Mass CasualtyManagement Hospital Emergency Response Plan

Transcription

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

26 What relation with outside providers and outside services providers? How to document actions and decisions on a regular basis, where documentation is stored, how? How to liaise with ICG? What possible role in decontamination procedures? What procedure for identifying ongoing hazards and for initiating fighting against (especially fire)? How to liaise with the Safety and Security Officer (in the HEICS model) regarding security problems and unsafe areas? How to start with light search and rescue efforts if necessary? Who identify salvage areas where immediate salvage efforts should be directed in order to save critical services and equipment? Who assign staff to salvage operations (how)? Who assign staff to repair operations (monitoring, etc.)? How the assessment of structural safety is performed; who does what and when? Who identifies areas where immediate repair efforts should be directed to restore critical services? How to develop a real-time tracking system for all resources requests? Is there a need for developing pre-established message forms to document all communication? Is there a need to open a Communication Centre in close proximity to the ICG (what staff, what equipment, role of runners, etc.)? How the communication is maintained between the hospitals of the network? How transportation is managed: use of litters, wheelchairs, stretchers, etc? How the ambulances off-load point is established, located, and signalized? How the transport outside the hospital is organized? How the equipment necessary to disaster triage area is dispatched to that area, who, what? What inventory of what equipment is done to assess the needs for re-supply? Who determine the pharmaceuticals needs, when, how? How food requirement and beverage requirement are assessed? Are SOPs necessary for food procurement and beverages procurements? How the in-house supplies are recorded? Is there a need for a short list of vendors? Component 13. The security This is a fundamental aspect that is too often overlooked by the emergency planning committees. Security is different than safety. Usually safety (a very important component, regrouping complex activities such as maintenance of essential equipment, buildings safety, etc.) is under page 23

27 the function Logistics. The function security is restricted to the police activities. The hospital must be secured. Security extends from the vicinity of the hospital (outside security) to the inner of the hospital. The close cooperation with police forces and internal security staff is of paramount importance. In some ERP security is regrouped under the function logistics, while in other ERP (HEICS model) it is a core function of the ICG (security commander). Each hospital will chose the best adapted solution according to what is in place in routine time. Who is in charge of the security outside the hospital? How coordination is organized between police forces and hospital internal security staff? Who is in charge of the security inside the hospital? Are there various security zones (restricted access), how are these zones selected, how are they signalized, secured? What equipment will be necessary (vest, ropes, etc.)? How security of the disaster triage area is ensured, by whom? What training for the security staff? Who is in charge of managing the ID of staff? Will the entry doors for accessing the hospital be limited to only main access, what signalization, who is in charge of security and ID check? Component 14. The areas for the families Often Hospitals have many family members visiting the patients in normal time. During disasters the patients are often brought to the hospital by the relatives and or the neighbors (not always by ambulances without family members). The management of the visitors is not easy in crisis situations, especially if patients are brought to hospital by relatives. It is normal that relatives may want to come to the hospital in order to find a missing person (this is frequent during evacuation of the local community from a geographical area after a disaster). Although the dead should not be transferred to the hospitals, it happens that they are. Relatives may want to come to identify their family members. The request from relatives to know if a member of the family is admitted in the hospital is legitimate. There are several more reasons for developing a response strategy to manage these issues. The opening of an Information Centre for receiving the families should be considered. See also the components management of information and psychosocial support activities. Where will be the area for the families? What staff will be necessary to run it; who does what? What activities will be developed in this area: practical support (food, etc.), social support, psychological holding, and logistics? How information is delivered to families, who, when (especially for the dead)? How the identification of the dead is organized? page 24

28 Component 15. The areas for the media The media should be allowed to come to the Hospital but there should be a clearly signalized area where the media people will meet the hospital s spokesperson. Media people should never be allowed to enter freely the hospital. Where is located the media area? What staff, what support? What is the strategy for communicating with media and providing information? Who prepare the information, who delivers the information? Component 16. The management of information The management of information is a central component of the management of hospitals in disasters. There is no activity that does not require the management of some kind of information. That is why the management of information has to be discussed in every component. For instance the revision of the ERP requires the management of many data. The updating of the staff lists is part of the information management. The tracking of patients is part of the management of information, such as also the damage assessment, etc. In the Incident Command Room, much information should be available to the members of the ICG. Part of the information is collected on a regular basis (updating of telephone numbers, lists of staff, etc.), part of the necessary information is collected immediately when the plan is activated (number of beds available, number of beds that can be made available, etc.). The members of the ICG must have immediate access to key information for managing the response (contacts inside the hospital, contacts with key partners outside the hospital, etc.). Some elements should be considered such as the list of telephone numbers of unusual use for a hospital such as the embassies (in places where tourists or foreigners may be present during the disaster time), the list of volunteer translators, the list of the religious leaders who could be called for support (to cooperate with the psychosocial support team), the list and phone numbers of the other HCFs (including private). In the Incident Command Room the following information should be accessible at any time: The ERP (in its full version, with all SERPs, all JAS, all SOPs) Maps of the hospital and of the buildings (with localization of the key safety devices such as water valves, fire fighting devices, air conditioning command, etc.) Organizational chart of the hospital and of the main care lines and service lines The storage of toxic products (localization and type) Safety check lists and procedures page 25

29 Security checkpoints Some key elements of information regarding the normal functioning of the hospital (to prepare information release to media) Contact of key suppliers (oxygen, life lines, etc.) Simple time line charts for following up the main activities and the work load, the use of resources, the staff, etc. A simple system for collecting and processing the data concerning the patients (tracking) A simple system for collecting and processing the data on actions developed during the crisis (this is important for assessing afterwards the response and to review the ERP) What are the key data that must be collected in any circumstances during a crisis situation, who collect, how, when, to whom to report, special forms? Is there a centralized information management function, how, who, where, what? How are managed and secured the information systems (electronic information)? What information must be accessible to whom (what is confidential)? Incident Logs All managers must maintain a log throughout the incident response The log will: keep track of outstanding issues maintain a record of all actions requests and decisions made key communications issues both outstanding and completed provide a legal record of the incident response that may be used at post incident evaluation (which may include legal scrutiny) Component 17. The management of the dead Disasters always generate injured patients. Some of them will die. Sometimes the dead are transferred to hospitals. The management of the dead is a central element of MCI (often MCI are also Mass Fatality Incidents). The management of the dead has several components: Body recovery Identification (including viewing by families, and returning the bodies to the relatives) Storage of the dead bodies Burial religious, ethical and psychological issues It is not recommended to transport dead bodies to hospitals (unless no other possibility and only if few dead that the hospital morgue can absorb). But hospitals should anticipate the problem and also count on the fact that many patients can die at an early stage after their transfer to the hospital. It can happen that the hospital is selected as the place where page 26

30 identification will take place in the community (forensic investigation). Where is located the area for the dead, signalization, security? What equipment, what procedures, who is in charge, what staff? How is organized the identification of the dead by the relatives? What procedures for the release of the bodies to the families? What information is collected, what information is given to whom and by whom, how and when? How dead bodies are stored, who is in charge? Component 18. The continuity of operations See reference note 12 Continuity of operations (COOP) planning allows for the continuation of the essential functions of the hospital, regardless of size, during any incident or emergency that may disrupt typical, normal operations. Evacuation procedures are discussed under COOP. What are the hazards (external and internal) that can affect the hospital in its normal functioning (fire, chemical incidents, floods, hurricane, power failure, etc.)? What are the key functions of the hospital that can be altered by these hazards? Does the vulnerability analysis process include specific conclusions on that issue? Should the hospital develop a contingency plan for continuity of operations: which functions should be considered, who develops the COOP contingency plan? What are the evacuation procedures, who decide, how, when? What are the alternate sites? What are the arrangements with the other Hospitals of the network? What training is needed, what exercises? Is there an organized discharge routine to handle large numbers of patients upon short notice? who is responsible for the removal and control of patient records and documents? Has provision been made for immediate refuge, care and comfort for the patients and staff on the hospital grounds during inclement weather? What procedures for urgent partial evacuation (internal disaster such as fire requiring a partial evacuation), who has the delegated responsibility to manage? When to decide to restrict the access to the HCF, what, how? Others? It can happen in extreme cases that the Hospital is isolated for several page 27

31 hours or days. If such a potential exists, then consider the following questions: has the plan assigned position leaders responsible for: Auxiliary power? Rest periods and rotation of staff? Rationing of water and food? Waste and garbage disposal? Rationing of medication, dressings, etc? Laundry? Staff and patient morale? Has consideration been given to utilize patients and visitors to assist staff with their duties? The maintenance of the key services is of paramount importance. These aspects are usually discussed under the component Logistics (assessment of the damages to critical equipment, loss of critical services, etc.). The ERP should have a section describing how safety and maintenance of critical infrastructure and essential equipment are managed during crisis time. Component 19. Training and exercises See reference note 14 Training of staff and exercising of some components of the plan are full part of the ERP. Plans must be developed, trained and maintained. Therefore the ERP must include a section on training of staff and exercising of some components or functions of the plan. What information must be given about the ERP to all staff, how, how often, when? What information to the key staff holding a special responsibility or having a special function, how often, by whom? What training, how often, when: Who, when, how should undergo regular training and exercises? The relation with the media? The relation with the families? The medical activities such as triage? Information management? Communications? Security? Logistics (especially maintenance of critical equipment)? Incident Command Group ICG? JAS: how to train staff, when? Activation of the plan and coordination with the different care lines and services lines? Coordination with the outside partners (police, rescue services, ambulances, fire department, etc.? ÌÌ What exercises, how often? ÌÌ Which partners should be involved? page 28

32 How drills, exercises are assessed? What monitoring mechanisms for assessing exercises and integrating the lessons learned? Component 20. Testing the plan and the ERP maintenance The plan must be tested. This is best done when there are national policy on ERP (prepared by the MOH) and guidelines regarding the requirements that the plan must fulfil. This is usually discussed in the accreditation protocols. Anyway each component of the plan must be tested before the plan can be considered as functional. The testing of the plan can be done by functions, by services and by components. There should be clear instruction about how the plan will be: monitored reviewed tested evaluated validated revised updated The ERP is a living document. The context changes rapidly; the environment, the resources, the capacities of the partners change over time. The organization of the care in the hospital, the staff, and the equipment also change over time. Therefore the ERP must integrate these changes. It is common sense to accept that a plan must be revised but it is rarely done as a systematic activity. Any activation of the plan should be followed by an analysis of what happened in order to decide if the ERP requires revisions (amendments to the plan, systems and procedures, control and coordination arrangements, information management systems and training, etc.). Exercises are also useful to revise components of the plan. The maintenance mechanisms of the plan must be described in the ERP What will be the mechanism for revising the plan? Who is in charge of the maintenance of the plan? How the plan is validated, by whom, according to what criteria? How changes are decided, integrated, tested, validated? How the plan is up-dated so that any change is integrated into the components of the plan being at the disposal of the staff? How the staff is informed of changes? Component 21. The psychosocial support activities See reference note 15 The psychosocial consequences of disasters are now well described and it is generally accepted that any disaster plan must include a section on mental health and psychosocial support. In hospitals the activities are necessary not only for the patients and the relatives, but also for the staff working under stressful conditions. Hospitals often have an important role page 29

33 in the management of public health in the community. Mental health is more and more integrated as an important component of public health in disasters. The ERP should include a special section on psychosocial support activities. Who are the professionals who will be involved in the development of psychosocial support activities? For the patients and the relatives? For the staff? How the activities are organized? What will be the composition of the psychosocial support team (identification, etc.)? What will be the role of the volunteers, the NGOs, the religious leaders in these activities, if any? How will they be selected, trained and supervised? What are the areas where the presence of members of the psychosocial support team will be ensured, how? What SOPs, JAS will be developed? What equipment should the team have? What forms will be used, where will the information be stored? Will the hospital develop standardized treatment protocols? What educational material should be developed and ready for distribution at any time for patients, for families, for staff? What will be the links of the hospital psychosocial support team with the outside world (especially the referral institutions for psychological care), the Information Centre? What services will be offered to the staff of the hospital, when, how? What are the ongoing educational activities of the staff that the team will carry out? What will be the activities developed for special groups such as the children, the bereaved families, etc? What will be the role of the psychosocial support team in the management of the identification of the dead by the relatives? Component 22. The management of the communications The breakdown of the communications is one of the most frequent problems encountered in hospitals during disasters. It can badly affect the effectiveness of the response. The management of information (critical for managing the response) requires efficient and well organized communication systems and channels. Often the communications are discussed in the function Logistics (see the section on that issue). Nevertheless the emergency planning committee must discuss in depth the communications as a topic per se. Testing of the equipment and regular training of staff are mandatory. page 30

34 What are the communication means that will be at the disposal of: The ICG? The various care line executives and service line executives? The ED and the main areas? The backup of the traditional means? The possible use of runners? Who is authorized to use what communication means? How the communications means are used for: Alerting other units about a problem? Sharing information with other units (templates messages, etc.)? Informing the staff? What forms, protocols are used, by whom and when; how record is kept? What training will key staff receive to use the communication means? How the situation reports are prepared, by whom, when, to whom are they delivered, through which communication mean? How the staff must use the telephones of their unit during the crisis? What will be the use of cellular phones of the staff? What will be the role of the electronic equipment for sharing information; for storing information; for processing information; How this electronic equipment is secured, who has access, when? Component 23. The Emergency Department Hospitals may have a number of roles in a disaster, including: Receiving patients and especially injured patients in mass casualty situations Provide triage to arriving patients for decision of admission and treatment priority Referral hospital or receiving hospital for patients transferred from other health care facilities Sending out specialized teams such as triage teams, disaster medical teams, ATLS teams, etc. Contribution to the dispatching of patients (in many countries) in coordination with the evacuation centre Role in public health Etc. The Emergency Department is in the front line of the Hospital. The page 31

35 organization of the management of routine emergencies is a prerequisite to any surge in the treatment capacity of the ED. This Department should be a full department (at least in major hospitals) with its own organization, staff, command mechanism etc. The institutionalization of the emergency medical care capacity is of paramount importance for preparing the Hospital to manage MCI. Its is beyond the scope of this toolkit to discuss in details what are the components of the ED, how the staff should be trained, what SOPs must be developed, etc. for rendering this ED effective even for managing limited mass trauma situations (a few injured arriving at once) and routine emergencies. But it is an illusion to think that the ERP will solve the problem in disaster situations if the ED is poorly staffed, poorly organized and poorly managed in routine time. The ED of hospitals is an key component of the EMS System (when such a System exists). The networking of hospitals in the same area is a sound approach to prepare the hospitals to respond to mass casualty situations. Each country has its own organization for linking together the trauma centres, the ED, the EMS components. When developing the ERP, the emergency planning committee should discuss in depth the role and functions of the ED in the system (and not only within the hospital). The upgrading of the ED is a prerequisite to the development of the surge capacity of the hospital. Some elements are discussed in the toolkit EMS System. The following questions may help: What is the role and what are the functions of the ED in routine emergencies? How the ED is staffed, organized, managed in routine emergencies? What are the SOPs, the existing guidelines, etc. for managing routine emergencies? What is the treatment capacity of the ED under routine conditions? What training is offered to the staff as a routine activity for managing emergencies? What are the weaknesses and the recurrent problems encountered in the management of routine emergencies? What is the role of the ED of the Hospital in the EMS System? What are the functions of the ED of the Hospital in the EMS System? What staff? What procedures (especially for the dispatching of patients, see toolkit on EMS System)? What coordination mechanism, with which other units, organizations? What will be the role and the functions of the ED when the ERP is activated? Staff? Activities (including organizational aspects such as traffic flow, etc.)? Re-organization of the areas? page 32

36 SOPs, protocols, etc? Equipment? Security? Logistics? What organizational chart? What command mechanisms? Disaster box (content, localisation, access, etc.)? Essential medicine (disaster stock)? Special training? Coordination with ICG, the other units? Relation with ambulances, role and functions? Relation with outside doctors (especially GP for minor cases)? If the ED is responsible for preparing medical teams or trauma teams or any other specialized team: What staff, how, when, what training? What equipment? What command structure? What logistics support? Component 24. The Preparation of the Hospital for chemical and biological incidents The ERP for mass casualty situations should also contain a section on chemical incidents. Usually this aspect is developed as a contingency plan, complementary to the ERP discussed here. With chemical and biological agents it should be remembered that there the onset can be acute or slow onset. Therefore the response plan should include an element that can detect as early as possible any increase of illnesses or medical conditions that may suggest the existence of an incident of that nature. The ICG should have permanent access to experts who can advise on these issues (for acute as well as for slow onset situations). The contingency plan for chemical incidents must be developed as a community response plan (not only as a internal business of the hospital). The cooperation with the specialized rescue services is mandatory. It should be remembered that hospitals s tore chemical products that can lead to an internal disaster. This aspect must also bi included. In chemical incidents it is not rare that there is a toxic cloud. Depending upon the site of the accident, the hospital could be in the area where the toxic cloud will be present. The hospital should anticipate (especially for managing air supply within the units, etc.) Some key aspects must be discussed such as: Special procedures (decontamination, containment, infectious barriers, etc.) Reporting system for routine and early warning? Cooperation with specialized agencies (outside the hospital)? Training of staff and information management with staff? Public information system (role of the Hospital9? Special procedures for treatment and follow-up activities of patients? page 33

37 Safety of the units (especially the ED) of the Hospital? Security and organization of the traffic flow under these special circumstances? What antidotes will be stocked, where and who can decide for their use? What special training and exercises (with which partners inside the hospital and outside the hospital) for these special conditions? How to train and exercise the coordination mechanisms with the EOC, the EMS System? Component 25. The Preparation of the Hospital for a pandemic influenza The potential for a pandemic influenza with catastrophic outcome exists. WHO (WPRO 7 ) has issued several documents urging the MOH to develop a national policy on that issue WHO has also developed recommendations and guidelines for the preparation of Hospitals to cope with such a catastrophic incident. These documents are management procedures for preparing the Hospitals to respond to a pandemic 11. This is a pragmatic approach, which is urgently needed considering the seriousness of the threat. Nevertheless it should be clearly understood that the adoption of such specific management procedures cannot be a substitute to develop a complete ERP for MCM. Reference Note 1 Risk management and vulnerability analysis in hospitals Risks are the consequences of the interactions between hazards (source of risks) and the elements exposed to this source (community, which is composed of 5 elements: people, property, services, environment, economy & assets). The formula used in WPRO is Risk is proportional to Hazard X vulnerabilities / Readiness. See reference documents for more information. Just remember that for each hazard there are vulnerabilities that are specific to the hazard discussed. Community is expressed in term of vulnerabilities/ readiness (for its 5 elements). Vulnerability analysis process may become a highly technical process (such as assessing the seismic vulnerability of the buildings of the HCF). The input from experts may become crucial. Nevertheless the HCF should adopt a 7 Avian Influenza, including Influenza A (H5N1), in humans: WHO interim infection control guideline for health care facilities. Manila, WHO Regional Office for the Western Pacific, WHO pandemic influenza draft protocol for rapid response and containment. Geneva, World Health Organization, Assessment tool for national pandemic influenza preparedness. Stockholm, European Centre for Disease Prevention and Control in collaboration with the European Commission and the WHO Regional Office for Europe, WHO checklist for influenza pandemic preparedness planning. Geneva, World Health Organization, A practical tool for the preparation of a hospital crisis preparedness plan, with special focus on pandemic influenza. WHO page 34

38 pragmatic approach aimed at identifying the main vulnerabilities. Simple qualitative methods can be useful (cf. toolkit on vulnerability analysis for HCF). Prioritization of risks to be dealt with is necessary. It is impossible to consider all risks at once. In order to identify risks, it is necessary to identify hazards, analyze vulnerabilities (cf. section on vulnerability analysis), and generate risk statements. Focus only on actual risks (do not waist time in discussing a hazard that does not exist in the area where the HCF is located). Risk is the combination of the probability of occurrence and of the consequences. Be aware that often risks are underestimated just because the all hazard approach is not applied (cf. module on risk management). For instance the fact that lorries transporting highly toxic liquids are crossing the area is not considered (creating the potential for chemical incident). in HCF context the vulnerabilities are usually classified as: structural / non-structural / functional / administrative and personnel / external vulnerabilities interfering with the normal functioning of the HCF. Working on realistic scenarios is recommended. It is important to prioritize the vulnerabilities that can be addressed by mitigation programs. Focus on characteristics of the community that could have an impact on the service delivery of the HCF (remember that a community is composed of 5 elements) Surge capacity is an important component of MCM (cf. section on surge capacity). It is vital to assess how the HCF can contribute to the surge capacity of the whole system. HCF is not an isolated island. It is important for an HCF to work on realistic scenarios (in MCI: the potential number of victims and the types of injuries or medical problems). Surge capacity of an HCF is not infinite: to assess the maximum capacity is important so as to anticipate and to inform the overall management of what the HCF can do and not do to assist. Surge capacity is not limited to the number of available beds. Surge capacity requires a systemic approach (including the possible contribution of the private sector, especially in urban context). ERP should be a direct contribution to this surge capacity The ERP of the HCF must be compatible with the existing plans (whether community health sector plan or intersectoral plan). The ERP of an HCF belonging to a network of HCF (concept especially important in cities) should look for compatibility and synergy with the plans developed by the other HCF (including coordination with private sector). The existing intersectoral arrangements (intersectoral EOC and health sector EOC, etc.) should be identified before starting to develop the ERP so that the plan will become part of this overall organization. Patient evaluation and care in emergencies or disasters is provided page 35

39 primarily at community-based hospitals and integrated healthcare systems. These assets, therefore, must be centrally involved in the development of community plans. Efforts must extend beyond optimizing internal HCF operations and focus on integrating individual HCF with each other and with non-medical organizations. Such integration ensures that decisions affecting all aspects of the community response are made with direct input from medical practitioners, thus establishing medical care, along its continuum, as an essential component of incident management. Further reading 12 : y Policy and Strategy for w h o/e h a action in Disasters. April 2005 Table on health effects of hazards Protecting Public Safety Hazards and risks tree Checklist of preparedness components Logical framework of terminology Public Health Predictor Template Matrix of health needs PTC flow charts for emergency planning WHO strategy for disasters WHO reference values in disasters What is the name disasters and emergencies Reference Note 2 The Concept of Comprehensive Emergency Management Program The Comprehensive Emergency Management Program (CEMP) describes a general strategy for managing contingency situations in an efficient and effective manner using an all hazards approach. The program applies to any internal or external emergency situation. The CEMP is a concept where hazard reduction, capability development, and emergency operations are linked in an ongoing process of activities, which occur in four phases: Mitigation. Activities to eliminate risk to life and property from hazards. Preparedness. Activities developed prior to a disaster or emergency to eliminate or reduce effects of hazards (preparedness includes the creation of the disaster plan). It is also aimed at increasing the level of readiness to respond to and recover from Response. Activities that address immediate and short-term effects of disaster or emergency. Recovery. Activities and programs to return an entity to an acceptable condition. The CEMP incorporates the Hospital Emergency Incident Command System (HEICS). The CEMP applies to all staff. It is the written record 12 These documents have been published by WPRO and are available in separate folders page 36

40 of this on-going program, which includes the Environment of Care Standards, Safety and Quality Management Programs. All service chiefs, service line executives and care line executives have primary or support responsibilities for one or more essential positions based upon their normal day to day responsibilities and resources. All employees are responsible for responding according to this program and for performing their assigned duties in the event of a disaster or emergency. Hazards Analysis, vulnerability analysis and risk assessment is a key part of the process. The purpose of this policy is to chiefly identify actions to be taken at in the HCF to minimize any adverse impact on patient care and to protect patients, visitors, and employees from the effects of natural and manmade disasters. The protection of equipment and services should also be included. The program establishes a universal structure for a systematic, coordinated, and effective approach to emergency management, including (this is the more formal emergency plan): Fundamental policies and assumptions. A concept of operations that describes the process for organizationwide response to emergencies. An organizational structure that designates emergency assignments around day-to-day responsibilities and includes a process for decision-making on objectives and priorities. Assignment of specific, ongoing responsibilities for the prevention of emergencies or a reduction of adverse effects; development of capabilities needed to effectively manage and provide services in an emergency situation; response to problems caused by any emergency; recovery to resumption of services after an emergency, and a mechanism for corrective action y Testing. Exercises will be conducted at least twice a year to test this program and HCF readiness. These drills will be evaluated according to predetermined Environment of Care target measurements. When possible, additional tests should be performed to test noted high risk hazards as shown in the Hazards Vulnerability Table that must be prepared. Additional drills should provide important practice sessions for various teams, such as the Decontamination (DECON) Team, the Patient Reception Team (PRT), and the Emergency Medical Response Team (EMRT) if these teams do exist y Critiques. All members of the Emergency Management Program Committee (EMPC) will review oral and written critiques presented by the EMC in sessions to be called by the Chairman. These sessions should follow each drill or other implementation of the program. Critiques will be held within a reasonable timeframe after execution of a drill, exercise, or real unscheduled event. page 37

41 The following are brief descriptions of key activities in the four phases of the CEMP that promote integration with the larger response community. Mitigation Mitigation is the process of planning for and implementing measures to prevent the occurrence of potential hazards and or to reduce the consequences. It also includes actions undertaken to minimize the impact of a hazard should one occur. It is advantageous to collaborate with other HCF and with non-medical responders when identifying mitigation activities, as this (1) may help uncover hazards and vulnerabilities that the individual HCF might not otherwise consider and (2) allows for sharing of best practices or other solutions. Examples of mitigation activities include: Designing and constructing HCF to avoid or minimize potential hazards (e.g., build electrical systems above ground level in flood prone areas) Confining internal hazards, such as hazardous materials, in safe and secure areas to prevent their release during an internal event (e.g., a fire) Developing redundancy in hospital operating systems to ensure backup capability during an emergency. Backup systems should be evaluated for their vulnerability to hazards, particularly those most likely to affect primary systems Protecting communication systems (both internal and external) and computer infrastructure from accidental or deliberate disruption Establishing programs for testing, inspection, and preventive maintenance of backup systems and facility safety features Preparedness Preparedness activities are undertaken to build capacity and capability within an HCF so that it can meet potential patient and staff needs that arise after a hazard impact. Preparedness includes the development of disaster plan: Describes a well-defined management structure for emergency response Assigns important roles and responsibilities to the HCF incident management team and general staff during response Provides mechanisms to facilitate inter facility cooperation and integration into the community response (e.g., development of standardized data collection and information sharing protocols) Describes processes for requesting and receiving mutual aid, or for providing support to other HCFs whose operational thresholds have been exceeded Establishes mechanisms to conduct and evaluate semi-annual emergency response exercises. page 38

42 Regular meetings of the CEMP committee should be conducted as part of preparedness activities, and there should be an annual evaluation (and revision, if necessary) of the disaster plan. In addition, preparedness includes all training, drills, and exercises that are performed to stress and evaluate the HCF disaster plan. These activities are best performed in conjunction with other HCFs (Tier 2) or the community jurisdiction (Tier 3) to enhance their integration. Response Response actions address a specific hazard impact that has occurred (or an impending impact, such as a hurricane or tornado) and are guided by the HCF Crisis Command Group (HCF internal EOC). The primary goals of response actions are to: Prevent or limit the extent of a hazard impact on HCF staff, patients, and operations (e.g., proper isolation/quarantine measures, continuity of operations) y Maximize patient and population resistance to a hazard after exposure (e.g., administration of appropriate vaccination or medication prophylaxis) Promote healing of incident victims and the general population from a hazard impact (e.g., provision of definitive care, rehabilitation and mental health services) While these goals should be universal to all HCF during response, objectives and strategies to achieve these goals may vary. It is important that differing response strategies among HCF are coordinated (or at least clearly communicated to individual HCF) through a collective response planning process (see Tier 2, network of HCF). Recovery The activities of the recovery phase seek to return response personnel and the HCF to normal operations as quickly as possible. Recovery efforts should include a thorough evaluation of how the response system performed under stress, making note of specific strengths, weaknesses, and strategies to improve the HCF s ability to respond to future emergencies and disasters. Other important recovery activities include: Replacing or servicing equipment and supplies used during response Evaluating, cleaning, and/or repairing damage to the facility Accounting accurately for all costs incurred by the HCF as a result of a response, and applying for financial remuneration of those costs Attending to acute and long-term physical and mental health effects incurred by HCF staff during response (e.g., providing counseling services) page 39

43 Recovery activities should be coordinated with other tiers. Moreover, it is critical that each HCF report to the designated community (Tier 3) incident management authority when its recovery is complete and the facility has returned to normal operations. Rehabilitation of critical services (electrical power, water supply, etc.) is part of the response. Reference Note 3 The participation of the staff of the HCF to the development of the ERP To develop an ERP means to integrate the various institutional mechanisms necessary to ensure the functioning of the HCF (more than just medical care delivery). The main stakeholders involved in these mechanisms should attend (either as permanent members or as temporary members) the meetings of the planning committee (and later on, for some of them, to become the members of the Incident Command Group). The consultation with the end-users is necessary throughout the planning process (powerful approach to develop relevant SOPs and Job Action Sheets -JAS). It is unavoidable to face resistance from some staff (even chief executives). Advocacy for the development of the ERP is the direct responsibility of the planning committee. In private business when a company wants to develop its strategic action plan, major efforts are devoted to define the framework in which the strategy will be applicable. Similarly the development of an ERP will benefit from a clear view of what is desirable as outputs and outcomes (as a result from the development of the ERP). Reference Note 4 The management of the alert and the levels of activation of the ERP The processing of the alert and the early decisions. A hospital may be alerted to an incident from a range of points in the system dependent on the nature of the event. In most external incidents, the health authorities (role of EMS when existing) initiate the response outside the hospital. However, the alert may come from self-presenters to the Emergency Department and the hospital may then activate the process. Alerts can also originate from any of the essential services or the Department of Health. It is vital that the ERP clearly indicates how the alert is received by the hospital, who records what using what form; to whom this information is forwarded and by whom it is processed for further decision. There should be always a senior staff member who is on duty and who can manage the early response to the initial alert. SOPs are useful for managing the flow of information of the alert. It is also important that the plan specify the circumstances for which the plan can be activated. The plan should stipulate the position holder(s) who has the authority to activate/ deactivate the plan including during the quiet hours, weekend and holidays. Many HCF develop ERP with 2 or 3 possible levels of activation. It is useful to have a simple Incident response Flow Chart. page 40

44 Incident Response Flow Chart Notification (Alert) Confirmation Code Stand-by Hospital notified via: y ED Switchboard to Hospital Emergency Controller From Health Authorities via Switchboard Notifies Switchboard, Emergency Department or Emergency Controller (depending upon the organization) Emergency Controller liaises with senior hospital clinician to review info received. Details of Emergency are verified and Director of Emergency Medicine or ED senior staff consulted Assess and verify the alert and type of incident with ASV/Police Determine any special needs eg CBR Make decision re Code activation stages Emergency Controller instructs switchboard to announce the respective Code & notify Incident Coordination Team Action Cards accessed and relevant tasks assigned Code Activation Code Stand-Down Hospital Operational Debrief Hospital Incident Coordination Centre activated. Incident Coordination Team activated. Follow procedures for stage of Code. Self presenting casualties arrive in ED Hospital Emergency Controller (in discussion with others) - or in a surge plan incident, the Director determines the situation is back to normal management To occur a few days after stand-down Depending upon the size of the hospital and its organization (who is the senior on-duty staff who can decide for actions) the alert is forwarded to one or another department. In major hospital there should always be an Emergency Controller on-duty. In some hospitals the full activation of the plan can be decided only by the Incident Command Group (and not by an individual). Anyway the processing of the alert (who does what, when and how, with whom) and the mechanism for activation must be specified in the ERP. The levels of activation of the ERP Many HCF have several levels of possible activation of the disaster plan. The full activation of the plan is very costly in major hospitals. It is possible to significantly increase the level of preparedness by mobilizing limited resources. That is why many disaster plans have 3 levels. It is always possible to go directly to the level 2 or 3 at any time. Some major hospitals in developing countries have only 2 levels. State of Preparedness (alert code white in the Philippines, Code Brown Emergency Department in Australia) used when the immediate needs of resources for medical care MIGHT exceed available capacity in ED and surgery means: increased preparedness with none/minimal mobilisation of extra-resources. Mainly mobilisation of the ED and surgical theatres. Incident Commanding Group mobilised/ Hospital staff ready to go home stays on duties. No elective surgery started, ED prepares for page 41

45 transforming its activities from routine to disaster mode (if there is a separate area for disaster triage and treatment of disaster patients: preparation of these areas) State of increased Preparedness (alert stand by colour blue in the Philippines, code Brown stand-by in Australia) used when the immediate needs of resources most likely/certainly will exceed available capacity but can be defined as limited. means: mobilization of limited amount of extra resources (emergency teams/surgical teams/beds) directed by the Incident Command Group as much as possible (or can be decided by the Incident Commander State of disaster (call out colour red in the Philippines, Code Brown Response Action or Code Brown call out in Australia) Used when the immediate needs clearly will exceed available capacity with threatening/manifest needs of a large amount of extra resources within very short time Means: automatic mobilization of all available resources within emergency discipline and supporting functions. Full activation of the plan. Several other possibilities exist for mobilizing specific units from the hospital (such as disaster triage teams, disaster medical teams, etc.) depending upon the health sector plan in the community and the role of the hospital. If the hospital is supposed to send out medical teams, then it must be clearly defined in the ERP (composition of the teams, leadership, equipment, duties, command, who can decide to mobilize, transport to the scene, etc.). It is part of the response of the hospital. When the request for standby of a medical team is received the team will assemble in the Emergency Department, check equipment, and discuss possible management plans. Where possible the team will continue normal duties until a stand down is notified other is a request for attendance at the scene. page 42

46 Level of Activation of the State of Response Alarm Decision No action Level of preparedness 1 2 State of preparedness Specific actions and procedures 3 State of disaster Activation command group 3 Full mobilization of all resources State of increased preparedness Specific actions and procedures Reference Note 5 The Incident Command Group The Hospital Emergency Command System (HEICS) Hospital Emergency Command System HEICS- is an emergency management system made up of positions on an organizational chart. Each position has a specific mission to address an emergency situation. Each position represented on the chart has an individual checklists designed to direct the assigned individual in disaster response and recovery tasks (Job Action Sheet). The HEICS plan includes forms to enhance this overall system and promote accountability. The HEICS plan is flexible. Only those positions, which are needed, should be activated. The HEICS plan allows for the addition of needed positions, as well as the deactivating of positions at any time. This equates to promoting efficiency and cost effectiveness. The majority of more common emergencies will require the activation of few positions; usually the ED. Disasters will usually require the full mobilization of all available resources. More that one position may be assigned to an individual in limited emergencies or until enough staff is available. Situations of a critical nature may require an individual to perform multiple tasks until additional support can be obtained. This is made possible with the use of the individual position checklists (Job Action Sheets). The organizational chart needs to be revised regularly to keep it adapted to the actual management of services lines and departments. The Job Action Sheets JAS- are vital elements of the planning process and of the management of the response. JAS together with the HEICS chart and the SERPs (SOPs) are the backbone of the hospital disaster plan. The command structure of the HCF may mirror the command structure adopted for community emergency response plans (the notion of page 43

47 Emergency Operation Centre EOC). Usually in the EOC the functions are regrouped in a simple organizational chart 13. Incident Management system has usually 2 different command structures: one Incident Management Post at the site and one EOC. Management and Operations are primarily supported by three internal (within IMS) sections: Logistics, Plans/ Information, and Administration/Finance in the IMS at the site. However, in large-scale or complex events, incident management may require additional support from entities outside the responsibility/authority of IMS located at the site. For this to occur efficiently additional support must be established by the community jurisdictional level: the EOC. Usually the EOC functions are: Management: defines the incident goals and objectives. Includes an incident manager, safety manager, liaison officer, public information officer, senior advisors Operations. Establishes specific tactics (methods) to accomplish the goals and objectives set by management. Coordinates and executes tactics to achieve response objectives Logistics: supports management and operations in their use of personnel, supplies and equipment. Performs technical activities required to maintain the function of operational facilities Plans/Information: coordinates planning support activities for incident planning, as well as contingency, log-range, and demobilization planning; supports management and operations in processing incident information; coordinates information activities across the response system Administration and finance: supports management by administrative issues; coordinates financial issues Incident Command in an EOC Incident commander Liaison officer Administrative officer Public Information officer Security officer Emergency management coordinator Planning chief Finance chief Logistics chief Operations chief Recorder and situation report Labor pool Patient tracking Patient information leader Procurement manager Time and cost Facility manager Damage assessment and control Sanitation system leader Communications manager Materials supply manager Nutritional supply manager Warehouse supply Ancillary services Psychological support Main treatment areas Emergency department Disaster triage area Relation with families Laboratory Morgue manager 13 Medical Surge Capacity and Capability. A management system for integrating medical and health resources during large scales emergencies page 44

48 Incident Management System Core Concepts are: Common terminology Integrated communications Modular organization response resources are organized according to their responsibilities. Assets within each functional unit may be expanded or contracted based on the requirements of the event Unified command structure multiple disciplines work through their designated managers to establish common objectives and strategies to prevent conflict or duplication of effort Manageable span of control response organization is structured so that each supervisory level oversees an appropriate number of assets (varies based on size and complexity of the event) so it can maintain effective supervision Consolidated action plans a single, formal documentation of incident goals, objectives, and strategies defined by unified incident management Comprehensive resource management systems in place to describe, maintain, identify, request, and track resources Pre-designated incident facilities assignment of locations where expected critical incident-related functions will occur. The IMS provides guidance for how to organize assets to respond to an incident (system description). All response assets are organized into five functional areas: Management, Operations, Plans/Information, Logistics, and Administration/Finance. The Incident Management Process describes an ordered sequence of actions that: Establishes incident goals (where the system wants to be at the end of the response) Defines incident objectives (how to get there) and strategies to meet the defined goals Adequately disseminates information, including the following, to achieve coordination throughout IMS: Response goals, objectives, and strategies Situation status reports Resource status updates Safety issues for responders Communication methods for responders Evaluates strategies and tactics for effectiveness in achieving objectives and monitors ongoing circumstance Revises the objectives, strategies, and tactics as dictated by incident circumstances Unified Incident Management. Multiple organizations may have leadership responsibilities during a mass casualty or complex event. IMS has a designated model, Unified Incident Management (UIM), that allows page 45

49 multiple stakeholders to actively participate in incident management. When this occurs, the resulting Unified Incident Management Team (UIMT) promotes cohesive action within the response system, and provides a uniform interface for integration with other tiers. This concept is critically relevant for participation by health and medical disciplines since they bear a primary responsibility for the well-being of responders and the general population during emergencies or disasters. The unified management model provides a mechanism for direct input from health and medical practitioners at the decision-making level. UIM brings together incident managers of all major organizations involved in the incident to coordinate an effective response, while allowing each manager to carry out his/ her own jurisdictional or discipline responsibilities. UIM links response organizations at the leadership level, thus providing a forum for these entities to make joint decisions. Under UIM, various jurisdictions and/or agencies and non government responders may work together throughout the incident to create and maintain an integrated response system. UIM may be established to overcome divisions from: Geographic boundaries, Government levels, Functional and/or statutory responsibilities, or Some combination of the above. Each HCF has to identify which functions that the management wants to regroup under the headlines of the above model (see another organizational chart for the Royal Melbourne Hospital). For instance the management of data and their processing can be grouped under one key function or sub-divided into more than one key function. The key function planning may regroup the head of the care lines, the head of laboratory, pharmacy, etc. In this model the Liaison Officer is responsible for the relationships with the external world. Each HCF has its own identity and should accommodate this generic template so that it suits best the actual HCF context. Although flexibility is recommendable and although each HCF should develop its own model emergency management structure, it is advisable that the core elements are similar to all HCF of the country and as close as possible of the intersectoral EOC organization. The IMS (or Incident Command System) refers to the combination of facilities, equipment, personnel, procedures, and communications operating within a common organizational structure and designed to aid in the management of resources during incident response. The MCM Management System emphasizes management rather than command because no inherent line authority exists in a multidisciplinary response by which assets can be commanded. page 46

50 Possible organizational chart for middle-size HCF (example: Royal Melbourne Hospital, 2004) Executive Emergency Controller CHIEF EXECUTIVE OFFICER EMERGENCY RECORDER Manager Corporate Affairs Manager Fundraising & Community Relations Medical Services Executive Director Radiology Nuclear Medicine Pathology Health information North Western Mental Health Pharmacy Divisional Directors Medicine Emergency Services Anaesthetics & Operationg Suite Surgical Services ICU Services General Medical Services Nursing Services Executive Director Divisional Directors Nursing Bed Manager Nurse Unit Managers Clinical Assistants Allocations Office Outpatients Department Allied Health Director of Infrstructure Switchboard Security Transport Services Biomedical Engineering Food Services Supply Environmental Services Car Parking Engineering Linen Services Retail Manager Director of Human Resources Peer Support Pastoral Care Volunteers Safety Officer In this example, some key functions are: y Executive Emergency Controller. The Controller takes the responsibility to decide for the initial commitment of the hospital to prepare and to respond to a MCI. The Controller directs the work of the ICG, ensures that communications links exist within the hospital and to the EOCs; ensuring that inpatient services are maintained; delegates specific responsibilities to units chiefs; conduct briefings, etc. y Executive Director medical services. He/she assists and liaises with Executive Emergency Controller with overall supervision of the response and evaluation of the response; he/she ensures the availability of medical services in term of resources to meet the demands of incoming casualties; he/she maintains medical ser vices to those patients within the hospital requiring medical treatment prior to, during and following the disaster situation; he/ she redeploys medical staff to meet clinical demands; he/she has a liaisons role with the health EOC in the case of a radiological, chemical or biological incident y Executive Director Nursing Services. He/she assists and liaises page 47

51 with Executive Emergency Controller with overall supervision of the response and evaluation of the response; he/she ensures availability of nursing services in term of resources to meet the demands of incoming casualties; he7she maintains nursing services tot hose patients within the hospital requiring treatment prior to, during and after the disaster situation; He/she coordinates the clinical support staff to assist nurses with patient care y Director of Infrastructure. He/she assists and liaises with the Executive Emergency Controller with overall supervision of the emergency response and evaluation of the response; he /she ensures the availability of general services in term of resources to meet the demands for the management of incoming casualties; he/she maintain general services to the patients and staff of the hospital prior to, during and after the disaster situation; he/she maintains security and traffic control with the hospital vicinity during the emergency; he/she maintains clinical supplies and authorization to contact suppliers for replenishment of stock if required, he/she ensures communication channels (internal and external) are maintained through the emergency y Director Human Resources. He/she assists and liaises with the Executive Emergency Controller with overall supervision of the emergency response and evaluation of the response; he/she establishes volunteers reception centre and staff to register and coordinate volunteers; he/she coordinates non-clinical staff from hospital to act as volunteers and runners to meet the demands for the management of the incoming casualties; ; he7she coordinates staff support requirements; he7she ensures occupational health safety issues are considered throughout the emergency y Emergency Recorder. He/she is responsible for establishing and maintaining document handling procedures during the activation of the ERP ensuring that all documents are sited, registered and acted upon; he/she will locate a whiteboard (electronic if possible in the Emergency Command Room) from hospital management (and regularly print out copies of information written on the whiteboard time lines), he/she will record all actions /messages in and out from the Emergency Control Room (in the emergency disaster log book); he/she make sure that all entries include time, names and designation of staff involved, details of activities or responsibilities delegated and actions outcomes; he/she will keep record of contacts with external agencies, including the health authorities; he/she will keep copies of all situation reports sent and received y Manager of communications. He/she assists and liaises with the Emergency Control Team to manage information with regards to the emergency; he/she will liaise with key Emergency Services organizations personnel including Police, Public Media Liaison Officer to obtain media assistance as directed by the Executive Emergency Controller; he/she establishes the media liaison centre page 48

52 in the area specified of this purpose; he/she liaises with media and provide information other than details concerning patients including regular statements; he7she liaises with the health authorities for provision of patient information sheets and to ensure information is consistent; he/she provides regular information including statements for staff and members of the public; he/she establishes a relatives centre and liaises with appropriate Service Directors in the provision of facilities for relatives; he7seh develops strategies to manage incoming telephone inquiries from relatives staff and members of the public. Application to HCF: the Incident Command Group - ICG. It is of primary importance to organize the response according to ICS/IMS principles. Many hospitals have adopted the Hospital Emergency Incident Command System (HEICS). Others have implemented their own versions of hospital incident command. Some public health departments have begun to adopt systems approaches to managing complex health events. The adoption of these ICS/IMS principles will only increase in importance with the MOH adopting a clear policy on that issue. This system relies heavily on ICS/IMS management concepts. For health and medicine to be considered equal partners and fully integrated into the response community, the concepts put forth in ICS/IMS should form the basis of their response systems. Without this foundation, it will become increasingly difficult for public health and medicine to maximize their roles in incident response. The location of the ICG should be chosen with due consideration. This room should be devoted for the purpose of Command and Management of crisis only (as much as possible). It is not advisable to locate the ICG in the Office of the Director of the HCF for instance, unless no other possibility. The ICG must be organized in such a way that it can be activated 24/24 and 7/7 with less than 30 minutes for starting to be operational (even at the beginning with limited members). Usually the following individual positions are included in the ICG: Director of the HCF Chiefs of the care lines Chiefs or Senior managers of the main service lines Security Maintenance of the critical support services (electrical power, water), Assessment and control Human Resources Nursing staff Information Officer Logistics and supply page 49

53 Whatever the composition of the ICG, it should allow for integrating at anytime other key staff according to the actual situation. For instance if the crisis is an epidemics, key experts will have to be member of the ICG; similarly for a chemical incident. For each member (position) there should be designated deputies. It is easier to have to decrease the number of members of a ICG (if there are too many for a particular crisis) rather than extending the ICG by enrolling new members during the operations. There must be a designated spokesperson for the ICG. The missions of the ICG. The CCG is the ONLY command group for the overall management and the overall coordination of the operations. The ICG has the mission to decide the level of activation of the ERP and the extent of the call back procedure. There should be a provision in the ERP for allowing designated members (positions that are always filled in at any time by the person in charge or deputies) of the ICG to decide even in the absence of key members. The ICG organizes the dispatching of admitted patients among the units and departments of the HCF (including the tracking, recording of secondary transfer later on). The ICG identifies the actual needs and decides the redistribution of available resources (including staff ) according to these needs. The ICG organizes the relationship with families, media and VIPs. The ICG manages the information (complex issue, more than just collecting data: processing the data, making useful information out of the data, distributing the elements of information to the right stakeholders at the right time, etc.). The ICG is on permanent contact with the EOC and the other HCF of the network. When the missions of the ICG are clearly identified it should be possible to anticipate many problems and therefore to develop mitigation strategy and preparedness. For instance the formulation of criteria for assessing the scope of the crisis and its potential consequences on the HCF (number of expected patients, etc.), or criteria for decision making in staff mobilization and re-distribution; description of the organization of communications, etc. Each key member of the ICG should have permanently at disposition a summary of the key actions to undertake and the critical phone numbers (simple plasticized form). The maintenance of the ERP (organizing the revision, the exercises) of the HCF should also be one of the mission of the ICG, unless decided otherwise (if there is a CEMP with a full time CEMP Manager, who is dedicated to this action). y The function command. This function has the overall responsibility for the management of the incident including management of all personnel involved and liaison with relevant authorities. The control function approves and takes responsibility for a plan to deal with the incident. Responsibilities include: Assume Control Establish Control Centre Facilities Assessment of External Incident Situation page 50

54 Appoint Staff Approve Incident action Plan (IAP) Establish Liaison Conduct Briefings Allocate Tasks Ensure Safety Prepare Situation Reports Manage Media Manage Risks Review Progress Maintain Logs y The function planning.this function gathers and analyses all the relevant information about the incident. It predicts future development and plans a response, with a back up in case things change. It also keeps track of all the resources that have been deployed. Responsibilities include: Manage the Planning section Collect, collate and analysis incident information which develops Incident Action Plan Develop alternative control objectives Conduct planning meetings Conduct briefings Plan incident demobilization Estimate future support and resource requirements y The function operations. This function deals with the incident. It determines the effect of strategies and contributes feedback to the development of an action plan. Responsibilities include: Obtain a briefing from the Controller Establish an effective span of control Develop the operations portion of the Incident Action Plan (IAP) Manage and supervise operational activity Receive Situation Reports from operation teams Determine the need for additional resources Initiate recommendations for the release of resources Report special incidents/accidents Maintain a log y The function logistics. This function supplies all the resources needed to deal with the incident. It maintains all the facilities and services which are part of the operation. Responsibilities include: Obtain a briefing from the controller Plan organization of the Logistics section Allocate tasks to section personnel Prepare the Logistics portion of the Incident Action Plan (IAP) Process request for additional facilities, services and materials page 51

55 Establish and manage staging areas Consider future support and service requirements. Span of control is a concept which relates to the practical limit or resources and issues that one person can effectively manage. Training of staff having a command function is of paramount importance. Limits to the span of control will vary and depend on such factors as: The degree of uncertainty in decision making The degree of innovation or routine in the activity being undertaken The type of activities being undertaken The experience of staff The complexity of decision making The range and degree of risks Agency relationships Geographical area covered The volume of information flow The Incident/Emergency Command Room - ECR. This command room is the place where the ICG meets. It is also a working place for staff. It should be selected according to defined criteria such as accessibility, security, telephone lines, space for displaying maps, graphs, accommodating a team at work. It should not be in the office of the director (as it happens in heavily centralized hierarchical organization). As much as possible the ECR should be reserved for the specific purpose of emergency and crisis management (no other use of this room at any time, not used as a warehouse ), fully equipped, fully functional without delay. It can happen that several rooms are identified as the command room (some of them being used in normal time with easy possible switch in crisis situation). The ECR should NOT be located in the ED of the HCF. Alternate sites must be identified in the case the ECR can no longer be used (e.g. security problems such as fire with evacuation of part of the HCF). The ECR should have at least two independent telephone lines besides those using the general communication network of the HCF. It is advisable to have a computer devoted for this room only with complementary equipment. The use of intranet for information management and sharing (as an efficient tool) is more and more developed in many HCF. This room should allow for storing and securing information and key data. Other equipment must be considered such as printing machine. The information necessary for managing the response should be stored in a friendly way (the ERP, the SERPs, the JAS, the SOPs, the maps (including for instance safety valves, etc.), staff address and telephone list, and directories, the forms to be used during the crisis (for tracking, monitoring, ordering supplies, etc.), a pre-established timeline chart (in which all actions are recorded, with time bound mention); samples of various forms and protocols used by the various departments of the HCF; copy of the community MCI plan; useful information on some support logistics such as phototyping machine, check lists. If the ECR is page 52

56 locked it is vital that the key can easily be available at any time by the first arriving member of the ICG. It is advisable to develop at least twice a year exercises of activation (to test and to train) of the ICG. The objectives could be: To verify the activation times (until members are operational) To assess the effectiveness of the members of the ICG To evaluate how the various departments, care lines or services lines react when receiving a request, order, or an information coming from the ICG To test the coordination mechanisms The content of the exercise (should not exceed 2 hours) The announce of a sudden influx of patients The setting up of the room The activation of the members of the ICG (or deputies) Testing the communication between the ICG and the various departments, units and with partners outside the HCF Etc. The elements to evaluate Time for becoming operational The equipment (availability, operability, etc.) Documents (what, usefulness, updated, accessibility, etc.) Communication systems SOPs, JAS etc Organizational Charts. The organizational chart shows the variety of positions which may be needed to address an emergency situation. Another way to view this chart is to think of it, in the words of an Incident Command System (ICS) instructor, as a tool box. All the equipment necessary to perform a job can be found in this box, however, some tools are used immediately and more often than others. And, so it is with the HEICS Organizational Chart. One should try to refrain from thinking that each position represents a person, and each position must be filled as soon as possible. Each of these impressions is false. In conditions of minimum staffing, such as the middle of the night, there are not enough personnel to begin to fill each position. Each crisis is unique and should be confronted as such. Those positions which will be immediately needed to manage the emergency will be the first assignments made. These are the first tools pulled out of the box. There are some positions or roles which are not needed for hours or days after the onset of the emergency. Some may not be needed at all. It becomes very clear that the most important abilities needed to react to an page 53

57 emergency circumstance are the skill to identify the priorities created by the event and which positions are most important to mitigate its ill effects. When it is discovered that there are more jobs to be accomplished than people available, then it may be necessary to delegate more than one job to an individual. Another alternative is to realize that not every task can be accomplished at the time it needs to be done. This can lead to a re-prioritization of needs. In other words, there are limitations in resources which may need to be recognized. This uncomfortable realization may stimulate a revision in the manner in which day-to-day management is performed, or a change in the facility s emergency plan. Following the Organizational Chart is a chart identified as a Crosswalk. The crosswalk chart is a listing of possible positions which might have day-to-day responsibilities similar to those found in the Job Action Sheets. While it is not recommended that these be the only people trained for each position, it is reasonable to visualize how these individuals may be a logical first choice for filling a particular role. It must be remembered that the flexibility of having managers assume almost any officer s role is an important attribute to be retained in the HEICS program. Time line charts. This is a key managerial tool that the ICG should use to follow-up activities and assess evolution of the situation. This tool(s) should be accessible easily by the members of the ICG and permanently updated during the crisis. It is the visible living picture of what is going on, what has be done, what has to be done. It helps for anticipating, reviewing, and for the lessons learned assessment after the crisis. Some elements that must be considered when discussing the Command system that will be set in place: hospital must provided, on a 24 hour per day basis, the function Hospital Disaster Controller who will receive/give the initial notification that the hospital could be/is involved in a major incident/disaster and who will assume the overall command of the hospital and general resources during the time the hospital plan is activated, be it for an internal disaster or as a response to an external disaster hospital must develop a Command System with a Hospital Commander who will be responsible for the hospital s medical responses during the time the plan is activated describe how other key position holders who have a role in disaster management are identified and staffed there must be an appropriate notification system to alert personnel to a potential situation the plan must include lines of authority, role responsibilities and provide for succession (roles and responsibilities assigned in terms of positions rather than individuals) page 54

58 there must be a section describing how those who are expected to implement and use the plan are trained the development of JAS for all personnel involved in disaster response (with a specific role or function, plus a generic JAF for all staff ) the plan must designate how people will be identified within the hospital e.g. hospital staff, outside supporting medical personnel, news media, religious leaders, visitors, use of vests, etc? Incident Action Plan An Incident Action Plan is a record of the course of action taken for each period of time, e.g. 1 hour, 2 hours, 4 hours, 6 hours, etc. throughout the incident. An Incident Action Plan (IAP) can be used for a range of purposes. These include: Briefing personnel and agencies Informing the next level of Control Providing information to stakeholders Recording the response to the event The format of an Incident Action Plan is SMEAC, which stands for: S-Situation / M-Mission/ E-Execution/ A-Administration/Logistics/ C-Command/Control/Communication. An Incident Action Plan will include information about: Situation (current and forecast): Background; Intelligence; Duration; Damage/Casualty estimate; Weather; Hazards/Threats; Maps; Other agencies involved Mission: Objectives Execution: Strategies to meet the objective: Tasks; Timings; Location; Boundaries; Resources; Safety Administration/logistics arrangements in place Command/ control/ communication: direction of members and resources; direction of emergency management activities; bringing together of organisations and resources A written Incident Action Plan (IAP) should also contain: The name of the emergency it applies to Date and time of preparation Controllers sign off Distribution list Confidentiality restrictions page 55

59 Reference Note 6 The Standard Operating Procedures and the Supplemental Emergency Response Plans Supplemental Emergency Response Plans (SERPs). In major hospitals, 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 developed by the various units (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. A proactive approach is recommended to develop true Supplemental Emergency Response Plans (SERPs) within the HEICS framework. These SERPs are to be prepared by each service, service line and care line detailing the manner in which each will meet their assigned responsibilities. Each service chief, service line executive and care line executive will submit one copy of their respective SERPs to the emergency planning committee for approval. The SERP should be specific on various unique action plans to include evacuation procedures, inter-service communications, and inter-service management structure, activities specific to that service. Ideally, SERPs should include plans to address the four mentioned phases, mitigation, preparedness, response, and recovery. In addition to the emergency response plan, a current cascade system of emergency calls including home phone numbers will be submitted to the Facilities Management Service Line Administrative Officer (in major hospitals it is recommended to have this function), Emergency Management Coordinator (EMC), and the Area Emergency Manager (AEM) when these two functions exist. These cascade lists will be reviewed and updated as necessary. Some hospitals of middle size or small size develop SOPs only. The Standard Operating Procedures (SOPs) are an important component of the SERPs. The SOPS are equivalent to the JAS but instead of targeting the actions that has to be taken by an individual having a determined position, the SOPs target the activities that should be carried on in a particular functional area (e.g. ICU, ED for triage, ordering supplies, safety etc.). Standard Operating Procedures, SOPs, (or Emergency Procedures) are usually defined as documents where the activities of a specific person (whatever his/her position) or organisation to face a specific situation are described in a clear, logical, sequential and methodical manner. The terms standard operating procedure and emergency procedure are used interchangeably. Usually the SOPs have the following content: activity (e.g. evacuation procedure of unit x / name of the procedure/ objective/ steps / description and sequence / special situations / attachments / responsible / number of revisions and updating. SOPs are useful to standardize the procedures and activities to be undertaken and to enhance the quality of the management of these activities. Depending upon which activity is concerned they can content the description of the methodology to be applied, safety rules, type of material to be used, control and quality, etc. page 56

60 SOPs are extremely important to ensure that consistent and reproducible results are generated. They must be applicable and achievable, clearly written and easy to understand and follow, and kept up to date using appropriate technologies. Clear instructions should contain information to perform safely and efficiently the activity as well as information on reporting back, coordination with other activities and monitoring and control of the result. It is recommended to adopt a standardized format for the HCF so that each SOP will look the same but the content will differ. All procedures must specify which organisation or persons (position and deputies) is responsible for its execution in order to avoid confusion and chaos, only one organisation or authorized persons (position) within an organisation must be responsible for it. The responsibility is usually assigned according to the activities done permanently by that organisation or persons. The responsibility includes not only the execution of the procedure during an emergency, but its permanent revision, testing, updating and improvement, as well as the procurement of whatever resources are needed for its adequate execution. This has to be done within the framework of the emergency planning process. The ICG must have all SERPs and SOPs of the entire institution. Some SOPs require the assistance from partners from outside the institution. For instance the SOPs dealing with security and safety (fire, etc.). They must be developed in full coordination with these partners and must be shared and even trained with them. The sequence is an important aspect to consider: all the steps have to be written in a sequential order; this is, they have to be written as they have to be implemented through time: from the first step to the last one with all the intermediate steps in between. This is the true essence of any emergency procedure: to guide the responsible for its execution by the hand and telling him/her what he/she has to do during an emergency: from beginning to end, step by step so there ll be no mistakes and no time wasted. Special Situations: not all the activities (steps) are done one after the other (linear steps), some are cyclical (repeat themselves) and others are exceptions (If Then) due to different situations that can occur that would alter the normal and sequential flow of the steps of the procedure. This must be considered when writing a procedure. Special situations are situations that could happen and that have to be considered within the procedure. Attachments to the Procedure: every resource that is mentioned in the procedure such as equipment, specific personnel, material, and vehicles should exist and be listed as an attachment of the procedure itself in the form of a directory, list of personnel, inventory, etc. Every area, functional unit or safety equipment mentioned in the procedure where operations would be held, must be attached in the form of a map, chart or layout. So, every other information that is mentioned in the procedure must be included in the attachments (directories, maps, format, etc.). Thus, the attachments may include, depending on the case, the following items: Directories page 57

61 Inventories Lists of vehicles, equipment or materials Flow charts Checklists Forms/formats Maps Lay-outs Charts Figures Tables Appendices Etc. Updating the Procedure is of paramount importance: environment change (risk change), equipment change, management mechanisms change, etc. All procedures (responsibility, steps, attachments) must be revised and updated permanently (once, twice a year if necessary). This includes not only the written procedure, but also the state of resources. The revision must be done by the unit responsible for the execution of the procedure and in full coordination with the emergency planning committee or the ICG at later stage. There should be a formal and institutionalized mechanism for sharing the information (making known all change) timely and efficiently with key stakeholders (revisions should be known by those involved by the activities of the procedure). Testing the Procedure: all procedures must be tested through simulation exercises or other types of exercises. Procedures can be tested one by one, in a group or all together. All procedures must be revised and corrected after every simulation exercise (if necessary) and after a real emergency response or disaster. Dissemination of the Procedure: procedures are not secret or classified information. All procedures must be disseminated. It is recommended that each HCF assess what will be its maximum capacity and capability for receiving and treating patients or for delivering public services (in an epidemic for instance). There must be a special SOP for that purpose. Reference Note 7 The Job Actions Sheets JAS The Job Action Sheets, or job descriptions are the essence 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. There are two components of the Job Action Sheets which should not be changed under any circumstances: the job title and the mission statement. The universal titles and mission statements found in HIECS allow emergency responders from a variety of organizations to communicate quickly and clearly with other subscribers to the ICS style of management. page 58

62 Changing job titles and responsibilities (mission statements) would counter-serve the purpose which helped design this program. Possible content of a JAS: title of the position (with a number or not for identifying the JAS) mission: main responsibilities and duties actions to be taken order in which to perform these actions co-ordination with other functions/positions timeframe for actions and reporting (to whom, how and when) recalling the useful information: phone numbers, etc. provide unusual information names of people assuming the position (with phone, address ) and identification marks (vest, etc.) Date of last update Presentation and Storage of Job Action Sheets Job Action Sheets which are found within the facility s general emergency/ disaster plan should be sufficient to meet inspection and code requirements (quality assurance and accreditation). In order to make them useful at the time they are needed, a system of presentation and storage should be developed. Some hospitals have experienced success in laminating each Job Action Sheet in plastic so that the time of duty completion can be marked in the blank to the left of the duty. Using an erasable grease pen would allow a reuse of the sheet. Another approach would be to place the Job Action Sheet inside a clear plastic clipboard. Color coded clipboards coordinated with the color of the ICS section are also available. Some hospitals have reduced the Job Action Sheets into a pocket sized booklet, similar to one used by some fire services. This booklet contains key job descriptions, telephone numbers and maps locating the various special areas that are established following a declared emergency. Grouping the Job Action Sheets by section is the common sense approach in organizing and storing these command materials. This has been made easier by utilizing a color coded, plastic storage boxes. Some hospitals use special cupboard to store the section s Job Action Sheets, identification vests and forms/supplies necessary to carry out the section s mission (disaster boxes found in every unit). HCF can decide to have only one JAS for each position describing the actions for the various levels of activation of the plan or to have one JAS for each level for the more complex positions. The end-users should actively contribute to the development of these JAS, which must be validated by the emergency planning committee. There must be an institutionalized mechanism for ensuring the regular updating of these JAS as well as the training of the staff that could have to use them. page 59

63 In summary, the customizing of the Job Action Sheets and their distribution should result in making the implementation of the hospital s disaster plan as user friendly as possible. In time of crisis, the simpler a task can be made, the better its chances of being completed. Some examples of JAS as prepared by hospitals: Example 14 1 HOSPITAL EMERGENCY INCIDENT SYSTEM LOGISTICS SECTION Job Action Sheet Revised: 4-02 Reviewed: 4-02 LOGISTICS CHIEF Positioned Assigned To: You Report To: ALTERNATE: Logistics Command Center: Telephone: Mission: Organize and direct those operations associated with maintenance of the physical environment, and adequate levels of food, shelter and supplies to support the medical and administrative objectives in the event of an emergency. Immediate Receive appointment from the IC. Obtain packet containing Section s Job Action Sheets, identification vests and forms. Read this entire Job Action Sheet and review organizational chart on back. Put on position identification vest. Obtain briefing from IC. Appoint Logistics Managers: Facilities, Communications, Transportation, Material s Supply, Nutritional Supply, & Warehouse; distribute Job Action Sheets and vests. Brief Managers on current situation; outline action plans and designate time for next briefing. Establish Logistics Command Center. Attend damage assessment meeting with IC, Facility Manager / Damage Assessment and Control Leader. Intermediate Obtain information and updates regularly from Managers and officers; maintain current status of all areas; pass status info to Situation-Status Manager. Communicate regularly with IC. Obtain needed supplies with assistance of the Finance Chief, Communications Manager and Liaison Manager. Extended Assure that all communications are copied to the Communications Manager. Document actions and decisions on a continual basis. Observe all staff, volunteers and patients for signs of stress and inappropriate behavior. Report concerns to Psychological Support Manager. Provide for staff rest periods and relief. Other concerns: 14 HVAMC Hospital, Houston, Texas. page 60

64 Example 2 HVAMC HOSPITAL EMERGENCY INCIDENT SYSTEM LOGISTICS SECTION Job Action Sheet Revised: 4-02 Reviewed: 4-02 COMMUNICATIONS MANAGER Positioned Assigned To: You Report To: ALTERNATE: Logistics Command Center: Telephone: Mission: Organize and coordinate internal and external communications; act as custodian of all logged/ documented communications. Immediate Receive appointment from Logistics Chief. Read this entire Job Action Sheet and review organizational chart back. Put on position identification vest. Obtain briefing from IC or Logistics Chief. Establish a Communications Center in close proximity to EOC Establish a real-time tracking system for all resource requests Request the response of assigned amateur radio personnel assigned to facility. Assess current status of internal and external telephone system and report to Logistics Chiefs and Damage Assessment and Control Leader. Establish a pool of runners and assure distribution of 2-way radios to pre-designated areas. Use pre-established message forms to document all communication. Instruct all assistants to do the same. Establish contact with Liaison Officer. Receive and hold all documentation related to internal facility communications. Monitor and document all communications sent and received via the interhospital emergency communication network or other external communication. Intermediate Establish mechanism to alert Code Teams and Fire & Safety personnel to respond to internal patient and/or physical emergencies, i.e. cardiac arrest, fires, etc.. Extended Observe all staff, volunteers and patients for signs of stress and inappropriate behavior. Report concerns to Psychological Support Manager. Provide for staff rest periods and relief. Other concerns: page 61

65 Example Royal Melbourne Hospital, 2004 page 62

66 Example 4 Example 5 DIRECTOR PHARMACY SERVICES ACTION CARD APRIL 2003 Responsible for: Pharmacy Staffing In consultation with the Manager Clinical Support determine the need to call in additional pharmacy staff. Pharmacy Stock Held in Clinical Areas Receiving Casualties Liaise with the Emergency Department and Operating Suite regarding page 63

67 need for additional pharmacy supplies. i. Coordinate delivery of required pharmacy supplies to clinical areas receiving casualties ii. Maintain a manual record of stock provided if unable to access Merlin. Discharge Prescriptions Liaise with Bed Managers of Western, Sunshine and Williamstown Hospitals regarding patients to be discharged home or to Hospital in the Home (HITH) to make beds available for casualties. Determine the number of patients to be transferred to HITH and whether it will be feasible for staff available to prepare medications. In the event there is insufficient time, provide only those medications/iv fluids unlikely to be held by community pharmacies. Determine the number of patients to be discharged home from hospital and whether it will be feasible for medical staff to write discharge prescriptions. In the event that there is insufficient time for discharge prescriptions to be written, discharge medications may be dispensed from the drug chart. Community Pharmacies If the number of patients being discharged or transferred to HITH precludes timely dispensing of discharge prescriptions, patients may be referred to their community pharmacy for medication supplies. Under these circumstances the proforma letter (Appendix 11) should be faxed to the community pharmacy in the Western Health catchment s area (list held by Manager Pharmacy) Patients / family of patients to be given copy of drug chart and instructed to present to community pharmacy to have the medications dispensed. Director of Pharmacy to authorize payment of invoices from community pharmacies and to keep record of all payments authorized Pharmacy Stocks If necessary to replenish pharmacy stocks arrange supply by contacting: HSA Baxter After Hours Monday to Friday and Weekends/Public Holidays The On-Call Pharmacist to assume the above responsibilities until the arrival of the Director of Pharmacy Services page 64

68 page 65 Reference Note 8 The management and the staff and the redistribution of staff The management of staff in hospital is a complex and difficult process even for routine functioning of the institution. When the crisis superimposes many constraints on that process, the situation can become easily chaotic unless pre-established clear policy and procedures are prepared. Each hospital has its own personnel management culture for managing the staff. Therefore there is no universal model that could be applied in every HCF. The size and the complexity of the HCF greatly influence the system that will be adopted for managing human resources during disaster situations. The planning committee should develop an overall strategy. In order to achieve this goal, some key elements must be discussed, such as: Who alert who The nature of the crisis will or will not influence the type of expertise that should be activated (which staff to call back) and how many staff should be mobilized There must be SOPs (and protocols) for the call back of staff according to a logical decision tree Arrangements for keeping on duty staff and briefing this staff Listings of personnel and the information they contain should be considered as confidential documents (address, phone numbers) and managed accordingly Training of staff for working under crisis situations should be presented as a full part of the duties of each department / unit whatever the position of the staff members The meeting points where returning staff are coming should be known by all staff. This requires a formal decision: will the staff come back directly in their routine workplace? Will they have to first come to a central meeting point where they will be welcomed, briefed and dispatched to the wards according to the actual needs? Both procedures have advantages and constraints. Develop the support activities required by the presence of many staff members, especially for food, and beverages, places for resting if necessary, clothes, etc. Identification badges (identification vests) are of paramount importance to avoid the influx of foreign persons not being staff members. The system should provide for this security procedure taking place before the staff enters the units. It is generally advised to restrict the umber of entry gates that can be utilized during a crisis. Staff should enter the HCF by another entry point than the ED or the disaster area and should not be allowed to go for a sight seeing tour before taking on duty work As early as possible the planning of the shifts should be prepared so that the staff can know how long they will have to work, when to return. It is a common mistake to let some staff members to work until they become dangerous because they are exhausted The psychosocial support of staff involved in the activities in direct connection with the crisis (especially those having to work under

69 heavy stressful situation) should be part of the items discussed during the planning process. Each culture and each HCF has its own approach. Nevertheless human beings are all vulnerable to high levels of stress. The most effective strategy for redistributing the staff in the various departments and units of the HCF is to mandate the ICG to take over this responsibility. The ICG is the only body of the HC that has the full overview of the situation, of the needs and of the available resources call-back and personnel information a special procedure for off-duty personnel to initiate: ÌÌ what to do, how to wait (listening radio, keeping telephone line unused..) as soon as they become aware that a disaster potentially affecting hospitals activity has occurred or will they have to come back immediately. In some countries this approach is safer for the communication channels can break down in crisis and then it becomes impossible to have contact with the staff waiting at home. At least for key staff members it is safer to have them coming back to the HCF as soon as possible ÌÌ ensure that medical staff who respond are familiar with the SOPs and the JAS (do not assume that they anyway can easily understand what is expected from them): ¹¹ where to go (where the personnel pool is located if they have to come to a central collecting point) ¹¹ how to cross the check points ÌÌ ÌÌ ÌÌ ÌÌ Organisational aspects: ¹¹ who will provide arriving staff with orders and info ¹¹ how will physicians be made aware of specific procedures (in a chemical incident for instance) disaster situations are unpredictable, drills alone will not prepare the personnel for optimum functioning in every specific circumstance staff turnover/ excitement/ anxiety. Can confuse even experienced personnel: roles are easily forgotten in the urgency of the moment JAS are essential to manage effectively the staff. Remember that they are simple method for assigning and identifying roles and responsibilities and action to be taken ¹¹ no one has time to re-read the manual for directions ¹¹ all need to know what is expected of them ¹¹ activities to be taken point by point ¹¹ These card must be working documents: clear material, resistant, accessible anytime ¹¹ There should be a generic JAS for all staff page 66

70 The function Control of the ICS has usually the overall responsibility for the management of the incident including management of all personnel involved and liaison with relevant authorities. The control function approves and takes responsibility for a plan to mobilize staff and allocate staff to the various units. It must be remembered that the mobilization of extra-resources (more beds, etc.) almost always requires the allocation of staff. When on-duty staff is requested to stay in the hospital, they should receive support from the communications to inform their family and relatives. Reference Note 9 The disaster triage area and the disaster patients receiving areas Whatever the size of the hospital there are several functional areas that must be discussed thoroughly: Emergency Department, disaster triage area, disaster patients receiving areas (the units receiving patients just after the triage has taken place, usually according to the color tag for priority care). In major hospitals of developing countries these areas are often complex and clearly separated areas. In middle size hospitals it may be possible that some of the areas are limited to a single room within the facility. Whatever the complexity of the functional area under discussion is, what matters is to identify the managerial and logistical mechanisms (including staffing, etc.) necessary to achieve the overall goal of the ERP in terms of safety, services delivery and accountability. There are several areas that should be discussed as specific issues for their own: Reception area for disaster patients, also called disaster triage area (first contact with the hospital, where patients are unloaded from ambulances) Receiving area(s). This area(s) receive patients after they have been triaged. In many HCF the ED becomes the receiving area (often the ED is sub-divided into several sections for red urgent care red-, for less urgent care yellow- and for minor injuries -green). This is unfortunately often the only possibility although not ideal solution Emergency Department Main treatment areas (medical care, surgical care, X-Ray department, surgical theatres see other somponents Area for the families and the relatives Area for the media and the VIPs Area for the dead Others, according to the HCF Some aspects of this issue have already been discussed in the previous questions (SERPs and SOPs). The emergency planning committee can use the following set of questions as a reminder and as a tool box for facilitating the preparation of the SOPs and the SERP by the care lines and the service lines. Some areas do not exist (are not functional or not open) in routine work (such as the area for the media or the disaster triage area ). What are the areas that will be included in the ERP as specific areas requiring SOPs, staffing and or SERPs? page 67

71 What will be the overall organization for the reception and admission of the disaster patients? Will there be a special disaster triage area separate from the ED? Will the ED fulfill this function? How will routine emergency patients be admitted, where? The areas for disaster patients: disaster triage area and disaster patients receiving areas. It is recommended to have an area especially devoted to the particular purpose of admitting the patients from the disaster (as much as reasonably possible) where triage and first life saving procedures can take place. Stabilization of patient s condition should not be too ambitious so that disaster patients can be admitted to other areas for receiving further care as soon as possible. Usually the ED of most of the HCF is already busy in normal time so that it is difficult to substantially quickly increase its capacity. Depending on the rooms availability it can happen that the ED has to be selected (no other possible choice) as the receiving area for disaster patients. The surge capacity of this ED should be given priority (how to use open space, corridors for disposition of additional beds, how to discharge patients not requiring urgent care, etc.). SOPS must describe this surge capacity (see section capacity building) Major hospitals having big ED (but no other available rooms for disaster patients) made the choice to use ED for receiving and treating disaster patients (see below the example of the Philippine General Hospital of Manila. There is a medical triage system at the entry of the ED. The ED is sub-divided into sections (urgent: red; delayed urgency: yellow; non urgent: green). Each HCF should select the option that fits the best to the actual context. The triage area is located at the entry point of patients into the HCF (before the ED if the ED is selected as the receiving area(s). The ERP should define clearly what the activities in these various areas are, what staff will be allocated to these areas, what equipment will be available (who care for what, when, etc.). There are many aspects that must be discussed in order to develop the capacity of these areas. Some elements that must be included in the ERP: SOPs JAS of the key staff working in these areas Organization and command Monitoring of activities Recording of patients Logistics (supplies management, medicines, equipment, etc.) Protocols that will be used (triage protocols, etc.) Tags, forms, vests Traffic flow The notion of team work in disaster triage area and in receiving areas is of paramount importance Etc. page 68

72 Reference Note 10 The external and internal traffic flow and the control The traffic flow of patients is of paramount importance. It encompasses the traffic flow of ambulances 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 HCF, etc. It is vital that when developing the ERP the Emergency Planning Committee assesses the access roads (especially the potential vulnerabilities), the constraints that a disaster can create in the vicinity of the HCF, etc. The establishment of simple maps of the HCF is useful and should be considered as a complement included in the SERPs. Exercises and drills are important in this area for ensuring the optimum level of readiness. The traffic flow outside the HCF (the main access roads) should be discussed with the police department in order to have a strategy for ensuring a smooth access as much as possible. The immediate vicinity of the HCF should be secured by police. The Emergency Planning Committee must include this aspect in the planning process. If the HCF can be accessed by private ambulances or by patients directly (transfer of patients by public transport, etc.), then it becomes important to clearly notify the ways for entering the HCF, where to go, etc. The use of color codes and signs is helpful (for instance for pediatrics, for ambulatory patients, for critical cases, etc.) especially if the entry point (patients coming to the HCF in a disaster are not necessarily familiar with the HCF and the various locations of the services). It is important to avoid traffic jam (and RTA) within the area of the HCF and in the vicinity of the HCF. The signalization (use of arrows, signs of stop, etc.) is useful. The most suitable traffic flow is the one using one way traffic for vehicles arriving to the HCF (ingress road and egress road). An important aspect of the traffic flow is safety and security. Not rarely families or relatives can become aggressive and threaten the staff of the HCF if they cannot access easily the HCF. The area for the families for instance must be clearly signalized, the disaster triage area also without possible doubt, etc. The traffic flow inside the HCF is also important. When selecting the various areas (especially the disaster triage area, the disaster patients receiving areas, and the main treatment areas) the emergency planning committee must carefully assess what will be the problems inherent to the presence of many patients and their movements inside the HCF. The internal traffic flow starts with the unloading of patients from the ambulances (or other vehicles) and ends in the area of final destination of the patient (going through the ED, etc.). The traffic flow must also include the traffic for accessing key areas such as theatre rooms, X-Ray department, etc. The choice of the location of the disaster triage area is partly dependent of the expected traffic flow. External traffic control is usually under the responsibility of the hospital page 69

73 security function. Likely areas of congestions are: Approach to ED Emergency ambulance unloading point The main entrance of the hospital Entrance to car park (when it exists) The vehicles not being directly involved in the response should not be allowed to enter the hospital grounds. It is the responsibility of the Executive Emergency Controller to decide with police to block off some access roads for vehicles not directly involved in the response. Only vehicles transporting emergency patients should be allowed to access the ED area. No parking should be allowed in this area (at any time!). Vehicles coming to pick-up patients (patients discharged for freeing beds for instance, or minor injuries) should be directed to clearly indicated pick-up areas. Most of the time police assistance is required. It is vital to develop the traffic flow plan in cooperation with the local police department (exercises should be conducted jointly). If the local community has a well organized EMS having a direct responsibility for the dispatching of patients to the various hospitals of the community, then it becomes important to develop this section of the ERP in full cooperation with the local EMS (especially for directing ambulances; the EMS dispatcher should know what will be the organization of the traffic flow in the hospital grounds). The ambulances unloading patients on stretchers will have to get replacement stretcher (this aspect should be discussed in the plan and indication should be made on how to proceed). Reference Note 11 The function LOGISTICS The main goal of the logistics function is to organize and direct those operations associated with maintenance of the physical environment, and adequate levels of food, shelter and supplies to support the medical and administrative objectives in the event of an emergency. There are several key sub-functions in this logistics function: To maintain the integrity of the physical facility to the best level. Provide adequate environmental controls to perform the hospital s mission (damage assessment and control). To provide sufficient information regarding the operational status of the facility for the purpose of decision/policy making, including those regarding full or partial evacuation To identify safe areas where patients and staff can be moved if needed To manage fire suppression, search and rescue and damage mitigation activities. To organize and coordinate internal and external communications; act as custodian of all logged/documented communications To organize food and potable water storing areas for preparation and rationing during periods of anticipated or actual shortage To organize and coordinate the transportation of all casualties, page 70

74 ambulatory and non-ambulatory To arrange for the transportation of human and material resources to and from the facility To organize supplies and materials for preparation and rationing during periods of anticipated or actual shortage To maintain a high-low inventory for emergency reordering requirements To organize and supply medical and non-medical care equipment and supplies To evaluate and monitor the patency of existing sewage and sanitation systems To enact pre-established alternate methods of waste disposal if necessary. Each hospital will discuss what sub-function is under which line of authority. In the HEICS model the function logistics is a key function of the ICG and most of the sub-functions are regrouped at that level. Other hospitals prefer to distribute the sub-functions among the service and care lines according to their logical routine organization (for instance medicine ordering is done by the pharmacy, etc.). This is a strategic choice for many different activities are regrouped under the function logistics (communications, security, safety, re-supply, etc.) What matters is that all logistics issues are discussed and that a strategy is developed by the hospital for the efficient management of all logistics sub-functions. The discussion of these issues will require several meetings. The emergency planning committee will need the assistance of staff not being regular members of the committee. The contribution of the end-users is of paramount importance (those who will actually do during disaster situation). The following questions should not be discussed as isolated issues. The various aspects of the management of the function Logistics should be considered as a whole (each element being interdependent from another). The Emergency Planning Committee must take time to discuss these aspects in depth. The failure of managing the logistics component is often the cause of the chaos in hospitals during MCI, especially the breakdown of communications, the shortage of critical supplies, the loss of essential services. Reference Note 12 Continuity of operations and evacuation Continuity of operations (COOP) planning allows for the continuation of the essential functions of the HCF, regardless of size, during any incident or emergency that may disrupt typical, normal operations. Continuity of operations planning addresses the recovery of critical and essential operations in the event of an incident or emergency which disrupts service. This can be on a short-term basis, like a power failure, where having a backup capability (systems, personnel, processes, files, and etc.) page 71

75 can quickly resolve the situation. It can also be longer term such as in the case of a major hurricane or earthquake type of event where services are impacted for several days or in some cases weeks. For this long-term denial of services, hospitals will need to plan for relocation to an alternative facility (for some of the services or may consider the evacuation of part or totality of the hospital). Usually evacuation is discussed under the umbrella continuity of operations although the decision to evacuate is done because safety and security considerations. One of the major problems to solve during evacuation is to ensure the continuity of quality care (essential care). Many organizations such as the Business Continuity Institute and the Disaster Recovery Institute (in USA) have created time-tested models for providing contingency and business continuity planning for corporations and governmental agencies. Looking to this business continuity planning and project management models employed by business, COOP experts have developed a model for the COOP planning process. A COOP program consists of 7 phases: 1. Project initiation 2. Identification of functional requirements a. Mission impact analysis b. Risk assessment c. Mitigation strategies and plan 3. Plan design and development 4. COOP program implementation 5. Training, testing and drills 6. COOP plan revision and updating 7. COOP plan execution All too often, when COOP is being discussed, the misconception is that it deals only with the preservation of vital records or backup of data; however continuity of operations planning involves much more than such things, important though they are. It addresses the people, processes, systems, and infrastructure elements that are needed to continue to perform essential functions during a disaster or major incident. It is not rare that hospitals are badly affected by disasters and that the institution can no longer provide all required services. Hospitals should be concerned about their ability to continue operations should they be directly impacted by an emergency or disaster situation. Communities and local governments which have many different agencies and departments have to deal with events such as hurricanes, fires, or floods that can require them to relocate their operations for an extended period of time. Many such government organizations have developed thorough and complete continuity of operations plans that will include resumption plans for that governmental/community body, agency, or department to facilitate the operations of government/community services to its citizens. Hospitals are an important asset of the communities. page 72

76 For instance in USA, the Federal Emergency Management Agency (FEMA) has provided state and local planning guidance. FEMA recommends that COOP planning goals should include an all-hazards approach, the identification of alternate facilities, and the ability to operate within 12 hours of activation, as well as maintain emergency operations for up to 30 days. At minimum each governmental operation needs to ask and answer the following questions: What are the operation s essential functions and key personnel? How can the operation s facilities, vital records, equipment, and other critical assets be protected? How can disruption to the agency s or department s operations be reduced? How can damages and loss of life be minimised? Is it possible through proper planning to achieve timely and orderly recovery from an emergency to a full service to the services users? The following approach may be considered by the emergency planning committee y Step 1: Establish the COOP sub-committee y Step 2: Impact Analysis & Determination of Critical Functions used to determine what functions of the Hospital will require a COOP contingency planning effort y Step 3: Hazard and vulnerability Assessment Conduct a vulnerability analysis for the Hospital and identified critical functions. This will probably require establishing a subcommittee comprised of fire department, Police and IRM personnel to determine specific hazards and vulnerabilities, which may threaten the Hospital, its employees, patients and visitors. y Steps 4: Completion with a time line for the various stages of COOP Program development and implementation Some elements must be discussed by the emergency planning committee (or better by the COOP sub-committee) such as: power back-up system communications redundancy waste disposal in any circumstances water supply (and storage) information system stocks for essential medicines, equipment, supplies stocks for medical gasses manual ventilation of patients if necessary repartition of patients in the various services according to their capacity to move (can move, dependent, can be discharged, cannot be discharged, etc.) page 73

77 The partial or total evacuation of the HCF should be discussed under the concept of COOP. Reference Note 13 The management of patient information, the patient record 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. Therefore the emergency planning committee should discuss what will be the format and the items composing the medical record for the disaster patients (simplified record with some characteristics such as a identification number, etc.) In deed comatose patients can be transported to hospitals without any relative to accompany them. Several other constraints must be discussed. It is a common finding that when many patients are admitted in a short time medical records are no longer filled in and much information is lost. The management of information regarding the patients is often a weak element in many ERP. More and more hospitals make the choice to open a patient information centre -PIC - during crisis time. The PIC leader is responsible for the following: Liaise with Infrastructure Manager re clerical staff support (from OPD, Admissions, Interpreter Service, Medical Records etc) to set up Patient Information Centre Patient Information Centre to be located as per predetermined location listing Obtain Patient Information Clip Boards and Job Action Cards for the staff working in the PIC Advise the Central Communications Desk to transfer all enquiries from the family/friends of disaster casualties to the Patient Information Centre. The first entry point for casualties is the disaster triage area. The recording and the tracking of patients start there and should be permanent throughout the whole stay of the patient in the hospital. Special forms (Patient Information Slips) must be developed for this specific purpose. Each country has its own procedures for the identification of the disasters victims (national registration and inquiry systems). Sometimes the process is under the responsibility of the national Red Cross Society. Usually police department has the responsibility to provide advice to the general public regarding the location of casualties/evacuees. While overall responsibility for control and coordination of registration and inquiry rests with police, the management of the information can be delegated to another community based agency (such as the red Cross). In the general organization of the inter-sectoral response to disasters, the management of information regarding the victims (including those who are not page 74

78 physically injured) is a key issue that is managed by the Information centre set up by the EOC. The hospital patient information centre must liaise with this community based Information Centre. The contribution of the psychosocial support unit is of paramount importance. The permanent updating of patient information is necessary. There should be a mechanism for that. The ERP must provide clear instructions on that issue. Reference Note 14 Training and exercises Confidence in management is an essential component of the plan which no hospital administrator should overlook. It is essential that training is carried out as ongoing processes for all personnel who will participate in a response to a major incident/disaster. This training must include all aspects of the health and medical response such as the first responders role, initial medical site management, the liaison with other services, and an understanding of the overall picture of the inter-sectoral response to disasters. Most of the staff requires training and drills, which can be conducted in-house. However, where possible, exercises should be multiagency to enable a sense of realism and practical experience in managing a response. The HEICS identifies critical management functions in order for the hospital to develop and implement an emergency action plan. In the end, it is people who are truly the most important element of any emergency plan. There is no Job Action Sheet or Action Plan which can substitute for the well trained employee; including the medical staff. Training and exercise of the disaster plan builds the confidence of the entire staff. Those officers with a working knowledge of the facility disaster plan will be better able to exercise a command and control presence over those areas assigned to their care. Training of staff and plan exercising are often neglected by the emergency planning committee. They are full part of the ERP and a section must discuss these issues specifically. Honest critiquing will illuminate those areas which are in need of further revision or retraining. There are different types of exercises, drills and other training activities that are useful for preparing the hospital to be fully operational. The choice of the methodology, of the type of activities will depend on the goal of the exercise. Some components of the plan must be exercised regularly such as the management of the alarm, the activation of the Incident Command Group, the safety procedures, etc. It essential that exercises and training activities are well planned, monitored and assessed. Exercises are necessary to both test the plan and to train the staff. Drills can also be used to check equipment, to check the existing disaster stock, to assess equipment (especially for safety and security). Communications must be regularly tested and trained. The chain of command must be trained at least two times per year. page 75

79 Major exercises involving most of the staff are not more useful than well planned targeted smaller scale exercises. The exercises should be developed by a training committee. The goal and objectives should be clearly announced to the staff undergoing training. It is useful to have check lists for assessing the training activities and the drills. The scenario must be carefully selected (credible scenario) with interfering events (worst scenario should be considered). Reference Note 15 Psychosocial support activities Disasters are always stressful situations by the scope of loss, of suffering, of people injured and by the work under difficult conditions. For decades the tendency was in providing relief. There is a growing awareness of mental health consequences of disasters all over the world. This is reflected in the regular inclusion of mental health components as part of relief and rehabilitation efforts. Mental health professionals have become a part of the teams of professionals working with the disaster affected populations all over the world. There is strong evidence, based on meta-analysis, to show that disasters increase the prevalence rate of psychopathology by approximately 17-20% on average. It is generally accepted nowadays that mental health is a priority in any disaster whether at the individual level or at the community level for it will determine the long term outcome. It is no longer possible to improvise in this growing field: mental health must be part of any disaster plan, including hospital ERP. The need for cooperation, coordination and optimal use of limited resources calls strongly for the presence of skilled helpers, specialized organizational help and well planned programs. Acute reactions during a disaster may have several clinical features depending on the most prominent symptom. There is now scientific evidence that under certain circumstances PTSD can affect more than 30 to 40% of exposed individuals. There is no doubt that the fact of participating in rescue work or providing medical care in the chain of medical care during a disaster puts much psychological pressure on engaged personnel and exposes them to traumatic experience and even extreme stress. It is not rare that the rescuers and medical staff are directly exposed to an imminent threat (major fires, working under rough and uncertain conditions e.g. in the rubble after an earthquake...), that they have to face the injury or death of a fellow worker. The strong emotional reactions called stress reactions of the medical staff working in Intensive Care Units during peacetime and out of any disaster situation were described years ago. Working in an emergency and disaster situation elicits similar reactions: there are some specific aspects in these late circumstances that make the situation potentially more harmful than the one in an ICU because of the exposure to severe stressful and traumatic page 76

80 events. Medical and rescue personnel are not immune to traumatic stress. Distress leads to exhaustion. There is no universal model for setting up psychological and social programs. Each specific community has its own traditional way of dealing with suffering, each country has its own organizational arrangements for providing psychological care and social support in routine situations. Nevertheless Mental Health should be a part of disaster planning. Beside the provision of emergency services aimed at saving lives, limiting damages, etc. there is a need for organizing the activities so as to maximize the services offered in preventive measures (information, training...), in care and support at the site of the disaster and organizing continuing care and support during the immediate post-impact phase as well as in the long term. There is a need for proactivity and for the development of outreach components. The most severely affected are often the less prone to ask for psychosocial support. The best way to be efficient is to rely as much as possible on existing support structures. Psychosocial support activities in an hospitals are targeting: The staff of the hospital The patients The relatives being in contact with the hospital The community (often hospitals have a key role in the delivery of public health services in the community) page 77