Every project has first to clarify its goals. Any plan concerning the organization for a mass admission of patients in the hospital (OMP) - mostly known simply as disaster plan - is a pretentious project. The time invested for a definition of the goals will always be well spent.

In case of external mass accidents further goals are:

• to control the large number of patients and the resulting problems as good as possible

• by enhancing the capacities of admission and treatment,

• by treating patients based on the rules of individual medicine despite a greater number of patients

• by ensuring ongoing proper treatment for all patients who where already there

• by a smooth handling of all additional tasks caused by such an event.

• to support the damage area by means of medical consultation, medicaments, infusions, dressing material and any other necessary medical equipment

In case of an internal major accident (i.e., fire, explosion) the goals of appropriate, prepared measures are

1. to protect men, environment and properties as good as possible from any damage

3. by putting into effect the prepared measures,

4. by appropriate behavior of the staff who has to know its tasks for this case and has to give correct instructions,

5. by supporting help from outside in an optimal way,

In addition, a concept for internal as well as for external events has to be prepared

• for an optimal protection of patients, employees and rescue personnel

• to ensure the required handling for a quick preparedness on bases of the daily organization structures

• to guarantee a flexible and direct management at all times

• to realize an effective coordination of the available internal and external forces and resources.

Moreover in the course of the project all people involved should become aware of the problematic nature of the operation and do their best to keep it up to date.

The hospitals need special planning for both, mass accident as well as damage area management . This means that every hospital, regardless of its size, requires a practicable and well trained plan for such cases. This does not only include the enhancement and coordination of the medical performance, but also important additional tasks which have to be added to the daily practice. That s why a plan for the organization at a major accident exceeds the simple task of only alarming additional forces.

Basic requirements are as follows:

• This plan has to be based on existing organization structures as any re-organization holds the danger of failure

• Keep the plan as simple as possible but as comprehensive as necessary.

• Have the following principle in mind: The OMP-file is useful for preparation and training but in case of emergency only checklists will be helpful.

Every management requires organization and leadership. Especially in times of a crisis an additional need of immediate action arises and decisions have to be taken in a straight forward way.

Therefore, the following principles and requirements apply:

• a simple and clear organization should be mobilized within short notice - a crisis staff consisting of 40 members will prove inoperable

• the delegation of competencies to present executives with short ways of decisions

• headquarters at predefined and prepared site with the required infra-structure

• no re-organization but developing on the existing base

• to ensure that the remaining routine hospital work continues

In case of emergency the alarm has to be quick and reliable. The competence to set the alarm in motion has to be settled as low as possible in the hierarchy. Otherwise time is lost during early phases of the plan. This time is decisive and will not be compensated anymore. In conclusion, alarm has to be given early and generously even upon mere suspicion of a major accident. Delayed mobilization is irreparable. A surplus of personnel can always be dismissed later at any time. Alerting must never be a privilege of the director of administration or to the head of the physicians.

Mobilized people will have to know where to go (defined meeting point) and what to do. The communication network which will most likely be overcharged in such situations and must not be additionally strained. Checklists will be once more the only successful formula.

Competencies will influence to a great extend the ability to act in a timely fashion. The declaration of an emergency state in case of a major accident will be indispensable.

It may contain among others:

• premature discharge of patients from hospital

• transfer of patients

• postponement of scheduled admissions and operations

• release of beds and operations rooms

• preparation and reservation of rooms

• mobilization of personnel

• certain restrictions concerning visitors and patients

• protection of personnel and visitors

• instructions concerning right and duty to inform

• cancellation of the alarm and state of emergency

• instructions for evaluation of the emergency procedure

There are two common errors which may mislead the number of patients who are to be admitted in case of major accidents.

1. Neither the number of beds nor the admission capacities are a decisive criterion.

2. The treatment capacities are mostly estimated too optimistic by the hospital.

It is the treatment capacity which is of importance. This capacity can be defined by available operating rooms and surgical teams as well as available intensive-care-unit places. This number can be increased by cancellation of operations, calling additional surgical teams and premature transfer of patients from the intensive-care units to the normal ward.

Admission and registration of patients as it is performed during daily routine will not be possible because of lack of time.

Therefore, the following is needed:

• a simple and ready-for-use system,

• a method which enables to relate patients clearly to the event, e.g. for investigation authorities

• a reliable identification system of personal properties of the patients,

• a handling method which enables relatives to find the patient in the hospital

We highly suggest the use of the Casualty-Handling-System (CHS), a system developed in Europe. Please click here to get more information on the Casualty-Handling-System (CHS).

The CHS-pouch

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We recommend to stock CHS-pouches at the entrance of the emergency room to mark arriving patient without pouches . At the University Hospital of Zurich this kind of identification has proved to be a good tool in handling unknown patients.

A colored guiding system with respective floor marking can be useful and help to avoid chaos.

All medical measures have to start at the emergency entrance. Sorting has priority in order to ensure decisive instructions. Physicians at the entrance play a key-role and have to be highly trained.

Enhanced admission of patients require an enlargement of suitable spots, if necessary even by changing their function. In addition, the careful marking of additional areas (e.g. room for slightly injured persons, for the headquarters, for the catering and care of relatives, for the admission of media people including their identification) has to be prepared. All needs have to be exactly determined and realized on a basis of the existing possibilities.

Communication is one of the main problems in case of major accidents and disasters. Information has to be reduced to the most important facts. Wire and radio contacts as well as messengers have to be integrated into the communication concept. It also has to be taken into account that any systems may fail. Cellular phones often fail in such situations due to overcharge. Appropriate marking of the staff in charge is also an important part of communication.

Security services have to be operational at very early stages. Some of their duties are:

• to secure the driveways for authorized parties, namely ambulances,

• to restrict and strictly control the entry to the hospital

• to direct the entry for authorized persons into appropriate areas, e.g. for relatives or media people,

• to protect personnel and patients

Not only the treatment areas but also departments such as radiology, blood bank, laboratory, and pharmacies have to prepare for more extensive performances.

Information does not only include the contact between rescue staff and media at the damage area. Information flow is also important within the hospital. Information chaos with subsequent criticism can only be prevented by a clear information concept. This concept consists of:

• information of staff

• information of neighboring hospitals and operation partners, such as ambulances, police, etc.

• information of friends and relatives,

• information of media (Media always get their information - the better way is the controlled one)

Social care of relatives or personnel should not be neglected. Appropriate and available personnel, psychiatrists and pastors are compulsory elements of such a concept.

Traffic control and blocking access to certain areas help to avoid chaos in the case of a mass accident. Cooperation with police forces will be necessary.

Technical systems such as communication systems, powerplant, and medical gas supply may fail, due to overcharge or other reasons. At this stage of planning such possibilities have to be evaluated and expected. Counter-measures have to be prepared.

Planning documents are indispensable for training purposes but useless during disaster relief due to their large volume. Files are for the office! During disaster relief checklists are needed! Simple and easy-to-use checklists have to be created. They have to be readily available.

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Checklist examples for emergency physicians and paramedics working at the site of disaster (in German)

The organization for a mass admission of patients (OMP) is a special concept although it is based upon the daily structures. A carefully directed training is mandatory. Theoretical education has to be followed by periodical exercises. Mock disasters have to be well prepared and executed without announcement. Not to long ago, 25 severely and 25 slightly injured patients, a number of anxious relatives und pushing journalists were channeled into the daily routine of the University Hospital of Zuerich-Switzerland as a surprise. Analysis of this event led to improvements in the Hospital Disaster Plan.

Measures taken for the EXTERNAL OMP-plan also apply to the case of an INTERNAL emergency case in the hospital. The INTERNAL plan is based on the same concept but includes some modifications and additional measures. Again, hold on to the principle Change as little as possible of an existing and good management.

Additional or special measures are:

• to mark the patients

• special protection measures

• availability of rescue material such as escape-masks, fire-fighting equipment and fire-blankets etc.

• exit possibilities incl. elevators and an evacuation plan

• behavior of the personnel and patients with regard to psychological problems.

Evacuation in hospitals is a very demanding task. It will have to be differentiated between a total or a partial evacuation. Evacuations require serious planning and a good concept. Without adequate planning they will most likely fail.

Bruno Hersche, Civ. Eng. ETH/SIA
Riskmanagement Consulting
Austria - 3332 Sonntagberg 18
Phone +43 7448 4126
Fax Phone +43 7448 4126 6
Or
Switzerland -Freiestrasse 43, CH - 8032 Zürich
Fax Phone +41 1 262 62 32

This lecture was presented by Bruno Hersche at the 10th World Congress of Emergency and Disaster Medicine, September 24 - 27, 1997, Mainz, Germany.