Query: Hospital Preparedness -Disaster Management Plan and Incident Command System. Advice, Examples

Disaster Management Community Solution Exchange for the Disaster Management Community Consolidated Reply Query: Hospital Preparedness -Disaster Management Plan and Incident Command System. Advice, Examples Compiled by G Padmanabhan, Resource Person and Nupur Arora, Research Associate Issue Date: 31 March 2011 From Alinawaz Nanjee, Focus Humanitarian Assistance, Mumbai Posted 10 January 2011 Disaster put intense demands on the community health system. While certain disasters do it for a short period, others involving a large number of casualties place heavy continuing demands on the health system. Disasters lead to a growing threat of a mass casualty incident (MCI). Preparing for MCIs is a daunting task, as each disaster is different and so is the response. These differences hold challenging implications for the hospital preparedness and training. The hospital disaster preparedness therefore has to be given upmost importance. Hospitals would be among the first institutions to be affected after a disaster, natural or man-made. Because of the heavy demand placed on their services at the time of a disaster, hospitals need to be prepared to handle such an unusual workload. This necessitates a well documented and tested Hospital disaster management plan (HDMP) to be in place in every hospital. To increase their preparedness for mass casualties, hospitals have to expand their focus to include both internal and community-level planning. My organization, Focus Humanitarian Assistance is currently working on a Hospital Safety project Mumbai. The project has the following objectives: Protect the lives of patients and Hospital staff by ensuring the disaster resilience of health facilities. Make sure health facilities and health services are able to function in the aftermath of emergencies and disasters One of the activities of the project is to prepare a Hospital Disaster Management Plan. We are currently drafting the contents of this plan. Most of the plans we have studied so far are essentially response specific and do not mention about hospital's hazard and vulnerability. In order to prepare a comprehensive Hospital Disaster Management Plan, I request members to: Suggest components that should be included in the plan and share examples of HDMPs for reference and Advice on the appropriate Incident Command System for a hospital during an emergency and share examples of ICS systems for hospitals

The suggestions will surely be added in our plan and will also benefit those working on hospital safety. Responses were received, with thanks, from 1. Janak Raj Bhardwaj, Former Member, National Disaster Management Authority, New Delhi (Response 1, Response 2, Response 3) 2. Ravi Nitesh, Mission Bhartiyam, Lucknow 3. G. Premnath, AIRN Evergy, New Delhi 4. Aditi Umrao, GoI- UNDP DRR Programme, Uttar Pradesh 5. Shakeb Nabi, ActionAid International, Bangladesh 6. Yogendra Nanoskar, Mumbai Civil Defence, Mumbai 7. Sanjeevan Joshi, Civil Defence, Mumbai 8. Gaurav Varma, Vaastu Aakriti, Dehra Dun 9. N. M. Prusty, Sphere India, New Delhi 10. Abha Mishra, GOI- UNDP Disaster Risk Reduction Programme, New Delhi 11. Mrinal K Nath, GeoHazards International New Delhi Further contributions are welcome! Summary of Responses Comparative Experiences Related Resources Responses in Full Summary of Responses Hospitals are central to provide emergency care and hence when a disaster strikes the society falls back upon the hospitals to provide immediate support in the form of emergency medical care. The discussion seeking suggestions for preparing Disaster Management Plan and Incident Command System for Hospitals attracted a number of insightful responses. Disasters and other mass casualty incidents (MCI), members opined can cause great confusion and inefficiency in the hospitals and can overwhelm the hospitals resources, staffs, space and supplies. Hospital disaster management provides the opportunity to plan, prepare and respond in such cases. Lack of any tangible plan to fall back upon in times of disaster leads to a situation where there are many sources of command, many leaders, and no concert effort to solve the problem. Therefore, it is essential that all Hospital Disaster Management Plans have the primary feature of defining the command structure in their hospital, and to extrapolate it to disaster scenario with clear cut job definitions during disasters. Discussants opined that Hospital Preparedness needs to be an integral part of the Hospital Management Protocol of all types of hospitals right from small dispensary to medium size and large size multi specialist hospitals, rural to urban hospitals, private to Government and Corporate hospitals. Indeed the subject needs also find a place in the curriculum of medical and public health education. Members stressed on the need to make efforts to design and offer appropriate training programs in National Institute of health and State Institute(s) of health.

The hospital emergency planning members felt can be divided into three phases of pre, during and post. They detailed the following activities under each phase: Pre disaster phase Planning: Need assessment and preparation of hospital plans Awareness generation: Prepared hospital disaster plan and Standard Operating Procedures to be written down in a document form and copies to be made available in all the areas of the hospital. Staff education and training: Train staff on using the hospital disaster/emergency manual and conducting mockdrills Disaster Phase Phase of activation: Notification of emergency. Activation of the chain of command in the hospital. Operational phase: Tackling of mass casualties is performed according to the disaster/emergency plan. Phase of deactivation: when the administration/ command of the hospital is satisfied that the influx of mass casualty victims is not continuing to overwhelm the hospital facilities the plan is deactivated. Post Disaster Phase Discuss activities of the disaster/ emergency phase and the notice the inadequacies for future improvements. Respondents pointed out that both for human induced and Natural disasters careful handling by specialized and trained personals is a critical requirement. Recalling the incidence of Radio emission of Cobalt in a scrap market of Mayapuri area of New Delhi, members mentioned that hospitals then could not diagnose symptoms of radio emission as they unaware of such kind of a disaster. Therefore, they opined that the plan must be comprehensive enough to include disasters of any type, from general to specific, from human induced to natural and plans for of each type of disaster, their affect on health, recognition of disease and managing mass care. Members suggested the following the plan can include: List of trained personals and their back up references. List of approved vendors with contact numbers to procure apparatus/ materials in bulk in case of requirement in emergency situation. List of personals of other hospitals to handle emergency situation in case of emergency Details of Operational Areas (Patient Care Areas) including the existing patient care areas (Reception and Triage areas, Emergency and resuscitation areas, Definitive care areas, Intensive care areas, etc.) and certain areas which are free in the hospital area and can be optionally used as patient care areas during the initial surge of patients. Detailed Standing Orders and Protocols for patient management Hospital Triage Criteria Communication strategy (Intra and Inter Hospital) Pre-hospital transports arrangements Security arrangements Police networks Evacuation details Medico-legal responsibilities Plan for Disposal of the Dead (Role of Mortuary services and Forensic Departments in identification, storage and disposal of the deceased)

Apart from the above, participants proposed to include the following activities/programmes in the plan: Volunteer programme for special care of disaster affected patients. Awareness generation programme about common post disaster health problems and its prevention Emergency evacuation drills Annual Safety and security audits of the hospital Creating a cooperation network amongst the hospital in the local Area so that in Emergency medical help can be managed within the Area. Planning for giving special assistance to Handicapped, Children, age old persons Prepare for CBRN threats by planning of Personal Protection Equipment, Detection equipment, Anti dotes, Training etc Members shared the Guidelines on Medical preparedness for Mass casualty prepared by the National Disaster Management Authority and urged the Hospitals to implement the recommendations. The guidelines address all aspects for preparedness for mass causality incidence including a format of Hospital Disaster management Plan given as an appendix to the document. Highlighting the importance of Non structural hazard assessment and mitigation, members stressed that this must be included in the HDMP. Research in the subject indicates that over 50% of the losses in an earthquake are due to falling hazards or non-structural hazards (i.e. the contents of the building falling down and causing injuries and damage). Hospitals are critical institutions that community members rely on to save lives in an emergency and these critical buildings house a large number of objects that are required for operational and functional purposes. Discussants felt that although there is enough knowledge and literature available through various central ministries and state departments, implementation of various preparedness measures in the hospitals is still a challenge. Members felt that the concerned State Authorities those issue instructions need to be made aware of the infrastructural facilities required and the elements of Hospital preparedness. While issuing instructions it s important to indicate time bound actions to be taken and to accelerate this process, they suggested providing appropriate powers to medical authorities. Another critical concern highlighted by members was that the building byelaws and safety provisions as stipulated by various government departments are not followed. Participants brought to light an important issue of inadequate funds available to the States for medical services including Hospital preparedness. The survey conducted by WHO few years back showed that the total expenditure for health in the country ranged from 0.2 to 2 percent from state to state, where as developed countries spend about 8 to 12 percent of their budget. Members shared that recently the Government has agreed to create Disaster Mitigation Fund both the centre and States. Members opined that it can be been extended to District level also as envisaged in DM ACT 2005. They mentioned that the Planning Commission does allocate sufficient funds to central heath ministry but the benefit of this allocation is unfortunately not reaped by the State health Department. Health being a State subject central health ministry does not provide monetary support for State Programmes and when central programmes are not doing well the state suffers. They recommended implementing health programmes through Medical Authorities with proper funds, accountability and executive powers. Concluding the discussion members felt that this issue is a very important one, because it talks about the place which is really the most affected after disaster takes place anywhere, and a well formulated system (Disaster Management Plan and Incident Command System) can help to increase the efficiency of the total system, which in result may save more lives..

Comparative Experiences Bangladesh Hospital Safety and Mass Casualty Management, Bangladesh (from Shakeb Nabi, ActionAid International, Bangladesh) ActionAid under its various DIPECHO programs has been working with various government health institutions to ensure that hospital capacities are enhanced for any Mass casualty Incident. They Developed a thorough understanding on various aspects related with Mass Casualty Incident Management and carried out a baseline research to understand and estimate what work has already been done by different agencies towards mass casualty management. After this they advocated incorporating of a module on "Hospital Safety and Mass Casualty Management" in the National medical and nursing curriculum thus carried out comprehensive mass casualty management in the country Related Resources Recommended Documentation National Disaster Management Guidelines - Medical Preparedness and Mass Casualty Management (from J. R. Bhardwaj, Former National Disaster Management Authority, New Delhi) Guidelines; National Disaster Management Authority (NDMA); New Delhi; 2007; Permission Required: Yes, Contact NDMA to get a copy) Available at http://pib.nic.in/release/release.asp?relid=32654 Press release on the guidelines prepared by NDMA to manage public health emergencies with mass casualties in the country Guidelines for Hospital Emergency Preparedness and Planning (from Shakeb Nabi, ActionAid International, Bangladesh and Sanjeevan Joshi, Civil Defence, Mumbai)) Guidelines; by GOI-UNDP Disaster Risk Management Programme; New Delhi; Available at http://data.undp.org.in/dmweb/guidelines_hospital_emergency_2008.pdf (Pdf 234 KB) These guidelines are exhaustive and cover major aspects of Hospital Emergencies, including the problems created during natural or man-made disasters. Kindly refer them. Disaster Management Act 2005 (from N. M. Prusty, Sphere India, New Delhi)) Act; by Ministry of Home Affairs; Government of India, New Delhi; 2005; Available at http://nidm.gov.in/dm_act2005.pdf (Size: 1.67 MB) Act addresses the issue of management of disasters and plans for disaster preparedness in the country. Reducing Earthquake Risks in Hospitals from Equipment, Contents, Architectural Elements and Building Utility Systems (from Mrinal K Nath, GeoHazards International New Delhi) Manual; by GeoHazards International and Swiss Re; India; 2009; Available at http://www.geohaz.in/upload/files/hospitalsafetymanual.pdf (Pdf 233 KB) A comprehensive tool with numerous practical and graphic details to enable all hospital administrators and departmental in-charges to initiate safety measures within their area of influence.

Recommended Contacts and Experts Lt. General J. R. Bhardwaj, Former Member National Disaster Management Authority, New Delhi jrb2600@gmail.com With vast experience disaster management and health, he can be consulted on policies and documents on disaster management. Dr. Girish Joshi, Disaster Management and Mitigation Centre, Uttrakhand (from Abha Mishra, GOI- UNDP Disaster Risk Reduction Programme, New Delhi) Uttrakhand; Tel: 0135-2710334, 2710335, 2710233; Works with DMMC who has provided technical support to the various governmentt. and department s and has the requisite expertise Recommended Organizations and Programmes ActionAid, Bangladesh (from Shakeb Nabi, ActionAid International) House #8, Road #136, Gulshan 1, Dhaka 1212, Tel: +88 02 8837796, 9894331 mail@actionaid-bd.org; http://www.dipecho-bd.org/guideline.php; http://www3.actionaid.org/bangladesh/ Under its various DIPECHO programs, ActionAid works with various government health institutions for building hospital capacities for any Mass casualty Incident. GeoHazards International, United States 200 Town & Country Village, Palo Alto, California 94301, U.S.A.; Tel: +1 (650) 614-9050 ; Fax: +1 (650) 614-9051 webmaster@geohaz.org; http://www.geohaz.org/ Organization aims at reducing deaths and injury caused by natural hazards by focussing on the physical infrastructure of earthquake prone areas. Recommended Communities and Networks Safecommunities.info, making India Safer, India (from Shakeb Nabi, ActionAid International, Bangladesh) http://safecommunities.info/; contact@safecommunities.info. a user specific portal on Hospital Safety where the highest vulnerabilities and exposure exists, helps hospitals to share information and connect to each other. Related Consolidated Replies Addressing Vulnerability of Children, Pregnant and Lactating Women during Disasters, from Abha Jha, Delhi Disaster Management Authority, New Delhi (Experiences; Referrals), Maternal and Child Health Community and Disaster Management Community, Solution Exchange India, Issued 30 June 2009. Available at ftp://ftp.solutionexchange.net.in/public/mch/cr/cr-se-mch-drm- 21050901.pdf (PDF, Size: 245 KB). Seeking experiences and referrals for addressing the vulnerability of children, pregnant and lactating displaced women in post disaster situations especially in relief camps and temporary shelters. Maternity and Allied Services in Floods, from G Padmanabhan and Meghendra Banerjee, UNDP and Solution Exchange, WHO, New Delhi (Experiences, Referrals). Disaster Management Community and Maternal and Child Health Community, India,

Issued 30 September 2008. Available at ftp://ftp.solutionexchange.net.in/public/mch/cr/cr-sedrm-mch-22090801-public.pdf (PDF, Size: 210 KB) Lists possible services that can be offered to pregnant and lactating women and children in flood situations and organizations who can provide them Strengthening Pre-Hospital Care Systems during Emergencies, from Deepa Prasad, United Nations Development Programme (UNDP), Bhubaneswar (Experiences; Advice). Disaster Management Community, Solution Exchange India. Issued 28 February 2008 Available at ftp://ftp.solutionexchange.net.in/public/drm/cr/cr-se-drm-05120701.pdf (PDF, Size: 99 KB) Shares experiences of linking volunteers with public health systems and suggestions to improve pre-hospital care systems and involving volunteers in Mass Casualty Incidents Community Based Health Care and Psychosocial Interventions Following Disasters, from Deepa Prasad, United Nations Development Programme (UNDP), Bhubaneswar (Experiences; Examples). Disaster Management Community, Solution Exchange India. Issued 28 March 2008. Available at: ftp://ftp.solutionexchange.net.in/public/drm/cr/cr-se-drm-20020801.pdf (Size: 154 KB) Shares interventions on preventing disease outbreaks; strategies to involve volunteers in risk identification and community-based initiatives for psychosocial care during disasters Standardizing First Aid and Search and Rescue Kits, from Adesh Tripathee and Eilia Jafar, International Federation of Red Cross and Red Crescent Societies (IFRC) - Regional Delegation of South Asia, New Delhi (Advice). Disaster Management Community, Solution Exchange India. Issued 16 May 2008. Available at ftp://ftp.solutionexchange.net.in/public/drm/cr/cr-se-drm-21040801.pdf (PDF, Size: 114 KB) Brings out suggestions on preparing standardized first aid kits for family, school and trained volunteers and lists down items for them Responses in Full Janak Raj Bhardwaj, Former Member, National Disaster Management Authority, New Delhi (Response 1) I am very happy to note the you have taken up a very important subject which has largely not implemented in our hospital inspite of National Guidelines on Medical preparedness for Mass casualty.the guidelines are available on NDMA web site (http://ndma.gov.in/ndma/guidelines.htm). The guidelines address all aspects for preparedness for mass causality incidence including a format of Hospital Disaster management Plan given as an appendix to the document. I can personally help your organization in this task if you require. i shall request you to go through the national Guidelines. Ravi Nitesh, Mission Bhartiyam, Lucknow I found this query a very important one, because it talks about the place which is really the most affected after disaster takes place anywhere, and a well formulated system (Disaster Management Plan and Incident Command System) can help to increase the efficiency of the total system, which in result may save more lives.

Man made and Natural both types of disasters should be carefully handled by specialized and trained personals. If we recall the example of Radio emission of Cobalt in a scrap market of Mayapuri area of Delhi, where hospitals could not diagnose that patients were victims of radio emission. It happens because they were not aware about radio emission disaster, it was very specific type. I gave this example because we cannot make DMP area specific/type specific. We should prepare ourselves for every type of situation and we can definitely cover it through share of ideas. Disasters can be of any type, from general to specific, from man made to natural, anything. Therefore it needs an organogram of each type of disaster, their affect on health, recognition of disease and managing mass care. Contents should include: list of personals (preferably well trained for disaster affected patients) and their back up manpower. Training to communities for safe living after disaster takes place. List of approved vendors with contact numbers to procure apparatus/ materials in bulk in case of requirement in emergency situation. List of personals of other hospitals to handle emergency situation in case of emergency. Volunteer program for special care of disaster affected patients. Finally it s also essential to create awareness about common health problems (as an affect of disaster after disaster) and its prevention. G. Premnath, AIRN Evergy, New Delhi Pro active measures should include: Annual Safety and security audits of the hospital Emergency evacuation drills Additional Security to be deployed to cordon off the area and prevent theft and ensure life safety of vulnerable patients. Someone may use the disaster to mis behave with patients like women and children. Contracts with service providers to activate the plan for mobilising resources like additional ambulance, generators A system of additional power back up arrangements etc Ensure coordination of additional security while causalities are evacuated. You would remember that even hospitals were targeted by terrorists while casualties were brought in from the scene of bomb blasts. Aditi Umrao, GoI- UNDP DRR Programme, Uttar Pradesh Hospital disaster management provides the opportunity to plan, prepare and when needed enables a rational response in case of disasters/ mass casualty incidents (MCI). Disasters and mass casualties can cause great confusion and inefficiency in the hospitals. They can overwhelm the hospitals resources, staffs, space and or supplies. Lack of any tangible plan to fall back upon in times of disaster leads to a situation where there are many sources of command, many leaders, and no concerted effort to solve the problem. Everyone does his/ her own work without effectively contributing to solving the larger problem of the hospital. Therefore, it is essential that all Hospital Disaster Management Plans have the primary feature of defining the command structure in their hospital, and to extrapolate it to disaster scenario with clear cut job definitions once the disaster button is pushed. Chaos cannot be completely prevented during the first minutes of a major accident or disaster. But the main aim of Hospital Disaster Management Plan should be to keep this time as short as possible.

A plan should include the following:- Details of Operational Areas (Patient Care Areas) this should include the existing patient care areas (Reception and Triage areas, Emergency and resuscitation areas, Definitive care areas, Intensive care areas, etc.) the plan should also label certain areas which are free in the hospital area which can be optionally used as patient care areas during the initial surge of patients. Standing Orders and Protocols for patient management Hospital Triage Criteria Documentation details Communications (Intra and Inter Hospital) Networking including capacities and capabilities of health facilities Pre-hospital transports Security arrangements Police networks Evacuation details Medico-legal responsibilities Disposal of the Dead (Role of Mortuary services and Forensic Departments in identification, storage and disposal of the deceased) The hospital emergency planning can be divided into three phases: 1) Pre disaster phase a) Planning: Most of the assessment and planning is done in the pre disaster phase, the hospital plans are formulated and then discussed in a suitable forum for approval. b) The disaster manual: The hospital disaster plan should be written down in a document form and copies of the same should be available in all the areas of the hospital. c) Staff education and training: It is very important for the staff to know about and get trained in using the hospital disaster/emergency manual. Regular staff training by suitable drills should be undertaken in this phase. 2) Disaster Phase a) Phase of activation: Alter and notification of emergency. b) Activation of the chain of command in the hospital. c) Operational phase: This is the phase in which the actual tackling of mass casualties is performed according to the disaster/emergency plan. d) Phase of deactivation: An important phase of the hospital emergency plan when the administration/ command of the hospital is satisfied that the influx of mass casualty victims is not continuing to overwhelm the hospital facilities. 3) Post Disaster Phase This an important phase of disaster planning were the activities of the disaster/ emergency phase are discussed and the inadequacies are noted for future improvements. Shakeb Nabi, ActionAid International, Bangladesh Hospitals are central to provide emergency care and hence when a disaster strike the society falls back upon the hospitals to provide immediate succor in the form of emergency medical care.

Based on the experience in various post disaster scenarios where the capacities of the hospitals are overwhelmed many a times, the hospital infrastructure is itself affected and made redundant by the disaster, there has been significant amount of focus on Hospital Safety and Mass Casualty Incident Management. ActionAid under its various DIPECHO programs has been working with various government health institutions (Directorate General of Health Services, Center for Medical Education, Various tertiary level hospitals) to ensure that hospital capacities are enhanced for any Mass casualty Incident. Some of the interventions that we feel are highly critical are as follows: Develop a thorough understanding on various aspects related with Mass Casualty Incident Management (you can refer to (http://safehospitals.info/images/stories/3resources/guidline%20final.pdf) Carry out a baseline research to understand and estimate what work has already been done by different agencies towards mass casualty management. Advocate with government with authentic data and case studies to ensure that MCI management is given due space in government policies. One of the things that we advocated for in Bangladesh is the incorporation of a module on "Hospital Safety and Mass Casualty Management" in the National medical and nursing curriculum. Ensure that there is a disaster plan guideline and all the hospital are mandated to prepare its disaster management plan.the aim of a hospital disaster plan is to provide prompt and effective medical care to the maximum possible, in order to minimize morbidity and mortality resulting from any Mass Casualty Incident. You can also go to our website (http://www.dipecho-bd.org/guideline.php) and learn more about comprehensive mass casualty management. Other website which is highly recommended is http://safecommunities.info/ Yogendra Nanoskar, Mumbai Civil Defence, Mumbai The issue raised is really sensitive and important. We are not thinking hospitals from point of view of Disaster Management. The hospital staff and administration should be prepared and trained not only for medical emergencies of ROUTINE but also for various other types of emergencies such as CBRN (Chemical, Biological, Radiological and Nuclear) threats or Psychological trauma. I suggest as follows: The in-house capacity of resources should be considered and planned. The Response plan should be informed to each and every staff of hospital right from Administrator to a Sweeper / labour. The SOP for each post should be designed and that should be known to every person. For this regular In-house Mock drills should be conducted. The construction and planning of Field Mobile medical units should be considered, This should be planned from available resources of Hospital staff without affecting the inhouse requirement BUT only on demand A0by Authorities. A CO-OPERATION network amongst the hospital in the local Area should be formed and planned so that in Emergency medical help can be managed within the Area. This should be made MANDATORY FOR private hospital also.

Psycho medical help should be kept Ready in the hospital as it is the worst result of any disaster or Incidence. The planning for giving special assistance to Handicapped, Children, age old persons need to be considered. The Hospitals should consider and prepare for CBRN threats by planning of Personal Protection Equipment, Detection equipment, Anti dotes, Training etc I hope my suggestions will be helpful for you Janak Raj Bhardwaj, Former Member, National Disaster Management Authority, New Delhi (Response 2) Inspite of lots of knowledge and literature available through various documents issued to central ministries and state departments, implementation of various preparedness measures in the hospitals is still a challenge. The concerned State Authorities that issue instructions need to be made aware of the of the infrastructural facilities required and the elements and importance of Hospital preparedness. While issuing instructions it s important to indicate time bound actions. Appropriate powers may given to medical authorities to accelerate the process. Sanjeevan Joshi, Civil Defence, Mumbai Under the GOI-UNDP Disaster Risk Management Programme detailed Guidelines for Hospital Emergencies and Preparedness were issued. These can be accessed on the link: http://data.undp.org.in/dmweb/guidelines_hospital_emergency_2008.pdf These guidelines are exhaustive and cover major aspects of Hospital Emergencies, including the problems created during natural or man-made disasters. Kindly refer them. Gaurav Varma, Vaastu Aakriti, Dehra Dun At the onset I would like to introduce myself. I am a practicing architect in Uttrakhand for more than 15 years. During this period I had opportunities to work on projects for government as well as non government organization/companies. It is sad to observe that while the some agencies try and fulfill all the building and safety norms after, getting requisite approvals from the concerned departments, some other agencies unfortunately act in just the opposite way. Recently I had an opportunity to work on a project to design a hospital in the state. The building byelaws and safety provisions as stipulated by various government departments have not been followed. When the this was communicated to the, agency the response was not positive. Given the above mindset how can we expect to deliver proper infrastructure at grassroots level. When even in normal times such buildings cannot provide the basic civil/safety amenities and infra structure, how do we expect them to deliver results at the time of disaster and act as relief centres. I hope someone can tell me how this problem can be highlighted and brought to the notice of concerned authorities. N. M. Prusty, Sphere India, New Delhi I support the thoughts of Hon ble Dr. Bhardwaj, Former Member of NDMA who has done pioneering work in the field of Public Health Management in Emergency.

In my opinion Hospital Preparedness need to be an integral part of the Hospital Management Protocol of all types of hospitals right from small dispensary to medium size and large size multi specialist hospitals, rural to urban hospitals, private to Government and Corporate hospitals. Indeed the subject should also find a place in the curriculum of medical and public health education. The newly announced IRS Protocol should be an integral part of this. In my opinion these are some of the aspects of mainstreaming disaster management to the development programming. Medical Council, Health Ministry etc should pay attention to this. Efforts should be made to design and offer appropriate training programs in National Institute of health and State Institute(s) of health. The curriculum for Hospital Administration must embrace this as an integral part of the course both at Bachelors as well as Master level. While writing this the recent incident of Sabrimala reminds of repeated systemic failure in managing crowd especially for pilgrimage, we have seen several temple tragedies which can be very well avoided and also managed if occurs, but we see situation to the contrary, there is neither preparedness planning nor response management. MOST PRIORITY ACTION IS CALLED FOR. Janak Raj Bhardwaj, Former Member, National Disaster Management Authority, New Delhi (Response 3) Dr. Gandhi has brought out an important issue of providing adequate funds to the States for medical services including disaster medicine preparedness. Our country is not allocating adequate funds out of National Bugdet. The survey conducted by WHO few years back showed that the total expenditure for health in the country ranged from 0.2 to 2 percent from state to state, where as developed countries spend about 8 to 12 percent of their budget. Recently Government has agreed to create Disaster Mitigation Fund both the centre and States. Ideally it should have been extended to District level also as envisaged in DM ACT 2005. Planning Commission does allocate sufficient funds to central heath ministry but the benefit of this allocation is not reaped by the State health Department. Health being a State subject central health ministry do not provide monetary support for State Programmes and when central programmes are not doing well the state suffers. Implementation of health programmes should be controlled by Medical Authorities with proper funds, accountability and executive powers. Such suggestions have been made in the past but never considered seriously. Abha Mishra, GOI- UNDP Disaster Risk Reduction Programme, New Delhi I would like to respond to Gaurav Varma s point. I think one of the most progressive state in terms of working on disaster management is Uttarakhand. They have a large number of Government Engineers trained in safe construction practice and have also amended the Building byelaws as required by the states vulnerability. It has also constituted Hazard Safety Cells in each of the Districts and placed dedicated Human resource with funds in the Disaster Management Authorities.

You could approach them at the district level or I suggest that you approach Dr. Girish Joshi, Civil Engineer, working on these issues in Disaster Management and Mitigation Centre, Uttarakhand Secretariate (an body created by the government by the department of Disaster Management) to address your issues. DMMC has been providing technical support to the various govt. and department s and has the requisite expertise. Addressing concerns in the right forum and who to contact is very important. We can achieved what we want if we persist in our demands as Attitudinal, Behavior Change is not an easy task and will take time. Mrinal K Nath, GeoHazards International New Delhi The query is indeed very urgent and important. I like to mention a very important component of Hospital Disaster Management Plan (HDMP) which probably the members have not touched. Non structural hazard assessment and mitigation should get a prime focus in the HDMP. Research in the subject indicates that over 50% of the losses in an earthquake are due to falling hazards or non-structural hazards (i.e.: the contents of the building falling down and causing injuries and damage). Hospitals are critical institutions that community members rely on to save lives in an emergency and these critical buildings house a large number of objects that are required for operational and functional purposes. After an earthquake even though the building may stand undamaged the hospital may not be functional anymore. Because all the critical and valuable instruments inside would have gone damaged during the shaking. Those objects can be referred as non-structural components because they are not part of the building structure that resists forces. Research has showed that in modern hospitals the cost of the building structure is just 30 to 40 percent of the total cost of the hospital and the remaining percent is of non structural elements including costly equipments. These equipments may go damage during heavy earthquake shaking. These non structural objects can be anchored with a little effort which will help in business continuity. So, non structural risk assessment and mitigation should get priority in the HDMP. GeoHazards International (GHI) and GeoHazards Society (GHS) have been working for a long time to reduce the risk from non structural components in hospitals. They have also developed and printed a manual on Hospital Safety with support from NDMA and Swiss Re. Members may download a soft copy of the manual Reducing Earthquake Risks in Hospitals from Equipment, Contents, Architectural Elements and Building Utility Systems from the link: http://www.geohaz.in/upload/files/hospitalsafetymanual.pdf Many thanks to all who contributed to this query! If you have further information to share on this topic, please send it to Solution Exchange for the Disaster Management Community in India at se-drm@solutionexchange-un.net.in with the subject heading Re: [se-drm] Query: Hospital Preparedness -Disaster Management Plan and Incident Command System. Advice, Examples - Additional Reply.

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