Words by Laldevi Maharjan

 

Nepal’s vulnerability to natural disasters demands that hospitals be equipped to handle an influx of patients during mass casualty incidents, ensuring continuous operation amidst chaos.

A well-crafted Preparedness Plan is not just a document but a blueprint for action, involving all hospital departments and continuous training to ensure everyone knows their role in emergency situations.

The GIH Disaster Manual, influenced by global standards from the HOPE course, outlines specific operational strategies ensuring unified and effective hospital responses during emergencies.

Efficient disaster response in hospitals hinges on meticulous planning and role clarity among staff to prevent confusion and save lives when every second counts.

Regular drills and training sessions are not merely routine but are crucial for a hospital’s disaster preparedness, simulating real-life.

We all know that Nepal is vulnerable to natural disasters due to its geologic and climatic conditions. Earthquakes, floods, droughts and landslides are all regular phenomena occurring in the country. It is well documented that there is an increased frequency of disasters causing tremendous human casualties and economic loss. At the same time the road traffic accidents, air accidents, wild-fire, flood and drowning also are common in our setting and may convert into mass casualty incidents (MCI) for hospitals. In such situations hospitals can face a variety of adverse events and can have a huge impact on the facility, their employees and even the communities they serve. At the time of disaster hospitals must be able to handle the additional influx of patients, care for the ill and injured all while running the daily routine operations. Therefore, hospitals must prepare for the worst situation; disaster, any emergencies or MCI that may have a widespread impact on the hospital and community.

Preparedness Plan

Preparedness plan is a continuous ongoing and integrated process for the management of activities and resources during emergencies. It consists of a set of measures undertaken in advance by the hospital and its personnel to better respond and cope with immediate aftermath of a disaster or mass casualty incident. Improved practice and response mechanisms can save lives and strengthen the ability to reduce the impact of disasters. It must be well documented, disseminated to all staff as well as practiced repeatedly so as to avoid confusion and to close the loopholes before the actual response. It requires contribution from all department staff from different areas; like Medical, Nursing, Radiology, Pharmacy, Security, Administration, helpers and cleaners. In addition, liaison with local authorities, police and public is also very crucial.

Importance of Preparedness Plan

Hospitals play a critical and vital role in disaster and emergency conditions. The primary responsibility of hospitals is to save lives of the victims brought into the hospital and may need to serve beyond their capacity. Preparedness plans, systems and procedures must always be developed and adapted to suit individual hospitals. The number of casualties at a time and capacity of the hospital to manage those casualties is based on the hospital preparedness plan, training and practice and the ability to execute the plan in case of such an event. There may be confusion, inefficiency, role conflict, and multiple chain of commands which may overwhelm the logistics, supplies, staff, space, time and energy. There are risks of hazards and more damage leading to legal and financial concerns. It is important to ensure efficient response for any hospital during emergency. Preparedness is therefore crucial to ensure safety of patients, staff, visitors and hospital and its property.

A well prepared hospital emergency plan defines command and control system, job list for all key personnel and team captains, method of communication between authorities, departments and others, security and traffic flow, surge capacity and areas, evacuation plan and assembly point. This preparedness plan must be well informed to all hospital staff to prevent chaos and confusion during the emergency condition. An effective disaster preparedness plan helps in organization and management of resources ensuring the readiness in the event of emergency or disasters.

GIH Disaster Manual

Grande International Hospital (GIH) has prepared its own disaster preparedness plan to deal with disaster and emergency situations. The concept and principles of emergency preparedness plan is based on the Hospital Preparedness for emergencies (HOPE) course and is similar to other hospitals in Nepal. So that if incase there is need of help and coordination among hospitals everyone speaks the same language and understands the terms that is used during the emergency response time.

The HOPE course trained technical and administrative staff from GIH have prepared the “Disaster manual”. The first draft of GIH disaster manual was prepared on September 2013. The first revision was done on August, 2015 and second revision was done on May 2022. After which it was approved by the management and disseminated to all departments. This disaster manual is included for NABH accreditation process of this hospital.

Objective

• Provide policy for response to both internal and external disaster and emergency situations that may affect hospital staff, patients, visitors and the community.
• Identify responsibilities of individuals and departments in the event of that situation.
• Identify Standard Operating Guidelines (SOG’s) for emergency activities and responses.

Definition of Disaster or Emergencies

The GIH disaster manual defines both minor and major disaster for hospital. The Patients will enter into the hospital Emergency Department (ED) via the main entrance of ED. The disaster will be notified to all hospital staff by ‘Call Center’ (after declaring the disaster situation). The senior consultant present in hospital at that time assumes the role of Incident Commander for the time being until the actual Incident Commander reaches the hospital and takes over.

Triaging

Hospital has designated triaging place just in front of the emergency department on the right side of emergency gate (Bus parking area). The triage categories and triage protocol is developed and documented in the disaster manual. The treatment areas (Red, Yellow and Green Zone) are identified with signage in emergency department. The assembly point is allocated in parking area with signage stand. According to GIH disaster plan all the disaster patients MUST be assessed, triaged on arrival by triage officer, will be given triage Color Tag and directed to the correct treatment areas. Dedicated elevators and one way route has been indicated for smooth traffic flow of the victims and staff. Accordingly the patient will be transferred to the definite areas and the treatment will be done continuously based on triage categories.

In case of fire, earthquake or any other situation where the building could be unsafe, engineering department will assess the situation, if the building is deemed unsafe, the evacuation committee will be activated and the patients and victims will be shifted to the parking area with the help of hospital staff, patient’s family and relatives who are present at that time.

Organization

The disaster management activities in the hospital will be overlooked by the hospital disaster management committee compromising key members from the hospital. Hospital has implemented the Hospital Incident Command System (HICS) and the committee member will take over the role according HICS and carry out their jobs as mentioned in preparedness plan.

The position in hospital and their designation during disaster or emergency response is as mentioned;

Current Position In hospital	Designation during Disaster
Medical Director/CEO	Incident Commander
Emergency HOD	Operation Director
Nursing Director	Logistic Director
Chief Operating Officer (COO)	Planning Director
Assistant General Manager (AGM)	Communication & Security Director
Finance Head	Financial Director

The Role and function of various key positions

• Incident Commander – Takes decision to declare a “Disaster State” and command of the entire hospital. He stays in the command center and controls, commands and makes decisions concerning major changes in the disaster plan. The command center is located in the ground floor Medical Director (MD) room opposite of the orthopedic lounge.
• Operational Director – Oversees all the aspects of the disaster area, medical response and management, coordinates with the IPDs for the availability of beds, surgeon for surgery, requests doctors/nurses and other staff from command center (all doctors/nurses initially report to the command center followed by the operational director). The operational center is located inside HOD room in the emergency department.
• Logistic Director – Takes responsibility managing logistics in coordination with store, procurement, pharmacy and housekeeping for wheel chair/trolley holders. Checks and ensures enough logistic need of Red, Yellow, Green areas. Prepares for adequate floor staff capacity through calling/pulling.
• Planning Director – Accompanies with incident commander, financial director and coordinates with key personnel managing the disaster situation. Collects and analyzes data of the event, plans and gives advice to incident commander if modification is required. Makes sure that supporting departments (kitchen, maintenance, admission department) are prepared and ready when required. Communicates with the supporting departments, plan for shift change of staff if required and works to provide the environment that the hospital staff can work efficiently.
• Communication & Security Director – Communicates with operational director regarding name and number of victims, prepares list and their outcome and communicates with incident commander. Prepare the list for the press, communicate with reception and have it posted in prominent places of the hospital. Coordinates with department consultants and operational director, other hospitals, concern government ministries/departments, agencies and police (if required). In addition he will take charge of security of the hospital in coordination with security coordinator.
• Financial Director – Plans and gives decision on financial issues. Advice the incident commander in finance related issues. Ensures the availability of the materials, medicines, supplies and equipment. Keeps records of all financial transactions bought from outside and gives the final report after the disaster is over.

Supplies

The consumable and supplies (saline, IV cannula, IV drip set, blood transfusion set, bandages, splints, dressing sets, etc.) for disaster situation are kept in separate cupboard and stored in ED. As the need for any medicine arises, the medicines are collected from the pharmacy and the record in maintained. Dressing sets and gloves will be collected from the Central Sterile Supply Department. The key of the disaster store is kept in the ED and is opened only by ED In-charge or on duty nursing supervisor. Re-stocking will be done from pharmacy and medical stores if the disaster is large and requires additional supplies.

Training

This written disaster manual has been made available to all the departments and staff in the hospital. GIH disaster plan and preparedness orientation is regularly conducting training sessions to its staff. It is mandatory to take disaster orientation class at least once a year for every staff of the hospital and it is continuously going on.

Testing

For the real practical learning experience the drill is carried out on different times. The drill was carried out on 11/01/2023. Road traffic accident (RTA) scenario was created in Samakhusi Chowk. First of all call center staff informed about the mass causality to ER HOD and he informed to MD. MD ordered and activated the Code Yellow on 14:05 hours. The security team was activated and allocated different places according to disaster manual and they have maintained and managed the flow of ambulances and other vehicles as well as direct the people to appropriate entrances.

Emergency department staff prepared the triage area with triage tags and one of senior internal medicine doctor arrived immediately for triaging of patients. All ED was ready to receive the patients. Housekeeping staff was on standby position with trolleys and wheelchairs. The command center was established in ground floor. All disaster management committee and key persons were informed via telephone and they were present in command center immediately. At 14:25 hours the ambulance reached into the hospital premises and within next 5 minutes, a total of 10 patients arrived. Patients were triaged by the triage officer (medical officer), nursing and back office staff helped to put triage tags to victims. Other back office staff helped in documentation (writing demographic information) and housekeeping staff transferred the victims to the definite treatment areas. All 10 patients were triaged; one was tagged black (dead) and shifted to Mortuary. Two were tagged red and shifted to red zone (ED), three patients were tagged yellow and shifted to yellow zone (ED) and remaining four patients were tagged green and shifted to lobby area (in front of orthopedic OPD). In all areas medical, nursing and other staff were present with their given role. Operation director and incident commander was in coordination with incident commander. The press meet was done by communication director (role of media person was assumed by back office staff). The drill was continued for one and half hour and Code Yellow was deactivated at 15:20 hours.

After the settling of all patients the debriefing was conducted in orthopedic lounge in presence of all key personnel involved in the drill. Discussion and positive comments for good work and strong points as well as shortcomings and their corrections was suggested by key personals. All committee and staff members were satisfied with the drill activities and they suggested conducting such drills periodically to improve staff skill for handling crisis situations. All clipboards, tags and consumables and supplies were counted and replaced in proper places. The Medical Director thanked all staff for a wonderful response and asked to conduct the drill periodically.

GIH Disaster drill photos

Triaging of victims Transfering of victims

 

Examination and treatment Green area patients

 

Press briefing Post disaster debriefing

Conclusion

Preparedness plan helps to manage the crisis by anticipating the range of potential issues. Countries like ours have to cope with limited resources and its efficient use must focus on overwhelmed victims that would most likely occur. Therefore, Grande International Hospital has its own disaster and emergency preparedness plan in written, well documented form which is distributed and oriented to all department staff and gone through testing (drill), ensuring that at the time of the event everybody can work effectively and save the life of the victims affected by disaster.

References

1. Hospital Preparedness for Emergencies (HOPE) course, USAID/OFDA, NSET, Johns Hopkins Center for International Emergency, Disaster and Refugee Studies
2. GIH Disaster Manual