Mass CasualtyManagement Hospital Emergency Response Plan

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1 Mass CasualtyManagement Hospital Emergency Response Plan Regional Training Course on Mass Casualty Management and Hospital Preparedness

2 Contents Rationale for this toolkit and methodology 1 Methodology 4 The methodology recommended is the following: 4 A logical sequence of a series of questions 5 Component 1. Surrounding environment and community 6 Component 2. Preliminary audit of the Hospital the existing level of preparedness 8 Component 3. Emergency planning process for developing the ERP 9 Component 4. The management of the alert and the activation of the plan 10 Component 5. The composition, the role and the functions of the Incident Command Group ICG 11 Component 6. The Supplemental Emergency Response Plans of the various departments, services, and units of the Hospitals SERPs and the SOPs 14 The management of medical care and nursing care 16 Component 7. The Job Actions Sheets JAS - Individual Actions Cards 17 Component 8. The management of staff and the call back procedures 17 Component 9. The disaster triage area and the disaster patients receiving areas 19 Component 10. The medical record and the management of patient information 21 Component 11. The external and internal traffic flow and control (in and out the HCF) 21 Component 12. The Logistics 22 Component 13. The security 23 Component 14. The areas for the families 24 Component 15. The areas for the media 25 Component 16. The management of 25 information 25 Incident Logs 26 Component 17. The management of the dead 26 Component 18. The continuity of operations 27 Component 19. Training and exercises 28 Component 20. Testing the plan and the ERP maintenance 29 Component 21. The psychosocial support activities 29 Component 22. The management of the communications 30 Component 23. The Emergency Department 31 Component 24. The Preparation of the Hospital for chemical and biological incidents 33 Component 25. The Preparation of the Hospital for a pandemic influenza 34 page ii

3 Reference Note 1 Risk management and vulnerability analysis in hospitals 34 Reference Note 2 The Concept of Comprehensive Emergency Management Program 36 Mitigation 38 Preparedness 38 Response 39 Recovery 39 Reference Note 3 The participation of the staff of the HCF to the development of the ERP 40 Reference Note 4 The management of the alert and the levels of activation of the ERP 40 The processing of the alert and the early decisions. 40 The levels of activation of the ERP 41 Reference Note 5 The Incident Command Group 43 The Hospital Emergency Command System (HEICS) 43 The missions of the ICG. 50 Organizational Charts. 53 Incident Action Plan 55 Reference Note 6 The Standard Operating Procedures and the Supplemental Emergency Response Plans 56 Reference Note 7 The Job Actions Sheets JAS 58 Reference Note 8 The management and the staff and the redistribution of staff 65 Reference Note 9 The disaster triage area and the disaster patients receiving areas 67 Reference Note 10 The external and internal traffic flow and the control 69 Reference Note 11 The function LOGISTICS 70 Reference Note 12 Continuity of operations and evacuation 71 Reference Note 13 The management of patient information, the patient record 74 Reference Note 14 Training and exercises 75 Reference Note 15 Psychosocial support activities 76 page iii

4 Regional Training Course on Mass Casualty Management and Hospital Preparedness toolkit: Mass Casualty Management Hospital Emergency Response Plan Rationale for this toolkit and methodology Reference note 1 and 2 The aim of this document is to assist the directors and emergency managers of Hospitals to develop the emergency response plan (ERP, also called Disaster Plan). The planning process itself is as important as the written document. This written document (the paper plan) is only one of the outputs of the emergency planning process. Other important outputs of the emergency planning process are: Awareness rising among the personnel Promotion of a culture of risks management within the HCF Vulnerability analysis with possible recommendation for actions (mitigation, prevention, corrective actions) Motivation of key staff to become active partners to assist the managerial team of the hospital in risks management Development of partnership with key outside stakeholders Development of exercises (including multisectoral ones) Improvement in the management of daily emergencies (especially through improved ED procedures, training of staff, etc.) Etc. The simple transfer of information (what are the sections of the ERP, what could be the composition of the planning committee, etc.) does not equip the emergency managers with tools and a methodology enabling them to safely develop the plan. The goal of the present toolkit is to assist the emergency managers in their planning efforts, especially by introducing them to a methodology for developing the plan (with a supportive tool: the questionnaire). There are success stories of Hospitals having managed rather efficiently an emergency situation without having an ERP. But there are far more stories of failures because the Hospital had not managed effectively and efficiently the available resources. The quality assurance programs (and the accreditation) require the development of ERP anyway. More and more Hospitals develop programs for managing risks and health risks in the institution. The disaster preparedness program is one of them. Usually the following programs are considered as related to risks page 1

5 management in a HCF: On going surveillance programs (blood safety, nosocomial prevention program, drug safety, etc.). Most of these programs deal with regulated risks. Each country has its own set of regulated risks Quality assurance program (and accreditation) Disaster preparedness program (for major emergencies: fire in the HCF, MCI, etc.) 1 y Risks management program for common risks (most of the risks of this program are non regulated risks) Non medical risks (such as interruption of power in the theater section, interruption of water supply, accident in using equipment, etc.) Medical risks (mainly iatrogenic risks) Managerial risks It is vital that those in charge of developing or managing one of these programs identify the existing links with the other programs so as to search for synergy and complementarities. Ideally each HCF should come up with an integrated set of risks management programs 2. Some elements are similar in every program. For instance the vulnerability analysis process is the same (although different expertise is needed) whether the focus is on risks generated by structural vulnerabilities of the building or generated by the failure of electrical power in critical units of the HCF. The notion of Comprehensive Emergency Management Program is given more and more attention as the general framework within which the ERP is developed (see reference note 2) The Emergency Management program (disaster management) should include all aspects (not only the response, but also mitigation, rehabilitation, et.) and all hazards. This is the concept of the Comprehensive Emergency Management Program CEMP 3. Focus is usually put on protecting safety of people (staff, patients, visitors). The new trend is to also include the protection of equipment and services (the loss of equipment and the loss of services may have much more consequences than just economical losses) In this document the Command Structure in charge of the overall management of the emergency response when the ERP is activated is the Incident Command Group ICG. It is part of the HEICS (Hospital Emergency Incident Command System). Conclusion. Hospitals are highly complex settings: many stakeholders, special place in he community, expensive equipment, etc. The 1 Cf. special note on this topic together with notes on vulnerability analysis 2 Most of the hospitals in Canada, USA and Europe have adopted this strategy. Each hospital has a full time risks managers (several training centers offer a specific formation with a diploma on hospital risks management) 3 Cf. reference note 1 page 2

6 management of such settings is difficult in normal time. It becomes even more complex and more challenging during crisis and major emergencies. It is a dangerous myth to think that the development of an ERP can be achieved easily and safely by just training a very limited number of people of the Hospital during a short session of a course. The health authorities have to accept that developing an ERP is a fundamental activity (capacity building) that requires strong support from health authorities (more than issuing policy statements how good they may be) and from the local community. The training of those who will contribute actively to the development of the ERP is a key activity that deserves full support from the Health Authorities. The MOH should develop policy and guidelines as well as tools to assist the emergency planners. It is mandatory that the emergency planning committee developing the ERP has a clear mandate to do so, has full authority for achieving this goal. It is now accepted that by assisting the managerial component of the Hospital to develop the ERP through challenging questions is effective (quality and relevance of the planning process) provided there is a general framework within which the emergency planning process is developed (policy statements and recommendations for its application, issued by the MOH). A hospital disaster plan for external disasters (mainly mass casualty situations) is aimed at ensuring: Rapid and appropriate response activation Optimal situational care for victims Clearly understood command and control structures Clearly understood communication mechanisms. Clearly defined roles for all staff and partner organizations Action cards for all key staff involved. Key locations and clear roles of partners (SOPs for the main functions) Transition back to normal business with minimal disruption Therefore most of the hospital disaster plans are composed of: A letter of authorization The management of the alarm The levels of activation and the activation of the plan An organizational chart of command (Incident Command Group :location, equipment of the room, functions, staffing, relation with the outside world) A description of the main areas (functions, staffing, Command, SOPs) Logistics Communications Job Actions Sheets (80% of the total pages) Forms and protocols specific for disaster situations Maps and other relevant information Contingency procedures Exercises and revision of the plan page 3

7 Methodology The Director of the Hospital together with the risks managers should enter the planning process for preparing the Emergency Response Plan as a sustainable, long term activity, which never ends. The written document (the paper ERP) will require revisions (environment, resources, and systems change). The training of staff and the exercising of the plan is part of the process and must be discussed in the ERP. The most common reasons for failure of ERP (when activated and having to face real world) is not the lack of appropriateness of some components written down in the document but the following problems: The plan has been developed in isolation by a very limited group of staff (usually copying an existing model) End-users (staff ) are not part of the process (no sense of ownership, not consulted for preparing SOPs, JAS, etc.) and do not receive appropriate training Breakdown of communications and mismanagement of information Lack of coordination mechanisms with the outside partners (especially the pre-hospital component) The methodology recommended is the following: Constitute an emergency planning committee (authority, mandate, goal, objectives) Select members (major functions and disciplines) Train the members (emergency planning is an art) Conduct regular meetings (using the toolkits, especially the questions of the present toolkit); consult with experts when necessary Clear agenda for the meetings Chairman, recorder and process managers (plus permanent members and invited members depending upon the themes to be discussed) Decisions (actions to be taken, follow-up until next meeting, time table, etc.) First draft of the section of the ERP under discussion whenever possible Consult the staff and stakeholders as much as necessary (for developing JAS, SOPs, SERPs and revising draft components of the ERP). Validation of the sections already been discussed as soon as possible. See reference note 3 Prepare the complete version of the ERP (appoint a revising committee to analyze the internal coherence of all documents prepared so far) Conduct workshops for validating these elements with the endusers Test the plan Develop training and exercises page 4

8 Develop maintenance of the plan The development of the ERP is best achieved by running workshops and meetings of the emergency planning committee with the key informants (vulnerability analysis, risk assessment). Emergency planning is a process. In the past many MOHs published policy on that issue with guidelines for the application of the policy. Although apparently well balanced these guidelines revealed in many cases insufficient to guarantee a quality output (the written ERP) and failed to substantially improve the outcome (more efficient management of MCI by hospitals). The new trend is to equip the managing team of the Hospital with tools that the team can use to develop the plan. In this line some MOHs issued a guidebook for assisting the HCF to develop a crisis and emergency management capacity, which raises questions that should be considered by the emergency planning committee (and answered) when developing the plan and which provides suggestions for solving some frequent and infrequent problems linked with this process and or the management of emergencies (from Hospital perspective). The following sections will propose a series of sets of questions and some suggestions (reference notes) as a possible tool kit that can also be used by participants attending the Regional and the national MCM courses. In deed the answers to the questions will almost always require further work or discussions that will booster the emergency planning group for developing partnership with other key stakeholders, for searching for information (that experts can provide such as on vulnerabilities or from other staff of the Hospital not being permanently represented in the planning committee) outside the limited circle of the planning committee, for linking together prevention, mitigation, response and recovery. This approach does NOT eliminate the absolute need for a national policy on that issue. The presence of existing guidelines should be considered as a prerequisite. The present tool kit is rather a pragmatic methodological approach in order to develop the plan and its components (including exercises, networks and partnerships) A logical sequence of a series of questions The questions cover the various areas to be considered when developing a disaster plan in an HCF. These questions are not exhaustive. Each Hospital can decide to add some questions. The questions should be considered as an entry point to discuss further the issue with key informants, with stakeholders, experts or any knowledgeable person who can assist the emergency planning committee. These questions are mainly prepared to be used by the planning committee (especially the chairman of the committee) in its work, who has the final responsibility to prepare the plan and to prepare the agenda of the meetings of the committee. It is page 5

9 recommended that the emergency planning committee takes time to really go through the questions, resisting to the temptation to rush to the writing of a document. It is better to take several weeks to develop an efficient ERP rather than a few days for a bad plan. Emergency planning for HCF is a time consuming and energy consuming activity. It is best done when a senior manager is in charge of following up the meetings of the planning committee and when time lines are defined and respected. Although the two first sets of questions could appear irrelevant (time consuming and not immediately useful for writing a document which will be the plan), it should be remembered that any written document (the plan) that is not linked to real context will be of limited (if not of no use) use in MCM. Important remark: the questions are made to enhance discussion in the emergency planning committee. They do not all require a formal answer. Of course they do not need to receive written answers in the ERP. The ERP is a summary of what is needed to efficiently, effectively and timely manage the response. Component 1. Surrounding environment and community Reference note 1 and 2 Goal: to identify actual and priority risks faced by the Hospital and the global environment in which the ERP has to be developed Do we need to know the risks that threaten the Hospital (persons, services, equipment and assets) before starting to write the ERP? If yes: what is the necessary information we should gather for identifying the major risks and why? ÌÌ Industrial, technological, mass casualty, etc? ÌÌ What could be the scope of casualties (number, types: injured, burns, contaminated)? ÌÌ What could be the scenarios for their evacuations to receiving HCFs and how this could affect the Hospital? What are the external situations that could generate risks for the normal functioning of the Hospital ÌÌ Such as interruption of life lines (access road, power supply, water supply, etc.) What are the main vulnerabilities of the Hospital? ÌÌ Do we master the vulnerability analysis process? If not, what should we undertake to identify the main vulnerabilities that are present in the Hospital? ÌÌ What could be the impact of these vulnerabilities on the surge capacity of the Hospital for responding to a MCI? ÌÌ Could some of these vulnerabilities create a potential for an internal disaster (such as fire)? page 6

10 Do we need to identify what are the roles and the functions of the Hospital in the community? What are the characteristics of the surrounding community living in the catchments area of the Hospital? What is the overall organization for MCM in the community? What are the roles, functions, and missions of the other partners (especially the EMS system, other HCFs), especially for MCM? ÌÌ What does it imply for the ERP of the Hospital? ÌÌ How to coordinate with them, why, what and what for? ÌÌ What are the roles and functions of the intersectoral EOC and how the Hospital will relate to? ÌÌ What are the roles and functions of the health sector EOC and how the Hospital will relate to? What is the surge capacity of the health sector for MCI? What will be the contribution of the Hospital to this surge capacity? What is the existing EMS system in the community an how the Hospital is relating with it? ÌÌ What is the organization? ÌÌ Who are the partners and what are their main resources? ÌÌ How they relate to the Hospital in routine emergencies? ÌÌ Is there an emergency plan developed by the EMS? What could be the other partners (other HCFs) that can assist the Hospital should the evacuation of part of the Hospital be considered to ensure continuity of operations and critical service delivery? What are the existing laws, rules or procedures for MCM or common emergencies in the community? What are the existing policy documents (including guidelines) that could assist in developing the ERP of the Hospital or that have to be respected when developing this plan? Will the ERP be part of the effort of the Hospital to become accredited? What is the existing emergency preparedness plan of the health sector in the area? Especially if the Health Sector is a key partner of the EMS System? How will it contribute to the preparation of the ERP? What are the mechanisms that the ERP must respect? Is there any indicator (defined by the health authorities) for assessing, testing and validating the ERP (validation of the plan)? page 7

11 Component 2. Preliminary audit of the Hospital the existing level of preparedness Before starting to develop the ERP it is advisable to establish the overall picture of what already exists in routine work that could be part of the future ERP (procedures, coordination mechanisms, etc.). This set of questions is useful for those Hospitals that already have some elements of the ERP. For those Hospitals having no ERP, this set of questions can be included in the other questions according to the decision of the planning committee. If there is already a well structured existing ERP, the questions can be used for revising the plan. What are the existing documents describing (synthesis) the normal functioning of the Hospital (especially the key services: ED, surgery, blood bank, etc.)? What are the existing mechanisms (or indicators) in place in the routine activity of the Hospital for alerting when there is an emergency? Are they existing documents on vulnerabilities and risks? Was there an attempt in the past to develop an ERP? Is there any existing alert mechanism? Is there any emergency management structure in place? Is there a special command room? In the case of an internal emergency ÌÌ How alert is managed? ÌÌ Who is mobilized, when, by whom? ÌÌ What are the SOPs? ÌÌ Have the main care lines and services lines special SOPs? ÌÌ Are exercises conducted for safety procedures? If there is already an existing ERP: ÌÌ As the plan been tested, validated (when, how, by whom)? ÌÌ Is there a revision under way? Who, what, when, regular mechanisms, etc.? ÌÌ What are the provisions for training staff? ÌÌ What are the provisions for exercising components of the plan? What is the mechanism for communicating and sharing information with the service line executives and the care line executives? What is the policy adopted by the Hospital for promoting the activities of emergency planning in order to get support? From all staff? From key informants and key staff? From the community outside HCF (especially police and fire brigade)? page 8

12 Component 3. Emergency planning process for developing the ERP The planning process is as important as the production of a written document (paper plan). It is an ongoing process. Therefore the planning committee should start discussing some key elements of the process itself in order to enhance the efficiency, the efficacy and the effectiveness of the planning efforts. The set of questions mentioned in this section are useful for reminding all members of the emergency planning committee that preparing an ERP is a complex activity, which will require commitment, continuity, professionalism, and participation of all staff of the HCF. Members of the planning committee should be in a position to advocate efficiently for the process. What will be the methodology applied to develop the ERP (meetings, workshops, brainstorming sessions, expert consultations, questionnaires, etc.)? Who is responsible for the project (chief of the project)? How the meetings of the planning committee will be organized? Who chairs the meetings? Who convokes the meetings? Who prepares the agenda? Who prepare report of the sessions? Who will attend all meetings as a regular activity (permanent members)? Who will attend the meetings as contributors? Who will identify (and how?) the staff that should be consulted when discussing technical as well managerial issues involving all staff or specific staff? How the staff is consulted (interview, questionnaire, etc.)? What will be the key components of the ERP (identify them so as to develop objectives and a strategy as early as possible in the planning process to achieve them)? Suggested list: Alert processing and decision making for activation of the ERP (including levels of activation) The Incident Command Group ÌÌ Composition (positions to be represented), role and functions ÌÌ Incident Command Room Personnel management and call back procedures JAS (Job Action Sheets) 4 SERPs of care lines and service lines ÌÌ Care lines ÌÌ Technical (maintenance, engineering, security) ÌÌ Support ((administration, finance, personnel, social work, telephonists, volunteers) 4 Supplement Emergency Response Plans developed by the main care lines and administrative lines in major hospitals. In middle size hospitals SERPs can be composed of a few SOPs only. page 9

13 ÌÌ ÌÌ ÌÌ ÌÌ Logistics (medical supplies, etc.) Pharmacy and laboratory Ancillary services (kitchen, cleaners, laundry) Communications Or SOPs for critical services ÌÌ specialist units (burns, spinal etc) ÌÌ main areas ÌÌ medical supplies ÌÌ pharmacy ÌÌ laboratories, mortuary and blood bank ÌÌ radiology ÌÌ support services Areas ÌÌ ÌÌ ÌÌ ÌÌ ÌÌ ÌÌ ÌÌ Disaster triage area Disaster patients receiving areas (often the ED) Emergency Department Family area Media area Area for the dead Main treatment areas Mechanism and procedures for ÌÌ Review and Monitoring the plan ÌÌ Validating and testing the plan ÌÌ Exercises and training Maps and other critical documents How the ERP will be presented and displayed ÌÌ Who will have the full document ÌÌ Who will receive selected sections Component 4. The management of the alert and the activation of the plan Reference note 3 The management of the alert and the early management of the response (decisions taken for deciding the activation of the plan -partly or in totality) is an important part of the ERP. This section can be summarized in flow charts, a few SOPs and or JAS. Special forms should be developed for managing and recording this early stage of the response. Does the plan will provide for the prompt activation of the plan during normal and quiet hours including weekends and holidays? Does the plan will specify how notification within the hospital will be carried out? Will the ERP include an Incident Response Flow Chart? If yes: what will be the roles, the procedures, the forms, the SOPs, page 10

14 the JAS required? 5 Will the plan provide for an alternative system(s) of notification which considers people, equipment and procedures? Will the plan have several possible levels of activation? If yes: what will be the number of levels and for each level: ÌÌ What is the code for each level? ÌÌ What resources are mobilized? ÌÌ What command mechanisms are activated? ÌÌ Who can decide, how, when to activate? ÌÌ Which staff is informed, when, how by whom? ÌÌ What are the main actions that must be taken for each level? ¹¹ SOPs? ¹¹ JASs? ÌÌ ÌÌ The role and functions of the Incident Command Group? The decision for ending the activation? Will the plan specify the chain of command to notify internal and other appropriate hospital staff of the hospital s status? Will the plan detail responsibility to initiate a system for recalling staff back to duty? Will the hospital develope procedures indicating how the hospital will be able to supply resources and personnel to an external disaster? Will the plan include chemical hazard, biological hazard or radiological hazard component 6? Will the plan make provision for activating the hospital disaster medical team(s) in response to both internal and external disasters? page 11 Component 5. The composition, the role and the functions of the Incident Command Group ICG Reference note 4 The ICG is also called the Emergency Command for the management during the crisis time. This component of the ERP is a central piece of the puzzle, much emphasis should be given to discuss in depth this particular component and to get the full support of all care line executives and support line executives. The ERP consists mainly in putting together in a coherent whole the ICG, the JAS and the SOPs. Disaster Management is mainly the smooth addition and integration of: coordination mechanisms between these three components, the relevance of their content, the 5 The preparation of the JAS (writing) should be done when the emergency planning committee has decided the format, the main sections of the JAS. At this stage only the main elements that will have to be included must be recorded 6 Although these issues should not be discussed at that stage of the plan development, it is important to decide whether or not they will be included in the ERP (as special SOPs, or as contingency plans). In the processing of the alert and in the early decision-making regarding the level of activation of the ERP, the Incident Commander (the Incident Command Group) must decide whether or not special procedures will be activated (such as special decontamination, or the use of protective equipment for some staff, etc.).

15 capacity of the staff to use them efficiently and timely. The following questions are not aimed at presenting a model for organizing the overall command. They are aimed at supporting the work of the emergency planning committee so that all key managerial, administrative, logistical and technical issues are considered before deciding how the overall management will be achieved in the Hospital during disaster situations. What will be role of the ICG during the crisis? What will be the key functions of the ICG during the crisis/ emergency situation? Management? Operations? Logistics? Planning? Administration? How these key functions are staffed and managed (which positions are necessary)? ÌÌ How will be the service line executives and the care executives be grouped under these headlines? ÌÌ How each key function is directed (is someone head of )? ÌÌ What and how information is shared between these key functions? How the other functions can be requested to participate if necessary? What will be the composition of the ICG? Managerial, functional and technical functions of key staff members (selection according to the role, responsibility and authority of the function and not according to individuals. For instance Chief of Surgical Department, etc.)? What will be the procedure for activating the ICG? What is the maximum delay before becoming operational (this will help to prepare drills and exercises of the ICG)? Who can decide and for what? What will be the missions of the ICG? Activation of the ERP (which level)? Call back of staff (including volunteers if necessary)? ÌÌ Redistribution of staff according to needs and available resources? ÌÌ Coordination with the various departments of the Hospital? Centralization of the decision regarding the admission of patients and their distribution into the various units of the Hospital? Centralization of the information regarding the Hospital capacity and capability (present and future)? page 12

16 Recording and tracking of admitted patients? Relationship with the outside world, especially the EOC? Contribution to the dispatching of the patients medical regulation- depending of the particular situation of the Hospital in the community (see notes on medical regulation, chapter on Integrated EMS System) if not otherwise organized? Management of information and relationships with ÌÌ Families and relatives of patients? ÌÌ Media? ÌÌ VIP? ÌÌ Public information? Assessment of the consequences of the crisis on the functioning of the Hospital and anticipation of present and future needs ÌÌ Damage assessment if any? ÌÌ Needs assessment for responding to the crisis? ¹¹ Assessment of the needs for recovery? ÌÌ Management of communications? Where will be located the ICG? What will be the characteristics of the Emergency/Incident Command Room? What will be the alternate site if any serious problem makes the use of the normal location impossible? What support assistance will need the ICG? Secretary? Helpers? Telephone officer? Others? Rest room? What will be the logistical support required? Telephone lines, fax, printing capacity, and computers? Maps, forms, protocols, charts? Time lines (for decision making and follow-up)? Other? What will be the managerial support? SOPs? ÌÌ For each key function? ÌÌ For each identified mission? JAS? ÌÌ ÌÌ For each individual position of the members of the ICG? for the staff page 13

17 Will the ERP be available in its full version (including the SERPs/ SOPs prepared by the various departments)? The contact lists with the key stakeholders of the outside world? What are the key documents that should be available in the Command Room? What will be the exercises for activating and testing the ICG? How often, what, who, how? Monitoring and indicators? Testing the communications? Testing the logistical support? Component 6. The Supplemental Emergency Response Plans of the various departments, services, and units of the Hospitals SERPs- and the SOPs Reference note 5 Each care line (department or unit: surgery, ICU, ED, etc.) and each support line (laboratory, pharmacy, etc.) must have their own organization for commanding and coordinating the activities within their area of professional authority. It is beyond the scope of the ICG to directly command activities that are going on for instance in the pharmacy or in the theatre rooms. Therefore these lines of authority must develop SOPs and organizational charts for their own area of work and authority (together they are the SERPs). Standard Operating Procedures, SOPs, (or Emergency Procedures) are usually defined as documents where the activities of a specific person (whatever his/her function) or organisation to face a specific situation are described in a clear, logical, sequential and methodical manner. What will be the Command structure of the particular care lines or service lines? How it differs from routine work? What are the coordination mechanisms with the ICG and other departments, units (including with partners from outside the Hospital if this unit is authorized to have directs contacts with the external world)? What are the SOPs required for performing safely, efficiently and timely the critical activities in the particular department or unit? How are they prepared, by whom? How are they validated? What are the mechanisms for sharing them with the key stakeholders, especially the members of the ICG? How updating, revision, and distribution are performed? What will be the generic content (template) of SOP, if any? How and where are they stored (emphasis on availability)? What are the exercises conducted for using them? What are the protocols, forms, charts (e.g. simplified treatment page 14

18 protocols, decontamination protocols, infection control, etc.) and other similar documents that will be used (or activities will refer to) during emergencies? What are the procedures for freeing beds (contributing to the surge capacity of the various care lines)? Who count the number of beds that could be made available? Who reports, when? What are the criteria for deciding an early discharge of patients or a transfer to another unit and who decides? What can be the treatment areas for specific patients (such as several burns patients exceeding the burn unit capacity if any)? What are the receiving areas for infectious patients in case of an epidemic, and what SOPS will be developed? Special procedures? Special staffing? Universal measures for infection control? Traffic flow of patients in this area and relation with the other areas? For the main treatment areas, what SOPs will be developed: Who is involved, medical staff and support staff? How information is shared with the staff? How needs are assessed for getting outside support (staff, supplies, etc.), who? What logistical support is needed, how, when, who manage? For the support lines: Pharmacy Laboratory Laundry Kitchen Maintenance Security In summary has each department developed standard operating procedures to reflect how it will provide its services in a timely 24 hours manner? Such departments may include the following: Administration Emergency Department Nursing Radiology Laboratory Pharmacy Critical care Central supply Maintenance and Engineering page 15

19 Security Dietetics Housekeeping and Laundry Social and religious Mortuary in the Emergency Department a special section of the plan should consider the following details (requiring SOPs): Is there a separate entry to the Emergency Department for contaminated patients? Is there a dedicated facility for decontamination or a portable device for decontamination? Is there a water supply to the ambulance for decontamination? Can water run-off from the ambulance be contained? Can ventilation system in the Emergency Department be isolated from the rest of the hospital? The management of medical care and nursing care Disasters can impose such a heavy workload on medical care and nursing care that the ICG (together with the care lines executives) may have to decide to prioritize what can be done and when. This is not something that can be decided in advance in an EPR. The assessment of the situation and the evolving needs (present and future) compared with the available resources will dictate what decisions must be taken. The ERP cannot do more than defining who decides for what span of activities. It is mainly a matter of competence between the ICG and the care lines executives. This should be clarified in advance. Each unit/department must clearly identify how medical care and nursing care will be delivered during the crisis. The assessment of the needs for medical care and nursing care has to be done as early as possible. It is an ongoing process. Each unit/department must assess the present and future needs (according to the mission that the unit/department receives) in order to liaise with the ICG or the personnel pool. It is also useful to discuss how the hospital will relate with other health facilities if necessary (transfer of patients, discharge of patients, etc.). Some procedures should be discussed for assessing: What are the other units/departments, which could receive patients? What staff is present at the moment in the unit/department, skills, number, etc.? What number of patients, type of patients (walking, dependent, etc.) in the unit? What is the maximum capacity of the unit, what factors can influence this capacity, how? How much staff will be necessary and when: who make the assessment, to whom to report, how often? page 16

20 The assessment of the capacity of each unit/department is of paramount importance and should be know by the ICG as soon as possible What procedure for assessing the number of beds available? What procedure for assessing how many beds can made available by transfer of patients, early discharge; who does what, when, how? What procedures for getting more beds if they can be accommodated in the unit or department? What special problems has to be anticipated (for instance infectious patients, etc.), who report, how? Component 7. The Job Actions Sheets JAS - Individual Actions Cards References note 6 The Job Action Sheets or job descriptions for a specific position (e.g. on duty doctor of the X-Ray unit) are the essence of the ERP (and of the HEICS program). This is the component that tells responding personnel what they are going to do; when they are going to do it; and, who they will report it to after they have done it. JAS are prepared for positions not for nominative individuals. The emergency planning committee has to discuss several aspects, such as the general template for the JAS (items included, content, presentation, storage, validation, training, etc.). The JAS should always be developed with the direct participation of the endusers themselves (an not in isolation by an ad hoc group of experts ). In many hospital disaster plans the JAS constitute about 80% of the written document (disaster plan). What will be the format and what will be the items (sections) included in the JAS? How the functions/positions requiring the preparation of a JAS are selected? Who develop the JAS? What are the mechanisms for validating and testing the JAS? How are they stored and where (including accessibility)? What training (including exercises) of staff? What about the revisions, how, when, how to make sure that the new version becomes the one stored in the disaster boxes in the various units of the hospita? How to harmonize them and ensure compatibility and complementarities, and synergy between the functions/positions having to cooperate? page 17 Component 8. The management of staff and the call back procedures See reference note 8 The management of staff is a complex issue in an Hospital even during normal time. It becomes a critical function during a crisis. Several lines of authority are involved. The overall management of a system does not necessarily mean that those managing the system (for instance the ICG) also manage the staff performing specific activities as part of the system.

21 The management of staff in a crisis should mirror as much as possible the daily management in term of hierarchical organization and positions holding authority to do so. What has to change during a crisis is the overall command (the activation of the ICG) and the mechanisms for sharing and coordinating the available resources. Staff is the key resource for responding to a MCM. There are several ways to fulfill this function. What are the call back procedures and who can decide for which staff (when, how) to be called back? What is the role of the ICG? What are the roles of the various departments and units? What will be the SOPs and protocols? ÌÌ For call back? ÌÌ To keep on duty staff in the Hospital? Who is responsible for managing staff and activities of each category of staff in the various units, departments (day-to-day organizational chart, modified chart)? How the assessment of available personnel is done when the plan is activated (who does what and what are the report mechanisms)? How the listings of staff are managed? Address, telephone? Updating mechanisms (including sharing info with key positions)? Confidentiality of this information? What are the support activities to be activated when calling back staff? Is there designation of assembly points for all personnel to report to, be they hospital staff or participating organization staff? Briefing them upon arrival (who, where, when)? Food for called back staff or on-duty staff? Children garden or nursery (for key staff called back and having to care for their own children)? Where arriving staff has to go? Reception room for briefing and re-distribution, directly to their workplace? How identification of staff is managed (on-duty and arriving staff )? How working shifts are organized and by whom? What are the specific arrangements for volunteers? Who? How are they distributed to the wards and units? Identification, management, liability, accountability? page 18

22 Component 9. The disaster triage area and the disaster patients receiving areas See reference note 9 An important component of the ERP is the description of the various areas that will more specifically deal with disasters patients. There are two areas that must receive special attention: The disaster triage area (where casualties are unloaded from vehicles and have the first contact with the hospital. The area where hospital triage takes place. Only minimum life saving care is performed. Triage is a difficult activity that requires much preparation (tags, codes for priority, equipment, trained staff, etc.). The arriving patients are classified according to the priority for receiving medical care (usually the use of colors: red for really urgent; yellow for urgent; green for non-urgent. The patients do NOT stay in the triage area. They are immediately transferred to the disaster patients receiving areas The disaster patients receiving areas. They are the areas where the patients are transferred after having being triaged. Usually there are 3 sections: red, yellow and green. The patients will receive further treatment in these areas and then will be either admitted in the hospital (surgical unit, medical unit, etc.) or discharged when possible (for ambulatory care). Several organizations are used in hospitals in Asia. Each hospital must choose the solution that best suits the local context. This part of the ERP requires usually much work from the emergency planning committee and it is advisable to create a sub-committee working on these issues only (see reference note). Where will patients be unloaded from vehicles? Were will have to go the patients who can walk and come to the hospital? Where will be located the triage area for disaster patients? Who decides to open this area, procedure, information management, equipment, security, etc.? How this disaster triage area will be organized? ÌÌ Triage zone? ÌÌ Stabilization zone? ÌÌ Evacuation zone? ÌÌ What will be the circulation between this area and the ED, and the other care units, surgical theatre? ÌÌ Staffing? ÌÌ Triage activities ¹¹ SOPs for the triage area? ¹¹ Codes, protocols to be used, tags, etc? ¹¹ Who will perform triage activities (triage teams individual work)? ¹¹ Who is in command for triage and how the coordination with the ICG is organized? page 19

23 Who does what to set up the area (disaster boxes, etc.)? The traffic flow in the disaster triage area (from unloading patients from ambulances to evacuation to the care units)? How this triage area relates with the ambulances transporting patients? Contribution to the re-supply of ambulances? Use of stretchers? What are the characteristics used to select the receiving areas? Access and possibility to be secured? What equipment and supplies should be available 24/24-7/7? Logistics for re-supply, etc? Security and safety? Medicines, forms, SOPs, vests, O2, Disaster Box, etc.? If the ED will become the receiving areas, how the present patients are distributed, what arrangements must be done for setting up the equipment, signs, etc.? Where will be located the receiving areas for disaster patients? How the valuables of patients are collected and secured? How the patients are recorded? Identification of patients? How the command activities are organized in these areas (triage area and receiving areas)? Medical record (specific for disaster patients)? Record keeping and tracking of patients? Supply and re-supply of equipment, medicines? Management of blood? Information sharing with the main care areas (direct, through the ICG)? How safety of patients, of staff and equipment is ensured? How security is managed, by whom? Auxiliary staff and volunteers (if any)? Administrative support? What will be the training activities and the exercises? What are the specific arrangements for contaminated patients? Where decontamination is performed? How, by whom? What SOPs are necessary, what training of staff? What equipment? What are the specific arrangements for biological disasters (or epidemics)? page 20

24 Component 10. The medical record and the management of patient information Reference note 13 The management of information (especially medical information) is always a difficult issue in crisis time. Usually the medical record used in routine time is NOT adapted for its use during crisis. Therefore many hospitals develop a special medical record. Will the hospital develop a medical record for disaster patients? What will be the key elements that will constitute the record? What will be the characteristics of the record? Where the records will be stored? Who will be responsible for filling in the medical record? What information is given to whom regarding the medical record? How medical information is secured? How patient information is managed; will a patient information centre be considered? How information is shared with pre-hospital Information Centre (EOC)? How information is delivered to relatives, when, how? What are the contributive roles of the psychosocial support team, of the volunteers (Red Cross), etc.? What is the role of the ICG? Component 11. The external and internal traffic flow and control (in and out the HCF) Reference note 10 The traffic flow of patients is of paramount importance. It encompasses the traffic flow of ambulances (vehicles) arriving to the hospital, the reception of patients in the disaster triage area as well as the transfer of patients from that point to any other destination. Several elements must be considered such as security, safety, logical efficient flow of vehicles outside the triage area, of beds inside the Hospital, etc. It also includes the signalization of the areas (family area, media area, etc.) What are the access roads to Hospital that must be secured, by whom and how? How to organize the traffic of vehicles transporting patients, who, when? How to organize the traffic flow of: Ambulatory patients? Of families and relatives? For VIP and media? Who is in charge of security? The returning staff? Volunteers? Of private vehicles of staff? What is the internal traffic flow of patients from the disaster triage area? To access the receiving areas (ED)? page 21

25 To be transferred to main treatment areas (including surgical theatres, X-ray department, etc.)? What will be the areas that will be clearly identified and signalized (Who does what, what signalization is used, etc.) Ambulatory services? Disaster triage area? Information and support Centre? Psychological support? Mortuary? Identification of security staff, who, what function (vest)? Component 12. The Logistics Reference note 11 The function logistics support is of paramount importance to ensure the functioning of the hospital in crisis time. Many activities have to be organized and managed to match the important surge in supplies and other logistics requirements. What are the main sub-functions that will be included in the function Logistics in the ERP? How will the following main positions/functions be distributed? Facility manager? Logistic Chief? Damage assessment and control leader? Sanitation system leader? Communications manager? Transportation Manager? Materials supply manager? Nutritional supply manager? Warehouse supply Manager? How these positions/functions are identified (vest)? What are the SOPs necessary for supply management? Will it be SOPs for the generic logistics function only (HEICS model)? Will each units having a logistics function to also have SOPs? ÌÌ Pharmacy? ÌÌ Equipment? ÌÌ Maintenance? ÌÌ Communications? ÌÌ Transport? ÌÌ Etc? What JAS are required for which position in which unit, department? Is a Logistics Command Centre necessary (where, who is member, what relation with the ICG)? page 22

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