Emergency Hospital Service Delivery - JPRM 2011 - Third Deliverable - English

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Hospital External Disaster Response Plan Momeni A., Yousefi E. August 2011

APW for developing SOP for hospital emergency service delivery – Third Deliverable - English

APW for developing SOP for hospital emergency service delivery

Third Report

August 2011

Amir Momeni MD.

EHMTP Director

Principal Investigator

Elham Yousefi MD.

Technical Officer

World Health Organization

&

Ministry of Health and Medical Education of Islamic Republic of Iran

JPRM 2010-2011

©WHO/EMRO, August 2011





Acknowledgements:

We thank the staff of the Secretariat for Health Risk Management in Disasters of MOHME, especially

Dr. Gholamreza Masoumi without whose support and cooperation this project could not have been

completed. We must also stress our gratitude for members of EHMTP for their excellent field work.

Last but not least we must thank the staff of WHO’s Iranian office, especially Dr. Manuel Torres and

Ms. Laleh Najafizadeh, whose technical insight and guidance have greatly improved the quality of this

project.





Abbreviations:

WHO – World Health Organization

MOHME – Ministry of Health and Medical Education of Islamic Republic of Iran

EHMTP – Emergency Health Management Training Program

CHRMS – Comprehensive Hospital Risk Management System

EMS – Emergency Medical Services

ER – Emergency Room

HAZMAT – Hazardous Materials Team

HEICS – Hospital Emergency Incident Command System

IC – Incident Commander

ICU – Intensive Care Unit

OR – Operations Room

RACE – Rescue, Alert, Contain and Evacuate

S&R – Search & Rescue





Introduction:

This is the third deliverable of the JPRM 2010/2011 project entitled “APW for developing SOP for hospital

emergency service delivery” which is being completed with collaboration of world health organization and

ministry of health and medical education of Islamic Republic of Iran. In this third deliverable we provide a

framework for management of external disasters in hospitals with emphasis on the response phase.

For any inquiries regarding this project or the findings presented please contact me by email:

[email protected]

` Amir Momeni MD,

Project Manager

August 2011





Table of ContentsExecutive Summary: ....................................................................................................................... 7

Methodology: .................................................................................................................................. 8

Hospital Triage and Mass Casualty Management: ....................................................................... 10

Hospital Reception Plan:............................................................................................................... 13

Casualty Reception: ...................................................................................................................... 16

Hospital Triage: ......................................................................................................................... 17

Roles and Responsibilities in Hospital Triage: ...................................................................... 22

Redistribution of patients: ......................................................................................................... 23

Hospital Census: ........................................................................................................................ 24

First wave protocols: ................................................................................................................. 24

Surge Capacity: ............................................................................................................................. 25

Surge capacity planning: ........................................................................................................... 27

Human Resources Surge:........................................................................................................... 30

References: .................................................................................................................................... 32





Executive Summary:

This is the third report in a series of three developed for the JPRM 2011 project “APW for

developing SOP for hospital emergency service delivery”. In this second report a framework forhospital response to external disasters is provided.

External disasters are disasters that do not directly affect the hospital and usually affect the

hospital by means of casualty influx. While hospital may be spared from direct damage, thiscasualty influx can lead to disequilibrium between need and service delivery which can severely

disrupt the hospital’s service delivery functions.

We have in this reported provided an approach to external disasters through reception plans;these plans allow for hospitals to respond to mass casualty events. They are composed of two

main parts: the triage and mass casualty plan and the surge capacity plan. We have explained

these components and provided a general methodology for designing a reception in a hospital.The report starts with a general description of the reception plan, followed by an outline of triage

functions. The last section of the report is dedicated to surge capacity planning.





For the third report, the experience of previous external disasters on hospitals around the country

was examined. While many hospitals have had experiences with mass casualty management onlya few documented cases were available. These case studies showed that while the efforts have

been partially successful, a general and organized approach to the issue is missing. There ishowever a great deal of experience on the use of field hospitals in Iran, not only a guideline was

developed by the MOHME as part of the emergency health functions project but also the

experiences from the 8 years war with Iraq as well as the many disasters that have occurred in

Iran has led to a high level of expertise on the matter in the country and as field hospitals can

play a role in surge capacity planning we feel that the available guidelines on the matter can form

the basis for a more practical protocol to be developed. The issue of surge capacity planning has

not been addressed so far in the country; as a result this report provides a summary of the best

evidence available for the subject matter.

An explanatory software, in form of a presentation that can be used both as a teaching material as

well as a self-learning tool was then prepared. The findings were then summarized and Englishand Persian reports containing the framework for external disaster response were prepared.





HospitalTriageandMassCasualtyManagement:

Hospitals face two main categories of disasters; the first are the internal disasters that directly

involve the hospital and the others are the external disasters. In external disasters, the society

is affected by a disaster and needs the hospital medical services in order to respond to that

disaster. In other words, in external disasters, the hospital as a vital infrastructure needs to

provide services to the mass casuales caused by the disaster event. These needs are far

greater than the normal needs of the society and considering the fact that most hospitals

especially emergency departments of the hospital are already working at the full capacity, thesudden influx of paents can overwhelm the hospital, this in turn may lead to a shutdown of

hospital services leading to an internal disaster. As such, it is imperave that all hospitals be

prepared for responding to a mass casualty event.

The stascs show that the frequency of external disasters and mass casualty events requiring

a response from the hospital is far greater than internal disasters, and while planning for

internal disasters is an integral part of the hospital preparedness and risk reducon, planning

for external disasters forms the core of the society’s a&empts at preparedness and risk

reducon. Thus, even if hospital managers and staff consider internal disaster planning to be farmore important than external disaster planning, from the viewpoint of the society, external

planning should be given precedence over internal planning.

The most important capacity needed for a successful response to external disasters is a

recepon plan. Recepon plans consist of two main parts; the first part deals with triage and

mass casualty management and the second part deals with developing surge capacity.

Mass casualty events are defined as disasters or emergencies that lead to a considerable

number of fatalies and injuries. These events are either manmade or natural. The range variesand starts with vehicle accidents with a few injured to catastrophes such as a high impact

earthquake with many casuales. In fact the definion of a mass casualty event may vary from

a place to another place; disaster is defined as an event whose effects exceed the society’s

capacity to respond and as such it is dependent on the society, in the same manner, an influx of

5 paents in a rural hospital is considered a mass casualty event while a terary level medical

center can treat an influx of 40 paents without needing to acvate emergency plans. In a

sense, what turns a mass casualty event into an external disaster is when the equilibrium of





need and capacity is disturbed, when the need exceeds the capacity an external disaster

develops.

The need/capacity equilibrium can be disturbed by mulple factors. Some of these factors

affect the need; the number of paents seeking help and the meframe during which they seek

help are the most important ones. The argument for numbers is clear however it is the

meframe that usually overwhelms the hospitals, for example a hospital may be able to provide

neurosurgical care to 40 paents in each 24 hours but the simultaneous arrival of 5 serious

head injuries needing neurosurgical intervenon may overwhelm the very same hospital. There

are factors that affect the capacity side of the equilibrium as well, for example an internal

disaster may severely hamper the service delivery capacity of a hospital, if the remaining

capacity is less than the society’s needs then an external disaster also arises. So as you see, inan external disaster the society may not even be affected by a disaster event, but because the

need surpasses the capacity, an emergency arises.

For effecve handling of casualty influxes, a system is designed which is called “triage and mass

casualty management”. Mass casualty management is a connuum that starts in the field and

connues to the hospital. As we menoned in the first report, in the concentric model of

emergency health response, the hospital forms the inner most circle; for successful mass

casualty management not only each component should be funconing but the flow of paents

should also be managed and opmal. In other words we cannot ensure successful hospital masscasualty management if mass casualty principles in the field are being ignored.

An important concept in mass casualty management is triage which is the sorng of paent

based on the severity of their injuries or clinical status. This allows for priorizaon of care,

especially when the medical care capacity is limited this priorizaon ensures that those who

need care more urgently receive it first. In this manner paents are assigned different

categories based on some clinical findings and a predefined protocol is followed for each

category; these categories are idenfied by tags, which are usually color coded (with the

universal colors being red, yellow, green and black). This in turn not only maximizes the benefitsof medical care (those who need more care receive more) but also forms the basis of paent

flow through the field and also paent flow from the field to the hospital. While in recent years

some arguments have been made against the triage system, the current evidence suggests that

it is the most effecve approach to mass casualty management. Triage is a reiterave process,

which should be performed at the field (primary triage) as well as in the hospital or in the

definite medical care facility (secondary triage).





In mass casualty management, providing care is different from normal se7ng, while in normal

se7ng, the goal of the health system is to provide standard and comprehensive health care, in

mass casualty management the goal is providing necessary and adequate care. i.e. in masscasualty management saving lives takes precedence over saving limbs which in turn takes

precedence over providing comprehensive care and treang minor injuries. The overall

approach is thus to stabilize the paent, save the limbs and organs and then providing

comprehensive care. This approach ensures the principle of “more care for more people”.

Mass casualty management is performed in four phases:

1. Pre Hospital Acons (S&R, first aid and basic triage, field care and primary triage)

2. Transport3. Recepon and Hospital Care

4. Redistribuon and Transfer

The first phase is also known as the field phase, in which field medical units in cooperaon with

field emergency response units especially the S&R units, locate and extract the paents, assess

them, stabilize them (or buy them enough me unl they can reach a definite care facility) and

prepare them for transport. The second phase, the transport, is very crical and should follow

the triage protocols, it’s success depends on vehicle, personnel and route and thus it depends

on mulple factors (from competency of the medic to the route traffic). The third phase is alsoknown as the hospital phase and is the focus of this guideline and finally the fourth phase is

when a?er inial stabilizaon and provision of adequate care to paents they are redistributed

to other facilies for comprehensive care.

An outline of the hospital response to external disasters is provided in figure 1.





Figure 1: an outline of hospital response to external disasters

HospitalReceptionPlan:

The main problem of hospitals in a mass casualty event is the casualty influx. This influx causes

the hospital services to become strained or even become paralysed and as a result mass

casualty management is very important in hospitals. Mass casualty management in hospitals

requires three main elements, first is creang the extra capacity which is otherwise known as

the surge capacity, the second is to triage the casuales and the third element is service

delivery. An important issue is that even during a mass casualty event, the hospital sll faces itsnormal inflow of paents as well and they should be integrated into the mass casualty care

delivery system as well.

In order to ensure that the medical care delivery system can funcon even in the face of a

major mass casualty event, each hospital needs to have a recepon plan which can be acvated

with a short noce.





You must remember that hospitals are far from cost effecve and each extra empty bed or each

extra unused capacity has a considerable financial burden and thus it is not viable to maintain

an extra capacity in the hospital at all mes. This extra capacity should be created when theneed arises and with the eliminaon of the need the capacity should return to normal; this is

why it is known as the surge capacity, because it is a temporary augmentaon of capacity.

Surge capacity is not only concerned with number of paents, the surge capacity is realiscally

need related; in a disaster the need changes, this change may apply to scale, which would mean

that the hospital needs to deal with an increased paent load, or it may apply to scope, i.e. the

nature of the need may change, for example a hospital dedicated to children may have to serve

adults as well. Thus not only the numbers are a contribung factor in designing and

implemenng recepon plans but also the type of the injuries that hospital may face should

also be considered. For example, dealing with five mulple injuries paents is much harder thanmanaging fi?y minor injury paents, while the premier may need acvaon of a recepon plan

the la&er can be managed with simple triage and paent flow management.

It is recommended that in a mass casualty event, the hospital be nofied of the number of the

paents and the nature of their injuries prior to their arrival in the hospital. This needs close

coordinaon between the field units and the hospital’s ICS; this coordinaon is so important

that it is suggested that a representave of the field medical team be present in the hospital

and through constant communicaon with the field unit, guide the hospital’s response.

Unfortunately in most cases either informaon on the extent of the disaster and the casualtyload is not available or the hospital is kept out of the loop, this is usually the case in disasters

that necessitate a vast SR operaon for casualty extracon such as an earthquake with many

trapped vicms. In cases where the HEICS team do not have enough informaon, they need to

acvate the recepon based on the esmates from before the disaster event; any delay in

acvaon of the plan can severely disrupt the medical care delivery upon the arrival of the

casuales from the field. While it is likely that the hospital’s response is disproporonate to the

disaster event but it is sll preferred to no response at all.

If communicaons with the field units are established then based on the informaon received,the IC should decide whether it is necessary to acvate the recepon plan or not. The decision

should be announced, preferably using the common disaster codes. The recepon plan is

mullevel, so the IC should also announce which level of response is going to be acvated; in

the lowest levels only the emergency department, intensive care units and operaon rooms are

involved, at middle levels the whole hospital is involved and at the highest levels there may be

a need for temporary offsite care facilies to be established. The recepon plan should explain

the expected surge capacity at each level and explain the measures necessary for a&aining that

capacity, these measures apply to physical space, hospitalizaon space, medical supplies and





human resources. With the acvaon of the plan the HEICS should also be acvated; the roles

and responsibilies during an external disaster event should be predefined in the hospital’s

HEICS protocols.

Overall a recepon plans should contain three main elements. The first is the surge capacity

plans (mulleveled) and the triggers for each level, the second is the paent flow and triage

protocols, which should include the triage area plan and triage procedures and finally the third

element consists of the medical procedures for casualty events. In this guideline we have

explained the first two elements, the third element necessitates that a team of emergency

medicine experts develop a series of guidelines for medical management of paents during

mass casualty events.

The hospital recepon plan is necessary in order to ensure that a mely response to a disaster

event is implemented in the hospital. Thus not only the plan acvaon is crical but availability

of the necessary resources is also very important. The plan should specify that where can the

resources for each level of surge capacity be obtained rapidly, it may be necessary to store

necessary supplies beforehand and also design call back/call in systems for human resource

surges.

The hospital’s recepon plan should also address the other aspects of mass casualty

management. These aspects are explained briefly below.

In mass casualty events, the traffic flow is as important as the paent flow. The access of

ambulances or other vehicles used for casualty transport to the hospital should be facilitated,

this applies to both outside the hospital ground as well as within the hospital grounds, the

traffic authories should establish emergency access routes to the hospital that are only

available to emergency vehicles. The movement of ambulances within the hospital’s grounds

should also be directed and facilitated, the entry route and exit route should be defined and the

ambulance flow through the hospital grounds should be designed in manner that eradicates the

need for U-turns and also does not contain any bo&lenecks.

The security staffs of the hospital also play an important role; they need clear the grounds and

clinical spaces of all unauthorized individuals. They need to make sure that the concerned

relaves of the vicms do not disrupt the service delivery, to do so they need to direct them to

holding areas. The security staffs also parcipate in paent flow management especially in

direcng the paents with green tags to the predefined waing zones.





Apart from the medical supplies, the hospital needs an external disaster kit; this kit like the

surge capacity medical supplies kit should be stored near the area earmarked for paent

recepon and triage. Such a kit should contain the following items:

• Triage uniforms

• Triage Zoning Materials (coloured waterproof blankets, coloured tapes, …)

• HEICS uniforms

• Lab coats or arm bands for the surge staffs who are called back/called which can help to

idenfy them as part of the medical team

• Triage Tags

• Signs

• Copies of the recepon plan including the triage and medical protocols

• Staonaries

• Medical Charts

CasualtyReception:

Acvaon of the recepon plan allows for a mely response when the first wave of the

casuales arrives. In organized recepon three zones are necessary; the first zone is the “Inial

Assessment Zone”, if weather and environmental elements this zone can be established outside

the hospital building. In this zone the individuals are separated by a rapid triage into two

categories, the first are paents who need medical care and the second are those who either

have very minor injuries or are not injured at all. All individuals from the first category are

directed to the second zone while the individuals from the second category are directed to the

third zone which is the “Accommodaon and Outpaent Care Zone” which is otherwise known

as the holding area. The second zone is the Triage zone where paent triage and inial medical

management is performed. All casuales that are referred from the field who have gone

through the field triage should be sent directly to the second zone (triage area).

The triage zone should be a large space with at least two big entry points; these two entries

points are necessary so that the paents who are referred from the field with a red tag be

separated from the other paents and as such their treatment can begin immediately. Paents

who are not assessed in the field or who were assigned a yellow or green tag enter through the





other entry point and undergo triage. The green tag paents receive medical care in their

respecve zone or are directed to the accommodaon and outpaent care zone. Paents who

are given a red tag in the triage, are immediately sent to the red zone where they receivemedical care, the red zone should be adjacent to the triage zone and close to the entry point

allocated to red tagged paents from the field. The triage zone is further explained in the next

secon.

A?er triage, all paents should be registered. The idenfying informaon of all paents should

be provided to the local authories on a roune and cyclic basis so that they can use it in

developing a comprehensive casualty list. This list plays an important role in providing

informaon the inquiring relaves of the vicms.

A diagram depicng the triage zone is shown in figure 2.

HospitalTriage:

Hospital triage is also known as secondary triage. It is different from primary and field based

triage because in hospitals a wider range of medical services can be provided. Even some who

are assigned black tags (considered dead or unsalvageable) can be saved in hospitals and thus

in hospital based triage a new category is added which is called “Blue” paents who are

assigned a blue tag are severely injured paents who may be saved if highly specialized care is

available. Unlike field triage that is only concerned with clinical stabilizaon and priorizaon

for transport, hospital triage is concerned with providing definive care as well as priorizaon

and stabilizaon. As a result the paent should be assigned to clinical departments for

appropriate care a?er inial care and stabilizaon in the triage area.

Assigning an area to triage is a crical decision that needs to be made in the planning stages

and before a disaster strikes. Usually the emergency departments of the hospitals do not

provide enough room for a disaster triage zone to be established and as a result, alternave

spaces should be considered. One of these alternaves can be the main entrance of the

hospital; in most hospitals the main entrance consists of a large lobby which is ideal for se7ng

up a triage zone. In choosing the triage zone a few consideraon must be taken into account:

the triage area should preferably be near the ER, it should be large and spacious, there must be

no bends or bo&lenecks in its access route and it must have the minimum possible elevaon

and has as few stairs as possible. A?er triage is performed on the arriving paents and they

have received the necessary care for stabilizaon, the paents should be transferred from the





triage zone to the designated clinical spaces for receiving definive medical care. If weather and

environmental elements permit, the triage zone can be established outside the main building

for example in the ambulance bay of the hospital.

Figure 2: hospital triage zone

The triage zone should allow for an organized flow of paents and casuales, a diagram for

paent flow should be designed and integrated into the recepon plan of every hospital. When

the plan is acvated the paent flow should be organized and facilitated based on the diagram

and by using coloured signs and tapes.

In designing a triage zone some issues should be addressed: immediately next to the triage

zone, an area should be assigned for clinical stabilizaon of red tagged paents. Triage zone

should not only have two entries for easy access but it should also possess mulple exits and be

accessed by wide corridors, the access from the triage zone to OR, ER and ICU should be easy

and measures should be taken so that the paent transfer from the triage zone to the definive

care areas is performed rapidly and without delay. An area should be assigned to the triage





zone where any obstacle can be rapidly moved and cleared and a designated supply depot

should be near that triage zone.

It is imperave that an alternave access route be assigned for the roune visits to the

hospitals, the healthy individuals or individuals with only minor problems should not be mixed

with the casuales arriving from the field; this can complicate the triage and also delay the

provision of essenal care to the casuales. It is suggested that a temporary ER or a clinic be set

up that can serve these other individuals.

In the triage area paents are categorized into 4 major groups. The first group is the green

tagged paents; these individuals should be directed to the accommodaon and outpaent

care zone or a holding area, their exit and route should preferably be separate from the othercategories. They should be registered in the holding area and be provided with food, water and

warm blankets. The second group are the red tagged paents; these are those with crical

condion who need immediate intervenon in order to save their lives, they must be

transferred immediately to the emergency resuscitaon/stabilizaon area adjacent to the

triage zone and receive lifesaving clinical intervenon. The registry of these paents should be

delayed a?er clinical stabilizaon and even then idenficaon of them may not be possible

(due to the paent being unconscious or unable to idenfy him/herself), if paents are

stabilized and re-triage assigns them a yellow tag, then they can be transferred to the

designated clinical area for definive care along with other paents from the yellow tagcategory (third group). Finally the fourth group consists of those who are given a black tag

which essenally means that they are either dead or resuscitaon/stabilizaon a&empt would

be fule for them, these paents should be transferred to a holding area. The approach to black

tagged paents is a very controversial one, the current prevalent argument is that they should

be a&ended and cared for as well (a?er the high priority or red tagged paents are stabilized)

and at least palliave care should be provided and every a&empt made to preserve the dignity

of these individuals. It has been suggested that a “blue” tag be used in highly specialized

hospitals; for example a paent with an aorc artery rupture may be considered black in the

field, but in a hospital with an OR and a vascular surgery team, it should be considered blue andimmediate care should be provided to that individual.

The coloured triage system is easy and fast yet crude. While it is ideal for field, for advanced

and secondary triage the trend is moving away from coloured triage system. We have in table 1

demonstrated examples of paents assigned to each color code. Alternave systems have been

purposed and have successfully been implemented; two of the most widely used of these

systems include the Injury Severity Score (ISS) and the Revised Trauma Score (RTS).





Table1 : coloured tagging system

Examples of InjuriesCategory

• Massive yet controllable external bleeding• Severe yet correctable respiratory problems• Severe crush injury• Partial amputation• Severe laceration with open fractures• Severe facial and airway burn• Third and second degree burn covering more than 40% of body

surfaces• Loss of consciousness with no apparent cause

• Sign and symptoms of myocardial infarct• Status epilepticus• Signs and symptoms of eminent labor• Serious toxicity• Mild to moderate shock

Red (Immediate)

• Simple fracture of long bones• Moderate lacerations with minimal bleeding• Ocular problems• Noncritical neurological damage without coma• Uncontrolled diabetes without altered mentation• Non acute respiratory distress• Other non-outpatient medical problems

Yellow (Urgent)

• Minor injuries that are neither life or organ threatening and leaveno permanent sequel

• Mild soft tissue injuries• Fractures of small bones or hair line fractures• Mild burns (not including the airways)• Psychological problems• Ob&Gyn problems• Common outpatient medical complaint

Green (Delayed)

The ISS uses the Abbreviated Injury Scale (AIS). The AIS is an anatomically based global severity

scoring system that classifies each injury in every body region according to its relative severity

on a six point ordinal scale: 1 Minor, 2 Moderate, 3 Serious, 4 Severe, 5 Critical, and 6 Maximal

(currently untreatable). The AIS is determined in different body regions (9 of them in total)

including the head, face, neck, thorax, spine, abdomen, upper and lower extremities and etc.

The scores from AIS of different parts is calculated, the squares of the AIS scores of the three

regions with the highest level of injury are then added and the result is the ISS score of the

patient which is between 1 and 75. A score of 6 in any region is considered unviable (equal to

the black tag). A series of cut offs are used in order to categorize patients based on ISS.





RTS is a score produced by three main clinical examinations; the Glasgow Coma Scale (GCS), thesystolic pressure and the respiratory rate, with each being assigned a score of between 0 and 4

and as a result the RTS score has range of between 0 and 12. Unlike the ISS, a higher score

shows better clinical conditions. A score of 12 is considered delayed category (green tag), a

score of 11 is considered urgent (yellow tag), any score between 10 to 3 is considered

immediate (red tag) and black tag is assigned to patients with a score of 3 or lower. Table 2

shows the RTS system.

Table 2: RTS scoring system

System Score Glasgow Coma Scale

(GCS)

Systolic Blood Pressure

(SBP)

Respiratory Rate

(RR)

4 13-15 >89 10-29

3 9-12 76-89 >29

2 6-8 50-75 6-9

1 4-5 1-49 1-5

0 3 0 0

RTS and ISS have shown better correlation with morbidity and mortality than the original

coloured triage system. While RTS is easy to perform in a mass casualty setting, rapid triage

using ISS is difficult. Each hospital should then, choose a triage system based on the experience

and training of the staff as well as pilot studies.

In paent registry, idenfying informaon and emergency contact informaon along with

probable clinical diagnosis and triage category should be registered. Ideally the paent should

provide the informaon for idenficaon and emergency contact but if he/she is unable, then a

search for idenfying documents is permi&ed (providing that it poses no threats to the

paent’s condion or dignity). If a search for idenfying documents also fails, then a

photograph should be taken of the paents and a&ached to the registry informaon.

Again we must reiterate the fact that not all the paents who are taken to the hospital have

been evaluated by a field team. Many are brought by relaves or by passers or they themselves

come to the hospital seeking medical care, in other words not all of the casualty go through the

primary triage at the field. Thus as a result establishment of the inial assessment zone is very

crical, in that zone a rapid triage is performed and paents with serious injuries are directed to





the triage zone and healthy individuals or those with negligible injuries are directed to the

accommodaon and outpaent care zone.

Another important issue is that in the triage zone, no a&empts should be made at providing

definive care except for resuscitaon/stabilizaon intervenons, this can disrupt the flow of

paents; paents should be triaged, clinically stabilized and transferred to the designated

clinical care area. If a paent needs immediate surgical intervenon, a?er brief stabilizaon

he/she should be taken to the OR, there are some evidence that even queson delaying the

surgical intervenon for clinical stabilizaon, but these issues should be addressed by the

medical protocols which are the part of the recepon plan. The medical protocols should be

designed by parcipaon of surgeons, intensivists, anaesthesiologists, emergency medicine

doctors and triage nurses in focused group meengs and should be based on the best availableevidence and consensus.

RolesandResponsibilitiesinHospitalTriage:

One of the responsibilies in emergency recepon is the role of the “Entry Supervisor”. This is a

trained triage nurse who controls and guides the flow of paents into the inial assessment

zone and the triage zone. This individual can perform the rapid triage in the inial assessmentzone, he/she can even perform the rapid triage in cases when many casuales arrive

simultaneously at the ambulance door and priorize the paents’ entry into the assessment

and triage zones. When many paents with mild to moderate injuries arrive by a bus, the ES

boards the bus and based on the rapid triage, determines the order based on which the

paents should be transferred from the bus to the triage zone.

When the paents enter the inial assessment zone, a triage nurse or doctor who is responsible

for the zone, performs a rapid paent assessment and decides whether they must go to the

triage zone or to the accommodaon and outpaent care zone.

In the triage zone, the triage officer (preferably an emergency medicine specialist) should

assess the paents, triage those paents who have not been through the field triage and also

confirm the triage category of the paents who are already tagged, if the triage system of the

hospital is different from the field, re-triage is performed. Those with a red tag, however,

should not go through triage and should be directly taken to the emergency

resuscitaon/stabilizaon area (preferably through an exclusive entry designated to them).





Triage officers are either triage nurses or physicians with emergency medicine training or even

emergency medicine specialists. Physicians and nurses who have limited experience in

emergency se7ng are not suitable for the posion of the triage officer. These personnel can beused in the definive care areas or the stabilizaon area. Medical personnel who are not

employed at the hospital should also be used in the definive care areas; these individuals

usually lack the knowledge and understanding of the hospital response plan and emergency

procedures and their deployment in the triage zone can lead to confusion and delays. The

triage officer should have complete knowledge about the protocols of the recepon plan

especially the medical protocols, the officer needs to work closely with the operaons officer of

the HEICS and ensure that all the elements of the recepon plan are successfully acvated

before the arrival of the first casualty wave.

The roles of physicians in hospital triage include the following:

• Organizaon and management of the medical response

• Evaluaon of the paents in cases the triage nurse is unable to assign a category

• Declaring the dead (with declaraon, the medical team’s me and supplies will be

saved)

• Provision of care in the stabilizaon area or in the definive care areas

Redistributionofpatients:

In external disasters, the ability of the hospital for providing definive care especially highly

specialized care is limited. In cases where the hospital’s capacity cap for such services is

reached, the paents can be transferred to nearby hospitals for definive care; this is known as

paent redistribuon.

The decision for redistribuon should be made a?er considering all the facts and condions.

Things that need to be considered include: the paent’s clinical condion, the availability of

capacity in the desnaon, transport capacity, transit me and etc. Without considering these

facts and condions, a redistribuon a&empt can lead to a disaster as well. When the decision

is made, there needs to be close coordinaon and constant communicaon between the

coordinang officers of the two hospitals as well as between the hospitals and the dispatch

personnel.





In the planning stages, a list of hospitals based on the geographical locaon, distance from the

hospital, accessibility, capacity and service scope should be prepared. Essenal informaon

including the average free bed census, average service capacity and emergency contactinformaon should be obtained from all these hospitals. A mutual aid program should be

agreed upon between the hospitals in an area and the recepon and response plans of the

hospitals should be available in all of them.

In disasters with a considerable load of casuales, it is recommended that the nearest hospital

to the field be used for emergency medical services and clinical stabilizaon. All paents should

be taken to the hospital and a?er clinical stabilizaon be redistributed to nearby hospitals for

definive care. The EMS authories should also incorporate this into their response and design

the paent flow so that preferably stable paents and green tag paents are directlytransported to the definive care facilies thus reducing the paent load of the main

emergency response hospital.

HospitalCensus:

It is recommended that as part of every hospital disaster response plan, a comprehensive

census of the hospital capacity be included. This census should include informaon such as the

staff number, bed number, average occupancy rate, OR capacity, ICU capacity and etc. This

census should be made available to the EMS authories and be updated regularly. In case of a

disaster, the first wave of the paents usually arrive within 30 minutes, so an updated census

should be made available within 30 minutes and be provided to the disaster management

authories.

Firstwaveprotocols:

If hospital census is available, a protocol known as the “First Wave Protocol” should be

incorporated in the census reporng. This protocol ensures effecve distribuon of the paents

to the surrounding hospitals in an external disaster. This protocol ensures that the arriving

paent load is in balance with the hospital recepon capacity. Based on this protocol, a hospital

announces its capacity based on the number of paents from the most immediate triage





category that it can treat. For example, a hospital that can treat 3 yellow tagged paents and no

red tagged paents is called as a Yellow-3-First wave hospital.

SurgeCapacity:

As menoned in the previous secon a recepon plan has two main components: Triage and

Mass Casualty Management Plan and Surge Capacity Plan.

A hospital needs to acvate its recepon plan in two instances, the first is when a mass casualty

event has occurred in the society that the hospital serves which leads to a casualty influx and

the second is when a nearby hospital has had an internal disaster and needs to be evacuated, in

this case, the hospital should receive the paents evacuated. There are also instances that as a

result of an internal disaster a surge need has occurred, which requires the acvaon of the

surge capacity plan in order to ensure the connuity of services.

Developing surge capacity means increasing the service delivery capacity of the hospital;

increased service delivery capacity requires surge in the physical space available for service

delivery, surge in the medical supplies and surge in the human resources. Surge capacity

planning is concerned with developing these surges during an external disaster.

In emergency situaons, the survival of the casuales is affected by two factors; the first is the

rao of paent load to hospital capacity and the second is the duraon of the me from onset

of the disaster unl the arrival of the paent in the hospital. In fact the goal of every emergency

medical response plan is to reduce the meframe from onset to arrival of the paent and

increase the hospital service delivery capacity. The emergency medical response plan has many

components from which hospital recepon plan (especially the surge capacity plan) is very

important. Establishing emergency medical sites in the field is also another important

component; emergency medical sites can themselves be a part of the hospital surge capacity

plan as well. The current evidence suggests that surge capacity protocols can be more efficient

and cost effecve than approaches such as field hospitals especially in the urban se7ng.

There are three levels of surge capacity in a hospital. The first level is called the “Surge

Capacity” in which the funconal capacity of the hospital is increased. To do this several

measures are undertaken, for example all paents who are hospitalized for elecve





intervenons as well paents with favourable general condions are discharged. Another

measure is to increase the bed count by pu7ng hospital beds in corridors and other physical

spaces of the hospital building (including salons, halls and …). The hospital also needs toincrease the available staff numbers; to do this call back protocols are used. If hospital uses

redundancy measures (as part of the emergency isolaon plan) then these measures can

provide the necessary medical supplies and equipment for capacity increase at this level.

Overall, the hospital capacity can be almost doubled using these measures.

The second level is called the augmented capacity level. In this level the hospital needs to use

the physical spaces available nearby as well. These physical spaces are either located in the

hospital grounds or are close by and include covered parking spaces, covered stadium and

gymnasiums, empty warehouses, schools and etc. In the planning stages, these sites should beidenfied and inspected, it must be determined which can be used for medical purposes and a

plan should be drawn on how to transform the suitable spaces into temporary care sites in a

short noce. The necessary supplies and equipment including beds, bed sheets, and medical

supplies among other things should be stored nearby or in packed containers ready for

shipping. These supplies are part of the emergency surge kit. Each emergency surge kit should

contain a complete set of necessary supplies and equipment including the essenal drugs. The

human resource for the augmented capacity level is provided by using “call in” protocols which

are based on medical volunteers. Ideally at the augmented capacity level, the hospital’s service

capacity should be increased up to ten mes its normal capacity.

The third level is called the capacity cap. A hospital cannot reach the capacity cap on its own.

The capacity cap is usually more than mes greater the hospitals normal capacity and to reach

the capacity cap the hospital needs to incorporate external help in form of field hospitals

and/or emergency medical sites into its plans. At this level the capacity of nearby hospitals is

also used for service delivery. If even the capacity cap is not enough to absorb the casualty load

of the incident then alternave measures including redistribuon of paents to other cies and

provinces can be used. Foreign field hospitals can also be used at this level. Reaching the

capacity cap is a difficult task and needs extensive preplanning and coordinaon.

It is worth menoning that while it is ideal that the hospital connues to provide standard care

at surge capacity facilies but experience has shown that the quality of care suffers in the

temporary facilies used for surge care. As a result it is suggested that in the surge capacity

facilies sufficient care be provided while standard care be provided at the hospital to those

with far more serious injuries and clinical condion.

Table 3 lists the three different surge capacity levels.





Table3 : surge capacity levels

Capacity CapAugmentedCapacity

SurgeCapacity

NormalCapacity

External help in

form of field

hospitals, … in

addition to

resources of the

augmented capacity

Offsite planning/

Call in of medical

volunteers in

addition to the

resources of the

surge capacity

Use of nonclinical

spaces/Staff call

back in addition to

resources of the

normal capacity

Free hospital

beds/Available

hospital staff

Necessary

Measures

More than 10 times

the full hospital

capacity

Up to 10 times the

full hospital capacity

2 to 3 times the

full hospital

capacity

Full CapacityDegree of

CapacityIncrease

For example in a hospital with a 10 bed capacity, the recepon plan aims to increase the

capacity to 20 beds in surge capacity and increase it to 100 beds by using offsite planning in

augmented capacity.

In order to increase the physical capacity four different categories of measures are used; the

first category is known as indoor augmentaon and includes measures such as paent

discharge and transforming of the non-clinical spaces into clinical spaces. The second category

is called outdoor augmentaon; which uses the non-clinical buildings in the hospital grounds

(such as parking, warehouse, and gymnasium), the third category includes measures that use

the buildings near the hospital but not necessarily within the hospital grounds and is called

offsite planning (a nearby school or concert hall can be transformed into a temporary facility).

Finally the fourth category includes measures such as emergency medical sites and field

hospitals.

Surgecapacityplanning:

Surge capacity planning is a process that starts with predicon of the expected surge capacity.

Such predicon is a scienfic process itself; it involves determining the hospital service area and

the covered populaon, risk analysis, scenario building, determinaon of the probable casualty

load as well as the current hospital service delivery capacity. The next step is planning for this





expected surge capacity in the three stages of surge, augmentaon and capacity cap. The last

step is procurement of resources for the surge kits and developing emergency depots near the

surge capacity sites.

In surge capacity planning, the most important step is scenario building; this scenario building

relies on risk analysis and situaonal analysis. The scenario building starts with defining the

hospital service area; this refers to the geographical area to which hospital provides services

and the demographics of that area. The next step is a hazard analysis with risk ranking for that

service area. The results of the previous step are used for scenario building for each idenfied

high priority hazard a scenario should be built, this scenario can be a worst case scenario or the

most probable scenario. This scenario provides a crude predicon of the degree of damages

and the probable number of the casuales. HAZUS is a useful so?ware for casualty predicon.

The predicted casualty number of each scenario is used to determine the potenal vicm load;

this must include the overall number of paents, meframe and categories of injuries. Potenal

vicm load is calculated by using the numbers from the scenario building as well as aggregang

the data from previous similar disasters.

The next step is to compare the potenal vicm load with the hospital’s current funconing

capacity. The current funconing capacity is composed of several elements including bed

census, average occupancy rate, number of operaon theatres, ICU beds and etc. Indetermining the current funconing capacity it is best to determine the average number of

beds that are occupied by paents for elecve reasons; this can help the hospital authories in

knowing what percentage of paents can be discharged in case of a disaster in order to make

room for the arriving casuales.

The comparison between the potenal vicm load and the current funconing capacity will

point out the gaps that should be addressed in surge capacity planning.

Planning should consider the three levels of capacity increase. It is always easier and more costeffecve to implement surge capacity measures than augmented capacity measures and thus

the surge capacity plan should follow a stepwise pa&ern. A comprehensive surge capacity plan

will determine the capacity at each level, determine the holding areas and temporary hospital

sites and determine how the needed surge needs are addressed. Triggers for acvang each

level of the surge capacity plan should also be clearly stated in the plan.

In the surge capacity level, all measures are undertaken within the hospital’s building. These

measures include paent discharge and capacity expansion measures. For paent discharge a





rapid discharge tool should be designed and incorporated into the hospital’s recepon plan.

Rapid discharge tool allows paents to be selected for discharge by nurses with approval of the

supervising physician. An example of a rapid discharge tool is provided in table 5. It must,however, be menoned that if paents are going to be discharged holding areas should be

assigned for them and they should only be discharged into the custody of their relaves.

Capacity expansion measures start with the clinical spaces; the number of beds in the wards

can be increased, clinics can be transformed into wards and etc. the next step is to convert non-

clinical spaces into clinical spaces; halls and wide corridors can be transformed into clinical

areas.

For capacity augmentaon, first buildings within the hospital grounds or immediately adjacent

to them should be used. These building should have the necessary infrastructure includingelectricity, running water, waste disposal system and etc. the minimum condions for

alternave buildings are listed in the table 4. In the recepon plan, the target buildings should

be defined and their plan and blueprint be provided. The conversion process should be pointed

out and the trigger for their transformaon into a clinical space must be known.

Community centric measures for surge capacity include emergency medical sites. These sites

are predefined buildings or structures that can be transformed into an emergency care facility

within a short noce. These are especially designed for providing emergency care and can play

a major role in reducing the paent load of a hospital. They are usually considered as part of the capacity cap measures but can also be used as part of the augmented capacity measures.

Emergency medical sites act as satellites for the hospital’s operaons. Preplanning and

procurement of the emergency kits are essenal for the success of emergency medical sites.

These sites should incorporate a triage and sorng zone as well as the medical care zone. Some

countries have successfully ulized mobile emergency units with OR capability as part of their

surge capacity plan, such mobile units can act as core modules around which an emergency

medical site can be established in disaster se7ng. In the core/satellite model, the more serious

casuales should be taken to the hospital but paents with minor injuries can be taken to the

emergency medical sites. Field hospitals are also considered as one of the measures forcapacity cap level; they are widely varied but ideally can play the role of a fully funconing

hospital and thus increasing the hospital capacity considerably.

An important facts is that surge capacity measures are at best temporary and can only provide

care for a limited me (usually a me span of few days to a week), this means that if the

problem is ongoing then a more permanent soluon should be sought.





Table4 : criteria of alternative care facilities

• Wide corridors and steps

• Essential utilitities and infrastructures are present, redundancy systems (such

as generators for electricity) are also required

• There should be a potential for establishing clean rooms with environmental

(moisture, temperature, …) control and negative air pressure ventilation

• Multiple entrances

• Large and spacious interior with enough space for medical supplies depot

• Minimum obstacles or easily removed obstacles

• Good access route

HumanResourcesSurge:

Human resources surge is a step wise process. The priority of surge is using the hospital staff, so

at the surge capacity level, the extra need for staff is addressed by using a call back protocols;

this protocol essenally means that all off duty personnel and staff are called back to the

hospital. The second step which is usually acvated in order to address the needs of the

augmented capacity level is to use medical volunteers these include medical and nursing

students and interns as well as medical staff of nearby hospitals or medical staff from private

pracces, this procedure is known as the call in procedure. Finally, in capacity cap level, help

can be sought from other provinces or even internaonal medical teams. Non-medical

volunteers can also help with non-clinical tasks such as administrave work and support roles.

Volunteer management is very important and all ICS officers should be trained in volunteer

management, the recepon plan should also contain protocols for volunteer management.

Successful “call in” procedures usually require a registraon system that contains the names

and emergency contact informaon for the volunteers. Rered personnel are also good

candidates for human resource augmentaon.





Table5 : rapid discharge tool

Patients who can be discharged without physician’s approval:

o 24 hours after curettage

o 24 hours after uterine evacuation

o 24 hours after minor surgery

o 72 hours after labour

o 72 hours after surgeries not mentioned in following sections (e.g.

haemorrhoidectomy)

o Stable medical conditions

o Other patients as decided by the supervisor

Patients who should be evaluated by a physician prior to discharge:

o All major thoracoabdominal surgeries after 72 to 120 hours

o 24 to 72 hours after labour

o Newborns

o All cardiology patients with stabilized clinical condition

o All patients in need of drainage

o All patients with lesions which have active discharge

o Other patients as decided by the supervisor or the physician

Patients that cannot be discharged

o All major thoracoabdominal surgeries before 72 hours

o All other surgeries before 24 hours

o All postpartum women before 24 hours

o All cardiology patients prior to clinical stabilization

o All comatose patients or patients with head trauma who have yet

to undergo CT scan

o Other patients as decided by the supervisor or the physician





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Emergency Hospital Service Delivery - JPRM 2011 - Third Deliverable - English

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