Bheri zonal hospital disaster response plan

HOSPITAL PREPAREDNESS
AND

RESPONSE PLAN FOR
BHERI ZONAL HOSPITAL

Copyright. All rights reserved.
ActionAid Nepal
Lazimpat, Kathmandu, Nepal

Publication Year 2010.

This Bheri Zonal Hospital Disaster Response Plan has been prepared by the planning committee
formed as per the MOU signed among Bheri Zonal Hospital (VZH), Action-Aid Nepal (AAN),
Handicap International (HI), National Society for Earthquake Technology-Nepal (NSET) and
Bheri Environmental Excellence Group (BEE-Group). This plan was prepared with technical
support from NSET and financial support from AAN under DIPECHO V project. The project is
financed by European Commission Humanitarian Aid and Civil Protection department, and co-
financed by Australian Agency for International Development, AusAID.

ABBREVIATIONS

AFP Armed Police Force
BZH Bheri Zonal Hospital
CCU Coronary Care Unit
CDO Central District Officer
CEO Chief Executive Officer
EOC Emergency Operations Center
HCC Hospital Control/Command Centre
HDPP Hospital Disaster Preparedness Plan
HICS Hospital Incident Command System
HoD Head of Department
IAP Incident Action Plan
ICS Incident Command System
ICU Intensive Care Unit
IOC Incident Operations Chief
JAS Job Action Sheet
MLC Medico Legal Case
NA Nepal Army
NP Nepal Police
NRC Nepal Red Cross
OPD Out Patient Department
OT Operation Theatre
PSTD Post Stress Traumatic Disorder
RPM Respiration, Perfusion, Mental Status
START Simple Triage and Rapid Treatment

Preface
The Himalayan region lies in an active seismic zone. History of the region is full of
devastating earthquakes. Large earthquakes in Nepal are also expected in the future.

With possibility and expectation of large earthquakes in Nepal, we may witness unacceptable
levels of damage anytime and such damage would greatly impact the functionality of
hospitals in Nepal in terms of number of deaths and injuries as well as irreparable damage to
the hospital buildings. On the other hand, the large number of casualties coming to hospitals
during an earthquake will overwhelm remaining capacity of the hospitals. The preparedness
of hospitals to handle mass casualty situations will greatly influence the emergency response
of the hospitals. The better the preparedness in hospitals the better the response. However,
very little has been done in Nepal in terms of disaster emergency preparedness in hospitals
and health facilities; only a few hospitals have system of emergency preparedness planning
and periodic drills. The efforts of Bheri Zonal Hospital, Nepalganj is a cornerstone in this
direction. Current publication has tried to document and publicize such efforts of the hospital.

This publication “Hospital Disaster Preparedness and Response Plan” is an outcome of the
program “Developing and Implementing Disaster Preparedness Plan in Bheri Zonal Hospital”
implemented by the hospital with technical support from the National Society for Earthquake
Technology – Nepal (NSET) under DIPECHO V program of Action Aid Nepal. This
publication will not only help Bheri Zonal Hospital to respond to the disasters effectively, but
will also help other similar hospitals in planning and preparing for hospital disaster response
plan. We believe this publication would greatly assist concerned authorities and professionals
to safeguard critical facilities and lifelines during unexpected disasters.

We are thankful to Action Aid and concerned health sector authorities for their support in
Disaster Risk Reduction initiatives and trusting NSET for providing technical support in
preparing Disaster Response Plan of Bheri Zonal Hospital.

We extend our gratitude to all professionals from NSET who were involved in developing
this plan and Action Aid professionals for reviewing and finalizing to publish the plan. We
strongly believe that publication of this plan will hold very significant value to bring health
sector professionals and concerned authorities to work together for disaster risk reduction
initiatives.

Amod Mani Dixit
Executive Director
National Society for Earthquake Technology-Nepal (NSET)
December 2010

TABLE OF CONTENT

1 Disaster in The Context of Bheri Zonal Hospital _______________________________1
1.1 Disaster Definition ______________________________________________________ 3
1.2 Disaster Declaration _____________________________________________________ 4
1.3 Hospital Incident Command System (HICS) _________________________________ 5
1.4 Roles and Responsibilities of different Sections of HICS _______________________ 8
1.5 Incident Management Structure of BZH _____________________________________ 9

2 Incident Management Structure _________________________________________________ 11
2.1 Triaging ______________________________________________________________ 13
2.2 Flow of Patient Care ____________________________________________________ 16
2.3 Arrangement of Patient Care Flow during OPD Working Hours
(8:00am – 2:00pm) _____________________________________________________ 18
2.4 Arrangement of Patient Care Flow during OPD Closed Hours
(after 2pm and on holidays) _____________________________________________ 19
2.5 On-site/Field Medical Care ______________________________________________ 19
2.6 Everyone Must Know Their Job __________________________________________ 21
2.7 Team Work, Team Captains and Team Clipboards ___________________________ 21
2.8 Key Personnel _________________________________________________________ 22
2.9 Admission and Discharges_______________________________________________ 26
2.10 Logistics and Supply____________________________________________________ 27
2.11 Disaster Risk Communication ____________________________________________ 27
2.12 Inter-Agency Coordination ______________________________________________ 32
2.13 The Aftermath and Return to the Normal Health Operation ___________________ 34

3 Psychological Consequences_____________________________________________________ 35

4 Job Lists for Personnel ___________________________________________________________ 40

ANNEXES 41
ANNEX I Guideline for Triage ______________________________________________ 43
ANNEX II Map of Spatial Planning of Triage & Treatment Areas, Patients Flow ______ 47
ANNEX III Checklist for Disaster Patient _______________________________________ 49
ANNEX IV Job Action Sheets ________________________________________________ 51
ANNEX V List of Activities and Logistics to Support Plan Implementation ___________ 57
ANNEX VI Examples of Reactions of People who Experience Stress ________________ 61
ANNEX VII Photographs_____________________________________________________ 63

DISASTER IN THE CONTEXT OF

1
Hospital Preparedness and
Response Plan for Bheri Zonal Hospital 1

2 Response Plan for Bheri Zonal Hospital

DISASTER IN THE CONTEXT OF

1.1 Disaster Definition
A ‘Disaster’ is defined as
“any event that overwhelms the available resources.”

The decision to define an incident as “disaster” is made when resources at disposal at normal
times cannot cope. This may occur with a multi-casualty incident involving people in mass
and, requiring immediate medical care or even with a less number of casualties if there are
many cases in critical condition needing surgery simultaneously. However, a large multi-
casualty incident with mostly trivial injuries is not defined as disaster if resources normally at
disposal in at the time of day can cope without having to interrupt the normal running of the
hospital. Disaster is a relative term depending upon the capacity of the individual hospital.
Hence, disaster needs to be defined quantitatively for every hospital.

Considering Bheri Zonal Hospital (BZH) on the basis of this definition, it was found that
multi-casualty incidents are a common occurrence in the Emergency Department of BZH,
Nepalgunj, like in any other general hospitals. BZH has the history of operating up to 20
to 30 patients during Maoist insurgency and in bus accident cases. However, the BZH has
only 12 bed capacity in the emergency department, which is quite low. Even more than 10
serious patients at a time absorb its full human and other resources. Moreover, the incident
to be defined as disaster may not only depend on the number of patients of multi-casualties
in mass or smaller number with critical cases, but also on time of the day, i.e. whether it is
day time or night or during OPD hours. The availability of human resources really fluctuates
during these times. Considering all these factors, the disaster response plan is anticipating
the following two types of disaster scenarios:

Ü The first scenario might be when there are 30 or more than 30 patients of all categories,
including serious and non-serious or when there are more than 10 all-serious patients,
both in odd timing hours where the situation is serious enough to warrant additional
arrangement in the hospital.
Ü The other disaster scenario might be when the situation is anticipating a large number of
patients, say, more than 30 serious enough to warrant special arrangements across the hospital.
Any single incident of these types is a disaster and it is always effective to treat all such
incidents simply as disaster from incident-response perspective. Hence, both scenarios are
considered as disaster without differentiating the scenarios. This document is a hospital


disaster response plan and refers to the management of disaster, according to the definition
given below.

Ü The plan is capable of managing 30 to 100 casualties or more than 10 to 15 all-serious
patients by defining it disaster.
Ü Multiple casualty incidents, generally less than 30 cases or less than 10 all-serious patients
is within the capacity of Emergency Department to handle without calling it disaster.

1.2 Disaster Declaration
The decision to define an incident as disaster must be taken carefully and quickly and
then plan must be implemented. The decision is usually made by the chief or the most
senior medical personnel of the hospital who is in the hospital at the time and assumes the
responsibility of Incident Commander during disaster..

Based on the existing organizational system of the BZH, disaster declaration is to be made
as described in the box below:

The decision to declare “Disaster State” is to be made by on-duty Medical Officer
or on-duty Paramedical in consultation with the Medical Superintendent, the
chief of the hospital or HOD Surgery or HOD Medicine who is in the hospital
at the time and assumes the responsibility of Incident Commander during a
disaster.

The on-duty Medical Officer or on-duty Paramedical must be instructed to put
on the siren bell for declaring “Disaster State” from the Hospital Control Centre
(HCC) located in emergency store room at present, which is to be developed as
HCC with necessary arrangements such as telephone line, electricity supply and
loudspeaker. There is no landline telephone in all doctors’ and staff quarter and
no intercom system in the hospital at present. The four sirens are to be located in
four positions in the BZH premises to inform about the incident to the majority
(90%) of the hospital personnel residing in the area. The four locations for siren
are at hospital block, near Quarter No 3, near Post Mortem area, and near
Four Family doctors’ Quarter and are maintained by maintenance in charge.

The Incident Commander alerts the Information Officer to inform rest of the
staff living outside the complex in their mobiles phones and/ or using phone tree
system, which is yet to be developed.The entrance to Emergency, Gate Number
1 and 2 is closed immediately by the on-duty Gate Keeper and patients are only
allowed to enter through Gate Number 3 to the drive way area located between
two large garden areas in front of the Emergency when the Triage Officers are
ready. “One patient at a time per triage officer” concept needs to be followed as
far as practical.


INCIDENT MANAGEMENT STRUCTURE
There are various factors that make a hospital unable to provide the required services in
a disaster. They include the structural damage of the hospital buildings and non-structural
damage of lifeline facilities, equipment and contents and architectural components. A hospital
can still lose its ability to function in a disaster even without structural, operational and
functional components damage if the hospital staff are not organized in a system required
for handling such situation.

How hospital personnel are organized to respond in disaster situations is central to
functionality of the hospital during and after a disaster. Organization of the hospital staff
refers the general organization of hospital management, implementation of disaster plans and
programs, resources for disaster preparedness and response, level of training and disaster
preparedness of the staff, and the safety of the priority services that allow the hospital to
function. Organizational structure with clear roles and responsibilities is one of the most
crucial elements for managing an incident.

Many organizational structures have been developed over the years in response to disaster
management. A system known as Incident Command System (ICS) developed in the late
1980s is the most effective incident management structure for organizing response more
effectively to major disasters. Since then ICS is being applied by various institutions involved
in emergency response, including hospitals in their efforts to prepare for and respond to
various types of disasters. When the system is used in a hospital, it is called Hospital Incident
Command System (HICS).

1.3 Hospital Incident Command System (HICS)
HICS is being increasingly utilized by the hospitals across the globe. It is necessary to
understand HICS concepts, terminology, advantages, components and organization before
it is adopted for implementing the hospital disaster preparedness plan.

CONCEPT
Throughout the world, a major disaster, natural or human made, such as earthquake, fire,
landslide, flooding, hazardous material release or terrorist activity may cause conditions that
vary widely in scope, urgency and degree of devastation requiring various types of response,
including medical care under hostile and austere conditions. The magnitude of damage to
structures and lifelines rapidly overwhelms the capacity of the hospital to respond effectively
to basic and emergency human needs.

Disaster planning and response after disasters is primarily a local event. Communities, local
government and institutions like hospitals have to take the initiative and lead before, during


and after a disaster. Dependence on external assistance can become a false hope. It is best
to anticipate “You’re on Your Own for the first 48 hours after a disaster”. This is informally
known as the “YO-YO-48 Rule in the disaster management community.

Based on this theory and other experiences of the past disasters, a system called Incident
Command System (ICS) was developed in the late 1980s to organize an effective response
to major disasters. The Hospital Incident Command System (HICS) is ICS applied to the
hospitals in their efforts to prepare for and respond to various types of disasters.

ADVANTAGES
Adopting HICS has the following benefits:
Standard - HICS is a standard emergency response management system that promotes
greater standardization in terminology, response concepts, and procedures. By embracing
the concepts and incident command design outlined in HICS, a hospital will be in position
to be consistent with the International and National Incident Management System.

Flexible - HICS is flexible. Since the response management functions that have to be
carried out are the same, HICS can be used by all hospitals, regardless of size or patient
care capacities, and also be used to assist with emergency planning and response efforts for
all hazards.

Only positions or functions that are needed can be activated. HICS allows for
positions to be added or deactivated at any time during the lifecycle of the
incident. This will promote efficiency and cost effectiveness.

If a position is not activated, the position above it on the organizational chart
will assume responsibility of that function. For example, if the Incident
Commander (IC) does not activate the Liaison Officer, the IC will take
responsibility of the Liaison Officer.. Or, if the Operations Section Chief does not
appoint a Staging Manager, the Operations Section Chief will take responsibility
of the Staging Manager..

Clear Span of Control - The Span of Control means a designated number of staff/
subordinates to whom every manager/supervisor delegates tasks at the scene of the incident.

HICS has a clear span of control, which limits the span of control of each manager/
supervisor to three to four staff/subordinates (1:3-4) in the attempt for effective
supervision of the distributed work. It is hoped that this will lessen liability and
promote the recovery of financial expenditures.


Chain of Command/reporting - Chain of Command refers The system
to the orderly line of authority within the ranks of the incident expands to
management organization. HICS recommends that that every meet needs, and then
individual has one designated supervisor to whom s/he decreases as those
reports at the scene of the incident. needs diminish. What
does not change,
COMPONENTS however, are the
functions of response
The ICS structure includes five basic functional components
of command, operations, logistics, planning and finance. vmanagement. They
still have to be carried
These four sections will provide the Incident Commander out, regardless of scale
with all the information and advice that s/he needs to be able of disaster or numbers
to make operational decisions and to establish priorities of of personnel involved.
action. Depending upon the nature and the scope of response
demands, and personnel available, the sections may be further
subdivided into units. The number of persons comprising
each of the sections and its sub-units will, once again, be
determined by the needs of the disaster and the extent of the
hospital response being mounted. So, the system expands
to meet needs, and then decreases as those needs diminish.
What does not change, however, are the functions of response
management. They still have to be carried out, regardless of
scale of disaster or numbers of personnel involved. In fact, all
four functions may be successfully carried out by one person
is a small-scale incident.

Figure 1 below represents how authority and responsibility
are distributed in each section of the HICS System.

Incident Commander

Information Officer Safety & Security Officer

Liaison Officer Medical Specialist

Operation Section Chief Planning section Chief Logistics Section Chief Finance/Admin
Section Chief
Medical Care Resources Service

Security Situation Support

Infrastructures

Staging Figure 1 HICS Conceptual Structure


1.4 Roles and Responsibilities of Different Sections of HICS

Operations Section
The Operations Section manages tactical objectives outlined by the Incident Commander.
It is responsible for monitoring and managing all response operations (Red, Yellow, Green
and Black areas).

The essential positions of the Operations Section include the Operations Section Chief with
Staging, Medical Care, Infrastructure and Security Manager. Position descriptions for the
Operations Section are provided in the Job Action Sheets (JAS) (Annex IV).

Medical Care Manager - Inpatient, Outpatient, Casualty Care, Mental Heath, Patient
Registration, Clinical support, Morgue.
Staging Manager - Personnel, Vehicle, Equipment and Supply, Medication Staging.
Infrastructure Manager - Power/Electricity, Water Supply, Building and Ground Damages,
Medical-gases and Devices, Sewer, Environmental Services,
Food Services
Security Manager - Access Control, Crowd Control, Traffic Control, Search, Law
Enforcement Interface.

Planning Section
It is responsible for ensuring the development of strategic and tactical plans. Strategic
plans address broader, longer-range issues of the response, tactical plans and short-term
operational activities. So the Planning Section collects, evaluates, and disseminates incident
situation information and intelligence to Incident Command. It also prepares status reports
and develops the Incident Action Plan (IAP), including demobilization. The Planning Section
also coordinates documentation efforts of the incident. It is also responsible for maintaining
a file on all incident management information, including all forms submitted at the HCC.

The essential positions of the Planning Section include Planning Chief with Resources and
Situation Manager. Positions descriptions are provided in the Job Action Sheets (JAS) (Annex IV).
Resources Manager - Personnel and Material Tracking
Situation Manager - Patient and Bed Tracking

Logistics Section
It is responsible for the procurement and provision of personnel, equipment, and support
services needed to sustain the hospital’s response, including food, drink, linen, and supplies
that are critical. The Logistics Section, thus, coordinates support requirements of disaster
response and recovery, including acquiring resources from internal and external sources.


The essential positions of the Logistics Section include
Logistics Chief with Service and Support Manager. Position
descriptions for the Logistics Section are found in the Job
Action Sheets (Annex IV).

Service Manager - Communications, IT/IS, Staff Food and
Water
Support Manager - Employee Health and Well Being,
The essential
Family Care, Supply, Facilities, positions of
Transportation the Operations Section
include the Operations
Section Chief with
Finance/Administration Section
Staging, Medical Care,
This Section is responsible for maintaining financial and Infrastructure and
administrative records of the response activities. The Finance/ Security Manager.
Administration Section tracks personnel time, ordering items,
initiating contracts, arranging personnel-related payments/
Claims and Workers’ Compensation, and tracking response
and recovery costs and invoice payments.

The Finance/Administration Section Chief is the only essential
position for the section looking after time, procurement,
compensations/claims and cost. Position descriptions for
the Finance/Administration Section are provided in the Job
Action Sheets (Annex IV).
The BZH will
So, most disaster plans have similar organizational structures utilize Incident
with few modifications depending on the normal operations
Command System as
of a particular hospital departments concerned.
incident management
structure to manage
1.5 Incident Management Structure emergency operations
of BZH in response to events
affecting the facility
Emergencies can occur at any time. Emergencies differ in type,
and/or surrounding
size, scope, and duration. Nepalgunj area is threatened by
many hazards that may cause a significant number of injuries community.
to the local population and disrupt health care services. These
hazards include:
Ü Natural disasters, such as floods, earthquakes fires.
Ü Technological incidents and others, such as bus accidents.
Ü Disease outbreaks.


Ü Human-caused hazards, such as social conflicts.

The BZH will utilize Incident Command System as incident management structure to manage
emergency operations in response to events affecting the facility and/or surrounding
community.

In Nepal, ICS is also used by other national institutions such as Nepal Army (NA), Nepal
Police (NP), Armed Police Force (APF) and Nepal Red Cross (NRC). Hence, organizations
involved in disaster response can speak the same language as they have the same level of
understanding.

Details on personnel for different responsibilities of HICS in case of BZH will be
discussed in Section 3.8


PRINCIPLES & COMPONENTS OF
DISASTER RESPONSE PLAN

2

PRINCIPLES & COMPONENTS OF
DISASTER RESPONSE PLAN
2.1 Triaging
Ü Triage officers: On-duty Medical Officer, on-duty
Paramedical and Emergency in charge are assigned to
triage area to start the triage and return to emergency once
the allocated Triage Officers arrive.
Ü Patients MUST be assessed and triaged (sorted) on arrival at
the Triage Area, and directed to the correct Treatment Area.
Ü It is essential that the Triage is set up and manned near
Emergency building on drive way located between two
garden areas BEFORE patients are allowed to enter the It is essential
Emergency building to prevent the Emergency Room from that the Triage is
being swamped by people, which could result in total set up and manned near
chaos. Emergency building on
Ü At the Triage Area, Triage Officers assess the patients and drive way located between
put around their neck a colored disaster card. The cards two garden areas BEFORE
are in RED, GREEN, YELLOW and BLACK colors that patients are allowed to
symbolize the four categories listed below. enter the Emergency
Ü The Triage Officers will hand over patients to waiting building to prevent the
Transfer Staff who are assigned to transfer disaster patients Emergency Room from
to the appropriate treatment area according to seniority and being swamped by people,
severity of the patient’s condition, where doctors assigned
which could result in total
are waiting. These Transfer Staffs are the following:
chaos.
Ø On-duty non medical staff such as Peon and others (at
present, minimum of 10 such staff are always present
all the time)
Ø Nursing students who are always in the Hostel in the
hospital premises except in long holidays. The Transfer
Staff take the patients to the right area, according to the
color of the tag for patient care
Ø Volunteers.
Ü Patients already in the Emergency at the time of the
Disaster need”triaging backwards” in order to make as


much space as possible in the Emergency for new critical
patients. They should be sent to the Treatment Area that
best fits their condition, or else be admitted or discharged.

Guideline of Triage is given in Annex I

TRIAGE AREA
Triage area will be in front of existing Emergency area and
also in under-construction emergency building on the drive
way located between two garden areas (Exact location is
given in the map in Annex II). This Triage Area will remain
same even after the emergency is shifted in the new building
after its construction is completed. It is better to start triaging
in emergency regularly in multiple casualties incidents
on normal situation and practice continuously to be more
responsive during disaster.

Each card will TRIAGE CARD
have a capital
Ü Triage cards are to be kept ready in a box in the designated
letter that is placed
Disaster Store and maintained by Store In-charge. There
in front of the card are 100 triage cards are in stock and 100 more has to be
number. The letters added to maintain the number as 200.
are R, Y and G, which Ü The Triage card is colored (Red, Yellow, Green or
stand for Red, Yellow Black) and has room for recording initial assessment and
and Green treatment. This has to be attached to patients e.g. tied to
respectively. arm or put around neck.
Ü Each card will have a capital letter that is placed in front of
the card number. The letters are R, Y and G, which stand
for Red, Yellow and Green respectively. This, if a patient’s
is category Red and the triage card has number 57, he will
be R57. This will make it easy for the X-ray and lab staff to
prioritize the investigation and also help in identifying the
area where their reports have to be sent.
Ü Cards are numbered in advance and kept ready at all
times for multi-casualty and disaster situations. They must
be pre-numbered so that number duplication is avoided.
The cards in stock at BZH also need pre-numbering.


Changing Category
Patients may need to be upgraded in their category of care.

Ü They will retain their old card and receive a new card of appropriate color.
Ü Requests and reports will carry the old number with a cancel line through it, as well as
the new number.

TRIAGE CATEGORIES AND TREATMENT AREAS
Two types of scenarios are anticipated on the availability of the treatment areas, the areas
within the old buildings in particular. This requires two types of scenario-based spatial
planning. Both types are given in Annex I.

SCENARIO ONE
This is the situation when the casualty is caused by the disasters other than a big earthquake
and all existing building area is available for the treatment purpose.

TRIAGE CATEGORIES
Category Classification Treatment Areas
Red IMMEDIATE CARE Disaster Emergency Room
(life in danger) Capacity - 15 Mattresses
Emergency
Capacity - 12 Beds, 2 Oxygen, Suction
Yellow PROMPT CARE Newly-constructed OPD Waiting Area, extension
(serious, but life not in to OPD Corridor if available or drive way in
danger) front of the Waiting Area
Green MINIMAL CARE Garden area in front of the new emergency
(“Walking Wondered” – under-construction, new under-construction
cuts and bruises) emergency ground floor, garden area of quarter
number 3 and 4 and beyond
Black DEAD ON ARRIVAL Post-mortem block and its outside area
(death confirmed by two
doctors)

SCENARIO TWO
Situation may arise when the old emergency and OPD buildings are damaged as the
buildings are quite old and not available, particularly in big earthquake disaster. The newly


constructed OPD waiting and the emergency block under construction are less likely to be
damaged as they are new and constructed by incorporating earthquake resistant elements.

TRIAGE CATEGORIES
Category Classification Treatment Areas
IMMEDIATE CARE Ground floor of new Emergency Block
Red
(life in danger) under construction or Maternity Block
PROMPT CARE Newly-constructed OPD Waiting Area
Yellow
(serious, but life not in danger) and driveway in front of the Waiting Area
MINIMAL CARE
Green Same as scenario one
(“Walking Wondered” – cuts and bruises)
DEAD ON ARRIVAL
Black Same as scenario one
(death confirmed by two doctors)

2.2 Flow of Patient Care

PATIENT FLOW
Ü Disaster patients will be present in the Triage Area near the Emergency building on the
drive way between the two garden areas.
Ü Triage is done, and a colored and numbered treatment card attached to patients.
Ü Patients are handed over to a waiting Transfer Staff and accompanied to the treatment
area, according to their triage color.
Ø RED will go straight to the Disaster Emergency Room and Emergency Area and then
to the corridor of in patient Ward.
Ø YELLOW go to newly constructed OPD waiting area and OPD corridor.

Ø GREEN will go directly to the garden area in front of the new under-
constructionEmergency Building garden area of Quarter no 2 and 3.
Ø Patients who are re-triaged from Yellow to Green will go through driveway in front of
the Emergency Building
Ø Patients who are re-triaged from Red to Yellow will go through the corridor of the
Emergency Building.
Ü Patients who are re-triaged from Yellow to Green will go through driveway in front of the
emergency building
Ü Patients who are re-triaged from Red to Yellow or visa versa will go through the corridor
of the Emergency Building.


Ü Patients from the Green Area will follow the newly-
constructed road leading to the gate near Post-mortem
Block and eventually to the outside road
Ü Patients from the Yellow Area will go through the two exit
gates of the OPD patients
Ü Patients from the black area will be taken out from the
gate near Post-mortem Block.

PATIENT CARE
Ü The doctor assigned will continue patient’s care with
other staff posted to the treatment area.
Ü Blood taking and X rays will be done in the Treatment
Area and results brought back to the requesting doctor.
Ü Decisions to move a patient to OT or admit must be done Separate Disaster
through the senior doctor present in the respective treatment Registration
area in consultation with the Incident Operation Chief. Books for Red, Yellow,
Ü Patients will have a file created if they are admitted. Green and Black should
Ü Patients may be admitted from the treatment area, admitted to be kept in Disaster
from OT or discharged with or without follow up in OPD. Store. This is maintained
Ü Patients well enough to be discharged are to be brought by the Sister in charge of
back the next day for non-urgent investigations. Admitted each area for Red, Yellow,
patients also wait until the disaster is over for non-urgent Green and by Mortuary
investigations. in charge for Black.

PATIENT REGISTRATION
Ü Separate Disaster Registration Books for Red, Yellow,
Green and Black should to be kept in Disaster Store. This
is maintained by the Sister in charge of each area for Red,
Yellow, Green and by Mortuary in charge for Black. At
present, Emergency has a separate register for emergency
patient and has also maintained a separate register for
Medico Legal Case (MLC).
Ü Normal registration and Medico Legal Case (MLC)
registration system will be followed if the patients are
admitted to stay overnight once disaster is over. Patients
discharged the same day may be discharged without
converting to normal registration, but their MLC must be
registered.


BILL PAYMENT
Ü There will be no bill payment counter for disaster patients because it is not practiced
even in normal disaster cases at the moment. However, payment of bill is subject to the
policy and the decision of BZH Development Committee, which is responsible for the
overall development of this governmental hospital. This again is subject to the National
Policy. The following system exists:
» Some of the medicines and treatments such as iv canula, iv fluid etc are being
distributed free of cost.
» There is only one bill counter where both OPD and in patients pay their bills. OPD
patients pay their bills on the day of examination and in-patient pay during discharge,
if they pay at all.
» At present, bill payment is done manually and there is no computerized system.

MEDICAL STAFF FLOW
Ü Doctors, nurse and other staff residing in the quarters at the rear must enter the hospital
via corridors of Maternity Block. Those residing in Quarter No. 1, 2, 3, 4 including
doctors must enter from the emergency entrance road of the newly-constructed block.
Spatial Planning map of Triage Area with disaster patient flow and medical staff
flow is given in Annex 2.

2.3 Arrangement of Patient Care Flow during OPD Working Hours
(8:00am – 2:00pm)
Ü The OPD must be cleared off patients immediately. On an average, there are 500 OPD
patients per day in BZH.
Ü Patients should be told to come for the next clinic day and should not be charged if they
are done.
Ü Patients with request papers for investigations must return the next day.
Ü All patients must leave via the special two OPD back doors, one at the end near 19
number OPD leading to NSARC building and road, the other through store leading to
wide gate and eventually to the road. Patients must be directed by closing the entry gate
to the OPD, waiting and in-patient block. (Refer map in Annex II)
Ü OPD patients must be guided to exit the building by on-duty Gate Keeper by opening the
two gates and closing the channel gate to in-patient Block and entry gate of OPD waiting
hall.
Ü Keys of the gate of NSARC building must be made available to the on-duty Gate Keeper24
hours a day in disaster store.


2.4 Arrangement of Patient Care Flow
during OPD Closed Hours (after 2 pm
and on holidays)
Ü Keys for OPD waiting and its corridor must be available
with on-duty Gate Keeper 24 hours a day in disaster store.
Ü On-duty Gate Keeper will open OPD waiting and its
corridor on instruction from Operation Chief to use it as a
Yellow Treatment area
Ü The OPD staff and OPD doctors will need to be called in.
The contact numbers of staff will be listed up-to-date and
available at all times, particularly of those living outside
the hospital complex.

2.5 On-Site /Field Medical Care There are
situations
On-site medical care means providing medical care at the when a medical team
site of emergency itself. There are situations when a medical
is required to be sent in
team is required to be sent in the disaster-stricken area to
the disaster-stricken area
provide pre-hospital medical care or medical care either by
themselves or to supplement other medical personnel. A to provide pre-hospital
medical team in a bus accident site and international medical medical care or medical
teams in countries that are stricken by disasters are few of care either by themselves
such examples. or to supplement other
medical personnel.
Like Hospital Disaster Preparedness Plan, on-site medical care
is also very important from disaster preparedness perspective
though the situation is little different. The objective of medical
response is to provide medical care in the shortest possible
time. This is accomplished at the site of the major emergency
and with a chain of medical care. The links in the chain of
medical care are:

Ü Medical teams
Ü On-site medical facilities
Ü Effective transportation for medical evacuation
Ü Hospitals

It also requires an incident management structure as a
command organization at the incident scene for medical
response activities. Below is a basic diagram of the command
organization at an incident scene.


Incident Commander

Operations Chief

Medical Care
Director

Triage Group Treatment Group Transportation
Treatment Supervisor Group Supervisor

Figure 2. On-site medical care management structure

It is important to realize that the first action at the scene
should be not to initiate patient care. The following actions
need to be carried out in on-site medical care:

Ü Identify the need for assessment of a major emergency
scene.
Ü Explain the tasks to be performed before medical
treatment of casualties can commence.
It is important
to realize that Ü Identify the zones of field management of major
the first action at the emergencies.
scene should be not to Ü Identify the basic requirements of an on-site medical
initiate patient facility.
care. On-site medical care requires careful assessment, and
consideration for the medical response to be both safe
and effective. It is important to adequately understand the
situation, assess the availability of resources, and implement
mechanisms to ensure the overall safety of workers and
victims. All major incidents are unique and will demand
specific type of responses. Team members must be aware of
these requirements and of the reasons for these actions to be
taken before any patient care.


BZH has not been involved in any Field Medical Care till
now. So the doctors and other hospital staff do not have any
experience on this aspect. Generally, Nepal Army, Nepal
Police, Armed Police Force, Nepal Red Cross or Rescue
officers are closely involved in disaster situation to provide
pre-hospital medical care. Doctors and other medical staff
have only been providing the medical care at the hospital
premises on the arrival of the disaster patients.
Like actors in a
Since the situation is likely to be continued for some years in
play, everyone
the near future, preparation of the plan on on-site medical
must know their part,
care is postponed for the time being. However, BZH being a
zonal hospital, a medical team may be required for sending and start doing it without
to the nearby areas such as in diarrhea outbreak. In such being told. However, they
situation, members of the team will be decided by the Medical should be ready to follow
Superintendent of the hospital. directions according to
needs.

2.6 Everyone Must Know Their Job
Ü Regular education of whole Hospital is necessary so that
people know what to do.
Ü Like actors in a play, everyone must know their part, and
start doing it without being told. However, they should be
ready to follow directions according to needs.
Ü When called in no questions must be asked and there
should be no delaying.
A deputy (or
Ü When Department Heads/other Senior Staff are called for
Disaster, before moving from their residence, they should call anybody) from
key staff of their department, if they are living outside. Lists that team should assume
of telephone numbers of such department members should the team captain’s role
be maintained and kept near home phone at all times. immediately, and pass the
Ü Doctors should bring in their white coats, stethoscopes job over to more senior
and pens. Doctors in BZH, however, do not use white coat person, if available, later.
and so they do not have any.

2.7 Team Work, Team Captains and Team
Clipboards
Ü There are many “teams” of people taking part in the
Disaster Response Plan. Follow HICS such as Incident
Commander with Operation, Planning, Logistics and
Finance divisions.


Ü Each division needs a “Chief” to ensure all the jobs on his team’s checklist get done. Ideally,
the Chief should be a Department Head, but s/he may not be immediately available.
Therefore, a deputy (or anybody) from that team should assume the team captain’s role
immediately, and pass the job over to more senior person, if available, later.
Ü Each division has a “division clipboard” which defines the roles and tasks of that division.
There are boxes to be ticked when tasks have been done. These division clipboards are
located in the Disaster Store. When one arrives in the hospital, s/he has to go to Disaster
Store and first see if her/his division’s clipboard has been taken. If not, one must take the
clipboard, and assume the chief’s role until a more senior colleague arrives.
Ü If all clipboards are taken, one should move straight to his/her area of responsibility.

2.8 Key Personnel
While everyone is important in the Disaster Response Plan, certain people have key roles.
The following personnel will assume the following key roles.

1. Incident Commander – Medical Superintendent or HOD Surgery or
HOD Medicine. S/he:
Ü Carries ultimate authority.
Ü Generally oversees the outworking of the Disaster Response Plan.
Ü Makes decision concerning major changes in the Disaster Response Plan.
Ü Liaises closely with Information Officer, Safety and Security officer, Liaison Officer and
Incident Operation Chief and is available to give assistance to senior personnel as needed.
Ü Checks that all the teams have collected their clipboards from the Disaster Store.

2. The Information Officer – Health Assistant or Assistant Medical Recorder
Ü Makes the list of names of victims and their outcomes, and posts this on the inside of the
OPD doors and outside the hospital gates. This keeps enquirers satisfied, and out of the
way. One copy of the list should also be given to the Liaison Officer and the Information
Desk for telephone inquiries. .
Ü Communicates with the Incident Operation Chief regarding number of victims.
Ü Communicates with Department Heads as needed.
Ü Communicates with transport and security.
Ü Is responsible for giving information to relatives of deceased regarding post-mortems,
contact points, etc. and should delegate his/her staff to this job as necessary.
Ü Sets up the information desk next to OPD Inquiry, including an outside telephone line.


Ü Assigns staff to make patient records and collect information in RED, YELLOW and
GREEN areas.
Ü Communicates with Officer inside Emergency and with in charge of GOPD area.
Ü Updates the list at regular intervals throughout the disaster by liaising with Incident
Operation Chief.

3. The Liaison Officer – Administration Assistants
Ü Maintains communication with outside agencies to keep the public informed.
Ü Communicates to arrange transfers to other centres.
Ü Communicates with the other hospitals (after liaising with the Incident Operation
Chief concerning hospital’s resources and the numbers of victims) regarding necessary
transfers, available beds and medical personnel who might be called to help.
Ü Communicates with the Police.
Ü Communicates with the Press.

4. The Safety and Security Officer – On-duty Chief of Hospital Police Bit
Ü Controls traffic and crowds.
Ü Maintains peace and order
Ü Keeps traffic moving in one direction from Gate No. 3 to Gate No. 1
Ü Facilitates clearing OPD patients ensuring patients get to the right exit if OPD is opened.
Ü Guides disaster patients, ensuring they get to the right areas according to color.
Ü Guides the flow of disaster patients to follow the right exit according to the exit route.
Ü Controls number of patients according to how fast doctors are seeing the patients,
particularly in the Triage Area.
Ü Makes sure the keys of all gates are kept in a fixed place to have them available in
disaster for closing and opening doors when needed.
Ü Checks that on-duty Gate Keepers are in their correct locations.
Ü Liaises with Incident Operation Chief.
Ü Posts staff as necessary to direct ambulances, control crowds, direct traffic or collect
patients.

5. Incident Operation Chief – HOD Orthopedic or HOD Surgery
Ü Oversees all aspects of medical work.
Ü Liaises with the wards (renumbers discharges and admissions)


Ü Liaises with the Surgeon in Charge and Operating Theatres
Ü Liaises with all treatment areas.
Ü Redistributes doctors where needed.
Ü Allocates patients beds and helps in coordinating admissions in consultation with treating
doctors and patient needs.

6. Planning Chief – Head of House Keeping or Supervisor of House Keeping
Ü Ensures the development of strategic and tactical plans. Strategic plans address broader,
longer-range issues of response, tactical plans and short-term operational activities.
Ü Collects, evaluates, and disseminates incident situation information and intelligence to
Incident Command.
Ü Prepares status reports and develops Incident Action Plan (IAP), including demobilization.
Ü Coordinates documentation efforts of the incident.
Ü Maintains a file on all incident management information, including all forms submitted at
the HCC.

7. The Logistics Chief – Store in charge or Assistant Store Keeper
Ü Keeps a separate Disaster Store up-to-date with disaster supplies.
Ü Reviews supplies in all areas every three months and after every disaster.
Ü Keeps supply cupboards ready in each treatment area with staff responsible for their
upkeep.
Ü Prepares for increased food supply for patients, staff and volunteers.
Ü Provides free food to staff working for prolonged periods of overtime – and records
details.
Ü Provides food to OT and RED area as requested.
Ü Orders more supplies from outside, if necessary.

8. Finance and Administration Chief – Finance Officer or Store Keeper
The Transport Officer –
Ü Keeps vehicles and drivers stand by for calls.
Ü Arranges transport for dead victims to the morgue.
Ü Arranges transport for extra-supplies from General and Medical Stores.
Ü Arranges transport for patients requiring transfer to other hospitals.
Ü Liaises closely with Incident Operation Chief who identifies victims requiring transfer.


The Finance Officer –
Ü Maintains records and creates accounts for people being admitted in the Disaster from all
areas.
Ü Coordinates tracking of personnel time.
Ü Coordinates ordered items.
Ü Initiates contracts.
Ü Arranges personnel-related payments/claims and workers’ compensation,
Ü Coordinates tracking response and recovery costs and invoice payments.
Ü Calculates bills for patients being discharged and collects money.

9. The Triage Officers - On-duty Medical Officer, On-duty Paramedical
and Emergency In-charge in the beginning and Doctors assigned
and decided by Incident Operation Chief afterwards.
There will be up to three Triage Officers at a time.
Ü Reports and remains in the Triage Area
Ü Rapidly assess all patients, determines the triage category for all patients, allocates triage
category and tag by attaching the card to the patients with the string (to the arm or
around the neck).
Ü Pass the patients on to the respective waiting Transfer Staff to take them in their respective
Treatment Areas according to the seriousness.

10. Treatment Area In Charge
On-duty staff are assigned in the treatment areas for the initial stage and are back to their
respective duty once the staff assigned arrive and take on the following responsibilities:

Ü Reporting to the respective Treatment Areas.
Ü Assessing and managing patients in the respective Treatment Areas.
Ü Working with Incident Operation Chief, Orthopaedics and Anaesthetics to make OT lists.

Allocating/assigning staff to OT.
Ü Assessing, superviseing and carrying out resuscitation, treatment, and management of
patients (plan for surgery, emergency investigations, admit, discharge) in the respective
Treatment Areas.
Ü Liaising with the Incident Operation Chief for OT times.
Ü Keeping disaster cupboards in their areas in order.
Ü Reviewing supplies every three months and after every disaster.


Red Area: Doctors from Department of Surgery and Orthopaedics with the following
nursing and paramedical staff:
Ü General Ward on duty Sister
Ü Gyaene Ward on duty Sister
Ü Four Family Nursing Quarter - First Floor
Ü New Family Quarter - Ground Floor
- 6 No Quarter – all

Yellow Area: Doctors from Department of Gyaene and Paediatrics with the following
nursing and paramedical staff:
Ü Paying Ward on-duty Sister
Ü Old Family Quarter - First Floor

Green Area: Doctors from Department of Medicine with the following nursing and
paramedical staff:
Ü New Family Quarter - First Floor
Ü New Family Nursing Quarter - Ground Floor
Ü All staff outside

Black Area: Staff from Forensic Department /Unit
Ü Ensures that all dead bodies are covered with sheets and transported to the mortuary.
Ü Performs necessary post-mortem.

Liaises with the Safety and Security Officer and police.

2.9 Admission and Discharges
Ü All Red, Yellow and Green patients, if they are to be admitted, have to follow the normal
procedure of admission i.e. Sister In charge in the respective wards will admit them with
the recommendation of Treatment Area in charge or Incident Operation Chief.
Ü If there are no OPD clerks to fetch X-ray and lab reports, they should be brought to a
common place as soon as they are ready and should be put with the patient’s notes or
taken to the ward of admission.
Ü Sister in charge of each ward prepares the list of patients that can be discharged from
his/her ward on the recommendation of on duty doctor, and gives it to the Incident
Operation Chief.
Ü They will leave the hospital via the OPD back door as the OPD patients exit gates.


2.10 Logistics and Supply
Ü There will be separate Disaster Store for disaster response
apart from Medical and General Store.
Ü Each treatment area will have a disaster cupboard that can
be wheeled out into the treatment area. It will be stocked
with treatment materials and stationery needed for the
area. It will have non-structural safety measures.
Ü Extra disaster supplies are to be kept in the Disaster Store
in a designated section and will be brought out as needed
to top up exhausted supplies in each area.
Ü Extra trolleys and mattresses are to be kept in Emergency/
Disaster Store.
Ü The other supplies to be kept in the Disaster Store are
mattresses, bandage, disposable dressing trays, drip
facilities and splints.
Ü Minimum stockpile is to be maintained and the
responsibility should be given to the Store in charge. Risk communication is
Ü Re-stocking from Medical and General Store may be an important aspect of
necessary if the disaster is large. disaster management, both in
pre-disaster as well as in post-
List of activities and logistics to support the implementation
disaster situation.
of the plan is given in Annex V. Some of them have been
already implemented. Others need to be implemented on
priority basis.

2.11 Disaster Risk Communication

INTRODUCTION
Risk communication means the imparting and exchanging
of information about the existence, nature, form, likelihood,
severity, acceptability, treatment or other aspects of risk
among individuals, groups and institutions. The information
includes risk types, risk levels and methods for managing the
risks. This helps people understand facts in ways that are
relevant to their own lives, feelings and values so they may
put the risk in perspective and make more informed choices
and decisions.


Risk communication is an important aspect of disaster management, both in pre-disaster as
well as in post-disaster situation. Pre-disaster risk communication is exchanging ideas with
different stakeholders, primarily with the local institutions and the community, and consists
of awareness program, early warning system, training and practice. The more prepared the
community is before disaster, the less work hospitals will have after disaster.

Post-disaster communication is conveying information and updates about disaster. It is also
about asking help in identifying patients, blood donations and other donations (blankets,
food, funds, etc). Similarly, it is also about guiding patients and community for better
disaster management. The communication and public relation officer and hospital disaster
management team need to understand the various aspects of disaster risk communication.

TYPES
There are various types of disaster risk communication:
Ü Mass media: TV, radio, print and internet.
Ü New types of media: SMS messaging, blogging, email, etc
Ü Traditional media: street theatre, radio, FM, puppet shows etc
Ü Alternative media: signage, parades, concert, etc

METHODS OF MAKING RISKS COMMUNICATION EFFECTIVE
Disaster risk communication consists of the following elements and understanding those
elements makes it more effective.

Information processing
There are innumerable sources of information, including on-site teams, emergency services,
operational personnel, other organizations, agencies and the general public. Yet it is likely
that the available information is incomplete, inaccurate or out-of-date due to the rapidly-
changing nature of disaster response operations.

Lack of information is rarely a big problem. It is usually the case that the available information
is not been adequately assessed or the consequences not identified. Hence, it is important to
evaluate the information and make good and timely decisions concerning it.

Information processing is sorting of information just as Triage is sorting of casualties.

The important steps for effective information processing are:
Ü Collecting Information – It is important to know the types of information the hospital
needs to know, the reliable source of information, measures the hospital needs to


take during preparedness to assure information collection capability during disaster
operations.
Ü Collating and Evaluating – The collected information needs to be checked and
weighed to establish its relevance and reliability, gaps have to be detected and additional
information has to be sought to make the information complete and useful for decision-
making purposes.
Ü Decision making – Based on the information collected and evaluated, an overview
has to be developed so that decisions can be taken in context and priorities can be
identified. Invariably, a hospital’s decision makers have to contend with some or all of
the complications such as insufficient information, limited time, competing priorities,
limited resources and media attention when making a plethora of decisions that disaster
demand of them.
Ü Disseminate – Decisions need to be distributed to all those who have a reason to know.
This dissemination can be accomplished through the media channels during controlled
media briefings.
Ü Monitor – Importantly, while some information may be ‘for information only’ purposes,
most of the information and decisions distributed will require an action or reaction as a
result. These actions can be from hospital departments and personnel, response teams in
the field, the media and general public or from other agencies or organizations.

Documentation
Collected information is useless unless it is properly documented. Documentation is
often overshadowed by other response activities in disaster and generally do not get due
importance. However, careful documentation is imperative. Accurate documentation is
required for patient management systems and for providing information on the hospital’s
response activities and level of preparedness. Hence, a variety of documentation is essential
in a hospital’s response to a disaster, including documentation of processes as well as actions
taken during the response. Hence, the hospital disaster management team needs to consider
the following while documenting:.

Ü Patient records – There has to be standard medical documentation with accuracy.
Ü Logs – Decision-makers and the personnel in the hospital’s command centre need to
keep logs to account for the actions and decisions they make, including shift changes and
changes of command and timings.

Following an emergency or disaster, particularly when deaths are involved, there may be an
investigation into the cause and effects of the disaster and the actions and reactions of disaster
workers. Accurate documentation at all stages of the hospital’s response and procedures
is necessary so that personnel can account for decisions, action taken and priorities. The
information may also be of use when identifying improvements to the systems, procedures,
plans and training in the hospital’s preparedness.


Management of the Media
With the advancement of modern technology, the media has become an inescapable aspect
with regard to disasters. It plays an important part in the disaster management community.
It has a legitimate role to play during disasters. Planning and understanding are the keys to
effective management of the media. Understanding what the media wants, how they operate,
and how you can best meet their needs ensures that you can manage the relationship and
benefit from the media’s participation. Hence, hospital disaster management team, including
the communication officer should always consider working with them and not trying working
against them. Some general rules to follow are:
Ü The media should be managed, rather than controlled.
Ü Cooperation is preferable to confrontation.
Ü The media is a communication medium to and between the community.

The hospital disaster management team needs to be aware of the following aspects of the
media to make the disaster risk communication more effective.

Knowing media issues
The common media issues in disasters are as follows:
Ü Security Issues – In major disaster situations the media can easily overwhelm a hospital
with requests for interviews or the latest facts. This may result in attacking the media
members by the family members of disaster patients and attempting to thwart hospital
security measures by the media personnel. It is important for any hospital working in a
disaster situation to have a security system and ensure that it is understood by members of
the media. Security should be trained to specifically handle the media in disaster situations.
Ü Communication Issues – The frequency of phone calls can crash hospital switchboards
or distract hospital workers from their main roles. Sometimes misinformation distributed
by the media can cause uproar in the community and influence crowds to descend upon
an already overwhelmed healthcare system.
Ü Psychosocial Issues – The media can cause problems with the grieving families of the
deceased. The reporting of gruesome details can worsen the grief of already distraught
survivors and families. The mediacan be be unfairly critical of relief workers or efforts,
contributing to a worsening of morale.

Assembling of information that the media seeks
The media generally seeks certain information that can be predicted. Assembling such
information is very useful in managing the media.
Ü Casualty Information - Number of dead and injured, percentage of seriously injured,
umber of uninjured, a whether there is any VIP’s in the incident How the injured were
managed? Where were they were taken? What happened to the dead?


Ü Health Risks – Shelter arrangements, food, water, sanitation, and infectious diseases.
Ü Damage to Health Facilities – Which health facilities have been damaged and how
badly ? what affects the disaster will have on patients.? How the disaster will affect the
operating capacity of facility ? Staff injuries.
Ü Response and Relief Activities – Who activated hospital response? Who is in charge?
What are hospital personnel doing?

Releasing Information
The hospital disaster management team also needs to know some tips on releasing
information that are vital in handling the disaster situation.
Ü Information should not be released or comments should not be provided on matter that
is not strictly a medical responsibility.
Ü Information should be released in on pre-formatted media release forms with accurate
information clearly printed with date and time. This saves time and also avoids
misunderstanding or misinterpretation of what they see and hear individually.
Ü Information should be released regularly even if there has been no change in the situation.
Reporting “no change” still constitutes the “latest information” for the event.
Ü Information should be provided immediately regardless of how inadequate the
information is, or how marginal the source is as immediacy is a canon of journalism. Any
delay makes them suspect that authorities are hiding information from them.

Response to the media is as an integral part of hospital preparedness and planning process.
Hospitals should have staff previously trained in media relations and they should be called in when
the disaster response is initiated. Having a defined media area will help the hospital with internal
security measures and provide a separation between the media and grieving family members.
Senior administration officials can use the media area to conduct interviews and give information.
An official hospital spokesperson should be appointed to help facilitate communication.

Handling of VIPs and the Relatives
A huge number of visitors seek to gain entrance in the hospital during disaster. This includes
relatives and friends of the injured and VIPs wishing to visit the hospital to view its response
operation, meet victims, and greet the staff. The hospital needs to make arrangements for
waiting areas separate from casualty area, information and public relations, matching of
potential visitors to actual patient, escorts for VIPs, and identification for visitors. Hospital
disaster management team, including Public Relation Officer in particular, needs to look into
the following factors:
Ü Making arrangements for counseling support to patient’s families and basic facilities
(tea, coffee, access to toilets). The influx of relatives and friends can cause chaos if not
handled well.


Ü Using outside agencies, such as the Red Cross, for
counseling to avoid unnecessary political pressure on
level of care and access to patients.
Ü Making best of VIPs visit by briefing on arrival by senior
VIPs are hospital personnel and escorting during their visit.
influential Ü Ensuring necessary supplies or resources to the hospital
in providing support and to boost staff morale.
to the hospital. Both
Relatives are important to the emotional and physical
families and dignitaries wellbeing of the patients of disaster. VIPs are influential in
should be handled in a providing support to the hospital. Both families and dignitaries
sensitive manner. should be handled in a sensitive manner.

2.12 Inter-Agency Coordination

INTRODUCTION
Assistance from other organizations is a must in disasters, as
by definition itself, it overwhelms the capacity of the hospital.
Much of the burden for disaster response falls on hospitals and
health facilities. It is imperative that the hospital be prepared
to respond and coordinate relief efforts. It is, therefore,
The Liaison crucial that the hospital be aware of the types of emergency
assistance available in the local as well as national agencies,
Officer as
including the government agencies and understands the way
per the HICS of BZH these organizations work so that they may better coordinate
of hospital disaster and integrate emergency response.
preparedness plan,
needs to be aware of The Liaison Officer as per the HICS of BZH of hospital disaster
the principles of inter- preparedness plan, needs to be aware of the principles of
inter-agency coordination to facilitate the hospital recovery
agency coordination to
process. This includes sources of available assistance, proper
facilitate the hospital
place for coordination based on disaster preparedness plan
recovery process. and coordination structure with outside agencies.

SOURCES OF ASSISTANCE TO
THE HOSPITAL
There are multiple sources of assistance in the immediate
disaster and post disaster setting at local, regional and national
level. All of these need to be identified and listed.


Ü Local Agencies – Local agencies such as district
administration, district police, hospital networks, pre-
hospital care providers and volunteers are important to
meet the initial needs, since they are available at the scene
and likely to assist. It takes time for regional, national and
international resources to be mobilized in the event of
disaster.
Ü Surrounding Health Facilities – Nearby facilities may
assist by accepting patients from the most affected hospital,
providing back up medical and surgical equipment and
human resources. It is important to establish a local
network of health facilities to be mobilized in the event of
a disaster and the network must be developed in the pre-
disaster phase.
Ü National Agencies – The hospital may require national
assistance for logistical support, financial support,
international coordination mechanism and a body of National and
policies, procedures and legal documents, depending international
on the type and complexity of the disaster, the number organizations may seek
of people affected and the overall scope of the disaster.
to provide relief and
The national agencies include Ministry of Home Affairs,
Ministry of Health and Population, National Hospital reconstruction aid. But
Association, National Medical Associations and National these organizations can
disaster Medical Officer as designated in the National also greatly complicate
Disaster Preparedness Plan. the relief process.

COORDINATING DISASTER RESPONSE
WITH OUTSIDE AGENCIES
National and international organizations may seek to provide
relief and reconstruction aid. But these organizations can
also greatly complicate the relief process. Thus, the Liaison
Officer also needs to set up a proper place within the Hospital
Command Centre and needs to know coordination structure to
coordinate all incoming assistance, personnel, and resources.
This office also serves the function of on-going networking
with agencies as well as coordinating reconstruction and
media relations separately or combined to coordinate the
response efforts by serving the following functions:

Ü Provide a forum for coordination meetings and constant
communication.


Ü Serve as a central repository of information relating to the disaster.
Ü Provide informational updates for stakeholders in a disaster.
Ü Provide an updated list of needs and issues.

2.13 The Aftermath and return to the Normal Health Operation
Once the acute phase of disaster is over, a lot of work still needs to be done. Staff should
check with their Heads of Department to make sure that there is nothing more to do before
leaving.

The disaster state should be considered over when:

Ü No further victims are likely to be brought in. (This should be clarified by the Incident
Commander with the Police and other relevant institutions.)
Ü All patients in Red and Yellow Areas have been stabilized, admitted or transferred.
Ü All patients in Green Area have been stabilized, discharged or admitted.
Ü Decision to reopen Emergency for normal function is made by Incident Operation Chief
in consultation with Incident Commander.

SUBSEQUENTLY
Ü X-ray and Lab will perform other necessary X-rays/investigations on disaster victims.
Ü The whole of Surgical and Orthopaedics teams will stay behind and do a detailed ward
round of the admitted victims. Heads of each department will be responsible for seeing
that this is done. (The mop up activity should not be lift only for the on call team.)
Ü If the number of patients is big, Surgical and Orthopaedics consultants in charge will
divide the patients between the two teams for continuing management.
Ü The Nursing Supervisor will delegate more nurse to Surgical and Orthopaedics wards
depending on the number of victims admitted.


PSyCHOLOgICAL CONSEquENCES

3

PSyCHOLOgICAL CONSEquENCES
INTRODUCTION
The loss of property and lives in the family caused by the disaster also has psychological
effects following a disaster. The emotional effects may manifest immediately or may appear
later. The more severe the disaster, the more negative is the outcome and it affects both, the
disaster patients as well as the workers, including medical staff. Hence, these psychological
consequences also need to be considered in the hospital disaster preparedness plan. The
medical personnel, particularly those responsible for dealing with it, should be aware of
the probable after-effects on psychological aspects, special needs groups and measures to
be taken. It is also important for all the medical staff to know the self-help and professional
techniques to come out from the event for themselves.

PEOPLE AFFECTED BY DISASTERS
Apart from the primary victims from the affected area, there are a number of other people
who are affected. Among them are the unaffected community members, and the rescue and
recovery personnel.

VULNERABLE GROUPS
Although every individual is susceptible, there are groups, which are vulnerable to the
psychological consequences of disasters. They are: the elderly, children and adolescents,
pregnant or lactating woman, single parent families, the bereaved, and rescue and relief
workers.

PSYCHOLOGICAL AFTER-EFFECTS
It is important for emergency medical personnel to recognize the after-effects. This would
help them to take care of survivors and in recognizing these changes in themselves. The
common psychological after-effects to a disaster are mainly divided into changes experienced
in thinking, feelings and behaviour as given in the table below.

List of activities and logistics to support the implementation plan is given in Annex
V. Some of them have been already implemented. Others need to be implemented on
priority basis.

Severe reactions such as post-traumatic stress disorder and depression are seen in a smaller
number of people than reactions such as sleeplessness, worrying, and anxiety.


MEASURES
Ü Provide simple, accurate, brief and to the point, readily understandable information in
local language repeatedly at regular intervals. Many affected people can respond to the
situation and make good decisions based upon the information they receive. Survivors
must take the necessary steps in putting themselves and their communities back together.
Ü Handle bereaved, special needs group very carefully by supporting their specific needs
including:
» Information about what happened.
» The option to see the body of their loved ones.
» Help to avoid unceremonious disposal of bodies of the deceased.
» Protection from media intrusion.

Ü Prepare for an extreme psychological trauma such as post traumatic stress disorder
(PTSD) with its diagnostic criteria and treatment as it can develop on some people
though they will be few in numbers. The usual psychological defenses are incapable of
coping.
Ü Provide training to disaster worker for emotional and cognitive preparedness prior to the
disaster. This reduces the risk of psychological effects of disaster for disaster workers.
The training should include:
» Simulation of possible scenarios prior to going to the field.
» Education on the potential psychological effects seen in survivors.
» Awareness on likely psychological reactions in self and other relief personnel.
» Education on simple self-care techniques.

Ü Learn coping skills. There are numerous methods people use when under stress. Active
or ‘action’ oriented coping is an adaptive response often utilized following a disaster.
People cope by engaging in activities such as assisting others, engaging in practical tasks
and setting up support groups.
Ü Be aware of possible symptoms of burnout. This can occur after a prolonged period of
time on the job. Some of the symptoms observed are cynicism, feeling unappreciated
or betrayed by the organization, loss of spirit, heroic but reckless behavior, neglecting
one’s own safety and physical needs (not wanting/needing breaks and sleep), excessive
tiredness, inability to concentrate, mistrusting colleagues and supervisors, sleep
difficulties, inefficiency, and excessive use of alcohol, tobacco or drugs.
Ü Create a supportive environment in the hospital, which is one of the many crucial factors
in minimizing stress by arranging regular and frequent meetings, adopting peer support
system, developing a culture of openly talking and sharing, accessible guidance and
support from managers and peers.
Ü Learn self-help techniques as shown in the table.


Remember that your reactions are normal It is helpful to express even frightening and
and unavoidable. strange feelings.

Be aware of your tension and consciously
Slow your breathing and relax your muscles.
try to relax.

Talk to someone with whom you feel at
You process the unpleasant experiences
ease. Describe to him/her what you were
when you talk about them.
thinking or feeling during the critical event.

Draw, paint, write, play music or exercise. Sometimes it is easier to express your
Look for a healthy outlet. feelings by doing rather than talking.

Listen to what people close to you say and It has affected them too, and they may share
think about the event. insight that will benefit you.

Try to keep eating well and limit alcohol
Take special care of yourself. and tobacco. Physical exercise is good for
you because it relieves tension.

Continue to work on routine tasks if it Tell your peers and team leader/supervisor
is difficult to concentrate on demanding about how the distressing event has affected
duties. you, so that they can understand.

If you cannot sleep or feel too anxious,
discuss this with someone you can trust.

Do not self-medicine. Get medical advice.

It takes time to evaluate how you will view
Get easy on yourself.
things after a distressing event has occurred.

Avoid inflated or perfectionist expectations, These can only lead to disappointment and
either about yourself or others. conflict.

After a few weeks, if you still feel uneasy
about your reactions, you should seek
professional advice.

Everyone who has ever experienced a disaster is affected psychologically in some way or the
other sooner or later. Being aware of psychological consequences, including psychological
after-effects, emotional and cognitive preparedness prior to disaster, burnout and using self-
help techniques can help reduce stress that disasters cause.


4. JOB LISTS FOR PERSONNEL
Lists of job descriptions and Job Action Sheets (JAS) of all the positions are provided in
Appendix 4. Individual Job Descriptions should be printed, and attached to a clipboard.
These should be kept in the cupboard of Disaster Emergency Store/HCC for collection at the
time of Disaster.


ANNEXES

ANNEXES


ANNEX I Guideline for Triage

Triage
Triage is a medical decision-making process of prioritizing patients based on the severity of
their condition so as to treat as many patients as possible when resources are insufficient for
all to be treated immediately.

ASSESSMENT OF TRIAGE:
Ü Assess victims’ vital signs and their conditions.
Ü Assess their likely medical needs.
Ü Assess their probability of survival.
Ü Assess medical care needed at the site.
Ü Prioritize management of casualties.
Ü Colour tag patients by priority.

SIMPLE TRIAGE AND RAPID TREATMENT (START)
START is a well-acclaimed triage system and has been field-proven in MCI, such as train
wrecks and bus accidents though it was developed for use after earthquakes. The START
plan aims to correct the main threats to life, blocked airways and severe arterial bleeding and
it allows personnel to triage a patient in 60 seconds or less by quickly making an assessment
of a patient’s:

Ü Respiration
Ü Perfusion
Ü Mental Status

Respiration – Every patient is assessed for their respiratory rate. If a patient is not breathing,
check for obstruction in the mouth and reposition the head. If the above procedures do not
initiate respiratory efforts, tag the patient BLACK. If the victim’s respiratory rate is greater
than 30 per minute, tag the patient RED. If respirations are less than 30 per minute, do not
tag at this time. Assess for perfusion.

Perfusion – The most reliable method to assess perfusion is the pulse.


Mental Status – The mental status evaluation is used for patients whose respirations and
perfusion are adequate. To test, simple command such as ‘open and close your eyes’ or
‘squeeze my hands’ can be used.

The three assessment components of START are:
Ü Respiration
Ü Perfusion
Ü Mental Status

The initial step in START is to separate out those victims that are awake and ambulatory.
They are asked to move to a safe, designated area before triage of the other victims takes
place. These people are the “walking wounded” and are tagged as GREEN. They will be
reassessed after triage of the more critical patients is completed. The remaining victims
undergo a quick assessment of respiration, perfusion and mental status that will divide them
into the three remaining categories identified below:

RED or Immediate: Ventilation is present only after repositioning the airway. They are also
placed into this category if the respiratory rate is greater than 30 per minute, if there is
delayed capillary refill (greater than two seconds), or the patient is unable to follow simple
commands.

YELLOW or Delayed: Any patient who does not fit into either the immediate or minor categories.

BLACK or Deceased: No ventilation is present even after clearing the airway.

HOW TO EVALUATE PATIENTS USING RPM
The START system is based on three observations: RPM--Respiration, Perfusion and Mental
Status. Each patient must be evaluated quickly, in a systematic manner, starting with
respiration. If the patient is breathing, the breathing rate must be determined.

Ü Patients with breathing rates greater than 30 per minute are tagged Red.
Ü If the patient is breathing and the breathing rate is less than 30 per minute, move on to
the assessment of circulation and mental status.
Ü If the patient is not breathing, quickly clear the mouth of foreign matter. Use a head-tilt
manoeuvre to open the airway. In this type of multiple or mass-casualty situation, one
might have to ignore the usual cervical spine guidelines when s/he is opening airways
during the Triage process.

Special Note: The treatment of cervical spine injuries in multiple or mass casualty situations
is different from what is normally taught. This is the only time in emergency care when there
may not be time to properly stabilize every injured patient’s spine.


Bheri zonal hospital disaster response plan

Bheri zonal hospital disaster response plan

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