Disaster Management Plan Zakir Hussain Municipal Hospital, Nashik
Prepared for Nashik Municipal Corporation By
Colonel (Retd) P P Marathe and Colonel (Retd) V N Supanekar Disaster Management Plan of Zakir Hussain Municipal, Nashik
Introduction
Reference: 1. Scrutiny of Zakir Hussain Municipal Hospital, Nashik Road, conducted in
December 2010.
2. Vulnerability Map of India.
Appendices: A- Hazard, Vulnerability and Risk Analysis of Zakir Hussain Municipal
Hospital.
B- Feasibility Study of Management of Mass Casualty Incidents Occurring
Outside the Hospital.
C- Resource Management.
D- Organisational Structure for Disaster Management.
E- Roles and Responsibilities of Various Appointment-holders.
F- Procedures during various Contingencies.
G- Communication and Warning System.
P- Sketch Showing Layout of Zakir Hussain Municipal Hospital.
General
1. Hospitals are a soft and vulnerable targets for any disaster. These threats emanate from the changed environmental conditions, life styles, inability of the civic bodies to meet the demands of fast track development and geo-political conditions in our country. Hospitals are organised to meet the medical and health requirements of the society and the staff of any hospital is engaged in investigating ailments of the suffering population and treating them. They are neither geared up to face any hazards that threaten their own facility nor are sufficiently equipped to counter any security threats. 2. For hospitals to counter any threats of natural and man-made hazards the job charts of the staff have to be essentially reorganised and additional help needs to be offered by the government to enable the hospitals to prevent, mitigate and effectively respond to the hazards. Thus, some degree of organisational restructuring, bring greater awareness and equipping them to counter the threats is essential. 3. This DM Plan has been deduced based on general aspects of geology, climatology, geo- political situation, probability of accidents due to human errors or faulty procedures, organisational structures and socio-cultural as well as economic aspects.
Characteristics of an Indian Hospital
4. A hospital provides medical services and facilities to a population that has ailments to be cured/ treated and the focus of the hospital staff and the patients is more on medical treatment rather than other forms of safety and security. Thus, a hospital in India is not competent to protect its staff and the inmates from other forms of threats. Their awareness about hazards is low and thus, this section of the society is highly vulnerable to any hazards. 5. The medical staff is engaged in technical activities related to investigation and treatment of ailments and has tremendous pressure of professional work. This is particularly so because of lack of sufficient staff. Thus the staff is engaged in their primary task of saving lives from ailments and is not available for responding to disasters. 6. The non-medical and administrative staff is similarly engaged and oriented towards fulfillment of their day-to-day requirements related to medical treatment and administration of the institutional and outdoor patients. They are not sufficiently trained to prevent, mitigate and respond to hazards/ disasters that are not in their normal course of duties. 7. A hospital has two responsibilities – firstly to prevent, mitigate and respond to internal threats arising from their own working and secondly to cater to extra load that they may have to bear in case of hazards/ disasters that may affect a large section of the population in the vicinity. 8. The hospital service has to work 24 hours without a break. Thus, hospital has to be in the state of operational efficiency round the clock and staff has to be accordingly managed to ensure efficiency and effectiveness at all times.
Characteristics of Municipal Hospitals in India
9. The Municipal Hospitals in India draw their patients from that strata of the society which shows the following characteristics:- (a) Low income group with poor living standards. (b) Low awareness level regarding prevention, mitigation and response to disasters. (c) Bear low level of social sense towards cleanliness, hygiene and personal habits. (d) Education level is below normal – most inmates are illiterates or semi-literates. (e) Hails from vulnerable sections of the society in terms of acts of violence, habits of consumption of alcohol and consumption of untreated tobacco or the likes. (f) Poorly fed and hence have poor standard of sustenance. Their post disease nursing is of poor quality and ailments of recurrent and recovery is slow. They are compelled by their economic condition to resume work at the earliest and do not have concerns for full recovery. They also look for speedy symptomatic relief rather than long term cure. 10. Ratio between medical staff and nursing staff to the institutionalized patients is mostly adverse. 11. There is a lack of all specialties in the hospitals because of varying sizes. 12. There is a lack of modern equipment, adequate supply of expendable essential commodities for treating the patients and often the serviceability and maintenance of equipment is not done regularly. It takes a long time for any equipment to be repaired and made serviceable. 13. Cleanliness of the entire hospital is a suspect and unclean environment results in spread of infections within the hospitals and the medical and non-medical staff as well as the patients become highly vulnerable. 14. Many buildings are old, sub-standard and have structural deficiencies. Repairs and maintenance of the buildings is not carried out on priority. This results in creation of structural threats. 15. The policy of revenue generation through municipal properties needs to be reviewed in case of Hospital Buildings. These buildings should be stand alone and not combined with shopping complexes. 16. Space available is not efficiently managed many times. Many a time the space is inadequate and stop-gap/ make-shift arrangements result in obstructions to the flow of human mass from one section to the other section within the hospital. This causes delays in evacuation, salvaging or inflow for treatment of emergency cases and men or material. 17. Accountability systems are not established towards Disaster Management and no specific job definitions or job contents are listed for each office bearer – medical or non-medical – in this regard. Most work is done on assumption. Procedural flow-chart of actions is not known to the staff, except the aspect of medical treatment. Thus, the hospitals are not geared up to face any emergencies – natural or manmade.
Hazards in Nashik
18. Nashik is an ancient place located astride Sahyadri Mountain ranges. River Godavari and some of its tributaries drain through Nashik. It is a growing industrial town and holds a great religious significance. Being an old city situated on the banks of Godavari River, the city has a typical old part along both banks of the river with building that are of considerable vintage. The streets in this part of the city are narrow and congested with traffic and economic activities. The modern areas of Nashik are well developed where the roads are broad and building construction is modern in outlook. However, the Municipal Rules have not yet taken into consideration the need for earthquake resistant designs and consideration towards the rock and soil structures and textures. The growth rate far outpaces the ability to cope up with the civic needs, particularly in the peripheral areas. Nashik faces the following Natural Hazards:- (a) Earthquakes: Nashik is in Seismic Zone 3 of India. Here, quakes of intensity measuring 7.0 on the Richter scale are possible. This may result into a large population getting affected. Old buildings may suffer total or partial collapse resulting into severe crush injuries and burying under the debris. (b) Floods: Godavari River is a major river that flows through Nashik. There are other minor tributaries of Godavari. During monsoons, the city does experience flood conditions affecting a large population. (c) Heavy Precipitation: Nashik receives moderate to heavy rainfall each year. The drainage system is not very efficient and water blockages resulting into accumulation and causing submergence is well on the cards. Precipitation may also result into building collapses. There is no possibility of major water logging because of natural slope in the ground. (d) Lightning Strike: The city being within the heavy monsoon region, the Cumuli-Nimbus cloud base is fairly low and probability of lightning strike is high. (e) Landslides: Nashik has hilly terrain around it. There are small villages and hamlets on the hill-slopes or at the bases. Landslides could occur due to natural phenomenon as well as human intervention.(resulting in to disruption of road communication) (f) Biological Threats: Nashik has approximate population of 11 Lac and it is increasing at a rapid pace due to industrialization. The old part of Nashik is unclean and densely populated. The hygiene and sanitation status as well as water filtration status is not adequate and hence the chances of the spread of contagious diseases are high. (g) Industrial and Chemical Disasters: Nashik is an upcoming industrial town. The safety and security status of industries is indifferent and variable. Chances of industrial accidents are fairly high. (h) Fire: The growing population has this common hazard. This is particularly predominant in slums. The dense layout of hutments in the slums and the flammable construction material used it spreads faster in surrounding areas hence affects larger population staying there. Incidents of fire during normal times and during festivities are on the rise. (i) Stampedes: narrow roads and lanes leading to river banks result in very high chances of stampedes during Kumbha Mela and other religious festivities are high. The past record also suggests the same. (j) Communal Violence: Being a growing industrial township, the politicization is bound to occur and with that inter-communal incidents of violence cannot be ruled out. (k) Road Accidents: Mix of transportation mode using common communication facility has increased the chances of accidents in near future. The growing number of vehicles would create greater traffic density and might result into greater chances of road accidents. The roads running astride the hospital are busy because of the vicinity of the market as well as Nashik Road Railway Station. This also may lead to congestion and blockades during emergencies, leading to chaos. (l) Terrorism: The geo-political situation in India has led to many incidents of terrorism. Such incidents in the form of bomb blasts, weapons firing, bio- terrorism and chemical induced terrorist attacks cannot be ruled out. Hospitals are invariably the secondary targets after any terrorist attack, and in such cases the casualties are evacuated to the municipal hospitals on priority and hence there is a need for sensitization of hospitals. The hospitals are the second most vulnerable soft targets and this has been amply evident from the 26/ 11 attacks in Mumbai and the serial bomb blasts in Ahmadabad.
Hazard, Vulnerability and Risk Analysis of Zakir Hussain Municipal Hospital
19. Zakir Hussain Municipal Hospital is located at Nashik astride the Mumbai-Agra National Highway and inherits most of the hazards that Nashik faces. Apart from these, the hospital also faces safety and security problems related to Disaster Management. These have been analysed at Appendix A of this document. The general location map of the hospital is shown below:
General Sketch Showing the Location and Outline Layout of the Hospital
To Mumbai Mumbai – Agra Dwaraka Hotel National Highway Misc Shops
Service Road
Main Entrance
Workshops Garden
Second Entrance
Feasibility Study of management of Mass Casualty Incidents occurring Outside the Hospital.
20. Nashik being a fast growing city with nearly 50% population growth per decade and natural hazards a plenty, incidents of Mass Casualty are highly possible. Though such incidents may not directly impact the safety and security of the hospital the hospital’s capabilities would have to be enhanced in terms of Triage, space utilisation for accommodating patients beyond the holding capacity of the hospitals, increased requirement of staff and medicines and their handling/ management capabilities. These will be highly testing times for the hospitals. A feasibility of the same is analysed at Appendix B attached.
Resource Management
21. For effective Disaster Management (DM), there is a requirement of acquiring, creating and employing resources effectively. Requirement of resources and their deployment/ usage has been given at Appendix C attached.
Organisational Structure for Disaster Management
22. The hospital is presently organised to cater to the normal period medical needs of the population and is staffed accordingly. However, the hospital is neither geared up to face any emergencies that may befall on the hospital itself nor is it geared up to face the “Mass Casualty Incidents” (MCI). Whenever a Disaster Strikes the hospital, the present staff needs to be reorganised to perform various duties related to crisis/disaster management. These duties suggested hereunder cover the entire spectrum of Pre-Disaster phase in terms of prevention, mitigation, preparedness and also cater to increasing the capacity of undertaking immediate response functions in order to minimise the losses, damages and safeguard the lives of the patients, visitors and the entire staff of the hospital, apart from the surrounding population. The organisational structure has been co- related with the Government of India (GoI) norms of India Response System (IRS) and also to ensure adequate emergency support through the regimen of Emergency Support Functions (EMF). Both these aspects have been inbuilt into the suggested organisational structure given at Appendix D and the roles and responsibilities have been enumerated in later appendices. (For this hospital, considering active involvement of all staff during disasters there is a greater need of coordination and participation of other stake holders, so that hospital staff is left free to their primary task)
Roles and Responsibilities of various Appointment-holders
23. It stands to reason that once an organisational structure is identified, the roles and responsibilities of various appointments within the structure should be clarified and their job definitions and contents should be crystallized. The same has been indicated at Appendix E attached.
Procedures during Various Contingencies
24. The procedures for Prevention, Mitigation and Response in respect of emergencies occurring from any disasters would form the bedrock of the hospital’s DM plans. The procedures include EMF (as mentioned earlier), all the in-house processes, handling and storage of equipment, procedures for access control and intrusion, actions during various disaster contingencies and seeking outside support, procedures for evacuating and safeguarding the patients and the staff and operationalising the IRS. The contingency of ‘Mass Casualty Incidents’ (MCI) occurring elsewhere is also considered. The procedures are given as annexure to the Appendix F attached.
Communication and warning Systems
25. Efficient warning system and dynamic communications would allow the staff to actualize the operations in case of any disaster. It would also allow the staff to seek expeditious help from other response agencies in Nashik. The communication and warning system is shown at Appendix G attached.
Present Status of Zakir Hussain Municipal Hospital from Disaster Management Perspective
(Note: The following points are based on the Observations taken during scrutiny of the hospital and some of them have been recorded in the Video Shooting)
Surroundings of the Hospital
26. The surrounding of the hospital is as follows:- (a) The Hospital has roads running astride it along the North- Western and Eastern Flanks. Both these roads have shops/ market and any incidence occurring on these roads may affect the hospital. On the Eastern Flank the hospital has some shops within the building premises with openings on the road. These shops include welding workshop and Distributors of Petroleum Products like the greases. Many shops have highly inflammable materials and any mishap or mishandling is likely to result in fires and the wards of the hospital immediately above these shops may be affected. Roads astride the hospital on the Eastern flank is a service road, running parallel to the Mumbai-Agra national Highway and the location is very close to a major road crossing near Dwaraka Hotel. The road has high traffic and is moderately threatened with any accidents concerning Hazardous Material/ Petroleum and gaseous material.
(b) On the North-Western Flank, there are garages for repair of vehicles and a semi- slum area. This poses hazards.
(c) There is a garden on the Western Flank and the hospital could be easily accessed from there.
Structural Status of the Buildings
27. Following observations are made:-
(a) The building is newly constructed and appears to be earthquake resistant. It is spacious and the space is under-utilised.
(b) There is no lightning conductor on the building. The nearest building on the Eastern and Western flank that is taller than the hospital building is more than 200 mtr away, thus leaving a fair gap for lightning strike.
Security Status
28. Access Control: The building has two gates to the compound and two entrances. While the main entrance has security staff, the second entrance is unguarded. Presently, anyone entering or leaving the hospital is not being checked nor the belongings are checked by the security guards. This leads to a threat of any anti-social elements entering and planting explosives that are likely to go undetected. Also, cases like thefts of material or infant lifting are likely to go unchecked as there is no control mechanism existing in the hospital. Even when emergency cases report at the hospital, the relatives flock the hospital in a large number and walk right upto the wards and are unstoppable.
29. Casualties from economically and socio-culturally vulnerable sections often report at the hospital and tend to become violent. There is no mechanism to control such cases. Procedural Issues
30. Fire Fighting Mechanism: The fire extinguishers are not regularly inspected and maintained. Many of them are unserviceable. The staff is not trained in handling the fire extinguishers.
31. Cleanliness: The cleanliness of the entire hospital is required to be upgraded drastically. The patients and their relatives spit on the walls and corners of the passages. The wards are unclean and linen used appears to be unclean. The toilets are not clean and susceptible to the spread of infections as these are used by the patients suffering from various diseases.
32. Oxygen cylinders are kept for use/ after use in the main foyer. They are loosely kept and are not kept captive with brackets/ frames attached to the walls. The tubing from oxygen cylinders to the wards is generally flexible and loose. This poses a threat.
33. Waste Disposal: The municipal corporation’s dry and biological waste disposal vans do collect the waste from the hospital once a day. However, during the next 24 hours the waste is kept by each ward/ department in plastic bags/ bins and is exposed to the atmosphere. This is a common biological hazard.
34. It was observed that the medical, nursing and other support staff does not use masks and protective gloves and head gears, normally. The culture of using protective gear is not seen in the hospital. Except the OT, Blood bank and the ICU, nowhere else was the culture of using protective gear visible. (Even the staff in the casualty department did not find it to be using it habitually).
35. Procedures for evacuation of immobilized patients, children, old persons and women as well as the staff and salvaging of inflammable material and any important samples, in case of building collapse or fire is not laid down and the staff is unaware (staff was questioned on this issue). Safe areas for assembly of evacuated persons are not earmarked. The garden on the Western flank and the open space of parking is a good place to be used as an assembly area.
36. Some costly equipment in the OT is unserviceable and no speedy action is being taken to make the same serviceable.
37. No triage area is earmarked to cater to mass casualty handling.
38. There is no centralised early warning system and inter-communications are through BSNL/ MTNL exchange only.
39. The DG set also takes considerable time to get switched on. 40. Entry to the patients in isolation ward needs to be independent and the screening of the isolation ward needs to be better. Presently, the chances of spread of infection from the isolation ward to the other patients and staff are quite high.
Signatures of the Individuals Conducting the Study and Analysis:
------
(Colonel (Retd) P P Marathe) (Colonel (Retd) V N Supanekar)
Place: Nashik
Date: Date:
Appendix A
(Refer to Para 18
Of DM Plan)
Hazard, Vulnerability and Risk Analysis of Zakir Hussain Municipal Hospital
1. Hazard, Vulnerability and Risk Analysis is given below. In the Hazard analysis, the present status has been indicated and risk reduction measures have also been suggested. The Hospital and the Municipal Authorities are expected to take appropriate risk reduction measures. The hazard intensities have been indicated on a scale of I1 to I5 in the ascending order of severity and the Threat Values, based on vulnerability factors, have been indicated on a scale of Very Low, Low, Medium, High and Very High.
2. Hazard 1: Earthquakes:
(a) Hazard Analysis: Nashik is in Seismic Zone 3 of India. Here, quakes of intensity measuring 7.0 on the Richter scale are possible. The design and structure of Zakir Hussain Municipal Hospital’s building appears to be fairly stable and would most likely withstand the tremors. The buildings are constructed on RCC columns. EQ is not likely to cause any appreciable damage. The Intensity of hazard is I1. However, rupture to some water and sewage pipelines, damage to electric wiring and rupture of connecting tubes of oxygen cylinders is possible as the cylinders are not placed in cabinets and secured; the cylinders are loosely kept. This may lead to leakage of oxygen and fires may ensue. The Fire Extinguishers have been found to be in expired state and would not be of use during such an emergency. There is a chance of panic driven exodus that may result into a stampede. The loosely kept furniture inside the wards may result into injuries and may block access. (b) Vulnerability Analysis: On an average, during day time, there are about 100 people in the hospital, including the institutionalized patients, the staff, OPD patients and relatives. The population strength at night may be as low as 50. The chances of injuries/ deaths due to falling debris are remote. However, injuries due to secondary effects may arise. The threat value is ‘Low’. (c) Risk Analysis: In case of earthquake hitting the hospital, there may be chances of 5 to 10 people getting affected due to secondary incidents like fire, loose fitment/ furniture items hitting the occupants or panic driven stampede. Threat Value: The threat value of this hazard is low. (d) Risk Reduction Measures: The following risk reduction measures are suggested for immediate action:- (i) Structural inspection of the building should be carried out and where required, strengthening and repair should be done. (ii) All oxygen cylinders should be placed in captive cabinets and the connecting tubing should be regularly inspected and secured. (iii) All fire extinguishers that are exhausted/ expired should be immediately refilled. (iv) Training should be imparted to the entire staff on usage of fire extinguishers. Training should also be given to some select staff (security staff and class four employees regarding rescue from debris and safe evacuation of women, old persons and children and those patients who are immobilized. (v) Entire wiring of the hospital needs to be inspected and frayed wires need to be replaced from time to time. (vi) Drills need to be tied up for seeking outside response and also launch internal immediate rescue and relief response.
3. Hazard 2: Flooding: (a) Hazard Analysis: The hospital is located fairly away from any major river and thus, chances of any major flood affecting the hospital directly is remote. (b) However, the hospital may have to cater to flood victims reporting there. This has been dealt with in Appendix G, later. The threat value is Zero.
4. Hazard 3: Heavy Precipitation: (a) Hazard Analysis: The hospital’s building is fairly strong and the precipitation is not likely to affect it. However, due to water leaks, the chances of electricity leakage due to wet and exposed wiring may occur. The hospital has a good slope and water accumulation is unlikely. Intensity of this hazard is I1. (b) Vulnerability Analysis: The vulnerability is low and short-lived unless structural damage takes place or short circuiting results into incidences of fire or electrocution. The Threat Value is ‘Low’. (c) Risk Analysis: The risk is minor. (d) Risk Reduction measures: The following measures are suggested:- (i) Inspection of buildings should be done during monsoon and necessary repairs should be undertaken at places that show seepage. (ii) Electric wiring should be replaced where required.
5. Hazard 4: Lightning Strike: (a) Hazard Analysis: The city being within the heavy monsoon region, the Cumuli-Nimbus cloud base is fairly low and probability of lightning strike is high. The hospital building, though not the tallest in the area does face probability of Lightning strike. In case of lightning strike, the hospital building may experience partial damage/ collapse. Fixing of lightning conductor is not enough; each year, before the monsoon the conductor’s pit needs to be dug and Zinc salt added to it. Intensity is I1. (b) Vulnerability analysis: Partial damage due to lightning strike may also result into burning of electrical gadgets, burying of some people under the falling debris. There is a I and fires may ensue in the form of secondary disaster. Considering that there may be about 100 people in the premises during day and approximately 50 during night, this population could be vulnerable. Threat Value is ‘Low’. (c) Risk Analysis: Risk is low. (d) Risk Reduction Measures Suggested: It is suggested that a lightning conductor be fixed on the hospital building and the maintenance should be carried out.
6. Hazard 5: Fire:
(a) Hazard Analysis: There are bright chances of fire ensuing in the hospital, due to initiation of fire in the shops or as a secondary hazard caused due to short- circuiting, accidents related to oxygen cylinders and may be due to quakes/ precipitation. The shops in the building astride the service road parallel to the Mumbai-Agra highway have materials that are inflammable. The probability of such material triggering fire is very high. The probability being high, the fire prevention and firefighting mechanism has to be of a high standard. Presently, the firefighting mechanism is not organised well in terms of serviceability of fire extinguishers and ability of the staff to handle such incidents. If fire breaks out in any section of the hospital, it might also result into stampede. There are chances of explosion if oxygen cylinders are involved and this may cause structural damage as well. The Intensity is graded as I3.
This section of the building has welding shop, distributors and retailers who are
storing large quantum of inflammable petroleum products.
(b) Vulnerability Analysis: All the institutionalized patients who are immobilized or physically incapacitated as well as the visitors and the staff are vulnerable. If fire breaks out in any section of the hospital, the vulnerable population due to fire alone may vary from 20 to 50 and additional population would be subject to stampedes. Threat Value is ‘High’. The hospital is presently not capable of responding immediately and would need outside response. (c) Risk Analysis: The probable number of deaths could vary from 5 to 10 and probable number of injured people may vary from 20 to 50. (d) Risk Reduction: The following risk reduction measures are suggested:- (i) Removal of inflammable material from the shops (the inflammable material may be exposed to hazards including the kind where fire-crackers are used by the public and accidental fires start at the shops or due to short-circuiting). (ii) Oxygen cylinders need to be placed in captive frames/ brackets and it should be ensured that the tubing is intact, daily. (iii) Repair and relaying of electric wiring. (iv) Removal of inflammable trash from the hospital area. (v) Ensuring serviceability of fire extinguishers and their correct placement and adequacy in type and capacity. (vi) Training 100% staff – medical, non-medical, support and administrative – in handling of fire extinguishers. (vii) There is a need to tie-up response from outside agencies like the Fire Brigade.
7. Hazard 6: Biological Hazards: (a) Hazard Analysis: The hospital has high chances of triggering biological hazards. Usage of protective gears by the medical, nursing and support staff is below standard (The gears are available with the hospital; however, these are not being used as a habit). Isolation ward patients easily mingle with the other patients. The standard of maintenance of toilets is far from satisfactory. Waste disposal system is not satisfactory because the biological waste is held by all wards and departments for 24 hours (even the one in the OT). At the time of holding the waste, the bags that are used are not being sealed and hence the infections could spread easily. Intensity Factor is I5. (b) Vulnerability Analysis: The chances of infections spreading within the hospital are high. The spread could be fast and wide. The number of people who could be affected due to infectious diseases is very large. Threat value is ‘Very High’. (c) Risk Analysis: The triggering of infections and diseases with hospital as the start point is highly probable. The patients who are vulnerable because of other ailments may suffer from the infections triggered within the hospital and this number could be large. This type of hazard is more dangerous because the spread is silent and cannot be officially attributed to the hospital, in public eyes. (d) Risk Reduction Measures: The following measures are suggested:- (i) The entire hospital should be scrubbed and cleaned immediately and the class 4 employees have to be tasked to clean the premises each day with disinfectants. (ii) Hygienic conditions of the toilets should improve immediately and the toilets of the wards should be cleaned every two hours with disinfectants. The hospital needs to employ additional staff for the purpose. (iii) Trash cans should be placed at many places in the hospital and patients and their relatives should be asked to use them and check those who are throwing the waste around and also stop people from spitting. (iv) Isolation wad needs to be shifted and placed away from other facilities and wards and entry/ exit should be separate. (v) The sewage lines and drainage pipes should be repaired and covered. (vi) The Nallah (drain) to the West of the hospital should be cleaned, blockages removed and covered immediately. The vegetable garbage that is thrown by the vendors should be cleaned on regular basis. Also, on the Eastern Flank, outside the casualty ward and along the road, the patients have piled up garbage of leftover food. This needs to be immediately cleared out. (vii) All waste – biological and non-biological should be incinerated immediately and not held for 24 hours. The Municipal Corporation should install incinerators and decision regarding this should be taken immediately, consulting the environmental impact of the same. (viii) Except the administrative and security staff, the entire medical, nursing and support staff should be asked to wear protective gears at all times while inside the hospital premises. The protective gear should be regularly autoclaved for each ward and multiple sets of these should be held by the wards. Wearing aprons of different colours for different types of staff with a name-plate displayed on it should be made compulsory. (ix) Arrangements for fresh linen on the beds need to be made and system of using the same old unwashed linen repeatedly should be stopped immediately. Additional sets should be provided.
8. Hazard 7: Security Threats pertaining to Terrorism, Violence and Thefts: (a) Hazard Analysis: The geo-political situation in the country is ripe for terrorist attacks and the socio-cultural status leads to violence and thefts. Bitco Municipal Hospital faces these threats in abundance. The hospital has very few security guards, two at any point of time. This was authenticated with the Security Department of the NMC. The department has less manpower and is not geared up to provide much security. The security mechanism has no provision for checking anyone who enters the hospital. People are neither checked while entering nor is there any check of the material and baggage that is being brought in or taken out of the hospital. There is also no system to check vehicles. The Ahmadabad serial bomb blasts suggest that terrorists had planted bombs at the entrance of the casualty ward and the bombs were triggered when the casualties of bomb blasts were brought into the hospitals. Such possibilities are quite high at Bitco Hospital. The cases of thefts of material and organs and also of child lifting cannot be ruled out at this hospital as such cases have occurred in the past in hospitals in other cities. Such incidents in the country are on the rise. Bomb blast could lead to fire and stampede and structural damage to the building. The area outside the entry gates has shops just outside it and vegetable vendors also sell their goods on the foot path. These shops need to be relocated. The Intensity level of this hazard is I3, as and when it happens. (b) Vulnerability Analysis: In case of bomb blasts within the hospital premises, the entire number of people present in the hospital may be vulnerable due to blast and shrapnel injuries and also due to the ensuing fire and stampede. The hospital lacks control mechanism and the effects are likely to be compounded. The Threat Value is ‘Moderate’. (c) Risk Analysis: From earlier similar incidents, it could be deduced that the deaths due to blast effects could be 10 to 15 and injuries due to blast/ shrapnel could be as high as 40 to 50 in intense activity period. Additional injuries due to fire and stampede cannot be ruled out. During such incidents the ability of the hospital to treat the injured would have degraded and thus the response mechanism would be placed out of gear, till outside help arrives. (d) Risk Reduction Measures: The following measures are suggested:- (i) Access Control mechanism needs to be instituted at the entrance of the hospital. This should include metal detection by metal detection frames, hand-held detectors and frisking as well as baggage checking. (ii) Only one relative should be allowed to meet the patient at a time with timing restrictions like 11 am to 12 noon and 6 pm to 7 pm. During other times, the patients should not be allowed to have visitors. Pass system should be started for the visitors and the nursing staff in the ward should be very strict about the visitors entering the wards. Any person other than the institutionalized patients should have a visitor’s pass at any time. There should be a check between the OPD area, the pathology lab and the rest of the hospital wards so that people should not be able to access the wards. Patients in the ICU should not be visited by their relatives except one person per patient in the ICU who should have a separate waiting area. Relatives of the patients should not be allowed to stay overnight in the hospital except the ones in the ICU. (iii) A separate gate is required for ambulances carrying casualties. No other vehicles should be allowed through that gate. Feasibility to do this exists at the Northern flank of the hospital. The space near the North-Western gate should be utilized for ambulances as waiting area also. This entrance is presently unguarded and no security exists. (iv) Visitors should not be allowed parking inside the hospital premises. There is a need to have vehicle under-carriage checking mirrors. (v) Security guards need to be trained in metal detection, frisking and baggage checking duties. Both entry gates must have a guard room and a separate area for frisking. Lady security guards should also be deployed for frisking. (vi) Relocate the shops along the road on the South-Eastern Flank.
(e) General Suggestions: (i) There is an urgent need to institute an Early Warning system within the hospital to warn all staff and patients about an impending danger. (ii) Presently, there is only one entry and exit gate. This is likely to cause blockage during emergency. There is a need to open another gate on the Eastern Flank wall, near the present vehicle park. (iii) In rainy season access to ICU is such that the patients/ casualties have to be shifted through open area. (iv) There is a need to increase bed strength in Pediatric ward and also size of room. Considering the vulnerability of children to infection and necessity of mother being there with child there is a need for utmost hygiene and sanitation in pediatric ward.
Appendix B (Refer to Para 20 of DM Plan)
Feasibility Study of Management of Mass Casualty Incidents Occurring Outside the Hospital.
1. Disasters that may happen outside the hospital resulting into Mass Casualties: Road and rail accidents, earthquakes, landslides, floods in the rivers, fire, epidemics, industrial accidents and terrorist attacks are some of the disasters that may lead to mass casualties and all municipal and government hospitals, including Bitco Municipal Hospital may have to receive these. Such scenario may also develop during Kumbha Mela days. Because of the present arrangements inside the hospital and its safety/ security status, the hospital may not be in a position to do justice to the needs of such mass scale disasters and in case casualties are received in large numbers the hospital will face enhanced threats of fire, biological threats and threats pertaining to accessibility/ terrorism and violence. The rate of flow of casualties is likely to be high during the intense period and traffic will be intense. This appendix deals with the feasibility of managing incidents of mass casualties.
2. The following aspects need to be planned and executed:-
(a) Space provision and management to deal with the additional casualties. The hospital is spacious and the entire space has not been effectively utilised. Managing space for additional casualties would not pose much problem. However, this needs to be planned well in advance. (b) Trafficability of ambulances and other vehicles. (c) Adequacy of medical and nursing staff and the helpers to move the casualties. This area is quite critical to Zakir Hussain Hospital. Class 4 staff appears to be much lesser. (d) Adequacy of material (including medicines, bandages, cotton, syringes etc to deal with the mass casualties). (e) Provision of triage area. (f) Change in the procedures to cater to the incidents of ‘Mass Casualties’. (g) Since the hospital does not have a mortuary, in case of MCI, arrangements to keep large number of dead bodies for a short period and their early shifting to mortuary need to be tied up.
Space Management Issues
3. Zakir Hussain Hospital has space available to create additional wards on each floor. The verandahs are quite spacious and the space could be well utilised. If this space is utilized, about 150 to 200 beds can be accommodated. Accessibility has to be arranged. 4. In case of a ‘Mass casualty’ episode, the present access to the casualty ward should be through the North-Western gate that is presently not being used. 5. There may be a requirement of an additional OT to be added. This feasibility exists in the hospital, utilizing the space on the ground floor, close to casualty. Also, space should be arranged for bleeding areas because in such episodes, blood donors could flock the hospital.
Trafficability of Ambulances
6. Both the roads adjacent to Hospital need to be sanitized/ barricaded to ensure no vehicle movement except Ambulances. All vendors outside hospital need to be evicted and if such an action is not possible no one should be allowed to function in case of such incidents till cleared by authorities. The vehicles, except the ambulances should not be allowed inside the hospital premises. The ambulance flow should be directed towards the North-Western gate. The triangular piece of land (which is in dispute) can be used as Ambulance waiting area during such episodes.
Medical, Nursing and Helpers
7. In case 150 to 200 casualties have to be treated, the present authorised strength may be inadequate. The following additional staff would be required and may be arranged from the local resources. The requirement of staff would be as follows:- (a) General medical staff - 4 per shift X 2 shifts = 8. (b) Surgeons - 2 per shift X 2 shifts = 4. . (c) Specialised in Gen medicine - 1 per shift X 2 shifts = 2. (d) Nursing staff - 4 per shift X 3 shifts = 12. (e) Helpers - 6 per shift X 3 shifts = 18.
Note: In such emergencies, there may be a need to have an orthopedic Surgeon, an Anesthetist and a Gynecologist on additional duties from the private sector.
Medical Equipment and Medicines
8. Additional medical and other equipment that may be required may include the following:- (a) X-ray machine. (b) Sonography machine. (c) Syringes and needles. (d) Autoclave arrangements. (e) Operating table and Overhead lights. (f) Stretcher trolleys. (g) Blood testing equipment. (h) Additional Oxygen cylinders. (i) Suturing equipment. (j) Bandages, Gauges and Cotton. (k) Blood pressure machines and stethoscopes. (l) Anesthesia equipment. (m) Splints. (n) Suction machine and tubes. (o) Nasal feeding tubes. (p) Feeding cups, urine and stool pots. (q) Beds and linen. (r) IV stands, IV sets. (s) Emergency lights and torches. (t) Medicines to cater to burn injuries, crush injuries, food poisoning, gastroenteritis related medicines, water borne diseases related medicines, bleeding related medicines, shrapnel and blast injuries related medicines etc.
Triage Area
9. Presently, there is no triage area in the hospital. It is suggest that the present OPD area and space on the ground floor be used as triage area. The area needs to be segregated by screening it. Shifting of casualties to/ from the ICU is feasible. General ward patients can be discharged or moved to additional wards created on the second floor. Ambulances will be able to deliver the patients at the North-Western gate of the hospital
Change in Procedures
10. The casualty department will have to have an additional set of doctors and staff to handle these casualties and the normal casualty department would deal with the patients that report normally and not as Mass Casualty Incident (MCI). The OT for the MCI incidents will be separate and their treatment being of the same category, the equipment required will be earmarked separately. However, till full administrative and medical facilities are brought to the optimum level to handle the casualties of ‘MCI’, permanent staff and the equipment will be shared through a logical division. 11. Procedure for procurement will be expeditiously done. For this purpose, the Municipal Corporation will have to have pre-contracted rates and MOUs ready. The Hospital Superintendent will be given a sanction to order the required material from pre- sanctioned dealers, expeditiously, within a laid down sanctioned amount. Further requirements should be met through sanctions by the Municipal Corporation. Extra duty allowance should be given to the staff performing duties over longer hours and the records will be maintained. Similarly, to make up for the requirements of specialists from the private doctors (specialists), MOU will be signed with them to treat cases requiring the specialist treatment. The specialists will be pre-contracted on pre-decided rates. 12. The detailed sequence will be as under:- (a) On occurrence of ‘MCI’, the Municipal Corporation’s EOC will declare the incident as ‘MCI” incident and will inform the same to the hospitals. (b) The Hospital Superintendent will start procurement actions for medicines, equipment and other logistics and seek additional manpower for establishment of the ‘MCI’ centre. A record of the same will be maintained through issue – expense vouchers/ registers. (c) Staff will be divided and round the clock handling will start. (d) The superintendent will requisition additional staff that is pre-contracted (even private nurses and helpers can be pre-contracted). (e) Demand for the additional staff will be placed on the Municipal Corporation and the Municipal authorities will requisition the staff from the District Collector and the State Govt. Once such additional Govt. staff reports at the duty, the private staff will be released. The requisitioning record will be maintained and “Sign-in and Sign-out” record will be produced by the hospital for scrutiny by the Municipal Corporation for onward compensation to the private staff that had been requisitioned. (f) In case the additional staff is made available to the hospital from outside the municipal area, their lodging and boarding will be tied up by the Municipal Corporation. (g) The ‘MCI’ incident will be declared closed after most of the patients admitted under the ‘MCI’ are discharged from the hospital. Record of such patients will be maintained for ‘Compensation’ purpose and produced to the Municipal authorities when asked for.
Flow Chart of MCI Incidents
MCI Incident Occurs in the City and the Hospital is warned
Hospital warns the police station Hospital Emergency Support system is activated
Establish Traffic Control on the Roads with the help of Police.
Triage area Staff is Patients Arrangem is warned and from ents to established reorganized General shift dead for Ward bodies treatment. shifted to made. Additional make ‐shift staff is arrangeme demanded. nts on the terrace.
Appendix C (Refer to Para 21 of DM Plan) Resource Management
1. Resource Management is an important and complex function. The resources need to be managed for prevention, mitigation, preparedness and response. The following table spells out the resources required for each phase. It also indicates the structural issues that need to be handled by the hospital for preventive purpose. Ser No Name of the Resource Quantity/ Scale To be used in How deployed and which phase handled
Material Resources
1 Fire extinguishers DCP 15 After fire 1 outside each Type 10 kg weight breaks out and department, before that casualty ward, keep these pathological lab, serviced - ICU, Blood Bank, Immediately OPD, Burn ward, Pediatric ward, Female wards, All OTs, Gynecology and Obstetrics Ward, Male Surgical and Medical wards, Canteen (when operative).
2 Fire Extinguisher DCP Same as above Same as Same as above Type 5 kg weight above
3 Fire Extinguisher CO2 Same as above Same as Same as above Type 10 kg weight above
4 Brackets to fix Oxygen 4 Immediately One each outside Cylinders ICU, OT and casualty ward. One cabinet should be made outside the building for empty oxygen cylinders.
5 Water pipe 1” diameter 2 To be used To be kept centrally and 100 mtr long during in a central store. Disaster phase when fire breaks out
6 Metal Detector Gate and 2 gates and 4 To be used in At each entrance Hand-held metal detectors hand-held all phases and exit detectors
7 Warning siren 1 To be used Kept with the when disaster casualty ward is imminent (because it is and also when always manned and emergency CMO’s room is breaks out. close by.
8 Vehicle under-carriage 4 sets (two at All phases – reflector mirrors each gate) Immediate action
9 Incinerators 2 sets (for All phases – To be suitably incinerating the Immediate placed and all the entire bio-waste action waste needs to be of the hospital) incinerated without waiting for municipal corporation’s van to collect the waste once a day.
10 Masks and gloves 1 per staff (to be In each phase. In each department autoclaved Immediate regularly or many action. disposable ones to be used with abundant supply)
11 Waste receptacles in each Sufficiently large All phases. ward and department receptacles Immediate should be provided in each action ward for the patients to throw their litter. 15 of such receptacles are immediately required.
12 Inter-communication 15 sets of inter- Pre-disaster network. communication Phase. network are required to be installed.
Repair/ Replacement, Maintenance and New Construction
1. Relocation of shops that The inflammable All phases. are dangerous from within material storage Immediate the building and welding one time activities pose a action. threat of fire to the hospital. These shops should be relocated. Also, shops that do business in waste material should also be relocated.
9 Relocating the car park The present car park area should be discontinued. All visitors must park their vehicles outside the hospital premises. Only the vehicles of the doctors should be allowed inside. These vehicles should enter at the North- Western gate and parked there.
10 Lightning Conductor 1 system of Pre-disaster lightning phase. conductor with Immediate annual action (This maintenance. can be re- fixed when the hospital shifts to new location)
11 Security Cabin at each 2 security cabins entrance gate are required, one per entry gate. The security staff at the gates will perform their duties from this cabin. The security cabin at the main gate must have one room for frisking of personnel.
Manpower Requirement
1 Need to have 4 security The three guards All phases. 4 guards would be guards at any one time should be located Immediate on 8 hourly duties. shift X 3 shifts = 12 as under: action. The lady friskers security guards + 2 lady will be employed guards for frisking during 2 guards at the only during visiting day time. Thus, a total of main entrance – hours. 14 security persons are one each to check needed. people and controlling the traffic; 1 each at other two entrance gates.
2 At least 1 additional 5 All phases. Cleaning staff needs to be Immediate enrolled for each floor and action. two staff for garbage clearance should be enrolled. Thus, a total of 5 more cleaning staff is essential.
Appendix D (Reference Para 22 of DM Plan)
Organisational Structure for Disaster Management
1. The Hospital should have the following Organisational Structure from Disaster Management viewpoint:- (a) Hospital Emergency Management Committee – during Pre-Disaster and Post Disaster Phases. This will have the following sub-committees:- (i) Security Management Sub-Committee. (ii) Medical Aspects Management Sub-Committee. (iii) Non-Medical Aspects Management Sub-Committee. (b) Incident Response System structure – to respond during disasters.
2. These committees will be responsible collectively to the Municipal Corporation’s Health/ Medical Branch for all aspects of Disaster Management.
Hospital Emergency Management Committee (EMC)
3. Structure: The committee will comprise of the following office holders:- (a) Hospital Superintendent - Chairman of the committee. (b) Senior surgeon posted at the hospital. (c) Senior doctor in medicine/ gynecology/ pediatrics posted at the hospital. (d) Doctor in charge of Pathological Laboratory. (e) Doctor in charge of Blood Bank. (f) One resident registrar – will act as the secretary of the committee. (g) Chief Matron. (h) Senior-most person from accounts. (i) B & CD Department Dy Engineer from NMC. (j) Dy Engineer from Water Department of NMC. (k) Dy Engineer Electrical Dept of NMC.
4. Functions: The committee is required to perform the following functions:- (a) The committee will meet once every month, preferably in the first week of the month. The minutes of the meeting of the committee will be recorded and a copy of the same will be sent to the head of the Health/ Medical department of the Municipal Corporation. (b) Security Systems: The committee will continuously review the security system to include:- (i) Check on access control and performance of duties by the security staff. (ii) Standard of training of the security staff in frisking, checking of vehicles and baggage checking. (iii) Adequacy, positioning, serviceability of fire extinguishers and other fire fighting means. (iv) Cleanliness of the entire hospital and area adjoining the hospital. (v) Check leakages in the water and sewage pipes and recommend their repairs and replacements. (vi) Inspection of the drainage lines and their repair and serviceability. (vii) Structural inspection of the building once a year through a structural engineer, after the same is sanctioned by the Municipal Corporation. (viii) Serviceability, maintenance and functioning of the equipment and instruments in the hospital and placing of additional demands. (ix) Use of protective gear by the entire medical and non-medical staff. (x) Serviceability of incinerators and the system of waste disposal. (xi) Daily disinfection of the hospital premises and periodic fumigation. (xii) Cleaning of the overhead water tanks. (xiii) Inspection of the electric wires, their maintenance and putting up recommendation for replacement. (xiv) Functioning of all the departments, for cleanliness, equipment serviceability, procedures and records. (xv) Serviceability of ambulance vehicles. (xvi) Handling and security of Oxygen cylinders and their tubing. (xvii) Cleanliness of wards and toilets. (xviii) Review the arrangements for handling episodes of handling Mass Casualties. (xix) Review the training needs and conduct mock practices. (xx) Liaise with other govt. agencies including response forces (Like Police, Fire Brigade, Home guards and Civil Defence etc) and emergency support organisations (Like MSEB/ MSDCL, Water, B & CD, etc). (xxi) Assess training needs of security and Class IV employees for Incident Response and organise the necessary training in ‘Fire fighting’, ‘Casualty evacuation’ and ‘Rescue’. (xxii) Ensure that the entire hospital staff takes training to function within the concept of IRS under the circumstances when the hospital is struck by a disaster and when the hospital has to deal with Mass Casualty incidents affecting the town. (c) The committee will ensure that the doctor residing in the hospital on night shift is also given duty to take rounds and ascertain various aspects that could be observed at night. (d) An inspection form will be prepared (See sample at annexure attached) and the members of the committee will be asked to inspect the entire hospital premises from time to time throughout the month, periodically and make observations. These forms should be compiled and put up to the Chairman of the committee each week and reviewed during the committee meetings for actins. Any action that is felt to be emergent should be initiated immediately.
Security Management Sub-Committee (SMC)
5. Structure: The committee will comprise of the following:- (a) Resident Doctor (Registrar). (b) Chief Matron. (c) Senior most office bearer from Accounts.
6. Functions: (a) Chalk out duty roster of security guards. (b) Chalk out security instructions for the hospital and responsibilities of the security guards. (c) Check that the security guards are performing their duties appropriately, round the clock. (d) Ensure that the security gadgets are functional and warning siren is also functional. (e) Lay down visitors’ visit timings. (f) Ensure that after the visiting hours, a gong/ bell is sounded for all the visitors to go out of the hospital. (g) Ensure that the security guards are conversant with Warning system, frisking and metal detection system, rescue, fire fighting, casualty carriage and first aid. (h) Ensure that no vendours are allowed to occupy the foot path astride the entry gates. (i) Inspect the surroundings for any inflammable material within the campus and also of the shops occupying the same building. (j) Ensure that the fire fighting equipments are in place and functional. (k) Fill up weekly inspection forms and surprise check forms and put up the same to the EMC.
Medical Aspects Management Sub-Committee (MAMC)
7. Structure: The sub-committee will compose of the following:- (a) Senior most doctor from hospital (excluding the superintendent). (b) Doctor in charge of Pathology laboratory. (c) Doctor in charge of the Blood Bank. (d) Chief Matron.
8. Functions: (a) Check that medical, nursing and cleaning staff uses gloves and masks at all times while in the hospital premises. (b) Check that sufficient number of masks and gloves are available with each department and ward. (c) Ensure that biological waste is not dumped in the wards, awaiting collection by the Municipal Waste Disposal Vans but the waste is collected and incinerated every one hour. (d) Check that incinerators are in serviceable condition at all times. (e) Check that the hospital is disinfected every day and fumigated periodically. (f) Ensure that all medical treatment gadgets are serviceable. Project non- serviceability to the EMC. (g) Ensure that the oxygen cylinders are correctly placed in brackets and the tubing is properly attached. (h) Ensure that waste matter is not thrown by the patients and waste matter bins are used and are available in each ward and that the bins are covered by proper lids. (i) Check general cleanliness of all wards and especially that of the OT, Pathology Laboratory, Blood Bank, ICU, Pediatric ward, Burn ward, Isolation ward and the Casualty ward. (j) Ensure that the linen/ clothes used for a patient are not reused for another patient without ‘Disinfecting Wash’. (k) Liaise with the Health Department of NMC for progressing cases on repair of defective equipment/ instruments and buying of new ones as approved by the EMC. (l) Manage the additional medical staff, when allotted during emergencies.
Non-Medical Aspects Management Sub-Committee (NMAMC)
9. Structure: This committee will comprise of the following:- (a) Dy Engineer B & CD Dept of NMC. (b) Dy Engineer Water Dept of NMC. (c) Dy Engineer Electrical Dept of NMC. (d) Senior Accounts Dept person from the Hospital. (e) Resident Doctor.
10. Functions: (a) Check the structural aspects of the entire hospital building and point out the repairs. (b) Check leakages in water pipes and sewage pipes and point out repair works. (c) Check drainage channels and ensure that these are covered. (d) Check electric wires, connections, distribution points and ensure orderly lay out and ensure that there are no naked wires or criss-crossing the same is seen anywhere. (e) Check electricity loads. (f) Check serviceability of the generators. (g) Supervise all repair and reconstruction works and report progress. (h) Liaise with the NMC for progressing pending cases for sanctions/ allotments.
Incident Response Structure
11. While the committees mentioned above work during the non-emergency periods towards Prevention, Mitigation and Preparedness, the Incident Response Structure will be based on the Govt. of India approved Incident Response System (IRS). The ideal structure for IRS of Bitco Hospital is given below:-
Case 1: When the Hospital is struck by a Disaster:
Senior Most Officer from health Department of NMC – Act as the RO
Hospital Superintendent to Act as the Incident Commander
A senior Doctor will act Senior person Doctor next in seniority Fire Brigade officer or the Police Inspector to as the Logistics Section from Accounts to Hospital Chief, assisted by the Section will Act as Act as the Operation Superintendent to Act Chief Matron the Finance and Section Chief, as the Planning Section administration depending upon the Chief Section type of disaster Coordinator under affecting the Hospital the NMC
Resource Relief Resource Planning of area provisioning Group utilisation for Planning: evacuation of medical Officer patients and staff and planning for their continued treatment Traffic Fire fighting Search and Debris Salvage Control group Rescue Group Clearance group Group
Case 2: When the Hospital has to handle Mass Casualty Episodes:
Departmental Head of Health Dept of NMC to act as the RO
Hospital Superintendent to act as the Incident Commander
Senior Officer from Senior most doctor Assist. Senior Accounts the Health Dept of of the Hospital to Commissioner Officer of the NMC to Act as the act as the of NMC to act Hospital to act as the Planning section Operations section as the Logistics Finance and admin Chief Chief Section Chief Section Chief
Resource Planning Space and Control Planning Group: Officer Group: Chief from Health Dept Matron of NMC
Triage Control Treatment Blood Dead Disposal Group: Medical Control Collection group: officer Group: Group: Doctor Resident Resident in charge of Doctor Doctor Blood bank
Resource Food and Hygiene Lodging and Security Acquisition water and Boarding Provisioning group: Officer Provisioning sanitation Group for Group: persons from NMC Group Group Hospital Staff from Police Dept
12. Emergency Support System of the Hospital: The diagram below indicates emergency management functions of the hospital. The functions will performed by the Committees functioning during Normal Period, restructured through IRS, with additional support from the NMC and response forces.
EMC led by the Hospital Superintendent
B & CD Water and Medical Hygiene Security, Transport Triage and Support Electricity Resource and Search and and Traffic Treatment Function: provision Management sanitation Rescue Mngmnt Mngmnt NMAMC Function: Functions: Functions: and Function: Function: NMAMC MAMC MAMC warning NMAMC EMC system Functions: SMC
13. Nerve Centre of the IRS in the form of Site Operation Centre (SOC): The Hospital Superintendent acts as the Incident Commander. However, he/ she is required to operate from within the hospital premises as far as possible, unless the emergency is such that the hospital’s location is not suitable for operations. If the Hospital is tenable, the Hospital Superintendent’s office will act as the Site Operation Centre (a mini-EOC). When the hospital premises are not tenable, the nerve centre may shift to the location of the vegetable market at the eastern Flank. This will have to be coordinated with the NMC, during Normal periods. For this to happen, the premises of the vegetable market should be made approachable and the road leading to it from the main entrance of the hospital should be made motorable. The following should be organised:- (a) The Hospital Superintendent’s office must display a list of following important tele numbers on the wall in a chart form:- (i) Tele no of head of the Health/ Medical department of the hospital. (ii) Tele No of the Municipal Commissioner and the Dy Municipal Commissioner appointed for Disaster management. (iii) Tele no of the EOC of the NMC. (iv) Tele No of the nearest police station and the police control room. (v) Tele no of fire brigade and the fire officer. (vi) Tele no of other hospitals and specialists in the city. (f) Tele no of the medical distributors. (g) Tele Nos of the Hospital Superintendent’s residence, numbers of all doctors. (h) Tele no of the Matron and the Senior Accounts official of the hospital. (i) Tele no of private ambulance services, railway station and road transport. (j) Chart of EMC and ESF and the organisational chart of the IRS of the hospital. (k) Duty roster of all doctors and security supervisor. (l) A copy of DM Plan of the hospital. (m) Telephone log and Event diary.
Annexure
Format for Routine Inspection Report
Name: ------Appointment: ------
Date on which inspection carried out: ------.
Building and Structure: 1. Observations on building structure (Mention the place and anomaly specifically, if any else write “NIL”): (a) Details of cracks and damages observed: ------. (b) Details of leakages in water pipes and drainage observed: ------. (c) Are the drainage lines fully covered? Y/N. Give details of any observation ------. (d) Details of loose wiring or inordinate wire connections observed: ------. (e) Condition of fencing and boundary walls: ------. (f) Are the toilets clean? Y/ N. Specify any observations ------. (g) When were the water tanks cleaned? ------.
2. Security Issues: (a) Are the security persons giving duties appropriately, following access control measures and checks? Y/ N. (b) If there is any flaw, describe it specifically ------. (c) Are the security personnel equipped with whistles, rubber canes and torches at night? Y/ N (d) Are the visitors being restricted to visiting timings? Y/N (e) Are the security personnel conversant with frisking procedures? Y/N (f) Are the metal detectors in working condition? Y/N (g) Are visitors passes being correctly issued/ Y/N (h) Are the security personnel conversant with rescue and fire fighting duties? Y/N. (i) Are all the fire extinguishers serviceable? Y/N. Those not serviceable are: (Type and Where placed)------.
3. Medical and Biological issues: (a) State of cleanliness of the surrounding area: ------. (b) State of cleanliness of the area inside the hospital premises: ------. (c) Are waste bins being regularly used? Y/N (d) Is biological waste being incinerated every hour? (e) Is the staff using protective gear? (f) Is protective gear available in sufficient quantity? (g) Is the linen used for patients clean? (h) How clean is the washed and laundered linen? (i) Are all medical treatment related equipment in serviceable condition and if not, what action has been taken/ proposed? (The departmental heads/ ward in charges should be contacted and actual status should be noted in consultation with them) (a) Equipment in the OT: ------. (b) Equipment in the ICU: ------. (c) Equipment in the Blood Bank: ------. (d) Equipment in the Pathology Laboratory: ------. (e) Equipment in the Casualty: ------. (f) Equipment in Pediatric ward: ------. (g) Equipments in other wards (specify): ------.
4. Are details of telephone numbers displayed in the CMO’s room and the Superintendent’s office? Y/N 5. Are the nursing staff and class IV employees aware of the evacuation procedures in case of emergency? Y/N. Add detailed comments: ------.
Date: Signature ------
------Date: Signature of the Hospital Superintendent
Appendix E (Refer to Para 23 of DM Plan
Roles and Responsibilities
1. Role of the Hospital Superintendent: The Hospital Superintendent plays a pivotal role during Pre-Disaster Phase and Active Disaster Phase. He/ She is the main planner and executor of Emergency Support Functions and the Incident response Functions during the disaster phase and through the Emergency Management Committee ensures prevention and mitigation of disasters by enforcing the right procedures and resource management. The roles and responsibilities are as follows:- (a) General Roles: (i) Acts as the Chair person of the Emergency Management Committee (EMC). (ii) Acts as the main coordinator of Emergency Support Functions. (iii) Acts as the Incident Commander when disaster strikes till the disaster is fully managed. (iv) Acts as a link between the Hospital and the NMC as well as the Response Forces from outside.
(b) During Pre-Disaster Phase:
(i) Hold meetings of the EMC once a month and record the proceedings. (ii) Put up the suggestions/ demands/ projections to the NMC’s health/ Medical Department with an advance copy to the Commissioner NMC. (iii) Compile feed- back from the sub-committees and take a review of the status by own inspection. (iv) Carry out surprise inspections of all wards, departments and procedures and order immediate rectification. (v) Keep the Hospital in a state of readiness to face any emergencies. (vi) Keep record of efficiency and effectiveness of all department, wards and functionaries and counsel them for better performance and motivate them. (vii) Order establishment of the IRS (pre-formed) and order its operationalisation on occurrence of an emergency. (viii) Order restructuring of the EMC and its sub-committees to act through the Emergency Support Function (a support function to the IRS). (ix) Create an organisational chart and distribute the manpower for IRS and ESF system to work hand-in-hand. (x) Issue Responsibilities to each functionary of IRS and ESF during Normal periods. (xi) Dissipate the Response Plans to all employees of the hospital. (xii) Liaise with all external agencies – NMC and the Response Forces. (xiii) Conduct IRS training, Response and ESF Training of the staff. (xiv) Order a Damage and Need Assessment Committee to estimate the damage and find out the needs of the patients and staff.
(c) During Emergencies: (i) Order activation of the IRS and ESF. The IRS should function from the office of the Hospital Superintendent and the ESF should be activated at the Nursing College premises that are within the premises of the Hospital. (ii) Coordinate the functions of the ESF. (iii) Control the IRS in the capacity of the Incident Commander. (iv) Perform Damage and Need Assessment when an emergency occurs and submit a first- hand assessment to the NMC.
2. Role of the Senior most doctor of the Hospital:
(a) During Pre-Disaster (Normal) period: (i) Act as part of the EMC and as head the MAMC. (ii) Advise the Hospital Superintendent on all matters of hospital functioning and also officiate in the capacity of the Superintendent in absence of the permanent incumbent. (iii) Be part of the purchasing committee for any medical related equipment or stores when ordered by the NMC. (b) During Emergencies: (i) Act as the Chief of Planning Section as part of the IRS. (ii) Act as the Operation Section Chief during the incidents of Mass Casualty. (iv) Continue to head the MAMC for ESF support during emergencies. (v) Manage the additional medical staff during emergencies.
3. Role and Responsibilities of the Resident and Other Doctors of the Hospital: They will perform the roles as part of the hospital EMC or its sub-committees as composed by the Chairman of the EMC. They will also form part of the ESF and IRS as allotted by the Hospital Superintendent. They will fully acquaint themselves with the DM plan of the hospital and participate in any mock practices. Inspect the premises and comment on various aspects freely and frankly as observed during tenures of duties.
4. Role of the Chief Matron:
(a) Be part of the Security Management Sub-Committee. (b) Brief the entire nursing staff and class IV employees on Security of the wards, the cleanliness of the wards and departments and the DM Plan of the hospital. (c) Be part of the EMC and ESF. Manage the nursing staff’s duties and security staff’s duties during normal period and during emergencies. (d) Manage the additional nursing staff, whenever deployed during emergencies. (e) In consultation with the EMC, work out the safe areas for evacuation and safe routes during emergencies and explain the same to the nursing and class IV staff. (f) Display evacuation routes in each ward for the nursing staff to follow. (g) Hold contact details of the entire nursing staff for ordering to duty in case of emergencies.
5. Role of the Senior Accounts official: (a) Be part of the Security management Sub-committee and control the movement of the OPD patients and their relatives during all phases. (b) Be part of the ESF and keep the pre-contracted rate lists of medicines and other equipment at hand. (c) Follow procedures of buying/ hiring of equipment and medicines in emergencies, as approved by the NMC. Do stock taking of all such stocks and equipment. (d) Keep accounting system updated during normal and emergency periods.
6. Role of the nursing staff: (a) Ensure cleanliness of the wards/ departments/ OT/ all facilities at all times. (b) Ensure that the waste disposal is done expeditiously through use of incinerators/ waste bins. (c) Ensure that the linen and clothes are washed and cleaned and no unclean material is recycled. (d) Use protective gears at all times. (e) Counsel the patients. (f) Control the relatives of the patients and follow the visiting hours strictly. (g) Ensure that the patients are moved to safety during emergencies. The nursing staff will not leave the ward till all patients are moved to safety during emergencies. (h) Control the class IV employees of the ward and direct them during emergencies to evacuate the patients speedily and to safe places.
Appendix F (Refer to Para 24 of the DM Plan
Procedures during Various Contingencies
Contingency 1- Earthquakes:
1. If an earthquake strikes the city of Nashik and the hospital building is also affected, the following procedure will be adopted:- (a) The doctor on duty/ CMO will order siren alarm to be sounded. If the same doesn’t work, the alarm will be given by shouts. (b) The CMO or doctor on duty will perform the following functions:- (i ) After issuing the warning, inform the nearest police station and the fire brigade and also the Hospital Superintendent, inform the NMC and the EOC of the NMC. Ask another doctor to man the SOC till arrival of the Hospital Superintendent. (ii) Move to the open patch where the present vehicle park is located. (iii) Ask the security staff and the Chief Matron to take stock as to which section of the building has been damaged and debris exists. (iv) Order debris clearance and removal of the trapped victims from under the debris. (v) Give immediate medical aid to the victims rescued from under the debris. (vi) Ask the staff of the wards to evacuate the institutional patients to the safe area of the present Vegetable Market. The priority of evacuation will be as under:- • Priority 1: Patients from the ICU. • Priority 2: Patients from OT, who are going through the surgery / delivery, will be stabilized at the earliest and removed to the CMO’s room or casualty room or another hospital. • Priority 3: Patients from gynecology ward and children’s ward. • Priority 4: patients from other wards. (vii ) Ask class 4 employees not involved in rescue and evacuation functions to perform salvage duties of salvaging the oxygen cylinders. (c) Hospital Superintendent takes the control. He/ she establishes the IRS and ESF system and informs all agencies that have not been informed. Maintain a telephone log and event diary. He/ she continues the efforts of evacuation, arranges medical treatment of patients at alternative location. Attempts are made to retrieves whatever medical and non-medical equipment that can be retrieved. (d) The IRS seeks help from all external response forces and assists in performing the response functions. Till external agencies arrive on the scene for response functions, the IRS and the ESF will have to perform the dual roles of Response, medical Treatment and the ESF functions. After the external response forces arrive on the scene, the IRS will by and large take up the responsibility of supporting the response forces and continue to perform the other ESF functions. (e) Be prepared to receive more casualties from outside. During such eventuality, follow the guidelines given in Para 2 below, with additional space being used at the Vegetable market that should immediately get vacated and vegetable selling activities must stop immediately and the area should be guarded by the police. (e) The security staff will perform the following duties:- (i) Switch off the main electricity. (ii) Entries into the hospital premises will be stopped immediately, except for fire brigade, ambulance and police. (iii) Except for the main gate and gate for the ambulance, all other gates will be closed. (iv) Spare staff will assemble at the present open area of car park and take orders from the doctor on duty. (v ) Start rescue efforts with the help of the class IV employees under the directions of the EMC.
2. When there is no damage to the hospital, the hospital would be required to undertake only ESF duties to cater to the Mass Casualty episodes. Under such circumstances, perform the following functions:- (a) The CMO/ Duty medical officer informs the Hospital Superintendent and all other doctors and the nursing staff (not on duty at the time) to reach the hospital immediately. (b) Stop entry of visitors. (c) Organise the additional areas for accommodating the Mass Casualties, including the Triage Areas. (d) Allot responsibilities to doctors, nursing staff and class IV employees in Triage and medical treatment activities. (e) Establish the ESF.
Contingency 2 – Fire 3. When a fire breaks out in the hospital premises, the following actions will be taken- (a) Issue warning. (b) Locate the fire. (c) Following simultaneous actions will be done:- (i) Inform the Fire Brigade and the Police. (ii) Stop entry of all visitors. (iii) Ask the security and class IV employees to restrict/ fight the fire with the help of fire extinguishers and the water pipe. (iv) Switch off the main electric supply. (v) Evacuate the people from the fire. (vi) Commence rescue activities. (vii) Commence salvage activities. (d) When the fire brigade arrives on the location, hand over the rescue and evacuation tasks to them and ask the security staff to assist them. (e) Establish the ESF and carry out the ESF activities of medical treatment and other support functions, as per Para 2 above.
4. If the hospital is asked to receive Mass casualties due to fires outside the hospital, follow procedures given in Para 2 above.
Contingencies Other than the ones given above:
5. In Most of the other contingencies, the hospital will have to face cases of Mass Casualty Episodes and hence the procedures mentioned at Para 2 above will have to be followed.
Contingency of Mass casualty Episodes:
6. The hospital will receive warning and will take the following actions:- (a) Warn the police station for traffic control. (b) Warn security staff to establish access control to disallow any vehicle except ambulances to enter the hospital and no visitors will be allowed in the premises. (c) Warn the medical and nursing staff. (d) Establish and organise Triage area and shift the less critical patients from the general wards to a temporary shed to be established on the terrace. (e) Receive the casualties and quickly stabilize them and shift to the wards. (f) Arrange for additional medical and nursing staff through NMC. (g) Arrange to dispose off the dead to other mortuaries. Ensure records are maintained for legal purpose. (h) Arrange for lodging and boarding of the medical, nursing and Para-medical staff.
Appendix G (Refer to Para 25 of the DM Plan)
Communications and Warning Systems 1. The hospital will have to deploy the following warning and communication systems:- (a) Communication systems: (i) An Intercom System connecting all the departments, casualty, the office of the hospital superintendent. (ii) An external communication system with independent telephone numbers allotted to the following:- • Hospital Superintendent. • Casualty Department. • CMO. • Chief Matron. • ICU. • Senior Accounts Official. • Blood Bank.
(b) Warning Systems: The hospital will fix up a siren system that could be operated from the Hospital Superintendent’s Office as well as the CMO’s room. The siren will be an electrically operated ‘variable notes’ siren (wailing and waning). The varying notes would mean an emergency has occurred or is imminent. Upon hearing the siren, the security staff and the duty MO/ CMO will immediately assemble at the vehicle park area (which will be used as the ambulance waiting area or a triage area from now onwards) to assess the situation and trigger all actions accordingly. This siren should be tested once a week for its effectiveness and will also be used during mock practices. (c) Whistles: The security guards will also have whistles. Short bursts of the whistles would mean onset of an emergency.