Workshop on CHEMICAL EMERGENCY PLANNING, PREPAREDNESS AND RESPONSE-BEST

PRACTICES AND INTERNATIONAL EXPERIENCES. (21st Oct. 2010)

Dept. of Factories, GoAP and National Safety Council

Chemical Off-Site Emergencies-Ambulance Services’

Dr G V Ramana Rao MD,DPH, PGDGM

Executive Partner & Head Emergency Medicine Learning Centre and Research

GVK EMRI

Agenda

• ‘108’ GVK EMRI emergency response services

• Chemical emergencies and pre-hospital care

Innovative Pro-Poor PPP (Public Private not for Profit Partnership)

Service Delivery Model to provide free Emergency Response Services

at one / Citizen / Month

Serving 1 Emergency every 8 seconds and Saving 1 Life every 8 minutes

GVK Emergency Management and Research Institute

A Non-profit organization

Why this Innovation ?Why this Innovation ?• 75,000 emergencies occur per day

• 80% are at the bottom of the pyramid • 80% deaths occur in hospitals in the first hour

• 4 M deaths p.a. (Cardiac, Road Accidents, Maternal, Suicidal attempts, Neonatal / Infant / Pediatric, Diabetic related, etc) due to absence of 4As :

• Access to a universal toll-free number• Availability of Life Saving Ambulance to

reach quickly nearest and appropriate health facility

• Affectionate Care by trained paramedics (Compassion, Ability, Resourcefulness & Energy)

• Affordability by every citizen independent of income, religion and community

•Hence, GVK EMRI was born in April 2005

• To respond to 30 million emergencies and save 1 million lives annually by 2011

• To deliver services at global standards through Leadership, Innovation, Technology and Research & Training

• To become One Of Eight Wonders of the World

Vision of GVK EMRIVision of GVK EMRI

Leadership R & TInnovation Technology

What is Unique in this What is Unique in this Innovation ?Innovation ?

• Integrated Emergency Response Services for Medical, Police and Fire emergencies with single universal toll-free number ‘108’

• Free services (no cost to citizen)

• PPP framework

• Government provides funds for OPEX & CAPEX

• Private Partner brings leadership, innovation, execution and technological capabilities

• Conducting Research and building capability in Emergency Medicine and Management

Launched on 15th Aug, ‘05 in Hyderabad and expanded to 10 other States

Andhra Pradesh

Gujarat

Sikkim

Karnataka

Orissa

Haryana

Punjab

Himachal Pradesh

Uttar Pradesh

Chattis

garh

JharkhandWest Bengal

Bihar

Arunachal Pradesh

Meghalaya

Tripura

Manipur

Nagaland

Mizoram

Uttarakhand

Madhya Pradesh

Tamil Nadu

Kerala

Jammu & Kashmir

Maharashtra

RajasthanAssam

Goa

Delhi

Successfully Implemented by GVK EMRI in PPP Framework

• Political will, Public Servants’ commitment and Public Support

• 100% of Capital expenditure and Operational expenses by Government (Public)

• GVK funds Leadership, Innovation (Infrastructure, Process), Collaborations, Research and Training, Knowledge transfer and Quality assurance

• Mahindra Satyam provides free IT solutions as technology partner

• GVK EMRI manages and leverages government resources for better outcomes to serve poor

• Partnership involving Pain and Pleasure

Building Blocks of GVK Building Blocks of GVK EMRI’s InnovationEMRI’s Innovation

Three digit toll-free No. Accessible from Land lines and Mobile phones

Cost effective ambulances to provide quality care for Indian emergencies with facilities for rescuing and balancing patient care with public safety and patients relatives comfort Trained personnel for providing PHC

Modern, spacious and open ERCGIS / GPS to locate victim / ambulance and hospital

Innovative ProcessInnovative Process

Sense Reach Care Follow upafter 48 hrs

• Developed detailed process understanding and well defined responsibilities through out the organization

• Maintained all information related to emergency in Patient Care Records (PCRs)

• Patient information is shared with the hospital on arrival

• 48 hour follow up with the patients admitted to hospital

Conference

CCT: Communication Control Toolkit; SCCS: Symposium Call Centre Server; ERCP: Emergency Response Center Physician; EMT: Emergency Medical Technician

SCCS, CCT & Voice Logger

Telephone DB ERS DB

Nortel Switch

Public Switching Telephone

Network (PSTN)

Dial 108Caller in distress GIS DB

ERCPDO Supervisor

CO Supervisor

Transfer

Dispatch Officers (DO) Communication Officers (CO)

EMT in Ambulance

Victim Shifted to Hospital

COM

PUTE

R SE

RVER

RO

OM

E R

CFI

ELD

Base Location Victim Location (Scene)

Ambulance

Innovative use of TechnologyInnovative use of Technology

Innovative Pre-Hospital Innovative Pre-Hospital CareCare

• Emergency Medical Technician (EMT) in the ambulance is trained not only to provide pre-hospital care but also to handle emergency situations

• EMT gets support over phone from qualified medical practitioner called ERCP (Emergency Response Centre Physician) located at the ERC

• ERCPs are in the ERC round the clock to provide support to EMT and to people at emergency scene until ambulance arrives

Singapore HealthServices

American Assoc of Physicians

Of Indian Origin (AAPI)

Shock Trauma Center,

USA

Stanford University,USA

American Academy for

Emergency Medicine in India

Carnegie Mellon University,

USAGeomed Research

Public HealthFoundation of India

Collaboration for transfer of Knowledge and Technology know-how, Best practices, Research & Training

Impact ..Impact ..

Size • One Center for 40 M population against one for every 0.05 M population in USA

• 372 M population covered in 9 States (increased reach of health care in rural , hilly and tribal areas)

• Trained 35,650 people (11,500 - EMTs, 10,000 – Pilots, 3,100 - Doctors, 2,100 - Nurses, 6,800 - First Responders and AHA/ ITLS  Certification for - 2,150)

• 12,170 + emergencies handled per day (9.3 Million cumulative)

• 2,600 Ambulances - 4.5 trips a day• 15,900 + GVK EMRI Associates

Speed • Went live in less than 4 months from signing MoU • 91% calls taken in first ring • < 15 minutes (urban) and < 25 minutes (rural)

Ambulances reached

Govt. ofA.P.

Govt. ofGujarat

Govt. ofMP

Govt. ofUttarakhand

Govt. of Tamilnadu

Govt. ofGoa

Govt. ofAssam

Govt. ofKarnataka

Govt. ofMeghalaya

Govt. ofChhattisgarh

Govt. ofHP

ImpactImpactType of Emergencies and Lives saved

• Pregnancy related - 29%, Vehicular Trauma – 18%, Acute Abdomen – 13% Cardiac – 4%, Respiratory – 4%, Suicidal – 2%, Animal Bites 1%

• 300+ lives were saved per day (247,021 + till now) and 11,870 victims per day received timely, high-quality pre-hospital care

Costs • Cost per ambulance trip Rs. 600 to Rs. 700 against $ 600 to $700 in USA

Qualitative Outcomes

• Angel of Mercy – 108 Ambulance• Successful PPP• Well documented systems, impressive EMT training,

high order management competence• A historic landmark in health care delivery system • Built more trust in the health system as a whole • Increased institutional deliveries and reduced maternal

mortalities by 20 – 25% • A model for replication across the Country in any state

Impact - Doing More with Less for MoreImpact - Doing More with Less for More

Bomb Blasts Ahmedabad

A Gandhian A Gandhian InnovationInnovation

July-Aug 2010

PRE-HOSPITAL CARE – AMBULANCE SERVICES

An injured patient needs

(i) Treatment for life threatening injuries to maximize the likelihood of survival,

(ii) Treatment for potentially disabling injuries to minimize disabilities and promote return to optimal functioning, and

(iii) Reduction in pain and suffering (Mock et al. 2004).

Chemical Industrial Emergencies

• Evacuation of Casualties • Decontamination• Triage• Resuscitation• Treatment• Transport

Ambulance

Advanced Life Saving Ambulance

S T R E T C H E R S

E X T R I C A T I O N T O O L S

AUTOLOADERWHEEL CHAIR

SCOOP

SPIINE BOARD

AIR LIFTING

AMBULANCE EQUIPMENT

MEDICAL EQUIPMENTSUCTION APPARATUS AUTOMATED EXTERNAL DEFIBRILLATOR

VENTILATOR VACUUM SPLINTS

Rescue and evacuation

Four common triage categories (IDME)

T4Expectant

T3Minimal

T2Delayed

T1Immediate

T3

DEAD

BREATHING BREATHING

WALKING

OPEN

AIRWAY

YES

YESYES

NO

NO

RESPIRATORY

RATET1

PULSE

RATET2

NO

less than 1030 or more

10 - 29

radial pulse <120/min

or >120/min

INJURED

NOT

INJURED

SURVIVOR RECEPTION CENTRE

radial pulse absent

Key Message 1

• Do Triage based on Airway, Breathing and Circulation when more than 3 patients are involved.

Triage and onsite treatment techniques

Andhra Pradesh: Mock Drill  at GVK EMRI, Secunderabad on 5th September ‘07

32

Andhra Pradesh: Mock Drill  at Secunderabad Rly Station on 17th October ‘08

33

Uttarakhand: Mock Drill  at Parade Grounds, Dehradun on 20th November’09

34

MCI- Important Roles – On site and Transportation

• Ambulance Incidence Officer (AIO)• Triage Officer(TO)• Treatment Area Supervisor (TAS) • Treatment Area Officer (TAO)• Logistic Officer (LO)• Equipment Officer (EO)• Ambulance Parking Officer (APO)• Ambulance Loading Officer (ALO)• Safety Officer (SO)• Public Information Officer (PIO)

Evacuation of Casualties – NDMA- MP-MPE-

Major Recommendations – Ambulances Reference NDMA EMRIResponse time

-Maintain minimum ( Golden hour)

Urban 14mts; Rural – 21mts<10mts – 2/3 of RTA & cardiac.

Medical Equipment

For resuscitation, Essential drugs,

Stretchers

2-way communication

Spine board/ CPR skills;106 drugs under medical directions; Collapsible / Scoop /Pediatric / Chair stretchers; Cell phones.

Support Staff

Well versed with equipment usageQuality checks

Yes (training)

Yes (OE wkly visits; Qrtly. Checks by quality teams)

SOPs Maintenance of vehicles Yes including preventive maintenance, repair/accident processes etc.(Fleet managers)

Evacuation of Casualties – NDMA- CIDM-

Medical Emergency Plans Reference CIDM EMRIDistrict Off-site Plan

Mock drills Yes

Dedicated institutes for CDM

To be identified / established Can be seriously considered for training and research.

Community awareness

Develop mechanism –kits. VoiCE program

SOPs To be laid out – Decontamination; risk and resource inventory, proper casualty chemical treatment kits,

can cascade and provide

Integrated EoC Services -EMRI and NDMA

• Computer – Cellphone Integration (CTI)• Ambulance network• Community Awareness (VoiCE)• Preparedness &Mock Drills (Medical/Police/Fire/ Railways)• First Responders (> 3000 trained and handbook)• Emergency Medical Technicians and Paramedics (PGPEC)• Standard Operating Protocols (SO,MD,CCPs,MCI)• Hospital Network (>6000 MoUs)• Documentation (Pre-hospital Care Record PCR)

Essential elements for IAN• Strategy partnerships • Strategic support – technology, training and research• Size and scale • SOP• Skills set• Surface ambulances • Site experiences• Simulation• SLA

Our legacy• Like so many other things that are Indian, Mahatma worked as volunteer in

South African war in 1899 and served injured people.

               

Thank you

www.emri.inRamanarao_gv@emri.in