mass casualtymanagement hospital emergency response …...the emergency managers with tools and a...

TOOLKIT

Mass CasualtyManagementHospital Emergency

Response Plan

Regional Training Course on Mass Casualty Management

and Hospital Preparedness

Regional Training Course on Mass Casualty Management and Hospital Preparedness

Mass Casualty Management Hospital Emergency Response PlanTOOLKITpage ii

Contents

Rationale for this toolkit and methodology 1Methodology 4The methodology recommended is the following: 4A logical sequence of a series of questions 5

Component 1. Surrounding environment and community 6Component 2. Preliminary audit of the Hospital – the existing level of preparedness 8Component 3. Emergency planning process for developing the ERP 9Component 4. The management of the alert and the activation of the plan 10Component 5. The composition, the role and the functions of the Incident Command Group –ICG 11Component 6. The Supplemental Emergency Response Plans of the various departments, services, and units of the Hospitals – SERPs– and the SOPs 14The management of medical care and nursing care 16

Component 7. The Job Actions Sheets JAS - Individual Actions Cards 17Component 8. The management of staff and the call back procedures 17Component 9. The disaster triage area and the disaster patients receiving areas 19Component 10. The medical record and the management of patient information 21Component 11. The external and internal traffic flow and control (in and out the HCF) 21Component 12. The Logistics 22Component 13. The security 23Component 14. The areas for the families 24Component 15. The areas for the media 25Component 16. The management of 25information 25Incident Logs 26

Component 17. The management of the dead 26Component 18. The continuity of operations 27Component 19. Training and exercises 28Component 20. Testing the plan and the ERP maintenance 29Component 21. The psychosocial support activities 29Component 22. The management of the communications 30Component 23. The Emergency Department 31Component 24. The Preparation of the Hospital for chemical and biological incidents 33Component 25. The Preparation of the Hospital for a pandemic influenza 34


Mass Casualty Management Hospital Emergency Response PlanTOOLKITpage iii

Reference Note 1 Risk management and vulnerability analysis in hospitals 34Reference Note 2 The Concept of Comprehensive Emergency Management Program 36Mitigation 38Preparedness 38Response 39Recovery 39

Reference Note 3 The participation of the staff of the HCF to the development of the ERP 40Reference Note 4 The management of the alert and the levels of activation of the ERP 40The processing of the alert and the early decisions. 40The levels of activation of the ERP 41

Reference Note 5 The Incident Command Group 43The Hospital Emergency Command System (HEICS) 43The missions of the ICG. 50Organizational Charts. 53Incident Action Plan 55

Reference Note 6 The Standard Operating Procedures and the Supplemental Emergency Response Plans 56Reference Note 7 The Job Actions Sheets JAS 58Reference Note 8 The management and the staff and the redistribution of staff 65Reference Note 9 The disaster triage area and the disaster patients receiving areas 67Reference Note 10 The external and internal traffic flow and the control 69Reference Note 11 The function “LOGISTICS” 70Reference Note 12 Continuity of operations and evacuation 71Reference Note 13 The management of patient information, the patient record 74Reference Note 14 Training and exercises 75Reference Note 15 Psychosocial support activities 76


Mass Casualty Management Hospital Emergency Response PlanTOOLKITpage 1


TOOLKIT:Mass Casualty ManagementHospital Emergency Response Plan

Rationale for this toolkit and methodologyReference note 1 and 2

The aim of this document is to assist the directors and emergency managers of Hospitals to develop the emergency response plan (ERP, also called Disaster Plan). The planning process itself is as important as the “written document”. This written document (the paper plan) is only one of the outputs of the emergency planning process. Other important outputs of the emergency planning process are:

Awareness rising among the personnel yPromotion of a culture of risks management within the HCF yVulnerability analysis with possible recommendation for actions y(mitigation, prevention, corrective actions)Motivation of key staff to become active partners to assist the ymanagerial team of the hospital in risks managementDevelopment of partnership with key outside stakeholders yDevelopment of exercises (including multisectoral ones) yImprovement in the management of daily emergencies (especially ythrough improved ED procedures, training of staff, etc.)Etc. y

The simple transfer of information (what are the sections of the ERP, what could be the composition of the planning committee, etc.) does not equip the emergency managers with tools and a methodology enabling them to safely develop the plan. The goal of the present toolkit is to assist the emergency managers in their planning efforts, especially by introducing them to a methodology for developing the plan (with a supportive tool: the questionnaire).

There are success stories of Hospitals having managed rather efficiently an emergency situation without having an ERP. But there are far more stories of failures because the Hospital had not managed effectively and efficiently the available resources. The quality assurance programs (and the accreditation) require the development of ERP anyway.

More and more Hospitals develop programs for managing risks and health risks in the institution. The “disaster preparedness program” is one of them. Usually the following programs are considered as related to risks



management in a HCF:On going surveillance programs (blood safety, nosocomial yprevention program, drug safety, etc.). Most of these programs deal with “regulated risks”. Each country has its own set of regulated risksQuality assurance program (and accreditation) yDisaster preparedness program (for major emergencies: fire in the yHCF, MCI, etc.)Risks management program y 1 for common risks (most of the risks of this program are non regulated risks)

Non medical risks (such as interruption of power in the theater section, interruption of water supply, accident in using equipment, etc.)Medical risks (mainly iatrogenic risks) Managerial risks

It is vital that those in charge of developing or managing one of these programs identify the existing links with the other programs so as to search for synergy and complementarities. Ideally each HCF should come up with an integrated set of risks management programs2. Some elements are similar in every program. For instance the vulnerability analysis process is the same (although different expertise is needed) whether the focus is on risks generated by structural vulnerabilities of the building or generated by the failure of electrical power in critical units of the HCF. The notion of “Comprehensive Emergency Management Program” is given more and more attention as the general framework within which the ERP is developed (see reference note 2)

The “Emergency Management” program (disaster management) should include all aspects (not only the response, but also mitigation, rehabilitation, et.) and all hazards. This is the concept of the “Comprehensive Emergency Management Program” –CEMP3. Focus is usually put on protecting safety of people (staff, patients, visitors). The new trend is to also include the protection of equipment and services (the loss of equipment and the loss of services may have much more consequences than just economical losses)

In this document the “Command Structure” in charge of the overall management of the emergency response when the ERP is activated is the “Incident Command Group” – ICG. It is part of the HEICS (Hospital Emergency Incident Command System).

Conclusion. Hospitals are highly complex settings: many stakeholders, special place in he community, expensive equipment, etc. The

1 Cf. special note on this topic together with notes on vulnerability analysis2 Most of the hospitals in Canada, USA and Europe have adopted this strategy.

Each hospital has a full time risks managers (several training centers offer a specific formation with a diploma on hospital risks management)

3 Cf. reference note 1



management of such settings is difficult in normal time. It becomes even more complex and more challenging during crisis and major emergencies. It is a dangerous myth to think that the development of an ERP can be achieved easily and safely by just training a very limited number of people of the Hospital during a short session of a course. The health authorities have to accept that developing an ERP is a fundamental activity (capacity building) that requires strong support from health authorities (more than issuing policy statements –how good they may be) and from the local community. The training of those who will contribute actively to the development of the ERP is a key activity that deserves full support from the Health Authorities. The MOH should develop policy and guidelines as well as tools to assist the emergency planners. It is mandatory that the emergency planning committee developing the ERP has a clear mandate to do so, has full authority for achieving this goal. It is now accepted that by assisting the managerial component of the Hospital to develop the ERP through challenging questions is effective (quality and relevance of the planning process) provided there is a general framework within which the emergency planning process is developed (policy statements and recommendations for its application, issued by the MOH). A hospital disaster plan for external disasters (mainly mass casualty situations) is aimed at ensuring:

Rapid and appropriate response activation yOptimal situational care for victims yClearly understood command and control structures yClearly understood communication mechanisms. yClearly defined roles for all staff and partner organizations yAction cards for all key staff involved. yKey locations and clear roles of partners (SOPs for the main yfunctions)Transition back to normal business with minimal disruption y

Therefore most of the hospital disaster plans are composed of:A letter of authorization yThe management of the alarm yThe levels of activation and the activation of the plan yAn organizational chart of command (Incident Command Group y:location, equipment of the room, functions, staffing, relation with the outside world)A description of the main areas (functions, staffing, Command, SOPs) yLogistics yCommunications yJob Actions Sheets (80% of the total pages) yForms and protocols specific for disaster situations yMaps and other relevant information yContingency procedures yExercises and revision of the plan y



The Director of the Hospital together with the risks managers should enter the planning process for preparing the Emergency Response Plan as a sustainable, long term activity, which never ends. The written document (the paper ERP) will require revisions (environment, resources, and systems change). The training of staff and the exercising of the plan is part of the process and must be discussed in the ERP. The most common reasons for failure of ERP (when activated and having to face real world) is not the lack of appropriateness of some components written down in the document but the following problems:

The plan has been developed in isolation by a very limited group of ystaff (usually copying an existing model)End-users (staff ) are not part of the process (no sense of ownership, ynot consulted for preparing SOPs, JAS, etc.) and do not receive appropriate trainingBreakdown of communications and mismanagement of information yLack of coordination mechanisms with the outside partners y(especially the pre-hospital component)

The methodology recommended is the following:

Constitute an emergency planning committee (authority, mandate, ygoal, objectives)Select members (major functions and disciplines) yTrain the members (emergency planning is an art) yConduct regular meetings (using the toolkits, especially the yquestions of the present toolkit); consult with experts when necessary

Clear agenda for the meetings Chairman, recorder and process managers (plus permanent members and invited members depending upon the themes to be discussed)Decisions (actions to be taken, follow-up until next meeting, time table, etc.)First draft of the section of the ERP under discussion whenever possible

Consult the staff and stakeholders as much as necessary (for ydeveloping JAS, SOPs, SERPs and revising draft components of the ERP). Validation of the sections already been discussed as soon as possible. See reference note 3Prepare the complete version of the ERP (appoint a revising ycommittee to analyze the internal coherence of all documents prepared so far)Conduct workshops for validating these elements with the end- yusersTest the plan yDevelop training and exercises y

Methodology



Develop maintenance of the plan y

The development of the ERP is best achieved by running workshops and meetings of the emergency planning committee with the key informants (vulnerability analysis, risk assessment). Emergency planning is a process.

In the past many MOHs published policy on that issue with guidelines for the application of the policy. Although apparently well balanced these guidelines revealed in many cases insufficient to guarantee a quality output (the written ERP) and failed to substantially improve the outcome (more efficient management of MCI by hospitals). The new trend is to equip the managing team of the Hospital with tools that the team can use to develop the plan. In this line some MOHs issued a “guidebook for assisting the HCF to develop a crisis and emergency management capacity”, which raises questions that should be considered by the emergency planning committee (and answered) when developing the plan and which provides suggestions for solving some frequent and infrequent problems linked with this process and or the management of emergencies (from Hospital perspective). The following sections will propose a series of sets of questions and some suggestions (reference notes) as a possible “tool kit” that can also be used by participants attending the Regional and the national MCM courses. In deed the answers to the questions will almost always require further work or discussions that will booster the emergency planning group for developing partnership with other key stakeholders, for searching for information (that experts can provide such as on vulnerabilities or from other staff of the Hospital not being permanently represented in the planning committee) outside the limited circle of the planning committee, for linking together prevention, mitigation, response and recovery.

This approach does NOT eliminate the absolute need for a national policy on that issue. The presence of existing guidelines should be considered as a prerequisite. The present “tool kit” is rather a pragmatic methodological approach in order to develop the plan and its components (including exercises, networks and partnerships)

A logical sequence of a series of questions

The questions cover the various areas to be considered when developing a disaster plan in an HCF. These questions are not exhaustive. Each Hospital can decide to add some questions. The questions should be considered as an entry point to discuss further the issue with key informants, with stakeholders, experts or any knowledgeable person who can assist the emergency planning committee. These questions are mainly prepared to be used by the planning committee (especially the chairman of the committee) in its work, who has the final responsibility to prepare the plan and to prepare the agenda of the meetings of the committee. It is



recommended that the emergency planning committee takes time to really go through the questions, resisting to the temptation to rush to the writing of a document. It is better to take several weeks to develop an efficient ERP rather than a few days for a bad plan. Emergency planning for HCF is a time consuming and energy consuming activity. It is best done when a senior manager is in charge of following up the meetings of the planning committee and when time lines are defined and respected.

Although the two first sets of questions could appear irrelevant (time consuming and not immediately useful for writing a document which will be the plan), it should be remembered that any written document (the plan) that is not linked to real context will be of limited (if not of no use) use in MCM.

Important remark: the questions are made to enhance discussion in the emergency planning committee. They do not all require a “formal answer”. Of course they do not need to receive “written answers” in the ERP. The ERP is a summary of what is needed to efficiently, effectively and timely manage the response.

Component 1. Surrounding environment and communityReference note 1 and 2

Goal: to identify actual and priority risks faced by the Hospital and the global environment in which the ERP has to be developed

Do we need to know the risks that threaten the Hospital (persons, yservices, equipment and assets) before starting to write the ERP?

If yes: what is the necessary information we should gather for identifying the major risks and why?

Industrial, technological, mass casualty, etc? ÌWhat could be the scope of casualties (number, types: injured, Ìburns, contaminated)?What could be the scenarios for their evacuations to receiving ÌHCFs and how this could affect the Hospital?

What are the external situations that could generate risks for the normal functioning of the Hospital

Such as interruption of life lines (access road, power supply, Ìwater supply, etc.)

What are the main vulnerabilities of the Hospital? Do we master the vulnerability analysis process? If not, what Ìshould we undertake to identify the main vulnerabilities that are present in the Hospital? What could be the impact of these vulnerabilities on the surge Ìcapacity of the Hospital for responding to a MCI?Could some of these vulnerabilities create a potential for an Ìinternal disaster (such as fire)?



Do we need to identify what are the roles and the functions of the yHospital in the community?

What are the characteristics of the surrounding community living in the catchments area of the Hospital? What is the overall organization for MCM in the community? What are the roles, functions, and missions of the other partners (especially the EMS system, other HCFs), especially for MCM?

What does it imply for the ERP of the Hospital? ÌHow to coordinate with them, why, what and what for? ÌWhat are the roles and functions of the intersectoral EOC and Ìhow the Hospital will relate to?What are the roles and functions of the health sector EOC and Ìhow the Hospital will relate to?

What is the surge capacity of the health sector for MCI? What will be the contribution of the Hospital to this surge capacity?What is the existing EMS system in the community an how the Hospital is relating with it?

What is the organization? ÌWho are the partners and what are their main resources? ÌHow they relate to the Hospital in routine emergencies? ÌIs there an emergency plan developed by the EMS? Ì

What could be the other partners (other HCFs) that can assist the Hospital should the evacuation of part of the Hospital be considered to ensure continuity of operations and critical service delivery?What are the existing laws, rules or procedures for MCM or common emergencies in the community?What are the existing policy documents (including guidelines) that could assist in developing the ERP of the Hospital or that have to be respected when developing this plan?Will the ERP be part of the effort of the Hospital to become accredited?

What is the existing emergency preparedness plan of the health ysector in the area?

Especially if the Health Sector is a key partner of the EMS System? How will it contribute to the preparation of the ERP? What are the mechanisms that the ERP must respect? Is there any indicator (defined by the health authorities) for assessing, testing and validating the ERP (validation of the plan)?



Before starting to develop the ERP it is advisable to establish the “overall picture” of what already exists in routine work that could be part of the future ERP (procedures, coordination mechanisms, etc.). This set of questions is useful for those Hospitals that already have some elements of the ERP. For those Hospitals having no ERP, this set of questions can be included in the other questions according to the decision of the planning committee. If there is already a well structured existing ERP, the questions can be used for revising the plan.

What are the existing documents describing (synthesis) the normal yfunctioning of the Hospital (especially the key services: ED, surgery, blood bank, etc.)?What are the existing mechanisms (or indicators) in place in the yroutine activity of the Hospital for “alerting” when there is an emergency?Are they existing documents on vulnerabilities and risks? yWas there an attempt in the past to develop an ERP? y

Is there any existing alert mechanism? Is there any emergency management structure in place? Is there a special command room? In the case of an internal emergency

How alert is managed? ÌWho is mobilized, when, by whom? ÌWhat are the SOPs? ÌHave the main care lines and services lines special SOPs? ÌAre exercises conducted for safety procedures? Ì

If there is already an existing ERP: As the plan been tested, validated (when, how, by whom)? ÌIs there a revision under way? Who, what, when, regular Ìmechanisms, etc.?What are the provisions for training staff? ÌWhat are the provisions for exercising components of the plan? Ì

What is the mechanism for communicating and sharing information ywith the service line executives and the care line executives?What is the policy adopted by the Hospital for promoting the yactivities of emergency planning in order to get support?

From all staff? From key informants and key staff? From the community outside HCF (especially police and fire brigade)?

Component 2. Preliminary audit of the Hospital – the existing level of preparedness



The planning process is as important as the production of a written document (paper plan). It is an ongoing process. Therefore the planning committee should start discussing some key elements of the process itself in order to enhance the efficiency, the efficacy and the effectiveness of the planning efforts. The set of questions mentioned in this section are useful for reminding all members of the emergency planning committee that preparing an ERP is a complex activity, which will require commitment, continuity, professionalism, and participation of all staff of the HCF. Members of the planning committee should be in a position to advocate efficiently for the process.

What will be the methodology applied to develop the ERP y(meetings, workshops, brainstorming sessions, expert consultations, questionnaires, etc.)?Who is responsible for the project (chief of the project)? yHow the meetings of the planning committee will be organized? y

Who chairs the meetings? Who convokes the meetings? Who prepares the agenda? Who prepare report of the sessions? Who will attend all meetings as a regular activity (permanent members)?Who will attend the meetings as contributors? Who will identify (and how?) the staff that should be consulted when discussing technical as well managerial issues involving all staff or specific staff? How the staff is consulted (interview, questionnaire, etc.)?

What will be the key components of the ERP (identify them so as yto develop objectives and a strategy as early as possible in the planning process to achieve them)? Suggested list:

Alert processing and decision making for activation of the ERP (including levels of activation)The Incident Command Group

Composition (positions to be represented), role and functions ÌIncident Command Room Ì

Personnel management and call back procedures JAS (Job Action Sheets) SERPs 4 of care lines and service lines

Care lines ÌTechnical (maintenance, engineering, security) ÌSupport ((administration, finance, personnel, social work, Ìtelephonists, volunteers)

4 Supplement Emergency Response Plans developed by the main care lines and administrative lines in major hospitals. In middle size hospitals SERPs can be composed of a few SOPs only.

Component 3. Emergency planning process for developing the ERP



Logistics (medical supplies, etc.) ÌPharmacy and laboratory ÌAncillary services (kitchen, cleaners, laundry) ÌCommunications Ì

Or SOPs for critical services specialist units (burns, spinal etc) Ìmain areas Ìmedical supplies Ìpharmacy Ìlaboratories, mortuary and blood bank Ìradiology Ìsupport services Ì

Areas Disaster triage area ÌDisaster patients receiving areas (often the ED) ÌEmergency Department ÌFamily area ÌMedia area ÌArea for the dead ÌMain treatment areas Ì

Mechanism and procedures for Review and Monitoring the plan ÌValidating and testing the plan ÌExercises and training Ì

Maps and other critical documents How the ERP will be presented and displayed

Who will have the full document ÌWho will receive selected sections Ì

Component 4. The management of the alert and the activation of the planReference note 3

The management of the alert and the early management of the response (decisions taken for deciding the activation of the plan -partly or in totality) is an important part of the ERP. This section can be summarized in flow charts, a few SOPs and or JAS. Special forms should be developed for managing and recording this early stage of the response.

Does the plan will provide for the prompt activation of the plan yduring normal and quiet hours including weekends and holidays?Does the plan will specify how notification within the hospital will ybe carried out?Will the ERP include an Incident Response Flow Chart? y

If yes: what will be the roles, the procedures, the forms, the SOPs,



the JAS required?5

Will the plan provide for an alternative system(s) of notification ywhich considers people, equipment and procedures?Will the plan have several possible levels of activation? y

If yes: what will be the number of levels and for each level: What is the code for each level? ÌWhat resources are mobilized? ÌWhat command mechanisms are activated? ÌWho can decide, how, when to activate? ÌWhich staff is informed, when, how by whom? ÌWhat are the main actions that must be taken for each level? Ì

SOPs? ¹JASs? ¹

The role and functions of the Incident Command Group? ÌThe decision for ending the activation? Ì

Will the plan specify the chain of command to notify internal and yother appropriate hospital staff of the hospital’s status?Will the plan detail responsibility to initiate a system for recalling ystaff back to duty?Will the hospital develope procedures indicating how the hospital ywill be able to supply resources and personnel to an external disaster?Will the plan include chemical hazard, biological hazard or yradiological hazard component6?Will the plan make provision for activating the hospital disaster ymedical team(s) in response to both internal and external disasters?

The ICG is also called the “Emergency Command” for the management during the crisis time. This component of the ERP is a central piece of the puzzle, much emphasis should be given to discuss in depth this particular component and to get the full support of all care line executives and support line executives. The ERP consists mainly in putting together in a coherent whole the ICG, the JAS and the SOPs. Disaster Management is mainly the smooth addition and integration of: coordination mechanisms between these three components, the relevance of their content, the

5 The preparation of the JAS (writing) should be done when the emergency planning committee has decided the format, the main sections of the JAS. At this stage only the main elements that will have to be included must be recorded

6 Although these issues should not be discussed at that stage of the plan development, it is important to decide whether or not they will be included in the ERP (as special SOPs, or as contingency plans). In the processing of the alert and in the early decision-making regarding the level of activation of the ERP, the Incident Commander (the Incident Command Group) must decide whether or not special procedures will be activated (such as special decontamination, or the use of protective equipment for some staff, etc.).

Component 5. The composition, the role and the functions of the Incident Command Group –ICGReference note 4



capacity of the staff to use them efficiently and timely. The following questions are not aimed at presenting a model for organizing the overall command. They are aimed at supporting the work of the emergency planning committee so that all key managerial, administrative, logistical and technical issues are considered before deciding how the overall management will be achieved in the Hospital during disaster situations.

What will be role of the ICG during the crisis? yWhat will be the key functions of the ICG during the crisis/ yemergency situation?

Management? Operations? Logistics? Planning? Administration? How these key functions are staffed and managed (which positions are necessary)?

How will be the service line executives and the care executives Ìbe grouped under these headlines?How each key function is directed (is someone head of )? ÌWhat and how information is shared between these key Ìfunctions?

How the other functions can be requested to participate if necessary?

What will be the composition of the ICG? yManagerial, functional and technical functions of key staff members (selection according to the role, responsibility and authority of the function and not according to individuals. For instance “Chief of Surgical Department”, etc.)?

What will be the procedure for activating the ICG? yWhat is the maximum delay before becoming operational (this will help to prepare drills and exercises of the ICG)?Who can decide and for what?

What will be the missions of the ICG? yActivation of the ERP (which level)? Call back of staff (including volunteers if necessary)?

Redistribution of staff according to needs and available Ìresources?Coordination with the various departments of the Hospital? Ì

Centralization of the decision regarding the admission of patients and their distribution into the various units of the Hospital?Centralization of the information regarding the Hospital capacity and capability (present and future)?



Recording and tracking of admitted patients? Relationship with the “outside world”, especially the EOC? Contribution to the dispatching of the patients –medical regulation- depending of the particular situation of the Hospital in the community (see notes on medical regulation, chapter on Integrated EMS System) if not otherwise organized?Management of information and relationships with

Families and relatives of patients? ÌMedia? ÌVIP? ÌPublic information? Ì

Assessment of the consequences of the crisis on the functioning of the Hospital and anticipation of present and future needs

Damage assessment if any? ÌNeeds assessment for responding to the crisis? Ì

Assessment of the needs for recovery? ¹

Management of communications? Ì

Where will be located the ICG? yWhat will be the characteristics of the Emergency/Incident Command Room?What will be the alternate site if any serious problem makes the use of the normal location impossible?

What support assistance will need the ICG? ySecretary? Helpers? Telephone officer? Others? Rest room?

What will be the logistical support required? yTelephone lines, fax, printing capacity, and computers? Maps, forms, protocols, charts? Time lines (for decision making and follow-up)? Other?

What will be the managerial support? ySOPs?

For each key function? ÌFor each identified mission? Ì

JAS? For each individual position of the members of the ICG? Ìfor the staff Ì



Will the ERP be available in its full version (including the SERPs/ SOPs prepared by the various departments)?The contact lists with the key stakeholders of the outside world? What are the key documents that should be available in the Command Room?

What will be the exercises for activating and testing the ICG? yHow often, what, who, how? Monitoring and indicators? Testing the communications? Testing the logistical support?

Component 6. The Supplemental Emergency Response Plans of the various departments, services, and units of the Hospitals – SERPs- and the SOPsReference note 5

Each care line (department or unit: surgery, ICU, ED, etc.) and each support line (laboratory, pharmacy, etc.) must have their own organization for commanding and coordinating the activities within their area of professional authority. It is beyond the scope of the ICG to directly command activities that are going on for instance in the pharmacy or in the theatre rooms. Therefore these lines of authority must develop SOPs and organizational charts for their own area of work and authority (together they are the SERPs).

Standard Operating Procedures, SOPs, (or Emergency Procedures) are usually defined as documents where the activities of a specific person (whatever his/her function) or organisation to face a specific situation are described in a clear, logical, sequential and methodical manner.

What will be the Command structure of the particular care lines or yservice lines?

How it differs from routine work? What are the coordination mechanisms with the ICG and other departments, units (including with partners from outside the Hospital if this unit is authorized to have directs contacts with the external world)?

What are the SOPs required for performing safely, efficiently and ytimely the critical activities in the particular department or unit?

How are they prepared, by whom? How are they validated? What are the mechanisms for sharing them with the key stakeholders, especially the members of the ICG?How updating, revision, and distribution are performed? What will be the generic “content” (template) of SOP, if any? How and where are they stored (emphasis on availability)? What are the exercises conducted for using them?

What are the protocols, forms, charts (e.g. simplified treatment y



protocols, decontamination protocols, infection control, etc.) and other similar documents that will be used (or activities will refer to) during emergencies?What are the procedures for freeing beds (contributing to the surge ycapacity of the various care lines)?

Who count the number of beds that could be made available? Who reports, when?What are the criteria for deciding an early discharge of patients or a transfer to another unit and who decides?

What can be the treatment areas for specific patients (such as yseveral burns patients exceeding the burn unit capacity if any)?What are the receiving areas for infectious patients in case of an yepidemic, and what SOPS will be developed?

Special procedures? Special staffing? Universal measures for infection control? Traffic flow of patients in this area and relation with the other areas?

For the main treatment areas, what SOPs will be developed: yWho is involved, medical staff and support staff? How information is shared with the staff? How needs are assessed for getting outside support (staff, supplies, etc.), who?What logistical support is needed, how, when, who manage?

For the support lines: yPharmacy Laboratory Laundry Kitchen Maintenance Security

In summary has each department developed standard operating procedures to reflect how it will provide its services in a timely 24 hours manner? Such departments may include the following:

Administration yEmergency Department yNursing yRadiology yLaboratory yPharmacy yCritical care yCentral supply yMaintenance and Engineering y



Security yDietetics yHousekeeping and Laundry ySocial and religious yMortuary yin the Emergency Department a special section of the plan should yconsider the following details (requiring SOPs):

Is there a separate entry to the Emergency Department for contaminated patients?Is there a dedicated facility for decontamination or a portable device for decontamination?Is there a water supply to the ambulance for decontamination? Can water run-off from the ambulance be contained? Can ventilation system in the Emergency Department be isolated from the rest of the hospital?

The management of medical care and nursing care

Disasters can impose such a heavy workload on medical care and nursing care that the ICG (together with the care lines executives) may have to decide to prioritize what can be done and when. This is not something that can be decided in advance in an EPR. The assessment of the situation and the evolving needs (present and future) compared with the available resources will dictate what decisions must be taken. The ERP cannot do more than defining who decides for what span of activities. It is mainly a matter of competence between the ICG and the care lines executives. This should be clarified in advance.

Each unit/department must clearly identify how medical care and nursing care will be delivered during the crisis. The assessment of the needs for medical care and nursing care has to be done as early as possible. It is an ongoing process. Each unit/department must assess the present and future needs (according to the mission that the unit/department receives) in order to liaise with the ICG or the personnel pool. It is also useful to discuss how the hospital will relate with other health facilities if necessary (transfer of patients, discharge of patients, etc.). Some procedures should be discussed for assessing:

What are the other units/departments, which could receive ypatients?

What staff is present at the moment in the unit/department, skills, number, etc.?What number of patients, type of patients (walking, dependent, etc.) in the unit?What is the maximum capacity of the unit, what factors can influence this capacity, how?How much staff will be necessary and when: who make the assessment, to whom to report, how often?



The assessment of the capacity of each unit/department is of paramount importance and should be know by the ICG as soon as possible

What procedure for assessing the number of beds available? yWhat procedure for assessing how many beds can made available yby transfer of patients, early discharge; who does what, when, how?What procedures for getting more beds if they can be yaccommodated in the unit or department?What special problems has to be anticipated (for instance infectious ypatients, etc.), who report, how?

Component 7. The Job Actions Sheets JAS - Individual Actions CardsReferences note 6

The Job Action Sheets or job descriptions for a specific position (e.g. on duty doctor of the X-Ray unit) are the essence of the ERP (and of the HEICS program). This is the component that tells responding personnel “what they are going to do; when they are going to do it; and, who they will report it to after they have done it.” JAS are prepared for “positions” not for nominative individuals. The emergency planning committee has to discuss several aspects, such as the general template for the JAS (items included, content, presentation, storage, validation, training, etc.). The JAS should always be developed with the direct participation of the end-users themselves (an not in isolation by an ad hoc group of “experts”). In many hospital disaster plans the JAS constitute about 80% of the written document (disaster plan).

What will be the format and what will be the items (sections) yincluded in the JAS?How the functions/positions requiring the preparation of a JAS are yselected?Who develop the JAS? yWhat are the mechanisms for validating and testing the JAS? yHow are they stored and where (including accessibility)? yWhat training (including exercises) of staff? yWhat about the revisions, how, when, how to make sure that the ynew version becomes the one stored in the disaster boxes in the various units of the hospita?How to harmonize them and ensure compatibility and ycomplementarities, and synergy between the functions/positions having to cooperate?

Component 8. The management of staff and the call back procedures See reference note 8

The management of staff is a complex issue in an Hospital even during normal time. It becomes a critical function during a crisis. Several lines of authority are involved. The overall management of a system does not necessarily mean that those managing the system (for instance the ICG) also manage the staff performing specific activities as part of the system.



The management of staff in a crisis should mirror as much as possible the daily management in term of hierarchical organization and positions holding authority to do so. What has to change during a crisis is the “overall command” (the activation of the ICG) and the mechanisms for sharing and coordinating the available resources. Staff is the key resource for responding to a MCM. There are several ways to fulfill this function.

What are the call back procedures and who can decide for which ystaff (when, how) to be called back?

What is the role of the ICG? What are the roles of the various departments and units? What will be the SOPs and protocols?

For call back? ÌTo keep on duty staff in the Hospital? Ì

Who is responsible for managing staff and activities of each ycategory of staff in the various units, departments (day-to-day organizational chart, modified chart)?How the assessment of available personnel is done when the plan is yactivated (who does what and what are the report mechanisms)?How the listings of staff are managed? y

Address, telephone? Updating mechanisms (including sharing info with key positions)?Confidentiality of this information? What are the support activities to be activated when calling back staff? Is there designation of assembly points for all personnel to report to, be they hospital staff or participating organization staff?Briefing them upon arrival (who, where, when)? Food for called back staff or on-duty staff? Children garden or nursery (for key staff called back and having to care for their own children)?

Where arriving staff has to go? yReception room for briefing and re-distribution, directly to their workplace?

How identification of staff is managed (on-duty and arriving staff )? yHow working shifts are organized and by whom? yWhat are the specific arrangements for volunteers? y

Who? How are they distributed to the wards and units? Identification, management, liability, accountability?



An important component of the ERP is the description of the various areas that will more specifically deal with disasters patients. There are two areas that must receive special attention:

The disaster triage area (where casualties are unloaded from vehicles yand have the first contact with the hospital. The area where hospital triage takes place. Only minimum life saving care is performed. Triage is a difficult activity that requires much preparation (tags, codes for priority, equipment, trained staff, etc.). The arriving patients are classified according to the priority for receiving medical care (usually the use of colors: red for really urgent; yellow for urgent; green for non-urgent”. The patients do NOT stay in the triage area. They are immediately transferred to the “disaster patients receiving areas”The disaster patients receiving areas. They are the areas where the ypatients are transferred after having being triaged. Usually there are 3 sections: red, yellow and green. The patients will receive further treatment in these areas and then will be either admitted in the hospital (surgical unit, medical unit, etc.) or discharged when possible (for ambulatory care).

Several organizations are used in hospitals in Asia. Each hospital must choose the solution that best suits the local context. This part of the ERP requires usually much work from the emergency planning committee and it is advisable to create a sub-committee working on these issues only (see reference note).

Where will patients be unloaded from vehicles? yWere will have to go the patients who can walk and come to the yhospital?Where will be located the triage area for disaster patients? y

Who decides to open this area, procedure, information management, equipment, security, etc.?How this disaster triage area will be organized?

Triage zone? ÌStabilization zone? ÌEvacuation zone? ÌWhat will be the circulation between this area and the ED, and Ìthe other care units, surgical theatre?Staffing? ÌTriage activities Ì

SOPs for the triage area? ¹Codes, protocols to be used, tags, etc? ¹Who will perform triage activities (triage teams – individual ¹work)?Who is in command for triage and how the coordination ¹with the ICG is organized?

Component 9. The disaster triage area and the disaster patients receiving areasSee reference note 9



Who does what to set up the area (disaster boxes, etc.)? The traffic flow in the disaster triage area (from unloading patients from ambulances to evacuation to the care units)?How this triage area relates with the ambulances transporting patients?Contribution to the re-supply of ambulances? Use of stretchers?

What are the characteristics used to select the receiving areas? yAccess and possibility to be secured? What equipment and supplies should be available 24/24 -7/7? Logistics for re-supply, etc? Security and safety? Medicines, forms, SOPs, vests, O2, Disaster Box, etc.? If the ED will become the “receiving areas”, how the present patients are distributed, what arrangements must be done for setting up the equipment, signs, etc.?

Where will be located the receiving areas for disaster patients? yHow the valuables of patients are collected and secured? yHow the patients are recorded? yIdentification of patients? yHow the command activities are organized in these areas (triage yarea and receiving areas)?Medical record (specific for disaster patients)? yRecord keeping and tracking of patients? ySupply and re-supply of equipment, medicines? yManagement of blood? yInformation sharing with the main care areas (direct, through the yICG)?How safety of patients, of staff and equipment is ensured? yHow security is managed, by whom? yAuxiliary staff and volunteers (if any)? yAdministrative support? yWhat will be the training activities and the exercises? yWhat are the specific arrangements for contaminated patients? y

Where decontamination is performed? How, by whom? What SOPs are necessary, what training of staff? What equipment?

What are the specific arrangements for biological disasters (or yepidemics)?



The management of information (especially medical information) is always a difficult issue in crisis time. Usually the medical record used in routine time is NOT adapted for its use during crisis. Therefore many hospitals develop a special medical record.

Will the hospital develop a medical record for disaster patients? yWhat will be the key elements that will constitute the record? yWhat will be the characteristics of the record? yWhere the records will be stored? yWho will be responsible for filling in the medical record? yWhat information is given to whom regarding the medical record? yHow medical information is secured? yHow patient information is managed; will a patient information ycentre be considered?How information is shared with pre-hospital Information Centre y(EOC)?How information is delivered to relatives, when, how? yWhat are the contributive roles of the psychosocial support team, of ythe volunteers (Red Cross), etc.?What is the role of the ICG? y

Component 10. The medical record and the management of patient informationReference note 13

Component 11. The external and internal traffic flow and control (in and out the HCF)Reference note 10

The traffic flow of patients is of paramount importance. It encompasses the traffic flow of ambulances (vehicles) arriving to the hospital, the reception of patients in the disaster triage area as well as the transfer of patients from that point to any other destination. Several elements must be considered such as security, safety, logical efficient flow of vehicles outside the triage area, of beds inside the Hospital, etc. It also includes the signalization of the areas (family area, media area, etc.)

What are the access roads to Hospital that must be secured, by ywhom and how?How to organize the traffic of vehicles transporting patients, who, ywhen?How to organize the traffic flow of: y

Ambulatory patients? Of families and relatives? For VIP and media? Who is in charge of security? The returning staff? Volunteers? Of private vehicles of staff?

What is the internal traffic flow of patients from the disaster triage yarea?

To access the receiving areas (ED)?



To be transferred to main treatment areas (including surgical theatres, X-ray department, etc.)?

What will be the areas that will be clearly identified and signalized y(Who does what, what signalization is used, etc.)

Ambulatory services? Disaster triage area? Information and support Centre? Psychological support? Mortuary?

Identification of security staff, who, what function (vest)? y

Component 12. The LogisticsReference note 11

The function “logistics support” is of paramount importance to ensure the functioning of the hospital in crisis time. Many activities have to be organized and managed to match the important surge in supplies and other logistics requirements.

What are the main sub-functions that will be included in the yfunction “Logistics” in the ERP?How will the following main positions/functions be distributed? y

Facility manager? Logistic Chief? Damage assessment and control leader? Sanitation system leader? Communications manager? Transportation Manager? Materials supply manager? Nutritional supply manager? Warehouse supply Manager?

How these positions/functions are identified (vest)? yWhat are the SOPs necessary for supply management? y

Will it be SOPs for the generic logistics function only (HEICS model)?Will each units having a logistics function to also have SOPs?

Pharmacy? ÌEquipment? ÌMaintenance? ÌCommunications? ÌTransport? ÌEtc? Ì

What JAS are required for which position in which unit, department? yIs a Logistics Command Centre necessary (where, who is member, ywhat relation with the ICG)?



What relation with outside providers and outside services providers? yHow to document actions and decisions on a regular basis, where ydocumentation is stored, how? How to liaise with ICG? yWhat possible role in decontamination procedures? yWhat procedure for identifying ongoing hazards and for initiating yfighting against (especially fire)?How to liaise with the Safety and Security Officer (in the HEICS ymodel) regarding security problems and unsafe areas?How to start with light search and rescue efforts if necessary? yWho identify salvage areas where immediate salvage efforts should ybe directed in order to save critical services and equipment? Who assign staff to salvage operations (how)? yWho assign staff to repair operations (monitoring, etc.)? yHow the assessment of structural safety is performed; who does ywhat and when?Who identifies areas where immediate repair efforts should be ydirected to restore critical services?How to develop a real-time tracking system for all resources yrequests?Is there a need for developing pre-established message forms to ydocument all communication?Is there a need to open a Communication Centre in close proximity yto the ICG (what staff, what equipment, role of runners, etc.)?How the communication is maintained between the hospitals of ythe network?How transportation is managed: use of litters, wheelchairs, ystretchers, etc?How the ambulances off-load point is established, located, and ysignalized?How the transport outside the hospital is organized? yHow the equipment necessary to disaster triage area is dispatched yto that area, who, what?What inventory of what equipment is done to assess the needs for yre-supply?Who determine the pharmaceuticals needs, when, how? yHow food requirement and beverage requirement are assessed? yAre SOPs necessary for food procurement and beverages yprocurements?How the in-house supplies are recorded? yIs there a need for a short list of vendors? y

Component 13. The security

This is a fundamental aspect that is too often overlooked by the emergency planning committees. Security is different than safety. Usually safety (a very important component, regrouping complex activities such as maintenance of essential equipment, buildings safety, etc.) is under



the function “Logistics”. The function security is restricted to the “police” activities. The hospital must be “secured”. Security extends from the vicinity of the hospital (outside security) to the inner of the hospital. The close cooperation with police forces and internal security staff is of paramount importance. In some ERP security is regrouped under the function “logistics”, while in other ERP (HEICS model) it is a core function of the ICG (security commander). Each hospital will chose the best adapted solution according to what is in place in routine time.

Who is in charge of the security outside the hospital? yHow coordination is organized between police forces and hospital yinternal security staff?Who is in charge of the security inside the hospital? yAre there various “security zones” (restricted access), how are these yzones selected, how are they signalized, secured?What equipment will be necessary (vest, ropes, etc.)? yHow security of the disaster triage area is ensured, by whom? yWhat training for the security staff? yWho is in charge of managing the ID of staff? yWill the entry doors for accessing the hospital be limited to only ymain access, what signalization, who is in charge of security and ID check?

Component 14. The areas for the families

Often Hospitals have many family members visiting the patients in normal time. During disasters the patients are often brought to the hospital by the relatives and or the neighbors (not always by ambulances without family members). The management of the “visitors” is not easy in crisis situations, especially if patients are brought to hospital by relatives. It is normal that relatives may want to come to the hospital in order to find a missing person (this is frequent during evacuation of the local community from a geographical area after a disaster). Although the dead should not be transferred to the hospitals, it happens that they are. Relatives may want to come to identify their family members. The request from relatives to know if a member of the family is admitted in the hospital is legitimate. There are several more reasons for developing a response strategy to manage these issues. The opening of an “Information Centre” for receiving the families should be considered. See also the components “management of information” and “psychosocial support activities”.

Where will be the area for the families? yWhat staff will be necessary to run it; who does what? yWhat activities will be developed in this area: practical support y(food, etc.), social support, psychological holding, and logistics?How information is delivered to families, who, when (especially for ythe dead)?How the identification of the dead is organized? y



The media should be allowed to come to the Hospital but there should be a clearly signalized area where the media people will meet the hospital’s spokesperson. Media people should never be allowed to enter freely the hospital.

Where is located the media area? yWhat staff, what support? yWhat is the strategy for communicating with media and providing yinformation?Who prepare the information, who delivers the information? y

Component 15. The areas for the media

Component 16. The management of information

The management of information is a central component of the management of hospitals in disasters. There is no activity that does not require the management of some kind of information. That is why the management of information has to be discussed in every component. For instance the revision of the ERP requires the management of many data. The updating of the staff lists is part of the information management. The tracking of patients is part of the management of information, such as also the damage assessment, etc. In the Incident Command Room, much information should be available to the members of the ICG. Part of the information is collected on a regular basis (updating of telephone numbers, lists of staff, etc.), part of the necessary information is collected immediately when the plan is activated (number of beds available, number of beds that can be made available, etc.). The members of the ICG must have immediate access to key information for managing the response (contacts inside the hospital, contacts with key partners outside the hospital, etc.). Some elements should be considered such as the list of telephone numbers of unusual use for a hospital such as the embassies (in places where tourists or foreigners may be present during the disaster time), the list of volunteer translators, the list of the religious leaders who could be called for support (to cooperate with the psychosocial support team), the list and phone numbers of the other HCFs (including private).

In the Incident Command Room the following information should be accessible at any time:

The ERP (in its full version, with all SERPs, all JAS, all SOPs) yMaps of the hospital and of the buildings (with localization of the ykey safety devices such as water valves, fire fighting devices, air conditioning command, etc.)Organizational chart of the hospital and of the main care lines and yservice linesThe storage of toxic products (localization and type) ySafety check lists and procedures y



Security checkpoints ySome key elements of information regarding the normal yfunctioning of the hospital (to prepare information release to media)Contact of key suppliers (oxygen, life lines, etc.) ySimple time line charts for following up the main activities and the ywork load, the use of resources, the staff, etc.A simple system for collecting and processing the data concerning ythe patients (tracking)A simple system for collecting and processing the data on actions ydeveloped during the crisis (this is important for assessing afterwards the response and to review the ERP)What are the key data that must be collected in any circumstances yduring a crisis situation, who collect, how, when, to whom to report, special forms?Is there a centralized information management function, how, who, ywhere, what?How are managed and secured the information systems (electronic yinformation)?What information must be accessible to whom (what is yconfidential)?

Incident Logs All managers must maintain a log throughout the incident responseThe log will:

keep track of outstanding issues ymaintain a record of all actions requests and decisions made ykey communications issues both outstanding and completed yprovide a legal record of the incident response that may be used at ypost incident evaluation (which may include legal scrutiny)

Component 17. The management of the dead

Disasters always generate injured patients. Some of them will die. Sometimes the dead are transferred to hospitals. The management of the dead is a central element of MCI (often MCI are also Mass Fatality Incidents). The management of the dead has several components:

Body recovery yIdentification (including viewing by families, and returning the ybodies to the relatives)Storage of the dead bodies yBurial yreligious, ethical and psychological issues y

It is not recommended to transport dead bodies to hospitals (unless no other possibility and only if few dead that the hospital morgue can absorb). But hospitals should anticipate the problem and also count on the fact that many patients can die at an early stage after their transfer to the hospital. It can happen that the hospital is selected as the place where



identification will take place in the community (forensic investigation).

Where is located the area for the dead, signalization, security? yWhat equipment, what procedures, who is in charge, what staff? yHow is organized the identification of the dead by the relatives? yWhat procedures for the release of the bodies to the families? yWhat information is collected, what information is given to whom yand by whom, how and when?How dead bodies are stored, who is in charge? y

Component 18. The continuity of operationsSee reference note 12

Continuity of operations (COOP) planning allows for the continuation of the essential functions of the hospital, regardless of size, during any incident or emergency that may disrupt typical, normal operations. Evacuation procedures are discussed under COOP.

What are the hazards (external and internal) that can affect the yhospital in its normal functioning (fire, chemical incidents, floods, hurricane, power failure, etc.)?What are the key functions of the hospital that can be altered by ythese hazards?Does the vulnerability analysis process include specific conclusions yon that issue?Should the hospital develop a contingency plan for continuity of yoperations: which functions should be considered, who develops the COOP contingency plan?What are the evacuation procedures, who decide, how, when? y

What are the alternate sites? What are the arrangements with the other Hospitals of the network?What training is needed, what exercises? Is there an organized discharge routine to handle large numbers of patients upon short notice?who is responsible for the removal and control of patient records and documents?Has provision been made for immediate refuge, care and comfort for the patients and staff on the hospital grounds during inclement weather?What procedures for urgent partial evacuation (internal disaster such as fire requiring a partial evacuation), who has the delegated responsibility to manage?

When to decide to restrict the access to the HCF, what, how? yOthers? y

It can happen in extreme cases that the Hospital is “isolated” for several



hours or days. If such a potential exists, then consider the following questions:

has the plan assigned position leaders responsible for: yAuxiliary power? Rest periods and rotation of staff? Rationing of water and food? Waste and garbage disposal? Rationing of medication, dressings, etc? Laundry? Staff and patient morale? Has consideration been given to utilize patients and visitors to assist staff with their duties?

The maintenance of the key services is of paramount importance. These aspects are usually discussed under the component “Logistics” (assessment of the damages to critical equipment, loss of critical services, etc.). The ERP should have a section describing how safety and maintenance of critical infrastructure and essential equipment are managed during crisis time.

Component 19. Training and exercisesSee reference note 14

Training of staff and exercising of some components of the plan are full part of the ERP. Plans must be developed, trained and maintained. Therefore the ERP must include a section on training of staff and exercising of some components or functions of the plan.

What information must be given about the ERP to all staff, how, how yoften, when?What information to the key staff holding a special responsibility or yhaving a special function, how often, by whom?What training, how often, when: y

Who, when, how should undergo regular training and exercises? The relation with the media? The relation with the families? The medical activities such as triage? Information management? Communications? Security? Logistics (especially maintenance of critical equipment)? Incident Command Group – ICG? JAS: how to train staff, when? Activation of the plan and coordination with the different care lines and services lines?Coordination with the outside partners (police, rescue services, ambulances, fire department, etc.?

What exercises, how often? ÌWhich partners should be involved? Ì



How drills, exercises are assessed? yWhat monitoring mechanisms for assessing exercises and yintegrating the lessons learned?

Component 20. Testing the plan and the ERP maintenance

The plan must be tested. This is best done when there are national policy on ERP (prepared by the MOH) and guidelines regarding the requirements that the plan must fulfil. This is usually discussed in the accreditation protocols. Anyway each component of the plan must be tested before the plan can be considered as “functional”. The testing of the plan can be done by functions, by services and by components. There should be clear instruction about how the plan will be:

monitored yreviewed ytested yevaluated yvalidated yrevised yupdated y

The ERP is a living document. The context changes rapidly; the environment, the resources, the capacities of the partners change over time. The organization of the care in the hospital, the staff, and the equipment also change over time. Therefore the ERP must integrate these changes. It is common sense to accept that a plan must be revised but it is rarely done as a systematic activity. Any activation of the plan should be followed by an analysis of what happened in order to decide if the ERP requires revisions (amendments to the plan, systems and procedures, control and coordination arrangements, information management systems and training, etc.). Exercises are also useful to revise components of the plan. The maintenance mechanisms of the plan must be described in the ERP

What will be the mechanism for revising the plan? yWho is in charge of the maintenance of the plan? yHow the plan is validated, by whom, according to what criteria? yHow changes are decided, integrated, tested, validated? yHow the plan is up-dated so that any change is integrated into the ycomponents of the plan being at the disposal of the staff?How the staff is informed of changes? y

Component 21. The psychosocial support activities See reference note 15

The psychosocial consequences of disasters are now well described and it is generally accepted that any disaster plan must include a section on mental health and psychosocial support. In hospitals the activities are necessary not only for the patients and the relatives, but also for the staff working under stressful conditions. Hospitals often have an important role



in the management of public health in the community. Mental health is more and more integrated as an important component of public health in disasters. The ERP should include a special section on psychosocial support activities.

Who are the professionals who will be involved in the development yof psychosocial support activities?

For the patients and the relatives? For the staff?

How the activities are organized? yWhat will be the composition of the psychosocial support team y(identification, etc.)?What will be the role of the volunteers, the NGOs, the religious yleaders in these activities, if any?

How will they be selected, trained and supervised?

What are the areas where the presence of members of the ypsychosocial support team will be ensured, how?What SOPs, JAS will be developed? yWhat equipment should the team have? yWhat forms will be used, where will the information be stored? yWill the hospital develop standardized treatment protocols? yWhat educational material should be developed and ready for ydistribution at any time for patients, for families, for staff?What will be the links of the hospital psychosocial support team ywith the outside world (especially the referral institutions for psychological care), the Information Centre?What services will be offered to the staff of the hospital, when, how? yWhat are the ongoing educational activities of the staff that the yteam will carry out?What will be the activities developed for special groups such as the ychildren, the bereaved families, etc?What will be the role of the psychosocial support team in the ymanagement of the identification of the dead by the relatives?

Component 22. The management of the communications

The breakdown of the communications is one of the most frequent problems encountered in hospitals during disasters. It can badly affect the effectiveness of the response. The management of information (critical for managing the response) requires efficient and well organized communication systems and channels. Often the communications are discussed in the function “Logistics” (see the section on that issue). Nevertheless the emergency planning committee must discuss in depth the communications as a topic per se. Testing of the equipment and regular training of staff are mandatory.



What are the communication means that will be at the disposal yof:

The ICG? The various care line executives and service line executives? The ED and the main areas? The backup of the traditional means? The possible use of runners?

Who is authorized to use what communication means? yHow the communications means are used for: y

Alerting other units about a problem? Sharing information with other units (templates messages, etc.)?Informing the staff? What forms, protocols are used, by whom and when; how record is kept?What training will key staff receive to use the communication means?How the situation reports are prepared, by whom, when, to whom are they delivered, through which communication mean?How the staff must use the telephones of their unit during the crisis?What will be the use of cellular phones of the staff?

What will be the role of the electronic equipment for sharing yinformation; for storing information; for processing information; How this electronic equipment is secured, who has access, ywhen?

Component 23. The Emergency Department

Hospitals may have a number of roles in a disaster, including:

Receiving patients and especially injured patients in mass casualty ysituationsProvide triage to arriving patients for decision of admission and ytreatment priorityReferral hospital or receiving hospital for patients transferred from yother health care facilitiesSending out specialized teams such as triage teams, disaster medical yteams, ATLS teams, etc.Contribution to the dispatching of patients (in many countries) in ycoordination with the evacuation centreRole in public health yEtc. y

The Emergency Department is in the front line of the Hospital. The



organization of the management of routine emergencies is a prerequisite to any surge in the treatment capacity of the ED. This Department should be a full department (at least in major hospitals) with its own organization, staff, command mechanism etc. The institutionalization of the “emergency medical care capacity” is of paramount importance for preparing the Hospital to manage MCI. Its is beyond the scope of this toolkit to discuss in details what are the components of the ED, how the staff should be trained, what SOPs must be developed, etc. for rendering this ED effective even for managing limited mass trauma situations (a few injured arriving at once) and routine emergencies. But it is an illusion to think that the ERP will solve the problem in disaster situations if the ED is poorly staffed, poorly organized and poorly managed in routine time. The ED of hospitals is an key component of the EMS System (when such a System exists). The networking of hospitals in the same area is a sound approach to prepare the hospitals to respond to mass casualty situations. Each country has its own organization for linking together the “trauma centres, the ED, the EMS components”. When developing the ERP, the emergency planning committee should discuss in depth the role and functions of the ED in the system (and not only within the hospital). The upgrading of the ED is a pre-requisite to the development of the surge capacity of the hospital. Some elements are discussed in the toolkit “EMS System”. The following questions may help:

What is the role and what are the functions of the ED in routine yemergencies?How the ED is staffed, organized, managed in routine emergencies? yWhat are the SOPs, the existing guidelines, etc. for managing routine yemergencies?What is the treatment capacity of the ED under routine conditions? yWhat training is offered to the staff as a routine activity for ymanaging emergencies?What are the weaknesses and the recurrent problems encountered yin the management of routine emergencies?What is the role of the ED of the Hospital in the EMS System? yWhat are the functions of the ED of the Hospital in the EMS System? y

What staff? What procedures (especially for the dispatching of patients, see toolkit on EMS System)?What coordination mechanism, with which other units, organizations?

What will be the role and the functions of the ED when the ERP is yactivated?

Staff? Activities (including organizational aspects such as traffic flow, etc.)?Re-organization of the areas?



SOPs, protocols, etc? Equipment? Security? Logistics? What organizational chart? What command mechanisms? Disaster box (content, localisation, access, etc.)? Essential medicine (disaster stock)? Special training? Coordination with ICG, the other units? Relation with ambulances, role and functions? Relation with outside doctors (especially GP for minor cases)?

If the ED is responsible for preparing medical teams or trauma teams yor any other specialized team:

What staff, how, when, what training? What equipment? What command structure? What logistics support?

Component 24. The Preparation of the Hospital for chemical and biological incidents

The ERP for mass casualty situations should also contain a section on chemical incidents. Usually this aspect is developed as a contingency plan, complementary to the ERP discussed here. With chemical and biological agents it should be remembered that there the onset can be acute or slow onset. Therefore the response plan should include an element that can detect as early as possible any increase of illnesses or medical conditions that may suggest the existence of an incident of that nature. The ICG should have permanent access to experts who can advise on these issues (for acute as well as for slow onset situations). The contingency plan for chemical incidents must be developed as a “community response plan” (not only as a internal business of the hospital). The cooperation with the specialized rescue services is mandatory. It should be remembered that hospitals s tore chemical products that can lead to an “internal” disaster. This aspect must also bi included. In chemical incidents it is not rare that there is a “toxic cloud”. Depending upon the site of the accident, the hospital could be in the area where the toxic cloud will be present. The hospital should anticipate (especially for managing air supply within the units, etc.) Some key aspects must be discussed such as:

Special procedures (decontamination, containment, infectious ybarriers, etc.)Reporting system for routine and early warning? yCooperation with specialized agencies (outside the hospital)? yTraining of staff and information management with staff? yPublic information system (role of the Hospital9? ySpecial procedures for treatment and follow-up activities of ypatients?



Safety of the units (especially the ED) of the Hospital? ySecurity and organization of the traffic flow under these special ycircumstances?What antidotes will be stocked, where and who can decide for their yuse?What special training and exercises (with which partners inside the yhospital and outside the hospital) for these special conditions?How to train and exercise the coordination mechanisms with the yEOC, the EMS System?

The potential for a pandemic influenza with catastrophic outcome exists. WHO (WPRO7) has issued several documents urging the MOH to develop a national policy on that issue8 9 10. WHO has also developed recommendations and guidelines for the preparation of Hospitals to cope with such a catastrophic incident. These documents are “management procedures” for preparing the Hospitals to respond to a pandemic11. This is a pragmatic approach, which is urgently needed considering the seriousness of the threat. Nevertheless it should be clearly understood that the adoption of such specific “management procedures” cannot be a substitute to develop a complete ERP for MCM.

Risks are the consequences of the interactions between hazards y(source of risks) and the elements exposed to this source (community, which is composed of 5 elements: people, property, services, environment, economy & assets). The formula used in WPRO is Risk is proportional to Hazard X vulnerabilities / Readiness. See reference documents for more information. Just remember that for each hazard there are vulnerabilities that are specific to the hazard discussed. Community is expressed in term of vulnerabilities/readiness (for its 5 elements). Vulnerability analysis process may become a highly technical process (such as assessing the seismic vulnerability of the buildings of the HCF). The input from experts may become crucial. Nevertheless the HCF should adopt a

7 Avian Influenza, including Influenza A (H5N1), in humans: WHO interim infection control guideline

for health care facilities. Manila, WHO Regional Office for the Western Pacific, 20068 WHO pandemic influenza draft protocol for rapid response and containment.

Geneva, World HealthOrganization, 20069 Assessment tool for national pandemic influenza preparedness. Stockholm,

European Centre forDisease Prevention and Control in collaboration with the European Commission and the

WHORegional Office for Europe, 200610 WHO checklist for influenza pandemic preparedness planning. Geneva, World

Health Organization,200511 A practical tool for the preparation of a hospital crisis preparedness plan, with

special focus on pandemic influenza. WHO 2006.

Component 25. The Preparation of the Hospital for a pandemic influenza

Reference Note 1Risk management and vulnerability analysis in hospitals



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



primarily at c

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