16. MIMMS Advanced CourseMIMMS Advanced Course
INTRODUCTIONINTRODUCTION
95% of All the Incidents
จัดการ ดูแล รักษาได้ด้วย
Local Medical Management & Support
EMS ในพื้นที่
จึงต้องได้รับการเตรียมพร้อม ฝึกหัด อย่าง
สมำ่าเสมอ
17. PRINCIPLES for ManagementPRINCIPLES for Management
ICS ต้องเข้าใจและแจกงานทั้ง 3 Phase
ของ Major Incident
Preparedness
P-E-T
Respons
e
Recovery
Reconstru
ct.
Rehabilita
tion
เพื่อ
Prevention
Pla
n
Equipment Training C-S-C-A-T-T-T
Protection
Identificati
on
Medical
Communica
tion
Logistic
Commander
Communicate
Capacity
Education
Exercise
1 Command and
Control
2 Safety
3 Communication
4 Assessment
5 Triage
6 Treatment
7 Transport
METHAN
E
MIMMS/DMAT
19. ICS Organization
โครงสร้างองค์กรประกอบด้วย ๕ ส่วน
หลักคือ
– ส่วนบัญชาการ (Command)
– ส่วนวางแผน(Planning)
– ส่วนปฏิบัติการ(Operation)
– ส่วนสนับสนุน(Logistics)
– ส่วนงบประมาณ(Finance)
Logis
tics
Sectio
n
Finance/
Administ
ration
Section
Opera
tions
Sectio
n
Planni
ng
Sectio
n
Incide
nt
Com
mand
32. MODULE 7. MASS CASUALTY MANAGEMENTPHEMAP 8 |
32
What is Medical Surge Capacity
The ability to provide adequate medical evaluation and
care during events that exceed the limits of the normal
medical infrastructure of an affected community
Medical surge capacity
• Evaluate and care for increased volume of
patients
• Extend beyond direct patient care
Medical surge capability
• The ability to manage patients requiring unusual
or very specialized / medical evaluation and care
34. MODULE 7. MASS CASUALTY MANAGEMENTPHEMAP 8 |
34
What Is Surge Capacity and Capability System ?
• Strategy to promote integration of existing
programs into an overarching management
system
• Strategy to define basic requirements for health
assets participation
• A management system – functional relationships –
systematic approach to organize and coordinate
available health and medical resources
• Mechanism for coordinating relationship between
Hospitals and other services providers and the
government response
• Adoption of Emergency Planning Process
principles and information management
( incorporating IMS)
• Provision of platform for effective training
35. MODULE 7. MASS CASUALTY MANAGEMENTPHEMAP 8 |
35
A complex partnership……
36. MODULE 7. MASS CASUALTY MANAGEMENTPHEMAP 8 |
36
Tiered approach and scalability of the response
• Tier 1 Individual Hospitals and other institutions
• Tier 2 Networks of the stakeholders of Tier 1
• Tier 3 Local level and Provincial level
• ICP ; EOC
• Tier 4 National level
• ECC (National EOC when a “national contingency
plan is activated”)
64. การพัฒนาโครงข่ายสื่อสารแบบ VOIP (E-
RADIO)
ระยะที่ 1 พัฒนาระบบ และบุคคลากร
ระยะที่ 2 เริ่มการใช้งานแบบ PC -> PC
ระยะที่ระยะที่ 3 PC -> PC &3 PC -> PC & วิทยุสื่อสารวิทยุสื่อสาร
ระยะที่ระยะที่ 44 วิทยุสื่อสารวิทยุสื่อสาร & PC -> PC && PC -> PC &
วิทยุสื่อสารวิทยุสื่อสาร
ระยะที่ 5 เสริมสร้างสมรรถนะระบบสื่อสาร
ผ่านดาวเทียม
The concept of medical surge forms the cornerstone of preparedness planning efforts for major medical incidents. It is important, therefore, to define this term before analyzing solutions for the overall needs of mass casualty or complex incidents.
Medical surge describes the ability to provide adequate medical evaluation and care during events that exceed the limits of the normal medical infrastructure of an affected community. Beyond this rather simple explanation, medical surge is an extraordinarily complex topic that is difficult to comprehensively describe. The first step in doing so, however, is to distinguish surge capacity from surge capability. Strategies to enhance medical surge capacity and capability (MSCC) require a systems-based approach that is rooted in interdisciplinary coordination and based at the local level.
Medical Surge Capacity. Medical surge capacity refers to the ability to evaluate and care for a markedly increased volume of patients—one that challenges or exceeds normal operating capacity. The surge requirements may extend beyond direct patient care to include such tasks as extensive laboratory studies or epidemiological investigations. Because of its relation to patient volume, most current initiatives to address surge capacity focus on identifying adequate numbers of hospital beds, personnel, pharmaceuticals, supplies, and equipment. The problem with this approach is that the necessary standby quantity of each critical asset depends on the systems and processes that:
Identify the medical need
Identify the resources to address the need in a timely manner
Move the resources expeditiously to locations of patient need (as applicable)
Manage and support the resources to their absolute maximum capacity
In other words, fewer standby resources are necessary if systems are in place to maximize the abilities of existing operational resources. Moreover, the integration of additional resources (whether standby, mutual aid, Provincial or National aid) is difficult without adequate management systems. Thus, medical surge capacity is primarily about the systems and processes that influence specific asset quantity. Basic example: If a hospital wishes to have the capacity to medically manage 10 additional patients on respirators, it could buy, store, and maintain 10 respirators. This would provide an important component of that capacity (other critical care equipment and staff would also be needed), but it would also be very expensive for the facility. If the hospital establishes a mutual aid and/or cooperative agreement with regional hospitals, it might be able to rely on neighboring hospitals to loan respirators and credentialed staff and, therefore, might need to invest in only a few standby items (e.g., extra critical care beds) that generate no income except during rare emergency situations. Cooperation between private and public sector is of paramount importance. Arrangements should be planed in advance.
Medical Surge Capability. Medical surge capability refers to the ability to manage patients requiring unusual or very specialized medical evaluation and care. It refers to the ability to manage patients requiring unusual or very specialized medical evaluation and care. It also includes patients problems that require special intervention to protect medical providers of services, other patients, and the integrity of the medical care facility Surge requirements span the range of specialized medical and health services (expertise, information, procedures, equipment, or personnel) that are not normally available at the location where they are needed (e.g., pediatric care provided at non-pediatric facilities). Surge capability also includes patient problems that require special intervention to protect medical providers, other patients, and the integrity of the medical care facility. Basic example: Many HCFs encountered difficulties with the arrival of patients with symptoms of severe acute respiratory syndrome (SARS). The challenge was not presented by a high volume of patients, but rather by the specialty requirements of caring for a few patients with a highly contagious illness that demonstrated particular transmissibility in the healthcare setting. Protection of staff and other patients was a high priority, as was screening incoming patients for illness, preventing undue concerns among staff, and avoiding publicity that could adversely affect the hospital’s business. Coordination with public health, emergency management, and other response assets was critical.
This slide should be printed out as one page handout and distributed to participants. The exercise at the end of the session will discuss the components and their contribution to the MCM process (see comments below for each component). At that stage of the presentation facilitator should limit himself/herself to only comments the various elements and links that are corresponding to the 5 boxes (mentioning that components will be discussed during the exercise). This conceptual framework has been developed by WPRO in April 2007. A key element to highlight is the central notion of “surge capacity”. When discussing all components we should always identify how they can contribute to the surge capacity and what it implies for the component in term of training, management of their resources; what are the coordination mechanisms that must be developed, what arrangements can be considered 8for instance if we discuss the use of field hospital, what role the military component can play, etc.
WHO policy on Emergency Preparedness states that mass casualty management must be considered in the broader context of emergency management. Mass casualty management preparedness is a sub-set of emergency preparedness. The core concept of a Mass Casualty Management System is public safety, supported by the concept of community risk management (all hazards approach, focus on risk, integration of response, mitigation, recovery, preparedness activities under the umbrella of risk treatment options). This Regional Training Course on MCM aims also at promoting the development of National Training Courses on MCM. The Hospitals are important contributors to the medical surge capacity of the Health Sector. Therefore this Regional Training Course will be followed by a Regional Workshop on Hospital Emergency Preparedness, and other activities.
Statement made during the WHO Geneva expert meeting of September 2006 (HAC and VIP) on MCM.
Seven fundamental terms for community risk management - WPRO 2003
What is a name disasters and emergencies – WPRO - 2003
Definitions in Emergency Management – WPRO 2003
The curriculum has been developed in December 2006 – WPRO, see annex 2
The Regional Training Course is more than just a training activity. Conceptual frameworks, Toolkits and recommendations have been developed so as to promote the concept of Regional Training Program (with the creation of a Regional Network of trainers and follow-up workshops). This course is inspired by the PHEMAP program and is complementary to this program.
Comments:
Community risk management is primarily an ongoing process with the aim of contributing to promote safer communities and doing thus to enhance sustainable development of communities/country. This implies that all stakeholders (institutions, agencies or individuals from public sector, from private sector and NGOs) are included and can contribute to the process according to their mandate, authority and their resources. The best adapted strategy for enhancing this process is to rely on the conceptual framework of public safety supported by the concept of community risk management (all hazards, multi-sectoral: integration of response and preparedness efforts, prepared community, and risks reduction oriented)
Community-wide preparedness and response (box 1)
Public Safety is the ultimate goal (safer communities and sustainable development) of Emergency Preparedness and Emergency management. MCM must be understood in this broad conceptual framework (reference: Hyogo Framework for Actions 2005-2015). Therefore the management of activities related to health services delivery and patients-care must be integrated into the community-wide framework.
Risk management is the key concept: all hazards; holistic approach: from prevention to recovery; prepared community; vulnerability reduction; emergency planning and readiness; integrated multi-sectoral strategy. Establishing the baseline capacity and identifying the potential risks is an important step of the emergency planning process.
MCM is a subset of Emergency Management. Emergency preparedness includes policy, development of plans, training of staff (from First Aid to specialized medical teams in chemical incidents) and exercises (for agencies such as hospitals, intra-sectoral and inter-sectoral), etc. The ultimate goal of Emergency Preparedness is an ever increasing level of readiness. This is applicable to the whole Health Sector. At country level recommendations and strategies for MC preparedness have to address a broad range of institutions (great diversity). In disasters health is influenced by many factors: not all of them are under the possible control of the Health Sector (such as access to safe drinking water for Internally Displaced People). Therefore MCM is a community-wide concern likely to require a broad array of community resources to supplement the health care system. The local community is the primary resource for initially responding to MCI and providing medical care through its health care delivery system (especially hospitals). In developing countries this capacity of the local community is often low (except in some major cities)
Community-wide preparedness should be based on a clear policy, on laws and legal procedures, on pre-established systems (such as EOC).
MCI: scope and causal events (box 2)
A broad range of causes (real context) and all potential scenarios and scope (up to international) must be considered. WHO advocates for the inclusion of all potential causes for MCI (natural hazards, chemical incidents, epidemics, BCRNE) into preparedness programs of the Health Sector for MCM. The development of response plans (including contingency plans - also for hospitals) must suit the local actual context –credible scenarios and priority issues- (risk assessment, vulnerability analysis) and must address the expected consequences on the community as a whole
Consequences (box 3)
Consequences on people. The consequences can be direct or indirect (short term or long term) such as trauma, burns, illnesses, disability, intoxication, death, displacement of people (security, public health issues, etc.), mental health, loss of income, etc.
Consequences on services. There is always a surge in needs for services in MCI. Often there is loss of some life lines with direct and indirect consequences on health and on health care delivery services; loss of critical services such as destruction of hospitals in an earthquake; etc. The loss of services can create major negative impact on health (often greater than the immediate trauma burden caused during the impact)
Consequences on infrastructures. Loss of home; many critical facilities of the health sector have vulnerabilities so that they can be badly affected; access roads, etc.
Consequences on environment: all factors having a direct or indirect impact on health (especially sanitation and communicable diseases but not limited to)
Management Systems (box 4)
MCI require the activation of Incident Management Systems (IMS). IMS are complex in their very nature and usually encompass three levels: Incident Command Post (ICP) on the scene; the Emergency Operations Centre (EOC; fixed Centre with overall command responsibility –usually under the leadership of political authority); Provincial Structure and or the National Structure (National Committee: varies from country to country). The government has always to be involved when there is a major event and it is its responsibility to assist the local community/ies. These various management systems require policy (also legal framework), emergency planning, training programs, exercises, resources and management systems mechanisms especially for coordination. The systems focus mainly on managing (every system has responsibilities, roles and functions according to its legal field of authority) resources (equipment, supplies, transport means), staff and logistics
Local governmental institutions are directly involved (both the public health authorities and also the emergency services such as fire department, and police).
The Health Sector has also its own intra-sectoral management systems: local health system community based; provincial health authorities, national MOH
Hospitals must develop an emergency preparedness system (comprehensive emergency management strategy) for managing not only the overload of patients but also the consequences of the event on its functional, structural and administrative capacity. Hospitals networking is a key component of the surge capacity of the Health Sector
EMS are not limited to clinical care delivery on the scene and during transportation by medical or paramedical staff. EMS should be considered as a System which includes many partners (capacity in First Aid of First Responders; ambulances whatever the agency operating them; Mobile Medical Teams; Emergency Department of hospitals, etc.). The management of EMS system –whatever its development and complexity- should be fully integrated into the overall management (especially for the key function of dispatching the patients and sharing information with hospitals)
Surge capacity is a key concept in capacity building for MCM (box 5) –at national level as well and at sub-national levels. This concept is powerful to enhance the development of appropriate systems, plans, policies, communications mechanisms, etc in the real local context of developing countries. It includes surge capacity & surge capability of the whole system, and of elements of the system such as hospitals and EMS. Surge capacity requires the integrated efforts of many stakeholders at all levels. The medical surge capacity for MCM is largely determined by the surge capacity of the Health Sector (at all levels; public and private) but is also determined by the active contribution of other sectors. The surge capacity is complex in its very nature for it deals with a broad range of activities, programs and systems such as the notion of networking of hospitals, training of community workers in First Aid, etc. The National Mass Casualty Management Plan should be based on a "tiered approach" to dealing with mass casualty incidents, in line with the guiding principles of scalability and enabling local responses. This approach recognizes although a national approach to policy and management of mass casualty incidents is essential, the preparedness of local health services will be the crucial element in the success or failure of the national plan. For the Health Sector, surge capability is of paramount importance (not only for managing new threats such as SARS epidemics as recently demonstrated but also at institutional level such as expertise in hospitals for managing contaminated patients in chemical incidents or mass burns incident involving children). The concept of “integration strategy” (use of existing resources/services as much as possible -strengthening and developing them when necessary (such as the epidemiology unit for adapting the surveillance system to the disaster context for collecting limited relevant data with the purpose of emergency management and decision making).Training of staff is a key element of the surge capacity and also of surge capability of the Health Sector In many developing countries the public health sector has very limited extra-resources to mobilize for MCI. The existing resources are already overstretched by daily demand for services (especially the ED of public hospitals). The development of cooperation mechanism (pre-established arrangements) with the private sector and the army can be of great help to enhance the surge capacity. The management of priority public health issues (including the management of the dead and the missing: HS has an important role to play) requires the management of many data. The system should allow for collecting and processing (including sharing mechanism) critical data necessary for managing the emergency response and for developing proactive urgently needed mitigation or preventive activities.
____________________________________________________________________________________________________
COMMENTS – COMPONENTS OF THE MCM FRAMEWORK - THIS PART WILL BE DISCUSSED IN THE EXERCISE
(Figure 1)
Emergency Preparedness Programs. The components of these programs must be developed according to the actual preparedness requirements of the country and of the Health Sector within the legal framework (see comment above). Communities need to develop horizontal and vertical relationships between the organizations, governmental and private, that will be called upon to work together (in synergy or in complementarily activities) in MCI. It is advisable to develop indicators for assessing these programs.
Response plans. Besides the generic MCM plans for mass injuries, there are several other contingency plans that must be considered such as for chemical incidents, epidemics. In some countries these elements are included as “contingency procedures” (or sub-plans) included in the MCM Response plan. There are several response plans (hospital, local community, provincial, national; inter-sectoral and intra-sectoral response plans). These plans should be developed within a legal framework with a clear policy (who does what, how and with whom) focusing on synergy, complementarities and compatibilities between all these plans. Plans must be exercised and staff trained accordingly.
Early Warning System. Some Mass Casualty events such as epidemics require the development of an efficient full-functioning EWS that delivers accurate information dependably and on-time. This concept is far more complex than usually thought and requires the cooperation of many stakeholders. To develop a proactive approach for responding to any type of MCI should be given more attention.
On-site activities and Management System on Site. The chain of survival (which should also include prevention of disabilities and not only preventing death) is complex. Many players from various agencies and organization can contribute to increase the effectiveness of patient-care and of public health services such as psychological support. The overall Command in the Incident Command Post (regrouping the main stakeholders: police, rescue, health, EMS) varies from country to country or even according to the type of event (chemical incident with ongoing threat on security of staff, terrorist attack, etc.). Several key activities are typically developed at the site such as triage (medical or non medical protocols), life saving procedures and first stabilization of the emergency patients before transport (when reasonably possible). What matters are the functions and the activities deployed on the site. For instance disaster medical teams can work in the “Advanced Medical Post” whether this facility is owned by the rescue services or by the health sector. In large scale disasters the use of “mobile hubs” or “field hospitals” can be considered. What matters is the framework within which these mobiles structures operate (and not who is the owner of the structure: army, NGO or international assistance). A major element in MCM is the dispatching of patients to the receiving hospitals. There are several models for managing this key function (as one component of the EMS system in the SAMU like organizational management of disasters; or as one role of the EOC or the ICP, etc.). What matter are the existence of a framework and coordination mechanism for managing information, resources and staff. Some MCI, especially chemical incidents, require the use of special safety protective equipment, special procedures (such as decontamination), special organizational arrangement of the site. The disaster response plans should provide clear lines of command for managing these events (usually contingency plans). The coordination of the pre-hospital activities with the hospital activities is of paramount importance.
Emergency Operations Centre. The roles, functions, field of authority and organization of this Centre (the “brain” of the response) are a full part of the multi-sectoral MCM response Plan. In some countries the EOC is a “provincial” Centre (under the authority of the Governor) while in some other countries it is always a national Centre. Depending upon the scope of the event it can happen that several EOC (when several provinces are affected) operate at the same time. The coordination requires national capacity and capability. The Health Sector should be a proactive member of the EOC in order to enhance the management of all issues having a link with health (not limited to critical emergency and surgical care delivery but also including the management of major public health issues, especially when there are internally displaced people living under precarious conditions).
Emergency Medical Services System. There are many models for organizing EMS. The notion of “System” is of paramount importance with the goal of using effectively all existing and available resources (for instance the ambulances from police, from Red Crescent/Cross, from private sector) and for developing the capacity in MCM. Some key functions -in the concept of EMS System- can be developed even if there is not a “formal structure” established with an emergency call number and having its own assets. These functions can be developed in urban as well as in rural context. Some elements can be even developed in remote areas such as training of community members in First Aid and survival procedures. The concept should be much broader than limited to the EMS to running ambulances or to having one emergency call number. The interoperability of the main stakeholders of the EMS system is of paramount importance. The strategy should be to promote “safer communities” (coordination and cooperation of the First Responders, coalition of hospitals, preparation of the ED of hospitals, etc.). Hospitals can actively contribute to the sharp increase of the medical surge capacity on the site by preparing Mobile Medical Teams that can be sent out within the conceptual framework of EMS System.
Hospitals. The preparedness standards for providing care and services vary according to the category of the hospital (hospital providing full-time emergency services, hospital providing only part-time emergency services, not providing emergency services etc.). The preparedness standards should focus on key areas: emergency management system; continuity of operations and rehabilitation of critical services, and security; special issues such as decontamination, internal disasters; training of staff; exercises. The development of “toolkit” of best practices in facility design, engineering operations, and facilities management systems are of paramount importance to promote best practices for hospital emergency planning and managing the response. MCI require that hospitals operate on three levels simultaneously for they must respond as: an organization in its own right; a part of the community’s health care system. Hospitals have an important role in EMS System (trauma coordination, networking of hospitals of all types); one component in the community-wide effort that extends far beyond the system (coordination with partners from other sectors; learning to work together; joint exercises). This implies that Hospitals work with other community partners and other sectors in developing their preparedness and in managing the response (integration of community-wide inter-sectoral plans); that they develop ongoing relationship with local health department (public health concern); that they conduct community-wide mass casualty drills with the active participation of all hospitals or health care facilities of the local and regional network; that they contribute to the development of system for sharing information so as to manage effectively and efficiently (agreement on data to be collected and shared; existing system for streaming data from institutional operations in order to match community needs to available resources). The use of their existing emergency medical system, trauma coordination, and other critical services as a framework on which to build expanded relationship for MC preparedness (communications linkages, sharing of resources, dispatching of patients among the members of the network, data management and information sharing)is of paramount importance.
Blood banks and laboratories. Each country has its own organization on how blood banks and laboratories operate for routine emergencies. The surge in demand for blood supply in MCM should be limited as much as possible (there is a tendency to overuse blood transfusions). Causal events for MCI such as epidemics can require the intervention of laboratories much beyond their routine capacity (and even beyond their routine capability). The MCM system should also anticipate such a demand (designation of reference laboratory, etc.). The notion of “laboratory surge capacity” should be considered more proactively (the use of all available resources, including from private sector or international cooperation).
Public Health. Very rarely MCI impose a sharp increase limited to only clinical/surgical services. More often the consequences of the incident impact directly and often sustainably on public health programs and or create new public health urgent problems: typically mass fatality and the management of the dead and the missing; internally displaced people and temporary shelters. This is a key component of MCM that is often overlooked. A proactive approach should be the rule in this area. Mental health (and psychosocial support programs) is full part of Public Health component. Public Health concerns include the management of communicable diseases, including of epidemics, but is not limited to. The concept of “intra-sectoral integration strategy” (as above described) is a key element of capacity building of the Health Sector for MCM. There are several routine programs (such as routine surveillance, early warning system for CD, etc.) that can be prepared so as to cope with the new demand created by the event. Damage and needs assessment is one of the key elements that must be considered when planning preparedness of the HS (not limited to the CD but also including hospital treatment capacity, etc.). It can discussed be under the “component” Public Health although the process is a crosscutting issue.
Public information is a central function of the health authorities during crisis and disasters that requires preparatory planning. Risk communication is not limited to rescue and legal authorities. The HS should develop its own capacity and capability in this area. Information management is a cross-cutting issue (for instance for tracing patients and providing information to the relatives; for managing the dead and the missing).
Community based organizations, private sector, NGOs, Red Crescent/Cross. The appropriate use of available resources from all potential stakeholders is a key element of surge capacity and surge capability (for health related issues). The management of these resources poses always a great problem when there are no formal agreements, coordination mechanisms and pre-established procedures. The potential of the private sector is too often overlooked by emergency planners of the health sector although this resource can contribute directly and efficiently to effectively manage health priorities (especially medical and surgical care). Examples of sound cooperation during disasters prove that it is possible to develop this component.
First Responders. Although the HS has no authority on the management and the activities of the traditional First Responders (police, rescue services, search and rescue agencies such as fire brigades), it has a direct responsibility in issuing policy, guidance and norms for health related issues (such as the equipment of ambulances and the training of staff for operating ambulances). The HS should advocate (and contribute to the training) for developing First Aid capacity among the staff of First Responders. The sharing of information with the First Responders is critical (interoperability of emergency call centers; organizing the activities on the site; evacuation process and dispatching of patients: safety and security). Coordination mechanisms have already been discussed (including inter-sectoral exercises)
Military assets. The appropriate use of military assets (military medical capacity and capability; transport capacity, mobile units) for managing mass casualty situations should be given more proactive attention by the HS. Too often arrangements are improvised on an ad hoc basis after the impact. Some training activities (and exercises) could be developed with the participation of military component.
Training programs. Training of high level and key technical staff is a pre-requisite for developing policy, for programming and planning for MCM. The whole process of capacity building for MCM (as a critical component of the concept of surge capacity) requires the development of different types of training activities for different stakeholders. Unfortunately the fact is that often the training programs are developed as vertical programs without sustainability. The MOH should develop a much more proactive strategy for ensuring consistency, sustainability (including synergy and complementarities), and local level capacity (including hospitals) in this area. There is NO emergency response plan unless staff has been trained!
Exercises and drills. They are vital for testing, developing, validating the plans. The exercises must be conducted as institutional activities, as intra-sectoral activities and as inter-sectoral activities. Different exercises with different objectives. The HS should adopt a much more proactive role for promoting inter-sectoral exercises, especially at local level.
International assistance and UN contribution. The recent major events have proven that the UN system is more and more an efficient active partner for assisting the MOH in MCM (the new cluster approach is a major step forward). The management of international assistance (donations, supplies, foreign medical teams) requires capacity building in many areas (systems for identifying, managing, distributing, etc.). The MOH has a leading role for assisting the Government to develop the policy on that matter. For instance it is unethical to accept that some unwanted and unprofessional NGOs develop psychological support programs for affected populations (often not culturally adapted). International Field Hospitals can be useful in some circumstances (provided there is a clear policy on that issue).
More comments on “components” of the Figure 1: annex 1
WPRO has issued several documents on community risk management as a strategy for building safer communities
Community has 5 elements: people, property, services, livelihoods, and environment, and has 4 major features: they own common assets for responding to an emergency (police, fire, hospital etc); have authority for decision making delegated by a higher authority; have responsibility for their own financial and human resources; are accountable for their actions
Risk reduction includes vulnerability analysis and reduction, mitigation, readiness, recovery and coping mechanisms. This conceptual risk management concept is widely accepted by UN ISDR and other Institutions
Public safety and risk management : see WPRO strategy
What the MSCC (management of medical surge capacity and capability) System Is
The MSCC Management System is designed to promote the integration of existing programs for incident management used by hospitals, public health, and traditional response entities into an overarching management system for major medical response.
It defines the basic requirements for medical and health asset participation in the overall response system.
Rather than focus on narrow topics (e.g., communications or training), the MSCC Management System examines functional relationships across the range of response needs. In so doing, it provides a systematic approach to organize and coordinate available health and medical resources so they perform optimally under the stress of an emergency or disaster.
The MSCC Management System seeks to enhance management integration and coordination by defining a system that integrates the management of local, Provincial, and National medical response to provide optimal surge capacity and capability, while protecting healthcare staff, current patients, and facility integrity.
Defining the management relationship between HCFs and providers, and the multiple levels of government response
Establishing incident planning processes and information management to promote an integrated medical response that is timely and accurate.
Incorporating incident management system principles to facilitate medical system integration with non-medical incident management during response, and to establish acute care medicine as “first responders” in the emergency response community.
Providing a platform for effective training of medical incident management and response, from the local to the National response levels.
The Medical surge capacity and capability Management System describes a system of interdisciplinary coordination that emphasizes responsibility rather than authority. In other words, each health and medical asset is responsible for managing its own operations, as well as integrating with other response entities in a tiered framework. This allows response assets to coordinate in a defined manner that is more effective than the individual, ad hoc relationships that otherwise occur during a major emergency or disaster.
What the MSCC Management System Is Not
does not address the internal management of individual public health and medical assets, nor is it specifically for hospital emergency preparedness. It does not attempt to redefine the operational methods of other entities (e.g., law enforcement, fire service, emergency management) that also have as primary missions the preservation of life and/or critical infrastructure.
A complex partnership
A variety of Ministries, agencies and other organizations have roles to play in emergencies, with Ministry of Health taking on a major one. Although the names and responsibilities vary from country to country, these will likely include: the Ministries of the Interior, Security, Communications, and Environment; the various branches of the military; Civil Defense agencies; Red Cross/Red Crescent, the private sector, and so on. Given the mix of roles and responsibilities, some form of coordinating structure (or structures) should be in place. These may have names like: Emergency Management Council or Cabinet Emergency Committee (comprising the head of state and key ministers); National Interdepartmental Emergency Committee (top-level civil servants); National Disaster Recovery Committee (a wider grouping which may include non-governmental as well as government figures).
These structures should have formal roles laid out in National Emergency Management plans and policies. Many countries also have a permanently staffed national Emergency Management Agency (or similarly named system) which assumes command, control and coordination responsibilities when large-scale disasters or emergencies occur.
No matter what forms that government and public administration take, national emergency management systems should include:
Identification of lines of authority, from the national to the local level
Financial arrangements for funding emergency work
Arrangements to ensure that government and community activities are maintained (for example, creation of parallel or “hardened” communications systems to take over if normal voice or data transfer systems are affected)
National stockpiling of appropriate resources (including provincial or state and local pre-positioning of stockpiles)
Database of national experts for advice on specific problems
Protocols and formal arrangements for coordinated efforts with other countries, or between provincial or state governments within the country.
Increasingly, governments are adopting decentralised models of national emergency management, devolving operational authority to the lowest possible level of government, recognizing that even though many emergencies can be handled effectively at local level, national political interest may require national involvement. However, some response capabilities may be maintained under national control. These may include Search and Rescue (SAR) teams and specialized functions such as Hazardous Material (“Hazmat”) units needed to deal with events such as chemical incidents or terrorist attacks. Figure 1 provides a generic outline of how national systems of emergency management are structured, showing lines of authority and a range of participating services or agencies.
The Ministry of Health: a leading partner
Whatever the formal institutional arrangements, the Ministry of Health must be heavily involved in all national emergency management potentially dealing with mass casualties, because of both its expertise and its normative role in the setting of health-related standards and rules and procedures. For instance even if the Ministry of Health does not operate ambulances — in some countries this may be the task of the Red Cross/Red Crescent, Civil Defense authorities, or even the private sector — the Ministry of Health is nevertheless likely to set the standards regarding how ambulances are to be equipped, the training of crews, the numbers of ambulances per thousand population, etc.
Because of its expertise, the Ministry of Health is usually well placed to help health care facilities and main health disciplines to develop their emergency plans, create training programmes, prepare drills and exercises, and so on. Finally, the Ministry is usually responsible for promoting standards and overseeing accreditation, for example in validating the plans developed by health care facilities and their local partners.
A dedicated unit within the Ministry of Health
In order for the Ministry of Health to meet its potential as a partner, it must organise itself in a way which maximizes its comparative advantages and brings together the people best suited to the task at hand. A necessary first step will be to form permanent structures with institutional responsibility for all Ministry of Health activities related to planning for mass casualty events. A recommended configuration is a dedicated emergency committee of senior staff, chaired by the Minister of Health, and a dedicated emergency preparedness and response unit whose head serves as secretary of the Committee. The Committee and the Unit should adopt a multidisciplinary, all-hazard, whole-of-health approach, and therefore will consist of experts in all relevant fields.
Formal and informal relationships with other partners
In most countries, when a mass casualty incident occurs that requires a national response, some form of national emergency plan exists which is invoked according to established procedures. Within such arrangements, the Ministry of Health’s immediate role will be to act as a focal point for liaison, coordination and communication between the various health system components (e.g., public, private, military, and NGOs) as well as with other ministries, the office of the head of state and, when necessary, international agencies. This should be done based on a health sector plan (see following chapter) that takes into consideration the need for interdisciplinary coordination with health partners . Because of the potential for confusion arising over issues such as legal authority, jurisdiction, customs importation procedures, and so on, the Ministry should sign Memoranda of Understanding (or equivalent agreements) with other partners to formalize the necessary arrangements. These agreements should be written with relevant national legislation in mind (see below).
Equally important, Ministry of Health staff should establish working relationships with staff in other organizations so that, during a crisis, the “players” (key individuals) are known to each other. This can be most effectively done by joint planning and exercises at all levels (discussed below), as well as regular meetings and periodic evaluations or reviews.
International cooperation
Although another part of government such as the Ministry of Foreign Affairs may have formal responsibility for requesting or accepting assistance from outside the country, the Ministry of Health will have an essential role of facilitating, and coordinating international health assistance if it is required. This applies when assistance is offered or received, and will normally be coordinated with other ministries, the national Emergency Management Agency, and the office of the head of state.
Once again, Memoranda of Understanding or other agreements for mutual aid, support and cooperation should be signed, particularly with neighboring countries, international agencies (including WHO) and international NGOs. It cannot be over-emphasized how important it is for these arrangements to have been prepared at a detailed level, in order for responses to work efficiently.
A solid legislative basis
The Ministry of Health should ensure (in concert with other ministries) that legislation exists which provides adequate authority for mass casualty management within the overall emergency preparedness and response plan. This goes well beyond providing special emergency powers when circumstances require, although that is of course an essential component. Responses from all levels of government (local, provincial or state, and national) must be defined and enabled in the appropriate laws, which will typically have titles like Emergency Management Act, Health Act, Community Services Act, Quarantine Act, etc.
At a minimum, legislation should define the roles of Ministers and other senior officials (e.g., Chief Health Officer, Health/Medical Emergency Coordinator) and provide legal authority for national emergency councils, committees and advisory groups. It must enable the essential Command, Control and Coordination models which form the basis for all emergency management systems.
If existing legislation or legislative gaps (i.e., lack of legally defined authority) act as barriers to effective mass casualty management, the Ministry of Health should help to draft the necessary amendments, according to the established law-making arrangements in the country.
Just a brief comment for introducing the notion of EOC, ICP and EEC. This slide will be discussed in more details in the session on management of operations (under Incident Management System). It is important at that stage that participants understand that there is no efficient MCM unless an efficient management system (for managing information, resources, logistics, activities, etc.). Discuss only “surge capacity” at that stage here
Level 1: using emergency response plans of the hospitals; developing operational plans to respond to a crisis
Level 2: information sharing; systems: mutual aid. Networking of hospitals
Level 3: there are several command and coordination mechanisms: at the site (Incident Command Post); the Emergency Operations Centre (EOC) at the local authority level (multi-sectoral). Depending upon the organization of the country (it size; level of development, resources available) the EOC can be at District level or even at Provincial level
Level 4: in some countries level 3 is assumed by level 4 in this diagram. The notion of Emergency Coordination Centre is important when the size of the incident justify the activation of national (or provincial in some countries) plans. In some particular circumstances the national level has not only a coordination function but also a “managerial function of the response” (it can be in the case of a pandemic; for managing the international donations, etc.)
The six-tier construct depicts the various levels of health and medical asset management during response to mass casualty or complex incidents. The tiers range from the individual HCF and its integration into a local healthcare coalition, to the coordination of Federal assistance. Each tier must be effectively managed internally in order to coordinate and integrate externally with other tiers.
The MSCC Management System describes a framework of coordination across six tiers of response, building from the individual healthcare facility (HCF) and its integration into a local healthcare coalition, to the integration of Federal health and medical support. The most critical tier is jurisdiction incident management (Tier 3) since it is the primary site of integration for health and medical assets with other response disciplines. Each tier must be effectively managed internally in order to integrate externally with other tiers.
Emergency management and Incident Management System (IMS) concepts form the basis of the MSCC Management System. Within IMS, response assets are organized into five functional areas: Management establishes the incident goals and objectives (and in so doing defines the incident); Operations develops the specific tactics and executes activities to accomplish the goals and objectives; and Plans/Information, Logistics, and Administration/Finance support Management and Operations.
The Plans/ Information function is particularly critical because it manages complex information across tiers and facilitates information exchange among responders to promote consistency within the overall system. Because multiple agencies may have leadership responsibilities in a mass casualty or complex incident, a unified management approach is essential. Unified management enables disparate entities (both public and private) to collaborate and actively participate in the development of incident goals, objectives, and an overarching response strategy. Participation by public health and medical disciplines in unified management is important since these disciplines have a primary responsibility for ensuring the welfare of responders and the general public. Where unified management is not implemented due to sovereignty issues (e.g., across State borders or between private facilities), effective mechanisms for management coordination
Jurisdiction Incident Management (Tier 3)
Tier 3 directly integrates HCFs with other response disciplines (e.g., public safety, emergency management) to maximize jurisdictional MSCC. It is the most critical tier for integrating the full range of disciplines that may be needed in a mass casualty or complex medical event. The focus of Tier 3 is to describe how to effectively coordinate and manage diverse disciplines in support of medical surge demands. This requires healthcare assets to be recognized as integral members of the responder community and to participate in management, operations, and support activities. In other words, health and medical disciplines must move from a traditional support role based on an Emergency Support Function (ESF) to part of a unified incident management system. This is especially important during events that are primarily health and medical in nature, such as infectious disease outbreaks
In many developing countries (or small countries) the tiers 3 and 4 are only one tier in MCI. The local level (District) has not the resources for really developing a response with an EOC. The EOC can be activated (and created) only if there are resources to mobilize, to coordinate and to manage. Having just on ambulance and one PHC Center does not constitute a “tier” of level 3. In major MCI many countries have local EOC (EOCs) with a Provincial ECC (Emergency Coordination Centre). In some countries the EOC is located at Provincial level (France) and not at local level.
The Medical Surge Capacity and Capability Management System describes a management methodology based on valid principles of emergency management and the Incident Management System (IMS). Medical and health disciplines may apply these principles to coordinate effectively with one another, and to integrate with other response organizations that have established IMS and emergency management systems (fire service, law enforcement, etc.). This promotes a common management system for all response entities—public and private—that may be brought to bear in an emergency.
The Management System emphasizes responsibility rather than authority alone for assigning key response functions and advocates a management-by-objectives approach. In this way, the Management System describes a framework of coordination and integration across six tiers (levels) of response:
Management of Individual Healthcare Assets (Tier 1): A well-defined IMS to collect and process information, to develop incident plans, and to manage decisions is essential to maximize capacity and capability. Robust processes must be applicable both to healthcare facilities (HCFs) that may provide “hands on” patient care in an emergency. Thus, each healthcare asset must have information management processes to enable integration among HCFs (at Tier 2) and with higher management tiers. Networking of HCF is of paramount importance (see dispatching and EMS system in another section)
Management of a Healthcare Network (Tier 2): Coordination among local healthcare assets is critical to provide adequate and consistent care across an affected jurisdiction.1 The healthcare coalition provides a central integration mechanism for information sharing and management coordination among healthcare assets, and also establishes an effective and balanced approach to integrating medical assets into the jurisdiction’s IMS
Jurisdiction Incident Management (Tier 3): A jurisdiction’s IMS integrates healthcare assets with other response disciplines to provide the structure and support needed to maximize MCM. In certain events, the jurisdictional IMS promotes a unified incident management approach that allows multiple response entities, including health and medicine, to assume significant management responsibility
Management of Provincial Response (Tier 4): Provincial Government participates in medical incident response across a range of capacities, depending on the specific event. The Provincial Authority may be the lead incident management authority, it may primarily provide support to incidents managed at the jurisdictional (Tier 3) level, or it may coordinate multi jurisdictional incident response, ensuring that the full range of Provincial health and medical resources is brought to bear to maximize MCM
National Support to Provinces and Jurisdiction Management (Tier 5): Effective management processes at the Provinces (Tier 4) and jurisdiction (Tier 3) levels facilitate the request, receipt, and integration of National health and medical resources to maximize MCM.
The tiers of the MCM Management System do not operate in a vacuum. They must be fully coordinated with each other, and with the non-medical incident response, for medical and health resources to provide maximum MCM. The processes that promote this coordination and integration enable medicine and public health to move beyond their traditional support roles (for example, as an Emergency Support Function) and become competent participants in large-scale medical incident management.
Response systems, by necessity, are adapted to address historically effective capabilities, available resources, specific laws and regulations, and the medical and health infrastructure in a given area. Many of the tenets of the MC Management System are not easily achieved. For example, garnering support and participation from medical clinics and private physician offices, while laudable, is by no means a simple task to accomplish. The existence of a clear policy on these issues helps to prepare arrangements in advance. The policy should deal with :
national response Health and medical response management across the intergovernmental and public-private partners
Inter Provincial Regional response
Provincial response
Municipality response
HCF network response
Individual healthcare facility response
Discussing key issues such as:
Defining a system that integrates the management of local, Province, and National medical response to provide optimal surge capacity and capability, while protecting healthcare staff, current patients, and facility integrity
Defining the management relationship between HCFs and providers, and the multiple levels of government response
Establishing incident planning processes and information management to promote an integrated medical response that is timely and accurate
Incorporating incident management system principles to facilitate medical system integration with non-medical incident management during response, and to establish acute care medicine as “first responders” in the emergency response community
Providing a platform for effective training of medical incident management and response, from the local to the Federal response levels