Disaster planning

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A common theme in public health and emergency medicine is a general complacency among health care workers with regard to disaster preparedness and a general lack of knowledge of the basic principles needed to mount an effective response. Most health care workers assume a low likelihood of being involved in a disaster, although this is not true on a lifetime basis and some believe that appropriate medical response during a disaster is merely an extension of everyday practice. Obviously such is common also in the population where their role with for example individual emergency response kits has been mandated in some societies. However appropriate organisation and training can do much to mitigate the health effects of disasters. Disaster planning also involves an understanding of the epidemiology of disasters as hazard risk is a function of the frequency of the hazard times the populations’ vulnerability to that hazard.

Contents

General principles

  • Integrated disaster plans covering the 4 key phases:
    • Mitigation (Reduction)
    • Preparedness (Readiness)
    • Response
    • Recovery
  • Test and modify these plans through integrated simulation drills and table top exercises
  • Institution (eg hospital/ambulance service)-wide drills are essential at appropriate intervals given staff turn over

Usual addressable failure points

  1. Insufficient coordination between hospitals and civil/governmental response agencies
    • Need for backup communication strategies repeatedly demonstrated
  2. Insufficient peak demand on-site critical care capability
  3. Lack of "portability" of acute care processes
    • Patient transport to where appropriate care can be delivered
    • Bringing care to the patient or transporting patients already needing care when infrastructure further fails
  4. Education shortfalls
  5. Routine competing priorities create inability of hospitals to align to disaster medical requirements

Common false assumptions

Assumptions are often at variance with disaster research studies. Most planning appears to be system constrained and while it correctly targets those most likely to be involved such as A&E staff, is likely to fail to identify say a second tranche of health employees who are more likely to turn up to help because they live close to a health facility and so are more likely to be available at times of infrastructure derangement. Planning should not assume[1]:

  1. Knowledge of the disaster will reach the correct parties promptly
  2. The correct emergency response units will be dispatched for the disaster
  3. Trained emergency personnel will carry out the initial field search and rescue
  4. Trained emergency medical services personnel will carry out the
    • Triage
      • This needs to be different in a major disaster and should involve (with those involved understanding their role):
        1. Contact triage
        2. Community triage (prehospital)
        3. Receiving hospital triage
        4. Regional triage
    • Provide first aid
    • Provide stabilising medical care
    • Undertake the decontamination of casualties before patient transport
  5. Casualties will arrive at hospitals by ambulance
  6. Casualties will be transported to hospitals appropriate and with capacity for their needs
  7. Authorities at the scene will update hospitals promptly and accurately of expected health needs of the victims
  8. The most serious casualties will be the first to arrive (often the opposite !)

Methodology

  • Incident Command System (ICS)[2]
    • This was developed in the USA: Principles are:
      1. Early implementation before an incident gets out of control.
        • Every 5 minutes that disaster evolves before response implemented results in 30 minutes longer to full control once command structure is activated.
      2. Adherence to the structure by all responders including medical and hospital personnel.
      3. Common structure regardless of the nature of the disaster.
        • Differences are in specific expertise of individuals assigned to key positions for a particular type of incident.
      4. Structure is modular, allowing for command to expand or contract according to need
      5. Concept of manageable span of control' with each command person supervising only 3 to 7 others
      6. Standard terminology, position titles, and communication procedures
    • Toplevel ICS structure
      1. Incident Commander (IC)
        • Safety officer
        • Public information officer (PIO)
        • Liaison officer
        1. Section chief - Operations
        2. Section chief - Planning
        3. Section chief - Logistics
        4. Section chief - Finance/administrative
  • Hospital Emergency Incident Command System(HEICS)
    • This uses same structure as ICS but introduces concepts of call-down mechanisms and preprinted job action sheets which should be now familiar to all hospital based health care professionals.
    • Dual command concept of hospital component: Medical and administrative
    • Medical response team concept
    • Unidirectional patient flow
    • Security responsibility
    • Surgeons' key role requires specific training to escape from their usual trained preconceptions

Epidemiology

Both man made and "natural" disasters have distinct epidemiology that reflect cultural and geographical issues. Population vulnerability is such a strong function of these that disaster planning needs a very strong local component[3]. Disaster preparedness does involve as well as the general principles, the planning for the most likely scenarios in a locality. Many natural disasters causing mass causalities can be analyzed for man made components that if addressed in a timely fashion would have mitigated the disaster. Examples are the influence of building codes on survival after earthquakes, planning restrictions on developments on floodplains and tsunami warning networks. There is the issue that if a society can afford the resources it should learn from disaster specific plans developed by experience elsewhere. So earthquakes may be rare in England, but incorporating building code lessons from earthquake zones might minimise infrastructure and net population vulnerability when relatively minor ones do occur.

This article is a work in progress. Please feel free to contribute to it.



See also Fire Flood Famine

References