for foreign bodies. Chin lift and jaw thrust.

• No reaction : BLACK
• If ventilation returns after simple maneuver or
  • RR ; 30- red tag
  • < 30 - assess perfusion
• Perfusion
  • Pressing nail bed or lips and release
  • >2sec -Red
  • <2 sec- mental status examination
• Mental status
• Use simple commands- Open and close eyes/ Squeeze my fingers
  • No responds RED
  • Responds well YELLOW
  • Minor injuries GREEN

Hospital command centre:

• oes communication with external agencies (police, hospitals for patient transfer), with the departments of the hospital
• Information processing
• Identification of capacity- current bed capacity, operation room capacity, ICU bed capacity & no.of units blood available in the lab.
• Resource management: Identification of resource requirement and resource sources
• Media management
• Record keeping

Personnel in the Command Centre

• Disaster overseer-medical director
• Communication officer
• Logistic officer (Nursing Director)
• Chairperson disaster response committee -MD

Key Personnel in Disaster

•  Disaster overseer(Medical Director)

  • Carries ultimate authority in the incharge of hospital command centre
  • Generally oversees the outworking of disaster plan
  • Makes decisions concerning major changes in the disaster plan
  • Assessment hospital beds
  • Checks that all teams have collected the clipboards from reception

•  The Communication Director/officer

  • Preparation of victim list/their outcome
  • Post list in prominent area.Communicates with the other Kathmandu Valley hospitals
  • Communicates with the clinical director/department heads
  • Communicates with the Police/Press

• The Clinical Director (OPD/ER chief)

  • Oversees all aspects of the medical work
  • Liaises with the wards (re: numbers of discharges and admissions)
  • Liaises with the Surgeon Incharge/ OR
  • Liaises with all Treatment Areas
  • Distributes all doctors and nurses where needed

• The Triage officer (Ortho consultant/SR/Registrar): 2 at a time

  • Remains at the Triage Area
  • Rapidly assesses all patients, allocates a Triage Category and tag
  • Passes the patient on to a doctor

• Logistic Officer (Nursing Director)

  • Liaises with Nsg supervisor & distributes all nurses where needed
  • Keeps disaster supply room in order
  • Checks stock periodically

• The Transport Officer (Administration officer)

  • Arranges transport for patients requiring transfer
  • Liaises with clinical director, hospital command centre
  • Communicates with receiving hospitals
• Receiving Team (from vehicles to trolley then to triage area :treatment area)
  • Physiotherapy department
  • House keeping
• Crowd Control
  • CRUCIAL because once the hospital is over-run it is impossible to work. Crowd should be
  • prevented from entering the clinical areas. Certain doors must be opened or closed by
  • security/administration, and all access points posted with guards. Each patient is allowed to enter the
  • Triage Area with one friend/helper
• The role of the emergency nurse in a disaster
  • As soon as the information is received about disaster she must communicate this to
• administration, to the doctor incharge, the nursing director and the disaster team who will
• activate the disaster plan.
  • All patients not in real need of treatment are sent home – discharge at once also by nurses.
  • Patients from emergency ward that are in need of medical aid are transferred to the wards.
  • Inform all staff to remain on duty.
  • Get ready extra equipment and supplies, emergency drugs, IV fluids
  • Get triage area cordoned of and get extra mattresses and blankets out of disaster room with

• Help of Assistants.

  • Inform pharmacists, laboratory staff and CSSD of the disaster. Remind them- no charges
  • Inform kitchen to cook food and tea.
  • Inform guards to let only one relative in with each injured person
  • Direct other nurses into their areas.
  • Nurses that are off duty and hear about the disaster must report on duty without delay.
  • Keep calm
  • Make sure there is a person responsible for information flow only.
  • During disaster no charges are made.

• Disaster Preparedness in Hospital

  • Formulate hospital policy and action plan for emergency preparedness for disaster

• management (EPDM)

  • Form the disaster management team
  • Strengthen the capabilities of health workers through training
  • Train volunteers about reception and transport of casualties, giving the first aid treatment, and
• managing information and crowd.
  • Establish triage protocol
  • Identify triage persons and specify triage space
  • Establish alarming system
  • Specify protocol for response to disaster
  • Keep the stock of medical supplies for the use of emergency
  • Identify means of transportation: ambulance and other vehicles
  • Have a back up plan for incessant flow of electricity, water, and fuel supplies
  • Carry out regular drills to be well prepared for genuine response to disaster.

• Disaster management in the hospital

  • 1. Before the arrival of victims
    • Collect information from the authorized person in the disaster site through phone- type of
    • Disaster, number of casualties and seriousness of injuries
    • Appoint commander and vice commander for disaster management.
    • Activate the disaster protocol
    • Specify the triage area
    • Alert different departments to remain standby-OT, all wards, lab., X-ray, kitchen, pharmacy
    • etc.
    • Assign definite tasks to people in disaster team
    • Establish center for information
    • Suspend all other regular hospital activities except for the critical one
    • Prepare standard tags in advance.

  • After arrival of the victims

    • Triage nurses or volunteers receive the victims
    • Keep the crowd away
    • The nurse in-charge mobilizes nurses and volunteers
    • Triage nurses screen the cases- carry out rapid, concise and focused subjective and objective
    • Assessment, categorize patients
    • Patients are tagged before moving from reception area ( name, age, sex, place of origin, triage
    • Category, diagnosis and initial treatment)
    • Triage nurse coordinates with different diagnostic facilities (X-ray, lab etc.), wards, kitchen, store etc.
    • The triage physicians decide appropriate place for the treatment of each patient.
    • Triage nurse constantly assess the progress of the patient
    • Depending on protocol, nurses may carry out some life saving measures like doing CPR,
    • Starting IV fluid, if needed
    • Maintains the accurate records
    • Coordinates with other hospital for the special care
    • Communication center is responsible to give out the information
    • Coordinates with transportation section
    • Completes all legal procedures before sending the dead bodies to morgue or to families.