A Disaster, as defined by WHO, is any occurrence that causes damage, ecological disruption, loss of human life, deterioration of health and health services, on a scale that is unprecedented and beyond the handling capacity of the local community.
It is a situation which implies unforeseen, serious and immediate threat to public life.
A disaster can be Natural (Storms, cyclones, floods, droughts, earth quakes, tsunamis, epidemics of communicable diseases or Man-made (riots, warfare-nuclear/biological/ chemical, mine disasters, rail, air or road accidents).
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It happens suddenly like a Tsunami or a Bhopal Gas Tragedy, inflicts wide spread destruction and mass casualties and leaves behind a trail of human misery and suffering.
Whatever the disaster, the hospitals in the area have the onerous responsibility of quick, organized and effective action to save as many lives as possible.
A comprehensive carefully planned and well rehearsed program of disaster management in a hospital can go a long way in reducing the impact of the disaster. However, it should be a part of the area wide integrated plan so that the situation can be handled in a coordinated manner with maximum efficiency and effect.
1. Peculiarities/Problems of a Disaster Situation:
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1. Sudden occurrence of the disaster, sudden information with little reaction time, resulting into delay in response.
2. Mass casualties, may be far beyond the handling capacity of the hospital in terms of the resources (staff, equipment, stores and the beds) available.
3. Problem of Rescue/Evacuation: The casualties may be brought to the hospital suddenly or may have to be collected from the place of disaster.
4. Problem of arranging heavy requirements of blood/blood products and medical Stores in emergency for treatment of large number of casualties.
2. Expectations from a Hospital in a Disaster Situation:
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These are rare, but very testing situations because a lot of human lives are at stake. Sudden influx of a large number of serious casualties can throw the system out of gear and lead to chaos.
But, if the hospital has a well rehearsed plan and an effective mechanism to swing into action with full force, coordination and at the speed desired, it can surely perform its job with maximum effect.
The ability of the hospital to rise up to such unexpected challenges depends upon its level of preparedness. The efficiency of a hospital in such situations depends squarely on two factors prior planning and periodic rehearsals.
3. Action Plan:
The salient aspects of a disaster management plan in a hospital are as discussed below:
1. The hospital should have a Disaster Management Committee chaired by the Chief Executive himself and with wide representation from all the departments.
2. Hospital must have a documented comprehensive disaster plan (Disaster Manual). The plan should be simple and practical, clear and concise, flexible and adaptable and should include:-
a. Identification of the potential external disasters in the area.
b. Identification of potential internal disasters within the hospital (accidental fire, building collapse) or impact of the disasters such as earthquakes on the hospital itself that may severely reduce its ability to provide relief to others.
c. Estimation of the type and number of casualties expected.
d. The analysis of the resources required/available (medical/paramedical/non medical, space, equipment, medical stores, casualty evacuation vehicles, stretchers/trolleys, wheel chairs) and additional requirements.
f. Details of the sources for emergency supply of additional requirements within the shortest possible time.
3. The plan should describe the chronological sequence of actions to be taken. It should include a system of activation of the plan including a quick communication (through a coded message such as CODE YELLOW-or whatever) to all concerned through SMS, telephone, paging and public address system in the hospital.
4. The plan should include spatial planning—earmarking the hospital areas for reception, triage (allocation of priorities to casualties for treatment and transfer), resuscitation, treatment, indoor facility and the space for keeping the dead bodies.
5. The plan should include the allocation of tasks and distribution of duties to the staff.
6. The plan should include a procedure for speedy information to police and civil authorities and getting assistance from nearby hospitals.
7. The plan should include arrangement for emergency supply of medical stores such as pain killers, antibiotics, bandages and dressings, and large quantities of specific antidotes (in poisoning cases).
8. The plan should include additional supply of blood, IV fluids for volume expansion, depending upon the number of casualties.
9. Arrangement for specialized treatment such as for chemical gas leaks (as in Bhopal Gas Tragedy) or in case of nuclear radiation disasters, special arrangements are needed for decontamination and for antidotes, as well as respiratory support.
These situations cannot be handled effectively, if the contingencies have not been foreseen and arrangements not planned in advance.
10. The plan should earmark an area for starting a Control Centre for organizing, coordinating and controlling all activities related to casualty management such as answering the queries of relatives and briefing the public periodically, about the casualties and their management.
MS or deputy MS in his absence should take over the command and assume the responsibility of directing, monitoring and coordinating all the activities.
11. Documentation. The disaster plan must include designing suitable forms (treatment forms, death certificates, list of the casualties/and their valuables collected), numbered identity tags/disks and other necessary documents that may be kept available in sufficient quantities along with the disaster plan in a box marked “Disaster Plan”.
12. The plan should include a documented procedure for Triage-allocation of priorities and review of priorities at every stage for most efficient management of casualties on the basis of the principle of maximum benefit to the most. For instance, as practiced in armed forces:
Category P-1 – Immediate resuscitation and immediate surgery
Category P-2 – Immediate resuscitation, surgery deferred
Category P-3 – Minor problems—to be attended to after P-1 and P-2
Or the priorities may be indicated by coded bands or discs such as
Red: Most urgent – Category I
Yellow: Urgent – Category II/III
Green: Deferred – Category IV
Black: Dead – Category V
13. There should be a procedure for crowd management with the help of police, security personnel, or even volunteers from the public on the spot.
14. A procedure for immediate and periodic briefing of press and public. Press releases, being a very important and sensitive job, should be done by the MS/or the DMS in the absence of MS.
15. The plan should include a procedure for quick and efficient communication. The normal lines will all be choked with calls from anxious public. Therefore, intercom facility, messengers or mobiles may have to be used.
16. A plan for provision of snacks/food to the casualties.
17. The plan should include efficient management and disposal of the dead. There may be many dead and the hospital mortuary may be inadequate. A separate room, away from the casualty reception, may be earmarked for the dead bodies, to be kept until the police take charge of them. It should also include arrangement for identification of the unidentified/dead by following measures:
i. At least two identification marks
ii. Photographs
iii. Thumb Impression
iv. Tissue samples for DNA testing.
18. A system of announcing the termination of disaster incident by the MS, once all the casualties have been attended to and definitive treatment given to all.
19. Mock drills with regular periodicity should be carried out realistically at different times of the day/night, (preferably in the presence of an outside observer).
20. A record of every mock drill carried out with the timings noted for various steps such as the time taken for informing all the staff (should not be >10-15 min), the response time of staff (should not be >15-30 min), time taken for the teams to be in their respective places, number of casualties (PI, P2, P3) received and the time taken in completing the emergency resuscitation and documentation, time taken to organize additional blood supplies and the time taken to open up an additional ward. The deficiencies observed and the corrective actions/amendments incorporated in the plan, should also be recorded.
21. A written, detailed record of the actual disaster situations ever handled by the hospital (if any), the problems faced and the lessons learnt, should be maintained.
22. What is important to remember in a disaster situation is that in an effort to manage all the casualties speedily, the principle of ‘safety first and foremost’ in respect of every patient is never forgotten.
Correct Identification of patient, correct assessment, correct treatment, arrest of bleeding, adequate pain relief, asepsis with appropriate antibiotic cover, and reassurance to the patients would always remain the valuable guidelines for efficient patient management.
While planning for the disaster situations, hospitals must not forget that a hospital itself may be afflicted by a disaster, that may be internal (major accidental fire, building collapse) or external such as earthquake which can affect the hospital as much as any other buildings in the area.
If the hospital has not planned and prepared for it, the losses can be multi fold because the staff themselves may be injured or dead along with the patients/public and the hospital may not be able to provide any relief to the outside casualties.
Therefore, it is of paramount importance that while planning for disasters such as Tsunami or earth quake or a major gas leak, the hospitals first plan for their own risk reduction and safety because they can provide relief to others only if they themselves survive.
For that, it is essential that the buildings and civil works of the hospital are reasonably resistant to disaster impact and adequate manpower and equipment are available.
Disasters are not events of routine occurrence. They happen rarely and suddenly and have the potential to cause colossal losses.
To test the efficiency or quality of a disaster management system in a hospital, one cannot wait for the disasters to happen because that may be too late.
Soundness of the disaster plan in a hospital, therefore, has to be judged from its efficiency and effectiveness in practical tests such as mock drills conducted with regular periodicity in different shifts on different days without any prior notice. It should be as realistic as possible and in the presence of some neutral observers.