hospitals_war_cover_april2003 9.6.2005 13:47 Page 1 ICRC HOSPITALS FOR WAR-WOUNDED HOSPITALS FORHOSPITALS WAR-WOUNDED This book is intended for anyone who is faced A practical guide for setting up with the task of setting up or running a hospital and running a surgical hospital which admits war-wounded. It is a practical guide in an area of armed conflict based on the experience of four nurses who have managed independent hospitals set up by the International Committee of the Red Cross. It addresses specific problems associated with setting up a hospital in a difficult and potentially dangerous environment. It provides a framework for the administration of such a hospital. It also describes a system for managing the patients from admission to discharge and includes guidelines on how to manage an influx of wounded. These guidelines represent a realistic and achievable standard of care whatever the circumstances. A practical guide 0714/002 05/2005 1000 HOSPITALS FOR WAR-WOUNDED International Committee of the Red Cross 19 Avenue de la Paix 1202 Geneva, Switzerland T +41 22 734 6001 F +41 22 733 2057 E-mail: [email protected] www.icrc.org # ICRC, April 2005, revised and updated edition This book is dedicated to the memory of Jo´n Karlsson (died in Afghanistan, 22 April 1992) Fernanda Calado Hans Elkerbout Ingebjørg Foss Nancy Malloy Gunnhild Myklebust Sheryl Thayer (died in Chechnya, 17 December 1996) HOSPITALS FOR WAR-WOUNDED A practical guide for setting up and running a surgical hospital in an area of armed conflict Jenny Hayward-Karlsson Sue Jeffery Ann Kerr Holger Schmidt INTERNATIONAL COMMITTEE OF THE RED CROSS ISBN 2-88145-094-6 # International Committee of the Red Cross, Geneva, 1998 WEB address: http://www.icrc.org CONTENTS vii CONTENTS FOREWORD ............................................. xi PREFACE .............................................. xiii ACKNOWLEDGEMENTS ................................... xv ABOUT THE AUTHORS ................................... xvii INTRODUCTION ......................................... xix Chapter 1. SETTING UP THE HOSPITAL ............... 1 1.1 PRIORITIES .................................. 4 Negotiation and information ....................... 4 Finance ...................................... 5 Protecting the hospital, patients and staff ............... 6 Physical protection and security of the hospital ........... 8 Communications ................................ 10 Logistics and transport ........................... 11 1.2 HOSPITAL INFRASTRUCTURE ................... 12 The buildings .................................. 12 Tents ....................................... 13 Water and power ............................... 14 Waste disposal ................................. 15 1.3 PERSONNEL ................................. 16 Key people .................................... 16 Additional staff ................................. 17 Recruitment ................................... 18 1.4 HOSPITAL EQUIPMENT AND SUPPLIES ........... 19 Standard lists .................................. 19 Hospital equipment .............................. 19 Hospital supplies ................................ 20 Sources of supply ............................... 22 Warehousing and storage .......................... 23 Chapter 2. RUNNING THE HOSPITAL ................. 25 2.1 ADMINISTRATION ............................ 25 Finance and book-keeping ......................... 25 Offices and secretariat ............................ 26 Purchasing .................................... 26 Inventory ..................................... 26 viii HOSPITALS FOR WAR-WOUNDED 2.2 FIRE SAFETY ................................. 27 2.3 PERSONNEL MANAGEMENT .................... 28 Terms of employment ............................ 28 Salaries ...................................... 29 Staff evaluation ................................. 30 2.4 MAINTAINING THE HOSPITAL INFRASTRUCTURE ... 31 2.5 THE HOSPITAL KITCHEN ....................... 32 2.6 THE LAUNDRY AND TAILOR .................... 34 The laundry ................................... 34 The tailor workshop ............................. 35 2.7 ORGANIZING THE HOSPITAL STORES ............ 36 Ordering supplies ............................... 36 Distributing supplies ............................. 36 The hospital pharmacy store ........................ 37 Chapter 3. MANAGING THE PATIENTS ................ 39 3.1 THE HEAD NURSE: A KEY POSITION .............. 40 3.2 ADMITTING THE PATIENT ...................... 42 The admission room ............................. 43 Equipment and supplies for admitting patients ........... 43 Admitting the individual patient ..................... 46 Patients’ records and documentation .................. 50 Patient flow ................................... 51 3.3 MANAGING THE WARDS ....................... 53 The nurse in charge of the ward ..................... 53 Organizing the workload .......................... 53 Keeping patients’ files ............................ 56 3.4 NURSING THE PATIENT ........................ 57 Ward and patient hygiene .......................... 57 Nutrition ..................................... 59 Wound management ............................. 62 Post-operative nursing ............................ 65 The intensive nursing ward ......................... 65 Limb injuries .................................. 66 Amputations .................................. 71 Abdominal wounds .............................. 72 Chest wounds .................................. 73 Head injuries .................................. 74 Skin grafts .................................... 76 Burns management .............................. 77 Drugs and antibiotic policy ......................... 83 CONTENTS ix Patients’ relatives ............................... 86 Discharging the patient ........................... 86 Deaths ....................................... 87 3.5 AN INFLUX OF WOUNDED AND TRIAGE ........... 88 Preparing for an influx of wounded ................... 88 Triage ....................................... 88 Triage categories ................................ 91 The triage area ................................. 91 Managing the triage process ........................ 94 Admitting patients in a triage situation ................. 95 Documentation ................................. 96 Patient flow during triage .......................... 100 Evaluation .................................... 102 3.6 SUPPORT SERVICES ........................... 103 Physiotherapy .................................. 103 Laboratory/blood bank ........................... 106 X-ray ....................................... 107 Chapter 4. THE OPERATING THEATRE ............... 109 4.1 PERSONNEL ................................. 112 4.2 EQUIPMENT AND SURGICAL SUPPLIES ........... 113 Equipment .................................... 113 Surgical supplies ................................ 113 4.3 THE STERILIZATION DEPARTMENT .............. 117 Autoclaves .................................... 118 Compresses ................................... 119 4.4 SURGICAL INSTRUMENTS ...................... 122 Care of surgical instruments ........................ 123 4.5 ORGANIZING THE OPERATING THEATRE .......... 124 The routine operating list .......................... 124 Emergencies ................................... 124 Keeping records ................................ 125 Cleaning and maintenance ......................... 127 Chapter 5. TEACHING UNTRAINED PERSONNEL ..... 129 Communication ................................ 129 Teaching basic surgical nursing ...................... 130 5.1 PLANNING TRAINING PROGRAMME .............. 131 First steps .................................... 131 Setting aims and objectives ......................... 132 x HOSPITALS FOR WAR-WOUNDED 5.2 ORGANIZING TEACHING ....................... 133 What to teach? ................................. 133 The next steps .................................. 137 How to teach? .................................. 137 Making the best use of resources ..................... 139 Evaluating the programme ......................... 140 APPENDICES ......................................... 143 1. LIST OF CONSUMABLE MEDICAL SUPPLIES NEEDED FOR 100 HOSPITAL ADMISSIONS OF WAR-WOUNDED 145 2. SURGICAL INSTRUMENT SETS ................... 153 3. BASIC ANAESTHETIC EQUIPMENT ............... 157 4. ABBREVIATIONS .............................. 158 FURTHER READING ................................... 159 INDEX ................................................. 161 FOREWORD xi FOREWORD The absence of adequate care and treatment for war- wounded prompted the founding of the International Committee of the Red Cross (ICRC) and the adoption of the first Geneva Convention in 1864. Today, the ICRC promotes respect for the 1949 Geneva Conventions and their 1977 Additional Protocols, which afford protection for all victims of war: the wounded, the shipwrecked, prisoners and civilians. Furthermore, they protect the medical and nursing staff who care for the sick and the wounded. Over the last 15 years, the provision of surgical care for victims of war, whether civilians or combatants, has occupied an important place in the ICRC’s activities. Hundreds of existing hospitals in many of the world’s conflict zones have received protection and supplies via the ICRC. Large, independent ICRC hospitals have admitted more than 50,000 wounded in the conflicts in Cambodia, Afghanistan, Somalia, Sudan and Chechnya. The experience of setting up and managing these hospitals for war-wounded is presented