DOH - HEMS Guidelines

This material was developed and produced by the Health Emergency Management Staff (HEMS) of the Philippine Department of Health (DOH) with the support of the World Health Organization (WHO). This manual may be reproduced or translated into other languages without prior permission from the HEMS, provided the parts used are distributed free or at cost (not for profi t) and acknowledgment is given to HEMS as the source. The HEMS would be grateful to receive cop-ies of any adaptations or translations of the manual into other languages. Copies may be addressed or delivered to:

The Director Health Emergency Management Staff Department of Health San Lazaro Compound Rizal Avenue, Sta. Cruz, Manila

Guidelines for

Health Emergency Management

Manual for Hospitals

Second Edition

Health Emergency Management StaffDepartment of Health

World Health Organization

Philippines2008 3 i

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The Manual of Guidelines for Health Emergency Management for Hospitals is one of the three manuals revised by the Health Emergency Management Staff. The two others are for the Operations Center and for the Centers for Health Development.

Grateful acknowledgment is given to:- All our colleagues whose first-hand experiences in the field – their insights, pains

and successes – served as the bases for the changes.- Technical and support staff in the office that facilitated the smooth flow of

activities.- De La Salle Health Sciences Institute, Dasmarinas, Cavite for promoting a critical

view among its contributors/writers and for administrative assistance in the systematization and organization of the final form of the manuals.

- World Health Organization, Western Pacific Regional Office-Emergency and Humanitarian Action, and WHO Philippines for technical assistance and financial support in the development and production of the three manuals.

Our thanks to God Almighty for guiding and leading us along the path in the realization of the manuals and their ultimate application for the protection and safety of our communities and our people.

- Health Emergency Management Staff

TECHNICAL WORKING COMMITTEE

Carmencita A. Banatin, MD, MHADirector IIIHealth Emergency Management StaffChairperson

Manual of Guidelines for Centers for Health DevelopmentAssistant Chairperson: Marilyn V. Go, MD, MHA Chief Health Emergency Preparedness Division Health Emergency Management StaffMembers: Eng. Aida C. Barcelona Health Emergency Management StaffElnoria G. Bugnosen, RN Center for Health Development - CARAtty. Annabelle C. de Veyra, RN Center for Health Development - VIIIFlorinda V. Panlilio, RND Health Emergency Management StaffNoel G. Pasion, MD Center for Health Development - IV AMary Grace H. Reyes, MD, MPH Center for Health Development Metro ManilaEdgardo O. Sarmiento MD Bicol Sanitarium

Manual of Guidelines for HospitalsAssistant Chairperson: Arnel Z. Rivera, MD Chief Health Emergency Division Health Emergency Management Staff

ACKNOWLEDGMENTS

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Members:Romeo A. Bituin, MD Dr. Jose Fabella Memorial HospitalEmmanuel M. Bueno, MD East Avenue Medical CenterAlexis Q. Dimapilis, MD San Lazaro HospitalMa. Belinda B. Evangelista, RN National Kidney and Transplant InstituteEdna F. Red, MD Health Emergency Management StaffRomeo J. Sabado, MD National Center for Mental Health

Manual of Guidelines for Operations CenterAssistant Chairperson: Teresita DJ Bakil, RN Supervisor, Operations Center Health Emergency Management StaffMembersElmer Benedict E. Collong, RMT Philippine Heart Center Mylyn G. dela Cruz, RN Health Emergency Management StaffRosalie A. Espeleta, RND Center for Health Development Metro ManilaMarlene F. Galvan, RN Health Emergency Management StaffVirgilio G. Gamlanga, RN Health Emergency Management StaffSusana G. Juango, RN, MPH Health Emergency Management StaffLuis Ferdinand G. Nonan, RMT Health Emergency Management StaffMerlina M. Villamin, RN Health Emergency Management Staff

De La Salle Health Sciences Institute Project TeamEstrella P. Gonzaga, MD Associate Professor College of Medicine CoordinatorJosephine M. Carnate, MD, MPH Professor College of Medicine Co-Coordinator for Centers for Health DevelopmentCynthia Lazaro-Hipol, MD, MPH Professor College of Medicine

Co-Coordinator for Operations CenterChristine Serrano-Tinio, MD, MHA Associate Professor College of Medicine

Co-Coordinator for Hospitals

World Health OrganizationArturo M. Pesigan, MD, MPH Emergency & Humanitarian Action Western Pacific Regional OfficeMaria Lourdes M. Barrameda, MD Philippines

Administrative and Secretarial Support: Aida N. GaerlanCopy Editors: Cynthia A. Diaz, Alicia Lourdes M. De Guzman, Mary Ann B. LeonesCover Design: Anthony E. Santos, Dario B. NocheLayout Artist: Dario B. Noche

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HEALTH EMERGENCY MANAGEMENT STAFF

VISIONAsia’s model in health emergency

management systems.

We are the leader in human resource development, technical assistance, and health emergency care, with state-of-the-art equipment and logistics. Our health emergency policies, plans, programs and systems are internationally acclaimed and benchmarked to guarantee minimum loss of lives during health emergencies

and disasters.

MISSIONTo ensure a comprehensive and integrated

health sector emergency management system.

As the health emergency management arm of the DOH, the HEMS was institutionalized, by virtue of Executive Order 102, to ensure a comprehensive and integrated Health Sector Emergency Management System to prevent or minimize the loss of lives during emergencies and disasters in collaboration with government,

business and civil society groups.

CORE VALUESGod-centered and God-inspired values

of commitment, respect for life and environment, and leadership

and excellence.

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Acknowledgments Message – Secretary, Philippine Department of Health Message – World Health Organization Foreword – Director, Health Emergency Management Staff Acronyms Glossary

PART I: The Health Emergency Management StaffChapter 1: Vision and Mission Chapter 2: Policy Base: National Policy Framework on Health Emergencies and Disasters Chapter 3: Action Base: Roles in Managing Health Risks of Emergencies Chapter 4: Legal Mandates

PART II: Health Emergency Management in HospitalsChapter 1: Introduction Roles and Responsibilities of Hospitals Chapter 2: Activities During the Emergency Preparedness Phase A. Development of Policies, Guidelines, Procedures and Protocols for Health Emergency Management B. Development of a Hospital Emergency Preparedness, Response, Recovery (HEPRR) Plan C. Development of the Organization D. Physical Infrastructure Development E. Systems Development Chapter 3: Activities During the Response Phase A. Activation B. Operations/Support Management C. Extension/Termination Chapter 4: Activities During the Recovery/Reconstruction Phase A. Activation B. Operations/Support Management C. Termination

PART III: GuidelinesSection 1. Guide to Policy Formulation Section 2. Guide to the Formulation of the HEPRR Plan Section 3. Job Action Sheets Section 4. Deployment of Response Teams Section 4.1. Ambulance Services for Emergencies and Disasters Section 5. Hospital Operations Center Section 6. Early Warning and Alert Systems Section 6.1A. Code Alert System for the DOH Central Offi ces Section 6.1B. Integrated Code Alert System for the Health Sector Section 6.2. Alert Signals Section 7. Rapid Health Assessment / Assessment for Recovery Section 8. Mass Casualty Management Section 9. Management of the Dead and Missing Section 10. Public Health Services Section 11. Mental Health and Psychosocial Support Section 12. Coordination and Networking Section 13. Human Resource Development Section 14. Logistics Management Section 15. Information Management System Section 16A. Health Promotion and Advocacy Section 16B. Risk Communication and Media Management Section 16C. Risk Communication in Hospitals Section 17. Health System in Emergency or Disaster Section 18. Evaluation Section19. Research and Development

STANDARD OPERATING PROCEDURES I. Information and Dispatch II. Advance Medical Post-Site Selection, Signage and Logistics III. Handling Equipment Attached to Patient

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CONTENTS

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FIGURES1. Emergencies and Health 2. Epidemic Emergencies 3. Example of a Hospital HEPRR Planning Group/Committee Structure 4. Basic Hospital Emergency Incident Command System Structure 5. Comprehensive Hospital Emergency Incident Command System Organizational Chart 6. Patient Care Stations S8.1. Rescue Chain in a Mass Casualty Management System S8.2. Role of the Hospital in a Mass Casualty Management System S8.3. Victim Flow: “Conveyor Belt” Management Diagram S9.1. MDM Functional Structure S12.1. The Spectrum of Coordination Activities S16B.1. Flow Chart: Steps in Communicating Health Risk S17.1. Strategy for Controlling Communicable Diseases

TABLES1. Timeline of Health Sector Roles by Health Emergency Management Phases 2. Timeline of the Three Phases of Health Emergency Management 3. Strategies Used in Health Emergency Management 4. 10 P’s of Health Emergency Management S1.1. Comparison of Policy Content of A.O. 168 s.2004 and A.O. 2007-001B S4.1. Human Resource Requirements by Alert Level Status in Hospital and CHD for On-scene Response S4.2. Competency Requirements and Required Training Course/Package for Responders S5.1. Standard Operating Procedures for Emergency Operations Centers (EOCs) S8.1. Triage Levels by Period, Location and Categories S8.2. Use of Color Tag for Prioritization of Care S11.1. Checklist of Minimum Mental Health and Psychological Services S13.1. Training Process S13.2. Competency Requirements and Required Training Course/Package by Roles S15.1. Data Collection Tools S18.1. Comparison of Key Activity Characteristics S18.2. Reasons to Conduct Exercise Program Activities

BOXESExamples in the Use of Terminologies Outline of Hospital Health Emergency Preparedness, Response and Recovery Plan Pointers in Formulating a Health Emergency Management Plan Key Information: Readily Available and Regularly Updated Rapid Assessment Surveys Basic Key Questions Required Within 24 Hours of the Event Field Organization Checklist Requirements from DOH Hospitals in MCM Metro Manila Hospital Network What Not To Do During a Crisis Seven Cardinal Rules of Risk Communication What Does Media Like

FORMSForm 1 HEARS Field Report Form 2 Material InventoryForm 2-1 Inventory ChecklistForm 3-A Rapid Health Assessment Form 3-B Rapid Health Assessment in Mass Casualty Incident Form 3-C Rapid Health Assessment in an Outbreak Form 5 List of Casualties Form 5-1 Patient List from Field Medical Commander Form 5-2 Mass Casualty Medical Case Record Form 6 HEMS Coordinator’s Final Report Form 6-1 Post-Mission Report

ANNEXES 1. Considerations in Hospital Design, Energy and CommunicationsS18.1 Five Types of Evaluation Exercises: Characteristics and Guidelines

REFERENCES

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MESSAGE

The Philippines has frequently been beset by health emergencies and disasters. These The Philippines has frequently been beset by health emergencies and disasters. These health emergencies have corresponding risks that affect people both physically and health emergencies have corresponding risks that affect people both physically and psychologically. Added to these are risks to their properties, disruption in services, psychologically. Added to these are risks to their properties, disruption in services, threats to their livelihood and environmental degradation. Hence, there is a need for threats to their livelihood and environmental degradation. Hence, there is a need for systematic monitoring, coordination and evaluation to mitigate the effects of these risks.systematic monitoring, coordination and evaluation to mitigate the effects of these risks.

The health workers involved in health emergency management play a vital role in all the phases of emergencies and disasters by assuming different tasks and responsibilities. Within the health sector, the hospitals and the regional health offi ces, in addition to the local health workers, form our implementing arm. In all phases spanning prevention, preparedness, response and recovery are different systems, policies, guidelines and protocols, which guide and equip our health workers to effi ciently and effectively man-age all types of emergencies.

Emergency management is evolving, dynamic, and should be continuously updated so as to keep up with the needs of our time. Hence, guidelines for emergency manage-ment, which were originally drafted in 2000, need to incorporate certain updates and revisions for enhanced emergency management.

I would like to commend the Health Emergency Management Staff for all their efforts and perseverance in revising these three important manuals, which are the Guidelines for the Operations Center, the Hospitals, and the Centers for Health Development. Last-ly, I thank the World Health Organization not only for their support in the development and reproduction of these materials but also for being our constant allies in responding to different health emergencies. I am highly recommending the use of these manuals to guide all health workers in disaster response.

Let us continue to work together for timely, reliable and a well-coordinated response to all forms of health emergencies and disasters.

Mabuhay!

FRANCISCO T.DUQUE III, MD, MScFRANCISCO T.DUQUE III, MD, MScSecretary of HealthSecretary of Health

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MESSAGE

It is a fact that the Philippines is one of the most hazard-prone countries in the world. It is a fact that the Philippines is one of the most hazard-prone countries in the world. The Government though has been wisely taking steps to continuously increase its pre-The Government though has been wisely taking steps to continuously increase its pre-paredness to hazards.

The Department of Health’s Health Emergency Management Staff (DOH-HEMS) is The Department of Health’s Health Emergency Management Staff (DOH-HEMS) is dedicated to overseeing its preparedness and response to health emergencies nation-wide, directly or by assisting local units. In line with this, it embarked on this project to develop manuals of operations for different responding units.

These manuals of operations which the DOH-HEMS developed together with those actually involved in health emergency response, like the hospitals and different Centers for Health Development, is a tool essential to smooth operations during emergencies. While a manual by itself does not guarantee the success of an operation, it can make responding to emergencies as predictable as possible without precluding the need to make adjustments whenever necessary.

The manuals are a testament to the amount of time and effort that were put into the review, planning, and coordination by these units in the process of writing and rewriting these manuals. Such links and understanding between responding units are crucial to the speed, effi ciency and effectiveness of any response to emergencies.

The manuals can very well serve other purposes other than their original purpose. They can also be tools for more detailed planning by the different units and other interested parties.

The challenge now is to ensure that the manuals are well-understood by all concerned, the protocols practiced, the necessary resources and tools made available at all times, and provisions made for later review and revision of these manuals as would be neces-sary in the future.

Congratulations to the Department of Health for developing these manuals. I am sure that this is a major step to improving further the effi ciency and effectiveness of health that this is a major step to improving further the effi ciency and effectiveness of health emergency response in the country.

DR. SOE NYUNT-UDR. SOE NYUNT-UCountry RepresentativeWorld Health Organization, Philippines

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FOREWORD

In year 2000, the Health Emergency Management Staff developed and disseminated In year 2000, the Health Emergency Management Staff developed and disseminated three manuals to guide health workers working in the Operations Center, Hospitals, three manuals to guide health workers working in the Operations Center, Hospitals, and Centers of Health Development in the fi eld of health emergency management. and Centers of Health Development in the fi eld of health emergency management. The manuals consisted of some protocols, guidelines and procedures being used in The manuals consisted of some protocols, guidelines and procedures being used in response to emergencies. Most were based on experiences, readings, and trainings. response to emergencies. Most were based on experiences, readings, and trainings. But times have changed with disasters coming in different forms and magnitude, risks and consequences getting more complex, human-generated disasters becoming more frequent, and most of all, some facts and procedures have slowly become outdated and defi cient.

Hence, there was a need to review and revise the three manuals. The process involved the review of the initial edition, resource materials compiled from previous trainings, both locally and internationally, and most of all, valuable inputs from actual fi eld experi-ences and best practices of the front-liners and key players. Key action points ranging from mandates and desirable level of preparedness in each phase of the disaster cycle were integrated in a manner that a very user-friendly guideline will be made available to all health emergency managers and program planners engaged in the fi eld of emer-gency management.

Although some might be generic in approach, these guidelines are basically adapted to the Philippine setting in consideration of the mandates of agencies, and observing the Local Government Code and existing laws and regulations. As we belong to the Health Sector, the manuals are specifi cally for health emergency managers at all levels of in-strumentalities. Each manual can exist on its own but complements the other manuals.

I hope you will fi nd all three manuals very useful in your planning activities, in respond-ing during emergencies and also in providing support during the recovery and rehabili-tation phase. In the process, I hope that every user will eventually become a contributor tation phase. In the process, I hope that every user will eventually become a contributor to its continuous evolution.

CARMENCITA A. BANATIN MD, MHACARMENCITA A. BANATIN MD, MHADirector III

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ACRONYMS

ACLS – Advanced Cardiac Life SupportADPC – Asian Disaster Preparedness CenterAFP – Armed Forces of the PhilippinesAO – Administrative OrderATO – Air Transportation Offi ce ATTF – Anti-Terrorism Task Force

BFAD – Bureau of Food and Drugs of the DOHBFAR – Bureau of Fisheries and Aquatic ResourcesBFP – Bureau of Fire ProtectionBFP-EMS – Bureau of Fire Protection - Emergency Medical ServicesBFP-SRU – Bureau of Fire Protection - Search and Rescue UnitBHDT – Bureau of Health Devices and Technology of the DOHBIHC – Bureau of International Health Cooperation of the DOHBLS – Basic Life SupportBOC – Bureau of Customs

CBRNE – Chemical, Biological, Radio-Nuclear Agents and ExplosivesCHD – Center for Health Development of the DOHCHO – City Health Offi cerCOA – COA – COA Commission on AuditCSSR – Collapsed Structure Search and Rescue

DBM – Department of Budget and ManagementDFA – Department of Foreign AffairsDMU – Disaster Management Unit of the DOHDND – Department of National DefenseDOH – Department of HealthDOT – Department of Tourism DSWD – Department of Social Welfare and Development

EHS – Environmental Health Service of the DOHEO – Executive OrderEOC – Emergency Operations CenterEOD – Emergency Offi cer-on-DutyER – Emergency Room

FIMO – Field Implementation Management Offi ce

GA – Government Agency

HAZMAT – Hazardous MaterialsHCF – Health Care FacilitiesHE – Health EmergencyHEARS – Health Emergency Alert Reporting SystemHEICS – Hospital Emergency Incident Command SystemHEMS – Health Emergency Management Staff of the DOHHEPO – Health Education Promotions Offi cerHEPR – Health Emergency Preparedness and ResponseHEPRRP – Health Emergency Preparedness, Response and Recovery PlanHRD – Human Resource DevelopmentHRM – Human Resource Management

IASC – Inter-Agency Standing CommitteeICS – Incident Command System

JAS – Job Action Sheets

LCF – Local Calamity FundLDCC – Local Disaster Coordinating CouncilLGE – Local Government ExecutiveLGU – Local Government UnitLGUTMH – Local Government Unit Teams for Mental Health

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LHAD – Local Health Administration and Development

MCH – Maternal and Child HealthMCI – Mass Casualty IncidentMCM – Mass Casualty ManagementMDM – Management of the Dead and MissingMFI – Mass Fatality IncidentMHO – Municipal Health Offi cerMIS – Management Information SystemMMD – Materials and Management Division of DOHMMDA – Metro Manila Development AuthorityMOA – Memorandum of AgreementMOU – Memorandum of Understanding

NBI – National Bureau of Investigation NCDPC – National Center for Disease Prevention and ControlNDCC – National Disaster Coordinating CouncilNEC – National Epidemiology Center of the DOHNGO – Nongovernment OrganizationNNC – National Nutrition CouncilNPCC – National Poison Control Center NPMC – National Program Management CommitteeNSC – National Security CouncilNTC – National Telecommunication Commission

OCD – Offi ce of Civil DefenseOIC – Offi cer-in-Charge OpCen – Operations Center

PAG-ASA – Philippine Atmospheric, Geophysical and Astronomical Services AdministrationPAR – Philippine Area of ResponsibilityPCG – Philippine Coast GuardP/C/MSWDO – Provincial/City/Municipal Social Welfare and Development Offi cerPD – Presidential DecreePET – Pocket Emergency ToolPGH – Philippine General HospitalPHEMAP – Public Health Emergency Management in Asia and the Pacifi cPHIVOLCS – Philippine Institute of Volcanology and SeismologyPHO – Provincial Health Offi cerPIE – Post-Incident EvaluationPMDT – Program Management and Development TeamsPNP – Philippine National Police PNP-CL – Philippine National Police - Crime LaboratoryPNRC – Philippine National Red Cross PNRI – Philippine Nuclear Research InstitutePO – People’s Organization PPE – Personal Protective Equipment

RA – Republic ActRDCC – Regional Disaster Coordinating CouncilRESU – Regional Epidemiologic Surveillance UnitRHEMS – Regional Health Emergency Management StaffRMHT – Regional Mental Health Teams

SEARO – Southeast Asia Regional Offi ce of WHOSOP – Standard Operating ProcedureSTOP DEATH – Strategic Tactical Option for the Prevention of Disaster, Epidemics, Accidents and Trauma

for Health

UN – United NationsUNICEF – United National Children’s FundUP-PGH – University of the Philippines-Philippine General Hospital

WHO – World Health OrganizationWMD – Weapons of Mass DestructionWPRO – Western Pacifi c Regional Offi ce of WHO

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GLOSSARY

All-hazard – An approach to emergency management based on the recognition that there are common elements in the management of responses to virtually all emergencies, and that by standardizing a management system to address the common elements, greater capacity is generated to address the unique characteristics of different events

Burn-out syndrome – A state of exhaustion, irritability and fatigue which markedly decreases worker’s effectiveness and capability

Capacity/readiness – An assessment of local capacity to respond to an emergency (a risk modifi er)Casualty – Victims both dead and injured, physically and/or psychologically Certifi cate of missing person believed to be dead in time of disaster – A document to be issued by Certifi cate of missing person believed to be dead in time of disaster – A document to be issued by Certifi cate of missing person believed to be dead in time of disaster

the National Disaster Coordinating Council indicating that the person is believed dead as a result of a disaster based on validation and recommendation by the concerned local government unit. This docu-ment is issued in lieu of a Death Certifi cate and can be used solely for the processing of claims for benefi ts.

Collective grave – Burial of two or more dead bodies/body parts in an orderly process, preserving the individuality of every body and maintaining individual characteristics of each body

Command post – Form of site-level emergency operations center, assembled as needed by the fi rst agencies to respond to an event

Community – Consists of people, property, services, livelihoods and environment; a legally constituted administrative local government unit of a country, e.g., municipality or district, that is small enough to be able to identify its own leaders (to make participation meaningful) and large enough to control its resources, e.g., village, district, etc

Coordination – Bringing together of organizations and elements to ensure effective counter-disaster response. It is primarily concerned with the systematic acquisition and application of resources (organization, manpower and equipment) in accordance with the requirements imposed by the threat of impact of disaster.

Complex emergency – A state where the normal social or economic order has collapsed to the extent that the national authorities are no longer able to guarantee security or provide services to all or part of the countryCremation – The process that reduces human remains to bone fragments of fi ne sand or ashes through

combustion and dehydrationCrisis – A state brought about by adverse life experiences wherein the normal coping mechanism or

problem solving is not workingCritical incident – Any event causing unusually strong overwhelming emotional reactions which have the

potential to interfere with work during the event or thereafter in the majority of those exposed

Death certifi cate – Documented proof of the death of someone; a legal instrument which includes the victim’s name, age, sex, the cause and manner of death, the time and date of death, as well as the professional who confi rms the death

Disaster – Any actual threat to public safety and/or public health where local government and the emer- Disaster – Any actual threat to public safety and/or public health where local government and the emer- Disastergency services are unable to meet the immediate needs of the community; an event in which the lo-cal emergency management measures are insuffi cient to cope with a hazard, whether due to lack of time, capacity or resources, resulting in unacceptable levels of damage or numbers of casualties; an emergency in which the local administrative authorities cannot cope with the impact of the scale of the hazard and therefore the event is managed from outside of the affected communities; any ma-jor emergency where response is also constrained by damage or destruction to infrastructure (i.e., the lack of resources plus loss of infrastructure overwhelms local capacity and event management from outside the affected area is needed to direct and support local response efforts

Disaster recovery – The coordinated process of supporting disaster-affected communities in the reconstruction of the physical infrastructure and restoration of emotional, social, economic and physical well-being

Donation – Act of liberality whereby a foreign or local donor disposes gratuitously of cash, goods or articles, including health and medical-related items, to address unforeseen, impending, occurring or

experienced emergency and disaster situations, in favor of the Government of the Philippines which accepts them

Donor – All persons, countries or agencies that may contract and dispose of cash, goods or articles, Donor – All persons, countries or agencies that may contract and dispose of cash, goods or articles, Donorincluding health and medical-related items, to address unforeseen, impending, occurring or experienced emergency and disaster situations

Embalming – Process of preparing, disinfecting and preserving a dead body before the fi nal disposalEmergency – Any situation in which there is imminent or actual disruption or damage to communities,

i.e., any actual threat to public health and safetyEmergency management – A management process that is applied to deal with the actual or implied

effects of hazards

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Emergency operations center – A place activated for the duration of an emergency within which person-Emergency operations center – A place activated for the duration of an emergency within which person-Emergency operations centernel responsible for planning, organizing, acquiring and allocating resources and providing direction and control can focus these activities on responses to the emergency

Emergency preparedness – An integrated program of long-term, multisectoral development activities whose goals are the strengthening of the overall capacity and capability of a country to be ready to manage effi ciently

Exhumation – Removal of dead body from its grave, usually done to carry out examination or to bury it in another place

Field management – Encompasses the procedures used to organize the disaster area to facilitate the management of victims

Formal acceptance – An instrument – Deed of Acceptance – issued by the Secretary of Health or his designated representative that acknowledges the consummation of the donation and the transfer of the ownership or interest over the donated item to the Department of Health

Hazard – Any potential threat to public safety and/or public health; any phenomenon which has the potential to cause disruption or damage to people, their property, their services or their environment, i.e., their communities. The four classes of hazards are natural, technological, biological and societal hazards.

Hazard-prone community – A community exposed to a number of hazardsHealth Emergency Management Health Sector – An organization of agencies each with a health unit Health Emergency Management Health Sector – An organization of agencies each with a health unit Health Emergency Management Health Sector

primarily devoted to and united to provide state-of-the-art, appropriate and acceptable technical assistance and/or direct services on health emergency preparedness and response to any entity – international or national

Incident Medical Commander – The highest representative of the Department of Health or Local Health Incident Medical Commander – The highest representative of the Department of Health or Local Health Incident Medical CommanderOffi ce as designated by the city/town local executive (depending on the extent of the disaster) who shall serve as the liaison offi cer of the Health Sector to the Command Post headed by the Incident Commander. For regional disasters, it should be headed by the highest representative from the DOH CHD.

Major emergency – Any emergency where response is constrained by insuffi cient resources to meet immediate needsManagement of the Dead and Missing Persons During Emergencies or Disasters (MDM) – Refers

to fi ve domains, namely: Search and Recovery; Identifi cation of the Dead; Final Arrangement of the Dead; Handling of the Missing Persons; and Assistance to the Bereaved Families

Mass casualty incident – Any event resulting in a number of victims large enough to disrupt the normal course of administrative, emergency and health care services

Mass casualty management – Management of victims of a mass casualty event to minimize loss of lives and disabilities

Mass Casualty Management System – Groups of units, organizations and sectors that work jointly through standard consensus procedures to minimize disabilities and loss of life in a mass casualty event through the effi cient use of all existing resources

Mass fatality incident – Any event resulting in a number of deaths large enough to disrupt the normal course of health care services, usually a result of natural and/or human-generated disasters, includ-ing terrorism or the use of weapons of mass destruction

Mass grave or common grave – Indiscriminate burial of more than two unidentifi ed bodies/body parts in the same excavated site

Medical controller – A designated senior Department of Health Offi cer appointed to assume the overall Medical controller – A designated senior Department of Health Offi cer appointed to assume the overall Medical controllerdirection of the medical response to mass casualty incidents and disasters. Control is established from a designated Operations Center, either in the Central Operations Center or the Regional Opera- tions Center, and whose main responsibility is to coordinate all the services of the sector

Mental health – A state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community

Missing person – Any person residing, working, studying or sojourning in a community which is directly affected by disaster and is nowhere to be found thereafter and has not been heard of since the

disasterMissing resident of the disaster-affected community – Any person residing in the community, whose

name appears in the community censuses, presumed to be in the community during the disaster, nowhere to be found thereafter and has not been heard of since the disasterMissing person from outside the community – Any person living outside the affected community, who

presumably went to the community and was directly affected by a disaster, then nowhere to be found thereafter and has not been heard of since the disaster. They can be classifi ed as workers, passersby and transient visitors.

Missing resident working/studying outside the disaster-affected community – Any person residing in the affected community, who works or studies outside this community but presumed to have not gone to work or school at the same time of the disaster, nowhere to be found thereafter and has not been heard of since the disaster

Networking – An approach to broaden the resources available to a person to achieve his personal and professional goals while supporting others to achieve theirs

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Preparedness – Measures taken to strengthen the capacity of the emergency services to respond in an emergency. Emergency preparedness is done at all levels.

Rapid health assessment – The collection of subjective and objective information to measure damage and identify those basic needs of the affected population that require immediate response

Recovery management – A process by which a disaster-affected community is restored to an appropriate level of functioning. Recovery is a developmental, rather than a remedial process.

Risk – Anticipated consequences of a specifi c hazard affecting a specifi c community (at a specifi c time); the level of loss of damage that can be predicted to result from a particular hazard affecting a particular place at a particular time; probable consequences to public safety of a community being exposed to a hazard (i.e., death, injury, disease, disability, damage, destruction, displacement)• Type of hazard determines the kind of risks, e.g., fl oods cause few deaths but earthquakes cause

many.• Vulnerabilities and capacity to respond determine how much risk is in the community, i.e., how

many deaths are likely, where they will occur and the kind of people likely to be killed (e.g., old, disabled).

Risk management – A comprehensive strategy for reducing risk to public safety by preventing exposure to hazards (target group – hazards) , reducing vulnerabilities (target group – elements of community), and enhancing preparedness, i.e., response capacities (target group – response agencies); a strat-egy for identifying potential threats and managing both the source of threats and their consequences

Strategic – Deals with the concepts of relatively long term and big picture in relation to the pattern or plan that integrates an organization’s major goals, policies and action sequences into a cohesive whole. Concept is always relative – what a local level of government sees as strategic from their perspective is likely perceived as tactical from the perspective of a more senior government.

Stress – A state where one’s coping mechanism is not enough to maintain balance or equilibriumSurge capacity – The health care system’s ability to rapidly expand beyond normal services to meet

the increased demand for qualifi ed personnel, medical care and public health in the event of large- scale public emergencies or disasters (Agency for Healthcare Research and Quality, USA, 2005)

Tactical – Refers to those activities, resources and maneuvers that are directly applied to achieve goals. Compare with “strategic” above.

Temporary burial – Shallow burial of two or more dead bodies/body parts in an orderly process, preserv-ing the individuality of every body, and maintaining individual characteristics of each body pending proper identifi cation and disposition

Terrorism – The premeditated use or threatened use of violence or means of destruction perpetrated against innocent civilians or non-combatants, or against civilian and government properties, usually intended to infl uence an audience (Memorandum No. 121)

Triage – The process of sorting victims needing immediate transport to health facilities and those whose care can be prioritized.

Vulnerabilities – Factors that increase the risks arising from a specifi c hazard in a specifi c community (risk modifi ers)

Weapons of mass destruction – Radiological, nuclear, biological or chemical elements in nature used for large-scale damage to life and property, usually by those perpetrating terrorist activities

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1 Vision and Mission

VISION VISIONThe Health Emergency Management Staff (HEMS) of the Department of Health (DOH) was created with the vision of becoming Asia’s model in health emergency management systems.

We are the leader in human resource development, technical assistance, and health emergency care, with state-of-the-art equipment and logistics. Our health emergency policies, plans, programs and systems are internationally acclaimed and benchmarked to guarantee minimum loss of lives during health emergencies and disasters.

MISSION MISSIONThe HEMS mission: To ensure a comprehensive and integrated health sector emergency management system.

As the health emergency management arm of the DOH, the HEMS was institutionalized, by virtue of Executive Order 102, to ensure a comprehensive and integrated Health Sector Emergency Management System to prevent or minimize the loss of lives during emergencies and disasters in collaboration with government, business and civil society groups.

CORE VALUES CORE VALUESThe HEMS adopts, above all, God-centered and God-inspired values of commit-ment, respect for life and environment, and leadership and excellence.

4

2 Policy Base:National Policy Framework on Health Emergencies

and Disasters

(Administrative Order No. 168 s. 2004; Joint Administrative Order No. 2007-001b)

The DOH’s role in health emergency management is to lead in Health Sector prepared-ness and response. For its vision, the national policy framework for management of emergencies and disasters has the Department of Health as Asia’s prime mover in health emergency and disaster preparedness and response. Its three-fold mission con-sists of:1. Leading in the formulation of a comprehensive, integrated and coordinated health sector response to emergencies and disasters;2. Ensuring the development of competent, dynamic, committed and compassionate health professionals equipped with the most modern and state-of-the-art facilities at par with global standards; and 3. Being the center of all health and health-related information on emergencies and disasters.

Ultimately, an effi cient and effective management of emergencies and disasters will de-crease mortality and morbidity, promote physical and mental health, and prevent injury and disability of both victims and responders.

Risk management, a comprehensive strategy for reducing risks to public safety by pre-venting hazards, reducing vulnerabilities and enhancing preparedness (i.e., response capacities), is central to the management process applied to deal with actual or implied effects of hazards. It permeates the identifi ed strategies of capacity building, enhance-ment of facilities, service delivery, health information and advocacy, health policy, net-working and social mobilization, research and development, resource mobilization, infor-mation management system and surveillance, standards and regulation, and monitoring and evaluation.

Programmatically, the components of Health Emergency Preparedness and Response are the following: • Holistic Health Emergency Preparedness and Response to cover all phases of the emergency/disaster: (1) pre-emergency/disaster phase for emergency preparedness mitigation and prevention; (2) emergency/disaster phase for response; and (3) post- emergency/disaster phase for recovery and reconstruction. • A focus on the Community Risk Reduction Strategy to include decreasing the hazard, decreasing vulnerability, and increasing preparedness.• Comprehensive coverage for an all-hazard approach, addressing all types of disasters (natural, man-made and technological) and all types of emergencies with a potential to be a disaster through Mass Casualty Management, Public Health, Mental Health, and recently with the Management of the Dead and the Missing. • Mental Health in Disaster as a major component institutionalized in all phases of disaster and provided to victims, relatives of victims, as well as responders.• Health Emergency Management integrated in health programs of the community, local government and the state.

Organizationally, all health facilities are to have a health emergency management offi ce/unit/ program, under the supervision of the highest offi cer, such as the Regional Direc-tor/Chief of Hospital or its equivalent offi cer, to ensure faster decision-making in times of emergencies and disasters.

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3 Action Base:Roles in Managing Health Risks of Emergencies

The roles of the health sector may be viewed by phases as articulated by the 6th Pub-lic Health and Health Emergency Management Course in Asia and the Pacifi c in 2006. Table 1 presents these roles at each phase of health emergency management.

*Adapted from the Sixth Inter-regional Training Course in Public Health and Emergency Management in Asia and the Pacifi c (PHE-MAP), 2006. Module 1: Health Emergency Management. Challenges and Roles. WHO (WPRO, SEARO) and ADPC.

TIME

PHASES

ROLES

0---------------

Pre-emergency/Disaster

Emergency Preparedness, Mitigation and Prevention

Assess risks ■ Anticipate the

problems.

Reduce risks■ Communicate

the risks; change behavior.

■ Reduce vulnerability, and strengthen resilience (community, staff, infrastructure and health care facilities).

Prepare for emergencies

■ Plan, train, exercise, evaluate.

■ Build capacities.■ Install early

warning systems.

■ Communicate the risks.

------------ N

Post-emergency/ Disaster

Recovery and Reconstruction

Institute measures for recovery and rehabilitation

■ Assess health needs over the long term.

■ Provide health services over the long term.

■ Restore health services, facilities and health systems.

■ Develop human resources.

■ Plan reconstruction to reduce risks.

Table 1. Timeline of Health Sector Roles by Health Emergency Management Phases*Timeline of Health Sector Roles by Health Emergency Management Phases*

--- EVENT ----------- EVENT ----------- EVENT --------

Emergency/Disaster Emergency/Disaster

Response

Respond to emergencies

■ Provide leadership in the health sector.

■ Assess the health consequences and impact on health services.

■ Determine the needs.

■ Protect staff and facilities.

■ Provide health services .

■ Communicate the risks.

■ Mobilize resources.

■ Manage logistics.

■ Manage health information.

■ Manage human resources.

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Table 2 shows the timeline of actions that need to be taken during emergencies and disasters – before, during and after the event. The lower part of the table magnifi es the timeline of actions during the response and recovery phases. It lists the general and health needs that need to be addressed at different stages of the timeline.

*Adapted from the Sixth Inter-regional Training Course in Public Health and Emergency Management in Asia and the Pacifi c (PHE-MAP), 2006. Module 1: Health Emergency Management. Challenges and Roles. WHO (WPRO, SEARO) and ADPC.

Control of diseases of public health signifi -cance

Control of acute intestinal and respira-tory diseases

Care of the dead

General curative services

Nutritional surveillance and support (including micronutrient supple-mentation)

Measles vaccination Vitamin A

Specifi c training programs

Health informa-tion campaigns/ health education programs

Disability and psychosocial care

Revision of policies, guide-lines, procedures

Upgrade of knowledge and skills, attitude change

Restoration of preventive health care services such as EPI, MCH, etc

Restoration of services for non-communicable diseases/obstetrics

Care of the disabled

FRAME

STAGE

GENERALNEEDS

HEALTH NEEDS

Immediate

End of First Month

Medium Term

End of First Week

Short Term

ConclusionEnd of 3 Months

Long Term

● Compensation/reconstruction

● Restitution/ rehabilitation● Prevention and preparedness

● Education● Agriculture● Environmental

protection

● Protection (legal and physical)● Employment● Public transport● Public Communica - tions● Psychosocial services

Emergency communication,

Logistics and reporting systems (including injury and disability registers)

● Search and rescue

● Search and recovery (dead)● Evacuation/shelter● Food● Water● Public information system

● First aid● Triage● Primary medical care● Transport/ ambulances● Acute medical and surgical care

Emergency epidemio-logical surveil-lance for vector-born diseases, vaccine-preventable diseases, diseases of epidemic potential

Reconstruction and rehabilitation

Evaluation of lessons learned

Establishment/re-establishment of health information system

● Security● Energy (fuel,

heating, light, etc)● Environmental

health services for - vector control - personal hygiene - sanitation, waste

disposal, etc

First 24 HoursEVENTTIME

End of First MonthEnd of First Week ConclusionEnd of 3 MonthsFirst 24 HoursEVENT

Table 2. Timeline of the Three Phases of Health Emergency Management*

TIME

PHASES

0 -------------------

Pre-emergency/Disaster

Emergency Preparedness, Mitigation and Prevention

----- -----------

Emergency/Disaster

Response

------------- N

Post- emergency/Disaster

Recovery and Reconstruction

Timeline of the Three Phases of Health Emergency Management*

----- -----------

Emergency/Disaster

Event ------------- N----- -----------0 -------------------

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4 Legal Mandates

The Philippine Disaster Management System came into existence through various legis-lations. Existing laws, like Presidential Decree (P.D.)1566 of 1978 (Strengthening of the Philippine Disaster Control Capability and Establishing the National Program on Com-munity Preparedness) and Republic Act (R.A.) 7160 or the Local Government Code of 1991, both support the goals and objectives of the disaster management program at the local level. These legislations are specifi cally geared towards organizing disaster coordi-nating councils at all levels, planning for all types of emergencies, and the delineation of tasks and responsibilities of national and local government agencies involved in disaster management.

Towards the end of instituting effective and effi cient disaster management programs, the Department of Health identifi es and enjoins all the major stakeholders of the health sec-tor to develop their inter-operability for a more effective and effi cient response to emer-gencies and disasters. Out of the many laws enacted, only those related to emergency management are cited in this manual (OCD, Region VIII, 2004; Stop Death Program, DOH, 2000a; HEMS 2007a). And only the parts or sections of these laws that are rel-evant to health emergency/disaster management are highlighted here.

MILESTONES OF PHILIPPINE HEALTH EMERGENCY MANAGEMENT

Through the years, health has been an important fi xture in disaster-related laws. This means that in every disaster or emergency, protecting the life and health of the popula-tion is the core of the Disaster Management System in the country. The DOH, thus, has always played a key role in all disaster management efforts. Milestone legislations in Philippine health emergency management include:

1. Two Executive Orders (E.O.) issued by the late President Manuel L. Quezon during the Commonwealth era, namely, Executive Order Nos. 335 and 337.

a. Executive Order No. 335 – Created the Civilian Emergency Administration (CEA) which was tasked primarily through the National Emergency Commis-sion (NEC) to formulate and execute policies and plans for the protection and welfare of the civilian population under extraordinary and emergency conditions. The overall manager of the NEC was the Philippine National Red Cross. Local emergency committees (LEC) from the provincial, city and municipal levels were likewise organized and headed by the local chief executive. The sanitary offi cer was an offi cial member of the LEC.

b. Executive Order No. 337 – Empowered the volunteer guards to assist in the maintenance of peace and order in the locality, safeguard public utilities, and provide assistance and aid to people during natural or man-made disasters.

2. Executive Order No. 36 issued by the late President Jose P. Laurel during the Japanese occupation – Created the Civilian Protection Service (CPS) tasked to for-mulate and execute plans and policies for the protection of civilians during air raids and other national emergencies. The CPS was handled by the Civilian Protection

8

Administration (CPA) composed of three members, namely, the Civilian Protection Administrator, Chief of the Air Warden and the Chief of the Medical and First Aid

Service. E.O. 36 likewise required the establishment of a provincial, city and munici-pal protection committee with the provincial governor, city and municipal mayor as respective chairmen. Members of the local protection committees included the high-est local offi cials – treasury, justice, engineering, schools, health and the police.

3. Republic Act 1190 or the Civil Defense Act of 1954 – Disaster Preparedness Ini-tiatives which created the National Civil Defense Administration (NCDA), whose principal task was to provide protection and welfare to the civilian population during

war or other national emergencies of equally grave character. Under this law, civil defense councils from national, provincial, city and municipal civil defense councils were established. Its operating services at all levels (provincial, city and municipal) were as follows: Warden Service, Police Service, Fire Service, Health Service, Res-cue and Engineering Service, Emergency Welfare Service, Transportation Service, Communication Service, Air Raid Warning Service, and Auxiliary Service.

4. Administrative Order No. 151 (December 2, 1968) – Created a National Com-mittee on Disaster Operation in view of the collapse of the Ruby Tower building in Manila caused by a powerful earthquake. The committee was composed of the Executive Secretary as chairman, and as members: the department secretaries of Social Welfare, National Defense, Health, Public Works and Natural Resources, Commerce and Industry, Education, Community Development, and Commission on Budget; the secretary-general of the Philippine National Red Cross; and a designa-

ted national coordinator. Under this order, the national committee ensured effec-tive coordination of operations of the different agencies during disasters caused by typhoons, fl oods, fi res, earthquakes and other calamities.

5. Formulation of the Disaster and Calamities Plan (1970) – Prepared on Octo-ber 19, 1970, after Typhoon Seniang, by an Inter-Departmental Planning Group on Disasters and Calamities as approved by then President Ferdinand E. Marcos. The plan created the National Disaster Control Center that was composed of the follow-ing: chairman – Secretary of National Defense, overall coordinator – Executive Secretary, and members – Secretary of Health, Secretary of Public Works and Com- munications, Secretary of Agriculture and Natural Resources, Secretary of Com- merce and Industry, and Secretary of Community Development.

6. Presidential Decree 1566 of 1978: Strengthening of the Philippine Disaster Control Capability and Establishing the National Program on Community Preparedness

7. Republic Act 7160 or the Local Government Code of 1991 – Contains provisions supportive of the goals and objectives of the disaster preparedness, prevention and mitigation programs. These provisions reinforce the pursuit of a Disaster Manage- ment Program at the local government level.

8. Department of Health policies on institutionalization of the Health Emergency Preparedness and Response Program at the local level.

9

RELEVANT LAWS RELEVANT LAWS

Presidential Decree No. 1566 of 1978: Strengthening Philippine Disaster Control Capability and Establishing National Program on Community Disaster Prepared-ness

Promulgated on June 11, 1978, P.D. 1566 is the basic law in the implementation of the Disaster Management Program in the Philippines. It contains the following provisions:

■ Section 2 – Creation of National Disaster Coordinating Council (NDCC).

The Department of Health is a member of the National Disaster Coordinating Coun- cil (NDCC) and the head of the Medical Service; it assumes command over the health sector.

■ Creation of the multilevel organizations in charge of disaster management.

This multilevel organization starts from the National Disaster Coordinating Council, the Regional Disaster Coordinating Council, the Provincial Disaster Coordinating Council down to the Municipal Disaster Coordinating Council.

■ Funding for a 2% reserve for calamities.

PD 1566 authorizes the local government to program funds for use in disaster preparedness, such as the organization of Disaster Coordinating Councils, the establishment of physical facilities, and the equipping and training of disaster action teams.

These are the salient provisions of P.D. 1566:

■ State policy on self-reliance among local offi cials and their constituents in responding to disasters and emergencies.

■ Organization of disaster coordinating councils from the national down to the municipal level.

■ Statement of duties and responsibilities of the NDCC, RDCC and local DCCs.

■ Preparation of the National Calamities and Preparedness Plan by the Offi ce of Civil Defense and implementation of plans by NDCC and member agencies.

■ Conduct of periodic drills and exercises.

■ Authority of government units to program their funds for disaster preparedness activities, in addition to the 2% calamity fund as provided for in P.D. 474 (amended by R.A. 8185).

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Calamities and Disaster Preparedness Plan, 1988

The Department of Health is a member of the NDCC, which is the lead agency in coor-dinating, integrating, supervising and implementing disaster-related functions. It is repre-sented by the Secretary of Health. As stated in the national plan, the DOH performs the following functions:

■ Organizes disaster control groups and reaction teams in all hospitals, clinics, sani - taria and other health institutions;

■ Provides for the provincial, city/municipal and rural health services to support all disaster coordinating councils during emergencies;

■ Undertakes necessary measures to prevent the occurrence of communicable diseases and other health hazards which may affect the populations;■ Issues appropriate warning to the public on the occurrence of epidemics or other

health hazards;■ Provides direct service and/or technical assistance on sanitation as may be neces-

sary; and■ Organizes reaction teams in the department proper as well as in the offi ces and bureaus under it.

The Department of Health organizes Health Service Units in all regions, provinces, cities, municipalities and barangays.

a. Constitution of Health Service Units Chairman: Department of Health Members (suggested as but not limited to):

■ Representatives of the Philippine National Red Cross■ Medical and allied professionals■ Chief of public/private hospitals/clinics/institutions■ AFP medical reserve personnel on inactive status in the community

b. Purpose of Health Service Units■ To protect life through health and medical care of the populace.■ To preserve life through proper medical aid and provision of medical facilities.■ To minimize casualties through proper information and mobilization of all

medical resources.

c. Sub-units of the Health Service Unit i. Medical and First-Aid Unitii. Field Emergency Hospitaliii. Sanitation Service Unitiv. Health Supply Unitv. Transportation and Ambulance Unitvi. Mortuary Unitvii. Records Unit

d. Responsibilities■ The DOH Secretary is responsible for organizing, training and supplying all

Health Service elements in the Philippines.■ The DOH Regional Director is responsible for providing support to the Health

Services in the provincial, municipal and city levels.

11

■ The DOH offi cials at the provincial, city and municipal levels are responsible for organizing their respective units.

■ The local government heads are responsible for the operation and support of Health Services.

■ The Philippine National Red Cross (PNRC) and the Department of Social Wel- fare and Development (DSWD), within their respective capabilities, are respon-sible for providing support to the Health Service.

e. Functions of the Health Service Sub-units

i. Medical and First Aid Unit■ Sorts cases at the scene of the disaster;■ Administers fi rst aid;■ Attends to the cases referred to emergency aid and stations;■ Evacuates patients to emergency hospitals; and■ Detects and controls communicable diseases in coordination with other

agencies specifi cally assigned for the purpose.

ii. Field Emergency Unit■ Pre-determines sites of facilities that may be used as fi eld hospitals;■ Administers appropriate treatment to less serious patients and attends to all

dispensary cases; and■ Attends to all medical cases, which should be referred to appropriate medi cal

institutions.

iii. Sanitation Service Units■ Supervises the sanitary conditions of the community during and after emer-

gency;■ Enforces sanitary regulations relative to housing facilities and shelter; and■ Promulgates and implements control measures in contaminated areas and

in evacuation centers.

iv. Health Supply Unit■ Procures, stores and issues medical supplies and equipment during emer-

gencies; and■ Keeps an accounting of the medical and fi rst aid instruments and supplies.

v. Mortuary Unit ■ Assists in identifying and tagging the dead; ■ Certifi es to the cause of death; and ■ Supervises the proper disposal of the dead.

vi. Records Unit■ Keeps records of the dead, injured, and sick; and■ Issues certifi cates pertaining to persons who were ill, injured and recovered,

or died, pursuant to existing, laws, rules and regulations.

Republic Act No. 7160: The Local Government Code of 1991

The Local Government Code of 1991 provides for the transfer of responsibilities from the national to the local government units (LGUs) thereby giving more powers, authority,

12

responsibilities and resources to the LGUs. Below are its provisions pertinent to emer-gency and disaster management.

■ Section 16 – General Welfare

Every local government unit shall exercise the powers granted, those necessarily implied therefrom, as well as powers necessary, appropriate or incidental for its effi cient and effective governance, and which are essential to the promotion of the general welfare. Within their respective territorial jurisdiction, local government units shall ensure and support, among other things, the preservation and enrichment of culture, promote health and safety, enhance the right of the people to a balanced ecology, encourage and support the development of appropriate and self-reliant, scientifi c and technological capabilities, improve public morals, enhance economic prosperity, social justice, promote full employment among their residents, maintain peace and order, and preserve the comfort and convenience of their inhabitants.

■ Allocation of fi ve percent (5%) calamity fund for emergency operations such as re - lief, rehabilitation, reconstruction and other works of services in connection with the occurrence of calamities.

■ Section 17 – Basic Services and Facilities Devolved to the Local Government Units

Basic services and facilities shall be devolved from the national government to provinces, cities, municipalities, and barangays so that each local government unit shall be responsible for a minimum set of services and facilities in accordance with established national policies, guidelines and standards.

Among the devolved functions and facilities are: health services which include hospitals and other tertiary health services; social welfare services which include programs and projects on rebel returnees and evacuees, relief operations, and population development services; and infrastructure facilities intended to service the needs of the residents of the province and which are funded out of provincial funds, including but not limited to provincial roads and bridges, inter- municipal waterworks, drainage and sewerage, fl ood control and irrigation systems, reclamation projects, and similar facilities.

■ Immediate and direct response to emergencies/disasters is the primary responsibility of the local government units. However, in cases where disasters have reached proportions which are beyond the capacity of the local government unit, the national government takes control (Under Section 105).

■ Section 105 – Direct National Supervision and Control by the DOH

In cases of epidemics, pestilence, and other widespread public health dangers, the Secretary of Health may, upon the direction of the President and in consultation with the local government unit concerned, temporarily assume direct supervision and control over health operations in any local government unit for the duration of the emergency, but in no case exceeding a cumulative period of six (6) months.

■ Chapter 11 of the Department of Health Rules and Regulations Implementing the Local Government Code of 1991 provides the legal basis for the DOH to establish

13

and maintain an effective health emergency preparedness and response program.

■ Section 389 and 391 – Powers, Duties and Functions of the Punong Barangay and Sangguniang Barangay.

■ Section 444 and 447 – Powers, Duties and Functions of the Municipal Mayor and Sangguniang Bayan.

■ Section 455 and 458 – Powers, Duties and Functions of the City Mayor and Sanggu- niang Panlunsod.

■ Section 465 and 468 – Powers, Duties and Functions of the Provincial Governor and Sangguniang Panlalawigan.

Generally, under the above provisions of RA 7160, the local chief executives and Sanggunian are expected to carry out the following disaster management functions and responsibilities:

Local Chief Executives:

1. Implement the emergency measures during and in the aftermath of a disaster or emergency. 2. Submit supplemental reports to higher authority or the Offi ce of the President regarding extent of damages incurred due to the disasters or calamities affecting the inhabitants. 3. Call upon law enforcement agencies to suppress civil defense/disturbance/ uprising. 4. Promote the general welfare and ensure delivery of basic services.

Sanggunian:

1. Adopt measures to protect the inhabitants from the harmful effects of natural or man-made disasters. 2. Provide relief and rehabilitation services/assistance to victims. 3. Adopt comprehensive land use plan. 4. Enact/review zoning ordinances.

■ Section 324(d) as amended by R.A. 8185 s.1997 – States that 5% of the estimated revenue from regular sources shall be set aside as annual lump sum appropriations for relief, rehabilitation, reconstruction and other works and services in connection with calamities occurring during the budget year. Provided however, that such fund shall be used only in the area, or a portion thereof, of the local government unit, or other areas affected by a disaster or calamity, as determined and declared by the local Sanggunian concerned.

Requisites for the use of the 5% Local Calamity Fund (LCF):

1. Appropriation in the local government budget as annual lump sum appropriations for disaster relief, rehabilitation and reconstruction; 2. To be used for calamities occurring during the budget year in the LGU or other LGUs affected by a disaster or calamity. 3. Passage of a Sanggunian resolution regarding declaration of calamity or disaster.

14

4. In case of fi re, the LCF can be used only for relief operations.

It will be noted that the 5% LCF cannot be used for disaster preparedness activities of the local government units unlike the National Calamity Fund (NCF). One of the rea-sons given by the authors of RA 8185 was that local government units should already program their preparedness activities in their respective budgets for the ensuing year.

Procedures for the allocation, release, accounting and reporting of Local Calamity Fund:

1. In case of calamity and upon recommendation of the local chief executive based on the reports of the local disaster coordinating council (LDCC), the local Sanggu - nian shall immediately convene within 24 hours from the occurrence of the calamity and pass a resolution declaring a state of calamity in the area(s) of the LGU affected by the calamity, and adopt measures to protect lives and properties in the area and implement disaster mitigation.

The Sangguniang Panlalawigan need not review the Sanggunian Bayan Resolution embodying the declaration. However, when the whole province is being affected by a calamity, the Sangguniang Panlalawigan, upon the recommendation of the Provin- cial Governor, shall declare the whole province under a state of calamity. In such cases, the Sangguniang Bayan of the respective municipalities need not declare their areas as calamity areas.

2. The local budget offi cer shall release the allotment of 50% of the Calamity Fund within 24 hours from the occurrence of the calamity, provided the following are present: Approved disbursement voucher Sanggunian resolution containing the calamity area declaration Local Disaster Coordinating Council report on damages

3. Pending the passage of the Sanggunian resolution on the declaration of the calamity area, the local chief executive may already draw cash advances from the General Fund which should not exceed 50% of the total Local Calamity Fund, subject to replacement after receipt of the above Sanggunian resolution.

4. The local treasurer shall submit a utilization report, duly approved by the local chief executive, to the Sanggunian concerned, Commission on Audit, and the Local Development Council, with copy furnished to the Local Disaster Coordinating Council.

5. Unused or unexpended balance of the LCF at the end of the current year shall be reverted to the unappropriated surplus for reappropriation during the succeeding year, except unused funds for capital outlay which shall be valid until fully spent or reverted.

Republic Act 8185 of 1997: Emergency Powers of the Local Government Units

Criteria for Calamity Area Declaration

At least two or more of the following conditions are present in the affected areas and lasting for at least four (4) days:

15

■ Twenty percent (20%) of the population are affected and in need of assistance, or 20% of the dwelling units have been destroyed. ■ A great number or at least 40% of the means of livelihood are destroyed (e.g., bancas, fi shing boats, vehicles). ■ Major roads and bridges are destroyed and impassable thus disrupting the fl ow of transport and commerce. ■ There is widespread destruction of fi shponds, crops, poultry and livestock and other agricultural products ■ There is disruption of lifelines such as electricity, potable water system, transport system, communications and other related systems, except for highly urbanized areas where restoration of the above lifelines cannot be made within 24 hours. ■ In case of epidemics or outbreak of disease, an area may be declared under a state of calamity based on the following: 1. There is an occurrence of an unusual (more than the previously expected) number of cases of a disaster in a given area or among a specifi c group of people over a particular period of time. To determine whether the number is more than the expected, the number should be compared with the number of cases during the past weeks or months or a comparable period during the last few years (at least 5 years). 2. There is a “clustering” of cases in a given area over a particular time.

Duration of Calamity Area Declaration

■ One year from the effectivity of the declaration. ■ Exception: When the effects of the disaster is recurring or protracted, in which case, the declaration shall be a continuing one. ■ Once 85% of the repair and rehabilitation works have been done and services have been restored, the declaration of a state of calamity may be terminated or lifted by the President of the Philippines or the local Sanggunian.

Memorandum No. 13 s. 1998 – Amended Policies and Procedures on the Provision of Financial Assistance to Victims of Disasters

Coverage – Disaster victims who died or got injured during the occurrence of a natural disaster.

Exception – Victims of man-made disasters such as fi res, vehicular accidents, grenade/ bombing incidents, armed confl icts, and air/sea mishaps, unless directed or approved by the President of the Philippines upon the recommendation of the National Disaster Coordinating Council (NDCC).

Amount of Financial Assistance: Php10,000.00 – for dead victims Php 5,000.00 – for injured victims

Validity of Claim – Within one (1) year from the occurrence of the disaster.

Procedure:

1. All claims for fi nancial assistance shall be fi led and processed at the Regional Disaster Coordinating Council (RDCCs). 2. Claims shall be accompanied with the following documents: For dead victims: • Local Disaster Coordinating Council report or police report • Original death certifi cate

16

• Certifi cation from the barangay captain • Proof of fi lial relationship with the victim • Endorsement for the payment of claims from the LDDC and RDCC chairmen For injured persons: • Medical certifi cate from the hospital or clinic where victim was confi ned for at least three (3) days • DCC/Police report • Endorsement for the payment of claims from the LDCC and RDCC chairmen

PRESIDENTIAL ISSUANCES PRESIDENTIAL ISSUANCES

Executive Order 948 S. 1994 – Grant of compensatory benefi ts to disaster volunteer workers (still for enforcement).

Proclamation No.296s. 1988 as amended by E.O. 137 s. 1999 – Declaring the fi rst week of July of every year as Natural Disaster Consciousness Week, now, the whole month of July as National Disaster Consciousness Month.

PMO No. 36 s. 1995 as amended by PMO No. 42 s. 1997 – Establishment of a special facility for the importation and donation of relief goods and equipment in calamity-strick-en areas.

Proclamation No. 705 – Declaring December 6, 1995, and December 6 of every year thereafter, as National Health Emergency Preparedness Day.

RELEVANT EXECUTIVE/ADMINISTRATIVE ORDERS RELEVANT EXECUTIVE/ADMINISTRATIVE ORDERS

DOH Administrative Order No. 6-B of 1999: “Institutionalization of a Health Emer-gency Preparedness and Response Program Within the Department of Health”

■ Institutionalized the Health Emergency Preparedness and Response Program of DOH. ■ Created the “STOP DEATH” Program as a comprehensive, integrated and responsive emergency/disaster-related, service and research-oriented program. ■ Aimed to promote health emergency preparedness among the general public and strengthen health sector’s capability to respond to emergency/disaster. ■ The program likewise gives advice and policy directions regarding health emergencies.

Executive Order No. 102: “Institutionalization of the Health Emergency Manage-ment Staff (HEMS)”

In view of the re-engineering of the DOH, the Disaster Management Unit (DMU) and STOP DEATH Program were merged.

The HEMS organizational structure places it directly under the Offi ce of the Secretary. It has two divisions: the Preparedness Division and the Response Division. Below are their respective functions:

Functions of the Preparedness Division ■ Develop plans, policies, programs, standards and guidelines for the prevention and mitigation of health emergencies.

17

■ Provide leadership in organizing and coordinating the health sector efforts for health emergency preparedness. ■ Provide technical assistance, consultative and advisory services to implementing agencies. ■ Facilitate capability building of implementing agencies. ■ Initiate advocacy activities. ■ Maintain/update the information center for emergencies and disasters. ■ Conduct/coordinate studies and researches related to health emergencies. ■ Conduct/facilitate monitoring and evaluation activities.

Functions of the Response Division ■ Maintain a 24-hour Operation Center to monitor health and health events nationwide. ■ Collect emergency and disaster reports nationwide, for the use of the Health Secretary, NDCC and other agencies and the public. ■ Lead in mobilizing health teams in anticipation of or in response to health emergencies. ■ Coordinate and integrate health sector response to emergencies and disasters. ■ Develop networks with government agencies (GAs), nongovernment organizations (NGOs), people’s organizations (POs), and health sector responders. ■ Develop plans, policies, programs, standards, guidelines and protocols for emergency response. ■ Conduct/coordinate studies and researches related to emergency response. ■ Conduct/coordinate monitoring and evaluation activities.

Administrative Order No. 182 s. 2001: “Adoption and Implementation of Code Alert System for DOH Hospitals During Emergencies and Disasters”

■ Mandates that all hospitals must get ready to respond whenever disasters are forseen and/or declared. ■ Introduces organizational shift and code alert system as mechanisms in the hospital set-up for the provision of medical services during emergencies or disasters. ■ Provides general guidelines on disaster codes: Code White, Blue and Red. ■ Defi nes the organization of the hospital to respond, including hospital manpower complementation, pre-positioning and mobilization of resources. ■ Advocates the activation of the Hospital Emergency Incident Command System (HEICS).

Administrative Order No. 168 s. 2004: “National Policy on Health Emergency and Disasters”

■ Defi nes the rules of engagement, procedures, coordination and sharing of resources and responsibilities, to include the varying levels of state of prepared ness and the desired response to emergencies and disasters in the health sector.

■ Applies to all DOH offi ces, hospitals, and its attached agencies, as well as to all disciplines and institutions, whether government, nongovernment or private entities whose functions and activities contribute to health emergency prepared ness and response.

■ Embodies the framework of Health Emergency Management (HEM), HEM strategies, organizational structure, human resource development, support systems, and roles and responsibilities of HEMS, DOH offi ces and attached agencies, and the health sector. ■ Defi nes program components as focused on community Risk Reduction for all phases and all types of disaster. It should cover mass casualty management, mental health and all types of emergencies with a potential to be a disaster,

18

Administrative Order No. 155 s. 2004: “Implementing Guidelines for Managing Mass Casualty Incidents During Emergencies and Disasters”

■ Includes pre-established procedures for resource mobilization, fi eld management and hospital reception in Mass Casualty Management (MCM).

■ Incorporates links between fi eld and health care facilities through a command post.

■ Acknowledges the need for multi-sectoral response for triage, fi eld stabilization and evacuation to appropriate health care facilities.

■ Covers mass casualty incidents related to weapons of mass destruction (WMD).■ Exemplifi es the components of MCM, which are: Policy and Planning; Capability

Building; Operation Center/Surveillance System; Facilities Development; Docu- mentation and Research.

Table 3. Strategies Used in Health Emergency Management

Strategies

1. Capacity Building (HRD) and Facilities Enhancement

2. Service Delivery

3. Health Information and Advocacy

4. Policy Development

5. Networking and Social Mobilization

6. Research and Development

7. Resource Mobilization

8. Information Management and Surveillance

9. Standards and Regulation

10. Monitoring and Evaluation

Activities

● Training on health emergency preparedness at all levels of the health sector from the community to the tertiary hospital level ● Enhancing facilities to improve the capacities of involved institutions

● Direct services (preventive, curative and rehabilitative services)● Timely, holistic and appropriate responses in emergency situations● Response services provided by competent, compassionate and dedicated personnel

● Activities informing the public on prevention and preparedness for emergencies and disasters● Basic First Aid in managing emergencies at home, schools, work place, public places, etc.● Activities empowering the community through health edu cation and promotion● Activities increasing awareness to gain support

● Development of plans, (EPRP, WFP/OPlan)● Development of policies, procedures, guidelines, protocols● Development of health emergency management systems

● Building up network● Networking meetings and other activities● Multi-sectoral activities (drills, benchmarking, etc.)● Establishment of MOAs and MOUs● Other collaborating activities

● Conduct of research studies● Case reports or other paper presentations

● Activities pertaining to resource generation and distribution (logistics, human resources, fi nances)● Mobilization of response teams ● Mobilization of ambulance teams

● Information generation, storage, and dissemination

● Standards setting, accreditation criteria setting● Activities empowering regulations

● Documentation of events and lessons learned● Post-mortem evaluation● Activities for sharing of good practices (e.g.,conventions)● Drills or simulation exercises

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■ Includes roles and responsibilities of various DOH Offi ces/Bureaus/Units in mass casualty management.

■ Provides guidelines on emergency response and dispatch.

Administrative Order No. 2007-001B: National Policy on the Management of the Dead and Missing Persons During Emergencies and Disasters

■ Acknowledges the critical role of government in standardizing and guiding the tasks of handling the dead bodies, ensuring that legal norms are followed and guaranteeing that the dignity of the deceased and their families is respected in accordance with their cultural values and religious beliefs.

■ Articulates the Guiding Principles in handling of the dead. ■ Highlights a multi-sectoral approach for a comprehensive, integrated and coordi-

nated response to Management of the Dead and Missing Persons (MDM) with the establishment of a coordinated body under the National Disaster Coordinating Council and led by the Department of Health.

■ Identifi es the local health offi cer of the concerned local government unit as the leader/ coordinator of MDM.

■ Defi nes the guidelines and procedures of the fi ve domains of Management of the Dead and Missing Persons During Emergencies or Disasters, namely: Search and Recovery; Identifi cation of the Dead; Final Arrangement of the Dead; Handling the Missing Persons; and Assistance to the Bereaved Families.

■ Includes the Management of Mass Fatality Incidents/MDM in the Emergency Preparedness, Response and Recovery Plan and as a component of the Emer- gency/ Disaster Management Program.

■ Applies to all Department of Health offi ces including its attached agencies, partner agencies, and stakeholders in the MDM.

Administrative Order No. 2007-0009: Operational Framework for the Sustainable Establishment of a Mental Health Program

■ Highlights goals of the National Mental Health Program with guidelines in service delivery, fi nancing, regulation and governance.

■ Sets objectives and strategies for the four priority sub-programs, namely: Well ness of Daily Living, Extreme Life Experience (such as disaster, epidemic, trauma) which threatens personal equilibrium, Substance Abuse and other forms of addiction, and Mental Disorder.

■ Adopts nine key approaches and strategies, namely: Health Promotion and Advo- cacy, Service Provision, Policy and Legislation, Development of Research Cul- ture and Capacity, Capacity Building, Public-Private Partnership, Establishment of Data Base and Information System, Development of Model Programs, and Monitoring and Evaluation.

■ Outlines the composition and functions of the implementing mechanisms – Na- tional Program Management Committee (NMPC), the Program Development and Management Teams (PDMT), the Regional Mental Health Teams (RMHT) and the Local Government Unit Teams for Mental Health (LGUTMH).

Administrative Order No. 2007-0017: Guidelines on the Acceptance and Process-ing of Foreign and Local Donations During Emergency and Disaster Situations

■ Highlights the critical role of the Secretary of Health in the formal acceptance of donations.

■ Specifi es the items for donations, particularly drugs, to be in accordance with the Philippine National Drug Formulary, the use of cash donations, and retention of reference samples.

20

■ Sets criteria for acceptance of items, e.g., food stuffs, and packaging of drugs. Excludes infant formula items.

■ Reserves the right to distribution with the Department of Health, disallowing its use for election purposes. Memorandum Circular, National Disaster Coordinating Council, May 10, 2007: “Institutionalization of the Cluster Approach in the Philippine Disaster Manage-ment System, Designation of Cluster Leads and Their Terms of Reference at the National, Regional and Provincial Level”

■ Designates government cluster leads to serve as main interlocutors for the different clusters and the counterpart Inter-Agency Standing Committee Country Team as support with defi ned roles and responsibilities.

■ Identifi es deliverables at regional and provincial levels.■ Forms nine clusters with the Department of Health as lead in four – Health,

Nu trition, Water and Sanitation Hygiene (WASH), and psychosocial clusters.

Administrative Order No. 2008-0024: Adoption and Institutionalization of an Inte-grated Code Alert System for the Department of Health

■ Contains the implementing guidelines for the conditions, human resource requirements, and other support requirements for each of the tri-color code alert status – white, blue and red – in the HEMS Central Offi ce, Center for Health Development, Hospitals and DOH Central Offi ces.

■ In the declaration, raising, lowering and suspension of code alert status, identifi es the Secretary of Health and Director of HEMS Central Offi ce as key national authorities, as well as the respective authorized designates for the HEMS Central Offi ce, Center of Health Development, Hospitals and Medical Centers.

Administrative Order No. FAE 007 s.1998: “Policies and Guidelines on the Trans-fer and Referral of Patients Between DOH Metro Manila Hospitals”

■ Focuses on Coordination, Networking, and Referral System.■ Contains guidelines and procedures in transferring emergency room (ER)

patients, as well as in referrals of admitted patients. ■ Applies to all DOH hospitals in Metro Manila and all additional hospitals placed

under DOH.■ Includes: general guidelines in the emergency room; guidelines in transferring ER

patients; guidelines for inter-hospital referral or request for procedures; guidelines for transferring in-patients; and guidelines for transferring of patients during disasters and emergencies.

Department Order No. 1-J, s. 2000: “Reporting Mechanism of Health Emergency Management Staff (HEMS) at the Central Offi ce and Its Units at the Centers for Health Development and DOH Hospitals”

■ Emphasizes that the Health Emergency Management Staff shall report directly to the Offi ce of the Secretary.

■ Duplicates the functions of the HEMS as its Units at the Centers for Health Devel- opment and DOH hospitals, serving as coordinators and reporting directly to the CHD director and Regional Hospital/Medical Center chief/director, respectively.

■ States that the CHD director shall be the overall coordinator for disaster preparedness and response at the CHD’s geographical jurisdiction.

■ Indicates that hospitals in Metro Manila shall report to the HEMS director through their respective Medical Center or Hospital director/chief during disaster response.

Memorandum No. 120 s. 2003: “Personnel and Ambulance Services for Emergen-cies and Disasters”

■ Pertains to resource mobilization.■ Reiterates the ever readiness of hospitals to respond to emergencies.■ Directs all hospital directors to actively be on top of any untoward event, espe-

cially in mass casualty incidents.■ States that personnel trained in emergencies, such as BLS, ACLS, EMT, MFR,

MCM and other related trainings, shall be included in the response teams of the hospital.

■ Orders that an ambulance be assigned for emergencies for easy dispatch of teams and be furnished with the necessary equipment, medicines, supplies, and necessary communication for proper coordination.

■ Emphasizes the authority of HEMS coordinators in the dispatch of these ambulances to prevent delays and the authority of any member of the team to drive in case there is no available driver.

Department Orders on Health Staff/Personnel

Department Order 2004-1679 – Creation of the Health Task Force on Health Emer- gency Management (DOH-HEMS Task Force)

Department Order 2004 – Creation of the Steering Committee and Technical Work - ing Groups in the Health Sector Responding to Emergencies and Disasters

Department Personnel Order 205-1324 – Amendment to Department No. 193-D s. 2003,dated October 8, 2003, Designation and Responsibilities of the Health Emergency Management Staff (HEMS) Coordinators of the Centers for Health Development and DOH Hospitals

Department Order 2003-193D – Amendment to Department Order no. 136-1 s. 2001 dated May 28, 2001, Designation and Responsibilities of the Health Emergency Management Staff (HEMS) Coordinators of the Centers for Health Development and DOH-Retained Hospitals

Department Order 2001-136-1 – Designation and Responsibilities of the Health Emergency Management Staff (HEMS)-Stop Death Coordinators of the Centers for Health Development and DOH Hospitals

Administrative Orders on Communications: Cell Phones

Administrative Order 2004-131 – Amendment to Administrative Order No. 164 s. 2000 re: Policies and Procedures for the Acquisition, Operation and Maintenance of Cellular Phones at the Central Offi ce

Administrative Order 2000-164 – Policies and Procedures for the Acquisition, Operation and Maintenance of Cellular Phones at the Central Offi ce

Memoranda on Budget

Memorandum 2000 101-A – Amendment to Memorandum No. 82 s. 2000 dated June 22, 2000, Stop Death Budget for CY 2000

Memorandum 2000 82 – Stop Death Budget for CY 200021

22

Part

IITh

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Em

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Man

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23

24

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1 Introduction

Every type of natural, human-generated, technological or societal disaster creates its own particular set of catastrophic features. Some events can be fairly predicted, such as typhoons, fl oods, and drought, whereas earthquakes, landslides and fl ashfl oods, given the suddenness and swiftness of their occurrence, result in unexpected outcomes.

People have continually been vulnerable to natural hazards but have further exposed themselves to various kinds of self-made disasters, such as war, riots, accidents, fi re, industrial, technological and ecological disasters, and recently to the threat of chemical, biological, radio-nuclear agents and explosives (CBRNE).

Hospitals play a very vital role in the management of emergencies. The facility should persist in functioning even if damaged as well by the disaster. Its main objective is to decrease mortality and morbidity and to prevent disability not only of its patients but also of its personnel and individuals within the facility or grounds. The hospital’s response in health/disaster management emphasizes the prioritization of treatment or triage, treat-ment of mass casualties, and crisis management, in particular increasing the number of hospital beds to provide services to the most number of patients at a very short notice.

Furthermore, hospital response highlights the need of bringing the right patient to the right hospital at the right time. Transport of casualties from the disaster impact site to the hospital must be communicated and coordinated with the receiving hospital. This is part of the response chain that ensures a smooth turnover of patient care and the choice of the most appropriate medical facility to render defi nitive patient care services. No longer limited to receiving patients, the role of the hospitals has expanded to include delivery of pre-hospital care.

Institutional preparedness of the hospital enhances the utilization of available resources during the response. Of crucial value is a thorough, carefully developed and updated hospital emergency plan that is activated when the need arises.

The hospitals, in crafting their plans, adopt an all-hazard approach that covers all phas-es of the health emergency/disaster cycle – from preparedness to response to recovery and rehabilitation. This approach considers the new challenges of natural, human-gen-erated emergencies, terrorist-related incidents especially the possible use of biological, chemical, radio-nuclear agents and explosives, and of emerging and re-emerging dis-eases.

Mass casualty incidents, a constant challenge to hospitals, test the surge capacity of the facility. Planning therefore centers on preparing the hospital in Mass Casualty Manage-ment. Equally important, the hospital’s Health Emergency Preparedness, Response and Recovery (HEPRR) plan should be written, simple, disseminated, tested and updated. This provides clarity in the identifi cation and the timely and appropriate performance of roles, functions and tasks, thereby preventing duplication, confusion and chaos and resulting in having more lives saved, both of patients and hospital personnel.

26

ROLES AND RESPONSIBILITIES OF HOSPITALS

For Health Emergencies and Disasters, the hospitals, based on A.O. 16B s. 2004, are to:

1. Observe all the requirements and standards (hospital emergency plan, HEICS, Code Alert, etc.) needed to respond to emergencies and disasters.

2. Ensure enhancement of their facilities to respond to the needs of the communities especially during emergencies.

3. Network with other hospitals in the area to optimize resources and coordinate transferring of victims to the appropriate facility.

4. Report all health emergencies to the Operation Center, and document all inci-dents reported.

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2 Activities During the Emergency Preparedness Phase

The hospital prior to a health emergency event undertakes development activities to en-hance its capacity to manage all types of hazards and systematically carry out response to recovery, ensuring a better level of function in health emergency management. (Go, 2007; DOH-HEMS, 2007a; WHO, ADPC, 2006). These activities are:

1. Development of policies, guidelines, procedures and protocols for health emergency management 2. Development of Health Emergency Preparedness, Response, and Recovery and Rehabilitation Plans 3. Development of the Organization 4. Physical Infrastructure Development 5. Systems Development

A. Development of Policies, Guidelines, Procedures and Protocols for Health Emergency Management

For the hospital to set Health Emergency Management as its appropriate priority and allocate needed resources for it, policies, guidelines, procedures, and protocols must be formulated consistent with those of the national plan but more importantly, they must be responsive to local settings. The subsequent sections provide details in the development process.

A1. DEFINITIONS

Policy is a formal statement by a government, organization or institution that Policy is a formal statement by a government, organization or institution that Policy expresses a set of goals, the priorities within those goals, and the preferred strategies for achieving those goals. It is primarily based on the mandate of the institution. It is the statement of what must be done. Guidelines state how to implement the policy; they deal more with the technical know-how required in implementation. Procedures likewise explain how to implement the policy but they are focused more on administrative know-how. Protocols still explain how to implement the policy, highlighting the observance of certain codes of etiquette and precedence. Plan, on the other hand, pertains to who does what and when in order to implement the policy.

These terms represent an interrelated set of processes in a sequential manner such that mandates are needed to set policies, policies are needed to defi ne guidelines and set procedures, and guidelines and procedures are needed to make plans.

The policy development process requires: the legal mandate of the institution; the authority (national, regional, hospital, local) of the agency; managerial and technical competence (such as in technical writing, etc); political will and support from the head of the agency; and that the policy be acceptable and doable.

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Examples in the Use of Terminologies Policy (What must be done)

Every dead victim has the right to be found, identifi ed and returned to his/her Every dead victim has the right to be found, identifi ed and returned to his/her family according to acceptable norm. family according to acceptable norm.

Guidelines (Technical know-how to implement the stated policy) Guidelines (Technical know-how to implement the stated policy)

Guidelines must contain the following: Guidelines must contain the following: • How to identify the dead • How to identify the dead • How to perform autopsy, DNA analysis, etc. • How to perform autopsy, DNA analysis, etc. • How to do the tagging and labeling of the dead bodies • How to do the tagging and labeling of the dead bodies

Procedures (Administrative know-how to implement the policy) Procedures (Administrative know-how to implement the policy)

Procedures must contain the following: Procedures must contain the following: • How to procure the reagents, equipment, the supplies for identifi cation • How to procure the reagents, equipment, the supplies for identifi cation of the dead of the dead • How to get funds for the procurement • How to get funds for the procurement • How to distribute reagents and supplies to all the laboratories • How to distribute reagents and supplies to all the laboratories

Protocol (Code of etiquette and precedence on how to implement the policy) Protocol (Code of etiquette and precedence on how to implement the policy)

Communication protocol must contain the following: Communication protocol must contain the following: • LGU request for assistance is coursed through the Center for Health • LGU request for assistance is coursed through the Center for Health Development, which channels to the HEMS – Coordinator. The response Development, which channels to the HEMS – Coordinator. The response follows the reverse direction. follows the reverse direction.

Plan (Who does what and when in order to Implement the above-stated policy) Plan (Who does what and when in order to Implement the above-stated policy)

The plan must contain the following: The plan must contain the following: • Objective • Objective • Strategies and activities • Strategies and activities • Person responsible • Person responsible • Resource requirement • Resource requirement • Time frame • Time frame • Performance indicator • Performance indicator

A2. POLICY DEVELOPMENT PROCESS

The policy development process includes:

a. Creation of Technical Working Group b. Review of existing policies at different levels (Republic Acts, Executive Orders, Administrative Orders, etc) c. Consultations (Multisectoral) d. Presentations for approval and signing e. Dissemination and orientation f. Monitoring and evaluation

An ad hoc Technical Working Group shall be formally created through an order (department order, hospital order, or regional order) which states their functions and outputs. With certain operational or program issues at hand awaiting directions, the group develops the policy to address these concerns. They review existing policies at different levels, such as Republic Acts, Executive

29

Orders, Administrative Orders, etc. before starting to craft the policy. Multisec- toral stakeholders are consulted in the whole development process to get their views through interactive brainstorming and critiquing sessions. The fi nal draft should be presented for approval prior to the signing by the head of agency. Policy never serves its purpose unless disseminated to all concerned implementers. Its implementation needs constant monitoring and evaluation to determine its sustained effectiveness or ineffectiveness, which may require updating or revision.

A3. POLICY CONTENT Below is an outline of what a policy should contain:

I. Background/Rationale II. Defi nitions of Terms III. Objectives IV. Scope and Coverage V. Framework VI. Strategies VII. Policy Statement VIII. Implementing Mechanism IX. Separability Clause X. Repealing Clause XI. Effectivity When formulating new policies, the hospital may use the national policies as a guide. However, policy formulation in the hospital is basically an adaptation process of the national policies to the hospital context. This may take the form of memoranda, special orders (regional orders), circulars, guidelines, etc. (Some details on the content of a policy are in Section 1, Part III of this manual.) Hospital emergency management policy may be needed in the following areas:

• Interaction between the hospital and other hospitals and medical centers • Interaction between the hospital and rescue, volunteer, and government organizations • Assignment of major responsibilities within the hospital for emergency prevention, preparedness and response • Acquisition and maintenance of emergency resources • Criteria for major evacuation of the hospital and for hospital relocation

B. Development of a Hospital Health Emergency Preparedness, Response and Recovery (HEPRR) Plan or Hospital Risk Reduction Plan The Hospital Health Emergency Preparedness, Response and Recovery Plan is also known as the Hospital Risk Reduction Plan. Considerations in its development are described below. (Go, 2007; DOH-HEMS 2007a; WHO, ADPC, 2006)

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B1. RISK MANAGEMENT

The Department of Health adopts the Risk Management Approach in its management process to deal with the actual or implied effects of hazards.

Risk Management is a comprehensive strategy for reducing threats and conse- Risk Management is a comprehensive strategy for reducing threats and conse- Risk Management quences to public health and safety of the community by: • Preventing exposure to hazards (target = hazards) • Reducing vulnerabilities (target group = community) • Developing response and recovery capacities (target group = response agencies)

Risk management includes the process of: selecting a hazard; identifying the communities exposed to that hazard; predicting the consequences of that hazard interacting with that community; analyzing each of the fi ve elements of community in relation to that hazard to identify the factors that will lead to each consequence (i.e., determining the vulnerabilities of each element); and identifying the capacities within the community to respond to that hazard. Analysis of the risk takes into account the relationships as follows:

This means that risk occurs if hazard affects a vulnerable community with a low capacity to respond. Even if there is a high possibility of hazard and a high vulnerability of the community, if the community’s capacity to manage is also high, then the probability of risk of a disaster to occur is low. Therefore, the community must have enhanced capacity or preparedness to prevent exposure to hazard, to reduce vulnerability, and to manage risk. Capacity is equated with preparedness of the community in risk management.

B2. DEFINITIONS

Defi nition of the seven common terms in risk management:

1. Hazard - Any substance, phenomenon or event that has the potential to cause disruption or damage to communities. - Any potential threat to public safety and/or public health.

2. Vulnerabilities - Factors that increase the risks arising from a specifi c hazard in a specifi c community (risk modifi ers). Examples of vulnerabilities of people: • Access to health care • Measles vaccination coverage rate • Under - nutrition rate • Under-5 mortality rate • Access to sanitation

3. Risks - Anticipated consequences of a specifi c hazard interacting with a specifi c community (at a specifi c time).

Hazard x Risk = Hazard x Risk = Hazard x Capacity

Vulnerability

31

Consequences of hazards (risks): • Death • Injury (mental and physical) • Disease (mental and physical) • Secondary hazards (fi re, disease, etc.) • Contamination • Displacement • Breakdown in security • Damage to infrastructure • Breakdown in essential services • Loss of property • Loss of income

4. Emergency - Any situation in which there is imminent or actual disruption or damage to communities, i.e., any actual threat to public health and safety which the community is able to cope with or manage.

5. Disaster - Any actual threat to public safety and/or public health where local government and the emergency services are unable to meet the immediate needs of the community, whereby the event is managed from outside the affected communities.

6. Capacities - An assessment of the ability to manage to an emergency (a risk modifi er). Total capacity is measured as readiness.

7. Community - People, property, services, livelihood and environment, i.e., the elements exposed to hazards. There are specifi c vulnerabilities or risks for each element of the community.

B3. CONSIDERATIONS

B3.1. General Considerations

In planning the Hospital HEPRR operations, the following general considerations should be taken into account (Stop Death Program, 2000a):

1. Disasters occur at any time without warning or signal. Everyone should be prepared at all times to render emergency response. 2. Disaster victims often needing quick medical assessment and prompt emergency care should be attended to immediately. 3. Disaster victims, often hurt and confused, should be treated with sensitivity and compassion. 4. Given that the volume of demand and the urgency of need for medical attention are unusually high during disasters, every human and material resources must be available, readily mobilized and organized for quick action. 5. Safety of personnel, patients, victims and the general population is of utmost importance in the delivery of services.

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B3.2. Specifi c Considerations

There are two aspects to hospital hazard and vulnerability assessment: (1) the vulnerability of the catchment area; and (2) the vulnerability of the hospital as a service provider. Emergencies can be purely internal, external or combined internal, external or combined internal, external internal/external (Stop Death Program, 2000a). Thus, there are three basic internal/external (Stop Death Program, 2000a). Thus, there are three basic internal/external scenarios that hospital emergency planning must satisfy:

• An emergency that disrupts the ability of the hospital to provide its normal services, but that does not cause harm to the community (an internal emergency); • An emergency that causes harm to the community requiring increased health/medical services, but that does not disrupt the ability of the hospital to provide medical services (an external emergency); • An emergency that causes harm to the community requiring increased medical services, and that also disrupts the ability of the hospital to provide medical services (an internal/external emergency).

Internal emergencies can be caused by a number of hazards, including fi re, explosion, hazardous material incident, food contamination, or loss of electricity supply, water supply, or other service. Internal emergencies can quickly multiply into a number of contingent emergencies. For example, a fi re may cause injury to patients and staff resulting in an overload on hospital services, hazardous materials incidents may lead to fi res or explosions, etc.

Catchment area vulnerability should be assessed to determine the likely demands on a hospital or hospital system (a series of linked hospitals and medical centers). The hospital must be prepared for a number of external emergency scenarios that may produce unusual medical demands on its existing capacity.

The capacity to manage routine emergencies is the foundation for further developing the capacity to manage the less frequent events of health emergencies which, in turn, provides the working base to build capacity in Mass Casu- alty Management. This existing capacity is known as surge capacity or the surge capacity or the surge capacity “health care system’s ability to rapidly expand beyond normal services to meet the increased demand for qualifi ed personnel, medical care and public health in the event of large-scale public emergencies or disasters” (a working defi nition from the Agency for Health Care Research and Quality, USA, 2005). The essential components are: trained and skilled staff, equipment, pharmaceuticals, supplies, and both physical structure and management systems such as Incident Management System. (WHO-WPRO, 2007a)

B3.3. Response Considerations

An overview of risk assessment and health response is presented as two frame works in Figures 1 and 2. (WHO, ADPC, 2006)

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Source: Sixth Inter-regional Course on Public Health and Emergency Management in Asia and the Pacifi c (PHEMAP), WHO (WPRO, SEARO) and ADPC, 2006.

Figure 1. Emergencies and Health

Community

DIRECT IMPACTS

VULNER-ABILITIESCAPACITIES

DamageandNeeds

ASSOCIATED FACTORS

Climate/weather/time of dayLocationSecurity situationPolitical environmentEconomic environmentSocio-cultural environmentMorale, solidarity, spiritCompetence, corruption

HEALTH RESPONSE

Search and rescueFirst aidTriageMedical evacuationPrimary care

Disease surveillance and controlCurative careBlood banksLaboratoriesReferral systemSpecial units (burns, spinal)

Evacuation centresShelterWaterFood and nutritionEnergySecurity

Environmental healthPrimary health care

Care of the deadPsychosocial careDisability care

RecoveryReconstruction

INDIRECT IMPACTSEMERGENCY

Source: Sixth Inter-regional Course on Public Health and Emergency Management in Asia and the Pacifi c (PHE-MAP), WHO (WPRO, SEARO) and ADPC, 2006.

Figure 2. Epidemic Emergencies

HEALTH RESPONSE

Case defi nitionAdmission criteriaCase confi rmationCase managementDischarge criteriaContact tracingVector controlEnvironmental controls

Surveillance systemReferral systemProfessional educationPublic information and awareness

Laboratory plansHospital plansSupplies and equipment

Border controlsQuarantineAnimal cullingCommerce/trade

NeedsOUTBREAK

Specifi c morbidity and mortality

- in thecommunity

- in healthfacilities

Risks for health and lab workers

Diffi cult access

Agent unknown

Spread of infec-tion

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Emergencies require a multisectoral response, as presented below. The contribution of health is highlighted in bold print.

• A Search and Rescue/Search and Recovery plan: In the Philippines, search and rescue is not a primary responsibility of the Department of Health. The conditions for its involvement have to be specifi ed and only by request. • Search and Rescue (Mass Casualty Incident); Search and Recovery (Man- agement of Dead and Missing) • An Evacuation/Temporary Shelter plan in coordination with other agencies • A Mass Casualty Management plan (networking multiple hospitals with the pre-hospital care system) • A Security plan • Specifi c Sectoral Relief plans (social welfare, public health, energy, shelter,

sanitation, food/nutrition, water, etc.)

B3.4. Recovery Considerations

The recovery phase in the hospital setting centers on the return of the response personnel and the hospital to normal operations the earliest time possible. Limited recovery or failure to recover can worsencurrent vulnerabilities or create new ones to future stressful situations. This is clearly seen when the hospital responds to an external emergency. The continuity of critical and essential functions of the hospital is vital, particularly in hazard-prone regions. The restoration may be on a short-term (i.e., within hours) or long-term basis (when services are disrupted for weeks or months). In the latter case, the hospital focuses on relocation of services within the facility or to an alternative facility either temporarily or permanently with construction of new facilities or change of hospital sites.

Recovery considerations are often described from the community perspective as shown below (WHO, ADPC, 2006b). This may provide the hospital insights in determining its contribution to this phase, when involved in external emergencies. It has to derive similarities and differences that will be useful in crafting its own recovery plan when affected by an internal emergency.

From Relief to Recovery • Disasters change social, political, economic and even demographic realities. • People begin almost immediately to re-house themselves and reestablish their social and economic networks after a disaster. • Most people have good ideas of what they want to do to rebuild their lives. It is essential to take their views into account when planning for recovery. • There is no clear-cut boundary between relief and recovery processes.

Purpose • To assist communities in reestablishing themselves quickly and effectively, recognizing that there will be a short-term need for external support to supple ment the personal, organizational and social structures which have been disrupted by the event.

Defi nition • Management plan and process – to restore the community to an appropriate level of functioning; to restore emotional, social, fi nancial and physical well- being.

• Developmental focus – – Not just a remedial process – Mitigates future disaster losses – Results in the creation of new legislation, institutions, programs, codes, land use regulations, and early-warning systems • Recovery – a long-term, slow and diffi cult process, i.e., creates confl icts and long-term grievance. • Reconstruction – not just building houses and physical infrastructure but full redevelopment of the affected area according to the needs of its population; restoration of emotional, social, economic, and physical well-being.

Process • Begins from the moment of the disaster impact. • Continues throughout the development process. • Is best when treated as a developmental activity. • Considers existing activities. • Takes into account services and structures. • Links to other processes: refl ects on social processes and physical reconstruction.

A well-managed recovery process helps a community/health care facility to return not only to its normal functions but to a better level of functioning and capability to address future disaster. Full recovery with satisfactory coping may be prolonged in hazard-prone and highly vulnerable communities.

The transition between response and recovery is a recognized gray area. Hospi- tals of the DOH need to be familiar with the existing defi nition of the local government to determine implications to its recovery plan. Republic Act. 8185 of 1997: Emergency Powers of the Local Government Units states the duration of Ca- lamity Area Declaration to be one year from the effectivity of the declaration. The declaration of the state may be terminated “once 85% of the repair and rehabilitation works and services have been restored.” However, when the “disaster effects are recurring or protracted, the declaration shall be a continuing one.”

In practice, recovery is often viewed to be more within the function of the Depart- ment of Social Welfare and Development.

B4. PLANNING

B4.1. Process Planning in health emergency management is a sequence of steps, listed as follows:

1. Determine the authority responsible for the process. 2. Establish a planning committee. 3. Conduct a risk analysis – hazards and community vulnerabilities. 4. Set the planning objectives. 5. Defi ne the management structure for the process. 6. Assign responsibilities. 7. Identify and analyze capacities and resources. 8. Develop the emergency management systems and arrangements. 35

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9. Document the plan. 10. Test the plan. 11. Review and update the plan on a regular basis.

These steps are generic to a planning process. Specifi c for risk management are the tools used in Steps 3 and 7 that focus on risk assessment, risk analysis and risk reduction. B4.2. Outputs

In Risk Management, three plans are of utmost importance:

a. A set of Health Emergency Preparedness or Risk Reduction plans – how can we prevent emergencies from occurring in the community. These include: • A Hazard Prevention plan • A Vulnerability Reduction plan • A Capacity Development plan (commonly referred to as Prepared- ness Plan)

In the Philippine setting, the Capacity Development plan centers on the elements of successful Health Emergency Management or the 10P’s, namely: • Policies, protocols, guidelines, procedures • Plans • People • Partnership building • Program development • Physical infrastructure development • Practices • Peso and logistics • Promotion of health • Package of services at the community, evacuation centers, hospitals, regional offi ces

b. A set of Health Emergency Response plans – who does what when, using existing capacity: • Organization • Activation of systems • Mobilization of resources – human and logistics (e.g., fl ow charts) • Partnership

c. A set of Health Emergency Recovery plans - who does what when after the termination or simultaneous with response operations: • Damage assessment and needs analysis • Psychosocial support • Restoration of utilized/ damaged resources and services • Post-incident evaluation

Every region, community or agency should have the three sets of plans with the sub-plans, collectively known as the “Emergency Preparedness, Response and

37

Recovery Plan.” For the Health Sector, this plan becomes the “Health Emer- gency Preparedness, Response and Recovery (HEPRR) Plan.”

At the national level, the Health Emergency Management Staff develops its: (1) National Strategic and Developmental Plan, (2) Annual Work and Financial/Opera- tional Plan, (3) Emergency Preparedness Plan in support of its Emergency Preparedness Program, (4) National Response Plan, (5) Recovery/Reconstruction Plan, and (6) Contingency Plan.

Contingency planning is a management tool used to analyze the impact of potential crises and to ensure that adequate arrangements are made in advance. It involves a predictive response element to an impending emergency by ensuring the availability of fi nancial, human and material resources, and by installing a mechanism for decision-making that can shorten disaster response. (UNICEF, 2007)

All plans promote greater coordination, networking, resource mobilization, dispatching of response teams for local and international humanitarian assistance, and logistics management (such as management of donations).

Hospital HEPRR planning is an integral part of both the multisectoral community Hospital HEPRR planning is an integral part of both the multisectoral community Hospital HEPRR emergency plan and the health sector emergency plan.

Hospital HEPRR Plan has two aspects: • Protection of the hospital, hospital services, patients and hospital staff from harm caused either internally or externally; and • Provision of hospital services to the community before, during and after an emergency.

B4.3. Outline of Hospital Health Emergency Preparedness, Response and Recovery Plan

The planning committee formulates and documents the HEPRR Plan as guided by the following suggested format. (Details of the formulation of an HEPRR Plan are in Section 2 in Part III of this manual.)

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Outline of Hospital Health Emergency Outline of Hospital Health Emergency Preparedness, Response and Recovery Plan Preparedness, Response and Recovery Plan

I. Background II. Plan description II. Plan description III. Goals and objectives III. Goals and objectives IV. Planning group IV. Planning group V. Management structures V. Management structures VI. Roles and responsibilities VI. Roles and responsibilities VII. Hospital Emergency Preparedness Plan VII. Hospital Emergency Preparedness Plan A. Hazards prevention A. Hazards prevention B. Vulnerabilities reduction B. Vulnerabilities reduction C. Capacity development C. Capacity development VIII. Hospital Response Plan VIII. Hospital Response Plan A. Organization A. Organization B. Systems activation B. Systems activation C. Resource mobilization C. Resource mobilization D. Partnership D. Partnership IX. Hospital Recovery and Reconstruction Plan IX. Hospital Recovery and Reconstruction Plan A. Damage assessment and needs analysis A. Damage assessment and needs analysis B. Psychosocial support B. Psychosocial support C. Restoration of utilized/damaged resources and services C. Restoration of utilized/damaged resources and services D. Post incident evaluation D. Post incident evaluation X. Annexes X. Annexes A. Glossary A. Glossary B. Abbreviations B. Abbreviations C. Directory of contact persons C. Directory of contact persons D. Inventory of resources/assets of the hospital and partner D. Inventory of resources/assets of the hospital and partner agencies agencies E. Hospital policies, guidelines, protocols, and other issuances E. Hospital policies, guidelines, protocols, and other issuances relevant to emergency or disaster management relevant to emergency or disaster management

B4.4. Next Steps

In Health Emergency Management, the process of plan formulation is the sec-ond critical step to save more lives, both of victims and of responders. To ensure that the consensus reached takes its form, is understood by all, is validated and practiced in its evidence-based mode, the hospital takes the following steps, an elaboration of Steps 9 to 11 in B4.1 Planning Process above.

1. Write the Hospital HEPRR Plan and have it approved by the Chief of Hospital. The Plan is not a plan until written and approved by the highest authority. A plan should be documented so as not to be forgotten.

2. Disseminate the plan to all the stakeholders and all the hospital staff. Everyone needs to know the plan so that in an emergency no one would

say “he does nothing because he knows nothing.” A plan should be simple to be understood. A plan should be disseminated to be in the hands of those who will implement it.

3. Test the plan. A plan is believed to be effective only when it is tested, i.e., to know its functionality, acceptability, and doability in the hands of the imple-menters. A plan should be tested to know the gaps and problems.

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C. Development of the Organization

C1. PREPAREDNESS PHASE

C1.1. Planning Group/Committee Health Emergency Preparedness, Response, Recovery and Reconstruction planning is a local activity carried out by end-users and it applies to specifi c circumstances. It is done by a group of authorized key individuals or implementers and not by a single person. The Planning Group/Committee of the hospital shall consist of all the hospital’s major decision-makers, including a representative from the community. The community representative may be a member of the Disaster Coordinating Council, a local offi cial, NGO or volunteer group, or a member of a health professional society (e.g., medical or nursing society).

The planning group may be an “ad hoc group” convened specifi cally for the formulation of new plans or for the update of existing plans after drills or after the emergency/disaster post-event evaluation.

Composition of the Hospital HEPRR Planning Group/Committee:

• Hospital director • HEM coordinator/assistant coordinator • Representative from the areas of hospital operation • Representative from the hospital’s administrative unit (the administrative offi cer or fi nance and logistics offi cers, or their representatives) • Representative from the hospital’s planning unit • Representative from the community (representative from the Disaster Coordinating Council, from the medical society, or from any nongovernment organization)

4. Implement the plan.

5. Monitor and evaluate the implementation of the plan.

6. Review and update. A Plan should be updated regularly to conform with the times.

Pointers in Formulating a Health Emergency Management Plan ■ Write it down or it will not be remembered. ■ Make it simple or it will not be understood. ■ Disseminate it or it will not be in the hands of those who need it. ■ Test it or it will not be practical. ■ Revise it or it will not be up-to-date.

(Source: Banatin, 2005)

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Functions of a Hospital HEPRR Planning Committee:

1. Develops, reviews and updates the Hospital HEPRR plan after every drill or actual disaster. 2. Gathers required information and gains the commitment of key people and organizations. 3. Initiates testing of the plan for its functionality and revises/updates it according to adaptability to the current situation. 4. Develops an Annual Operation Plan and other plans relevant to Health Emergency Management.

C1.2. Management Structures

The management structures in Health Emergencies and Disasters in the Hospital are provided for in A.O. 168 s. 2004 (Section V. Policy Statements, A. Organizational Structure) which states that:

1. All health facilities should have an Emergency Preparedness and Response Plan and a Health Emergency Management Offi ce/Unit/Program. Such offi ces, units or programs shall be under the supervision of the highest offi cer, such as the Regional Director, Chief of Hospitals or the equivalent offi cer so as to ensure faster decision-making in times of emergencies and disasters.

2. All health facilities shall establish a Crisis and Consequence Management Com- mittee to handle major emergencies and disasters, composed of people from operations, logistics and fi nance group.

3. An emergency coordinator shall be designated in all health facilities. He/she should be an integral member of any crisis or consequence management in his/

Figure 3. Example of a Hospital HEPRR Planning Group/Committee Structure

Chief of Hospital/HEM Coordinator

Representa-tives from the Areas of Hospital Operation

Represen-tative from Administra-tive Unit(fi nance/logistics offi cer, transport)

Represen-tative from Planning Unit

Representa-tive from the Community

41

her respective facility or institution. As such, he/she shall coordinate directly with higher offi cials for technical aspects during emergencies, and administratively, shall be answerable to his/her mother unit. He/she shall be given proper authority and support (personnel and material) by the management during operations.

4. An offi cial spokesperson who is accessible and available to the media shall also be designated. He shall be responsible for disseminating information that is accurate and updated.

C1.2a. Crisis and Consequence Management Committee

The Crisis and Consequence Management Committee is a lower committee that will provide technical as well as operational support to the Executive Committee and provide inputs for decisions and policy directions in crisis, emergency and disaster. Given the legal basis, a suggested composition of the Crisis and Conse-quence Management Committee is as follows:

Membership 1. Medical Center Chief II/Hospital Director 2. HEM Coordinator/Assistant Coordinator 3. Chief of Clinics 4. Chief Administrative Offi cer 5. Chief of Nursing Service 6. Head of Emergency Department 7. Public Health Unit/Epidemiology Optional membership 8. Chief of Surgery 9. Chief of Anesthesia 10. Chief of Medicine 11. Chief of Orthopedics 12. Chief of Pediatrics 13. Chief of Obstetrics/Gynecology 14. Chairperson of Security on Critical Infrastructure Program 15. Chief Security 16. Head of Maintenance Section 17. Chairperson of Hospital Center of Wellness Program

Health emergency function is a concurrent function of the assigned hospital staff. Under normal conditions, the assigned hospital Health Emergency Staff Coordinator/Assistant Coordinator may be part of a department (e.g., Medicine, Emergency Room, Surgery).

The Medical Center Chief/ Hospital Director shall exercise discretion in the for-mation and composition of the committee to fi t the organization (such as in the case of Special Hospitals). Where feasible, he/she optimizes the use of existing structures, e.g., Executive Committee, to reduce the existence of multiple struc-tures with duplicate functions and avoid concomitant operational issues such as attendance in meetings. To illustrate, the Crisis and Consequence Management Committee may be part of the Executive Committee.

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C1.2b. Hospital Health Emergency Management Staff (HEMS) Coordinator

As stated in Department Order No. 136-I s. 2001 and affi rmed in Department Personnel Order No. 2005-1324 dated June 14, 2005, the responsibilities of the Hospital HEMS Coordinator and the Assistant Coordinator are:

Coordinator1. Reports directly to his respective director in the hospital or CHD, and coordi-

nates with the HEMS Director in times of emergencies and disasters.2. Takes the lead in the preparation of the Emergency Preparedness Plan of the

CHD/hospital, duly approved by his chief, disseminated to all the staff, and regularly tested, evaluated and updated.

3. Prepares the annual work and fi nancial plan and takes the lead in the implementation of the health emergency activities.

4. Responsible for the organization and dispatching of teams to respond to emergencies and disasters as embodied in the plan. The team coming from the CHD should lead in the rapid assessment, monitoring, social advocacy and other public health activities. The hospital team should be prepared for but not limited to trauma-related disasters.

5. Make himself available and accessible in times of emergencies and disasters; hence must equip himself with the necessary communications.

6. Responsible for the training of the HEMS members in the region (CHD, hos-pitals) and the communities relative to health emergency skills and manage-ment.

7. Ensures that the necessary drugs, medicines, supplies and other necessary equipment are available and properly stocked for emergencies and disasters.

8. Takes the lead in public information and awareness concerning disasters and emergencies.

9. Networks with members of the Health Sector responding to emergencies and disasters within the hospital’s/CHD’s region/zonal catchment areas and the communities, as well as with other agencies responding to emergencies and disasters.

10. Follows the HEARS Plus reporting and coordinates with the DOH Central Operation Center for all emergencies and disasters.

11. Fully responsible for the implementation of the Memorandum Order, Circular, Administrative Order and Department Order issued by the Health Secretary and the Director of HEMS, especially in extreme emergencies.

12. Documents all related activities; this includes the preparation of a Postmor-tem Evaluation of each event responded to and submission of the report to the Director of the CHD/hospital with copy furnished the HEMS Director.

13. Develops research proposals that would aid the service in policy direction, implementation and improvement.

14. Submits quarterly reports to the HEMS Director.

Assistant Coordinator 1. Assists the HEMS coordinator in all his/her activities.2. Acts as an action offi cer on health emergency and disaster.3. Acts on behalf of the coordinator in the latter’s absence.4. Acts as training offi cer in relation to health emergencies and disasters.

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C2. HEALTH EMERGENCY RESPONSE PHASE

During emergency response, management structure is of prime importance as it shows the specifi c chain of command, control and coordination. Refl ecting the roles, functions and responsibilities of all key players involved, the management structure shows the fl ow of reporting, coordination and communication. The structure is best represented and explained with diagrams.

C2.1. Hospital Emergency Incident Command System (HEICS) vis-à-vis the Incident Command System (ICS)

Incident Command System (ICS) is a management system used in responding to an incident. There are two types of ICS: Single Command involving only one agency, and Unifi ed Command involving several agencies responding to the incident. This is a generic nomenclature and can be applied to any facility (WHO and ADPC, 2006). Hence, if the facility is a hospital where all responders are coming from the same agency, it is a single command type of ICS.

The hospital in responding to an incident at Code Blue alert now activates the Hospital Emergency Incident Command System (HEICS) which involves an

organizational shift to an emergency mode. While the basic structure of an Incident Command System is the same for all facilities, the command, coordination and control system can be adapted to the hospital conditions. During an emergency/disaster, as the hospital is in an emergency mode, other staff of the hospital may assume roles and functions as needed in an emergency. The HEMS Coordinator may assume the role of the Incident Commander, an operations head or a spokesman as deemed necessary by the hospital chief.

C2.2. Hospital Emergency Incident Command System

C2.2a. Hospital Emergency Incident Command System Structure

The HEICS is the prescribed organizational structure for command, control and coordination as stated in A.O. 168 s. 2004. It is a system which employs a logical management structure, defi ned responsibilities, clear reporting chan-nels, and a common nomenclature to help unify hospitals with other emergen-cy responders.

HEICS, the standard for health care disaster response, offers the following features (HEMS, 2000a):

• Predictable chain of management • Flexible organizational chart which allows fl exible response to spe

cifi c emergencies • Prioritized response checklists • Accountability of position function • Improved documentation for improved accountability and cost recovery • Common language to promote communication and facilitate outside

assistance • Cost-effective emergency planning within health care organizations

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The HEICS has fi ve basic personnel consisting of an Incident Commander, Op- erations Offi cer, Planning Offi cer, Finance Offi cer and Logistics Offi cer. Three other personnel – Security Offi cer, Liaison Offi cer and Public Information Offi cer – serve as staff to the Incident Commander and altogether compose the command staff. (See Figure 4.)

The hospital may revise the structure according to the need of the facility and available human resources. If the facility is not affected by the disaster, a designated group shifts to an emergency/disaster mode for the HEICS, while the rest of the staff conduct normal or regular hospital transactions/services.

If the hospital raises its alert status to Code Blue, normal offi ce transactions are suspended and the hospital is shifted to emergency/disaster mode.

C2.2b. Job Action Sheets

The Job Action Sheets (JAS) or job descriptions tell responding staff “what they are going to do; when they are going to do it; and, who they will report it to after they have done it.” Of the JAS content, the job title and the mission statement should not be changed under any circumstances. These are universal statements which allow emergency responders from different organizations to communicate quickly and clearly with other practitioners of the Incident Command System (WHO, ADPC, 2006). With regular use, the content may be updated or modifi ed to the hospital conditions. The JAS for the Department of Health facilities are presented in Section 3. Of the 16 sheets, half (A-H) are for the command post, and the rest for the key response offi cers.

Job Action Sheets A. Incident Commander B. Safety and Security Offi cer C. Public Information Offi cer D. Liaison Offi cer E. Logistic Section Chief F. Planning Section Chief G. Finance Section Chief H. Operations Section Chief I. Treatment Team Leader J. Triage (Initial) Team Leader

Figure 4. Basic Hospital Emergency Incident Command System (HEICS) Structure

Operations Planning Administrative and Finance

Security Offi cer

INCIDENT COMMANDER

Liaison Offi cer

Public Information Offi cer

Logistics

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K. Transport Group Supervisor L. Staging Offi cer M. Field Medical Commander N. Morgue Manager O. Medical Controller P. Incident Medical Commander (for pre-hospital incident)

In Mass Casualty Incidents, there are two positions for medical concerns at the Command Post (pre-hospital) based on A.O. 155 s. 2004. These are the Medical Controller and the Incident Medical Commander.

The Medical Controller is a designated senior Department of Health offi cer ap- Medical Controller is a designated senior Department of Health offi cer ap- Medical Controller pointed to assume the overall direction of the medical response to mass casualty incidents and disasters. Control is established from a designated Operations Center either in the Central Operations Center or the Regional Operations Center and whose main responsibility is to coordinate all the services of the sector.

The Incident Medical Commander is the highest representative of the Depart- Incident Medical Commander is the highest representative of the Depart- Incident Medical Commander ment of Health or the local health offi ce as designated by the local chief ex ecu- tive depending on the extent of the disaster. He serves as the liaison offi cer of the Health Sector to the Command Post headed by the Incident Commander. For regional disasters, the Incident Medical Commander should be the highest representative from the DOH CHD.

For quick retrieval and repeated use of the Job Action Sheets, the hospital specifi es the appropriate presentation and storage within its facility, which includes having JAS inside plastic sheets, with clear plastic clipboard or lami - nated in plastic. One option is to have the JAS in a pocket size booklet with other useful information, such as a telephone directory and maps, following a declared emergency. Organizing and storing the materials may use color codes and suitable placement areas, such as location by hospital units for a “user-friendly” approach, thereby increasing effi ciency in the accomplishment of tasks.

C2.2c. Organizational Chart

A comprehensive HEICS Organizational Chart for a hospital is presented in Figure 5 (Stop Death Program, 2000a). The positions are fi lled up based on the priorities created by the emergency/disaster and their importance to minimizing the harmful consequences. The fi rst assignments are given to those immediately needed while some are for later hours (particularly if the emergency occurs at night) or even for succeeding days. Some positions need not be fi lled up or a person may assume two or more positions depending on the human resources available and the capability of the hospital.

Cognizant of the uniqueness of each health emergency/disaster and of the limitation of human health resources, the plan has to provide for delegation of more than one job to an individual or for re-prioritization of needs given the emergency’s evolving conditions.

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C2.3. Roles and Responsibilities of the Hospital

In Mass Casualty Management, the hospital can be a responding facility, a receiving facility, and can be both a responding and receiving facility. This would depend on the classifi cation, designation and capability of the hospital.

To become a responding facility, the hospital must have a competent re-sponse team always available and ready to be dispatched in times of emergency. The response team is composed of a physician (or Hospital HEM Co-ordinator), a nurse, Emergency Medical Technician (EMT), trained non-medi-cal staff, and an ambulance driver with an equipped ambulance. The team must have the capability to undertake the following:a. Incident Command System - Team Leader or the HEM Coordinator must

have the capability to establish command, control and coordination in the fi eld, or must be capable of becoming an Incident Commander

Safety and Security Offi cer

INCIDENT COMMANDER

Liaison Offi cerPublic Information Offi cer

Logistics Chief

Facility Unit Leader

Damage Assesment and Control Offi cer

Sanitation and Systems Offi cer

Communications Unit Leader

Transportation Unit Leader

Materials Supply Unit Leader

Nutritional Supply Unit Leader

Planning Chief

Situation StatusUnit Leader

Labor Pool Unit Leader

Medical Staff Unit Leader

Nursing Unit Leader

Patient Tracking Offi cer

Patient Information Offi cer

Finance Chief

Time Unit Leader

Procurement Unit Leader

Claims Unit Leader

Cost Unit Leader

Medical Care Director

Medical Staff Director

In-Patient Areas Supervisor

Surgical Services Unit Leader

Maternal Child Unit Leader

Critical Care Unit Leader

General Nur-sing Care Unit Leader

Out-Patient Services Unit Leader

Treatment Areas Supervisor

Triage Unit Leader

Immediate Treat-ment Unit Leader

Delayed Treat-ment Unit Leader

Minor Treatment Unit Leader

Discharge Unit Leader

Morgue Unit Leader

Ancillary Ser-vices Director

Operations Chief

Human Services Director

Laboratory Unit Leader

Radiology Unit Leader

Pharmacy Unit Leader

Cardiopulomonary Unit Leader

Staff Support Unit Leader

Psychological Support Unit LeaderDependent Care Unit Leader

Figure 5. Comprehensive Hospital Emergency Incident Command System Organiza-tional Chart

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b. Rapid Health Assessmentc. Triagingd. Life support – Basic Life Support (BLS), Standard First Aid, EMT, or

Advanced Cardiac Life Support (ACLS)e. Proper communicationf. Proper coordinationg. Establishment of Emergency Operations Center on-siteh. Evaluation and provision of medical/health care to the victims

The hospital as a receiving facility must possess the following capacities:receiving facility must possess the following capacities:receiving facility a. Emergency room equipped for emergency care to handle all types of MCI b. Equipped critical areas to accommodate and provide necessary defi nitive care to the victims (Operating Room, Recovery Room, Burn Unit, Trauma Unit, Morgue, ICCU/CCU, Ancillary Services, Pharmacy, etc) c. Competent staff to provide defi nitive care to the victims d. Pre-identifi ed rooms or wards to accommodate infl ux of patients

As a receiving hospital it must be able to manage the surge of victims/patients through the following: a. Expansion of key services to accommodate infl ux of patients. b. Having operating rooms which can serve beyond their normal load of patients. c. Handling additional laboratory and radiological procedures, and other support services requirements. d. Postponement/cancellation of elective operations. e. Facilitation of rapid turnover of patients or coordination with other hospitals for patients’ transfer. f. Mobilization of additional human resources within the area or tapping the HEMS’ system using the entire DOH network.

The hospital can be both a responding and receiving facility if it pos- sesses both of the above capacities and capabilities.

C 2.4. Response Teams

C 2.4a. In-Hospital Response Team

The In-Hospital Response team provides the defi nitive medical care to the mass casualty incident victims who are either brought in or have walked in to the hospital.

While this is essentially the Emergency Unit/Department staff with the ad-mission area as the frontline, the rest of the hospital personnel on duty are also members of the In-Hospital Response Team (Refer to the Code Alert System for human resource requirements). But at the minimum, the key staff would consist of:

a. Head of Emergency Unit/Departmentb. Triage Offi cer and teamc. Treatment Offi cer and teamd. OR personnel

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C2.4b. On-Scene Response Team

This is a small group of competent and certifi ed physicians, nurses, ad-ministrative workers (utility workers) and drivers deployed to the emer-gency/ disaster site outside the hospital for external emergencies and/or inside the hospital for internal emergencies. They are responsible for the management of the fi eld/on-site activities from assessment, triage, treat-ment, evacuation and transport in coordination with the Command Post/Hospital Operation Center, Receiving Hospital Facility and the CHD and HEMS Operation Center. (Other details are in Section 4. Deployment of Response Teams.) The on-scene response team is composed of:

a. On-scene Response Offi cer (Team Leader)b. Surgeon/Anesthesiologistc. Internal Medicine d. Nurses/EMTe. First Aiders/Helpersf. Driver

D. Physical Infrastructure Development

The physical infrastructure is a critical resource to be examined in the hospital’s preparedness for health emergencies. The relevant sections of the WHO-WPRO Field Manual for Capacity Assessment of Health Facilities in Responding to Emer-gencies may serve as a guide in such a review process for the hospital in general and for particular sites. (WHO-WPRO, 2006)

The physical infrastructure involved are: 1. Health Emergency Management Unit/Offi ce

The HEM unit/offi ce is in compliance with A.O. 168.s 2004, “The National Policy on Health Emergencies and Disasters,” which provides that, where feasible, the hospital may provide separate physical space for a Health Emergency Manage-ment Offi ce/Unit/Program under the supervision of the Chief of Hospital. Often, the unit/offi ce is located in the mother unit of the designated emergency coordi-nator and assistant coordinator who perform these roles as concurrent functions.

2. Hospital Operations Center (Hospital OpCen)

This is the Nerve Center with the ability for command, control, coordination and communication in dealing with emergency or disaster situations. This is where the Incident Commander and his staff are located, and thus constitutes the head-quarters or focal control point from which the hospital emergency response plan is directed and coordinated. (Details of the physical design and functions are in Section 5.)

3. Hospital Service Areas

It is essential that certain areas of the hospital be designated for specifi c functions

49

Figure 6. Patient Care Stations

Source: Sixth Inter-regional Course on Public Health and Emergency Management in Asia and the Source: Sixth Inter-regional Course on Public Health and Emergency Management in Asia and the Pacifi c (PHEMAP), WHO (WPRO, SEARO) and ADPC, 2006.

Holding Area

Red Area

Hospital Reception -- Flow of Victims

Establishing a Mass Casualty Management System

Provision for Secondary Evacuation

Command Post

RedRed

Operating Operating TheatreTheatre

Green

YellowYellow

Yellow

TriageArea

Green

Accident and “E”Department

such as reception of casualties, treatment, and discharge of patients (DOH-SDP, 2000b). The plan should be specifi c as to the function of these areas, staffi ng re-quirements, basic supplies to be utilized, and other necessary features like venti-lation, alternative sources of energy, communication, and waste disposal. Some considerations in hospital design, energy source and communications are given in Annex 1. The development of these areas may involve either the improvement and/or upgrading of existing areas or construction of new ones as deemed ap-propriate for the hospital in compliance with the technical requirements of such areas. The hospital must have the following areas for managing health emergen-cies:

a. Emergency Room – Most important area for reception of mass casualties, triage and treatment. The emergency room must have:

■ Reception Area/Admission – The area should be available on short notice to receive multiple casualties for registration and admission.

■ Triage Area – The primary function of a triage area is rapid assessment of all incoming casualties, the assignment of priorities for management, and distribution of patients to various other patient care areas in the hos-pital. Without a triage area to manage the patient fl ow, the major treatment area may become overloaded.

■ Decontamination Area – Physically located before the entrance of the emergency room, the decontamination area is provided with facilities for security and privacy of the patient, bathing of the patient, disposal of con-taminated clothing and other materials, contaminated water disposal/drain-age, and draping of decontaminated patients and decontamination team. The decontamination team members should be provided with the appropri-ate personal protective equipment. Decontamination is not routinely done

50

to all patients. It is specifi cally used only if there is a high index of suspicion for biological, chemical and radionuclear incidents.

■ Patient Care Stations – One suggested method of organizing patient care stations is the designation of areas physically located in the Emer- gency Department for color-tagged patients (See Figure 6) (WHO and ADPC, 2006). Stations may be designated as: Red – Immediate Care Area: red tag patients Yellow – Urgent Care Area: yellow tag patients Green – Delayed Care Area: green tag patients

b. Admission Pre-surgical Holding

Most trauma patients stabilized in the Red Area (emergency department) will be sent to the Admission Pre-surgical Holding area.

c. Operating Room

The number of operating rooms that can be staffed is the main limiting fac-tor in the provision of defi nitive care for a large number of severely injured casualties. The most senior surgeon available must take the responsibility to prioritize and assign cases as rapidly as possible.

d. Intensive Care Units (Coronary/Medical/Surgical)

e. Special units ■ Burn Unit ■ Toxicology Center ■ Infectious Units (isolation rooms for SARS, etc) ■ Disability Care

f. Ancillary units ■ Laboratory ■ X-ray/other Radiologic Services (CT Scan, MRI, etc.) ■ Blood Bank Facilities

g. Psychosocial Care Area

This is physically located in a designated area in the out-patient department for individual and group consultations. Hysterical and diffi cult to control persons, whether patients, visitors or staff, who can be extremely disruptive to hospital disaster operations shall be placed in a separate isolated area and later trans-ported to Regional Centers and/or the National Center for Mental Health.

h. Morgue

Many disasters can result in a large number of fatalities. This may require that present morgue capacities be expanded or other outside facilities (such as a church or stadium) be temporarily utilized. The disposal of the dead shall follow the existing standard operating procedure for hospitals and the relevant guidelines from the National Policy on Management of the Mass Dead.

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i. Family Waiting Area

A separate area must be pre-designated for family members seeking information. Previous experiences with disasters have shown that families and friends would converge en masse to the hospital seeking information about victims. This con-vergence can seriously interfere with efforts of the hospital to respond effectively to the situation. This area may also be utilized to discharge in-hospital patients and victims of the disaster.

j. Social Worker Offi ce/Area

Given the confusion and the anxiety of converging families and friends of the victims, an area is designated to allow prompt, systematic and compassionate technical assistance for families inquiring about and seeking access to support from government and nongovernment resources.

k. Accommodations for Responders Sleeping/rest areas are provided to responders in-between duty shifts.

l. Media Room

There should be a designated area to hold and brief the media. The room should not be near the area where patients are treated like the Emergency Room or the Operating Rooms. Furthermore, provision should be made to conduct regular press conferences or give out press releases.

E. Systems Development

The effectiveness and effi ciency of Health Emergency Preparedness and Response of a health facility entail an understanding of a system’s perspective – the development of “connected parts functioning together for a common goal.” Given the com-plex nature of an all-hazard approach, some of the component systems by them-selves are unique to the approach (such as the Early Warning and Alert System and Mass Casualty Management). The others are existing ones that need to be modifi ed to support the approach (such as Training, Logistics, and Information Management).

These systems, guidelines and protocols specifi c to the hospital setting need to be described in the plan (Go, 2007). The hospital shall review and adapt the following components (presented in the indicated sections in Part III of this manual) as appropriate to their vulnerability assessment and defi ned level of function:

1. Early Warning and Alert System Section 6 2. Damage Assessment and Needs Analysis/ Rapid Health Assessment Section 7 3. Emergency Operations Center Section 5 4. Mass Casualty Management System Section 8 5. Management of Mass Dead and Missing Section 9 6. Public Health Services Section 10 7. Mental Health and Psychosocial Support Section 11 8. Coordination and Networking Section 12

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9. Human Resource Development Section 13 10. Logistics Section 14 11. Information Management Section15 12. Health Promotion and Advocacy Section 16A Risk Communication and Media Management Section 16B Risk Communication in Hospitals Section 16C 13. Health Systems in Emergency/Disaster Section 17 14. Evaluations Section18 15. Research and Development Section 19

In the design of these systems, the hospital develops or adapts the policies, guide lines and protocols that have been set at the national level for activation during the Emergency Response, as follows:

1. For Adoption/Adaptation

■ Early Warning System/Code Alert System/Integrated Code Alert System (A.O. 182 s. 2001; A.O. 2008-0024) ■ Health Emergencies and Disasters (A.O. 168 s. 2004) ■ Logistics Management System – on Donations (A.O. 2007-0017) ■ Mass Casualty Management (A.O. 155 s. 2004) ■ Management of the Dead and the Missing (A.O. 2007-001B) ■ Health Information Management System (D.O. 1-J, s. 2003) ■ Coordination, Networking, and Referral System (A.O. FAE 007 s.1998) (for Metro Manila only) ■ Resource Mobilization – (A.O, 13 s. 199; Memo No. 120 s. 2003) ■ Manual on Treatment Protocols of Common Communicable Diseases and Other Ailments During Emergencies and Disasters ■ Guidelines on WMD Response for the Philippines (A.O. 155) ■ Key Health Messages for Emergencies (compendium)

The policies cover specifi c provisions for operations such as emergency dispatch, identifi cation of the dead, etc. and for organizational structure, human resource development, logistics, communication, information management, networking and collaboration, and fi nance in support of the response operations.

2. For Adaptation from Other Offi ces

■ Epidemiology and Surveillance ■ Guidelines on Control of Communicable Diseases ■ Guidelines on SARS, Emerging and Re-emerging Infections ■ Guidelines on Infection Control (Hospital SOP)

3. For Development

■ Guidelines and Procedures in Evacuation ■ Public Information System and Management of the Media ■ Guidelines on Risk Communication ■ Guidelines on Communication ■ Guidelines and Procedures on Emergency Response ■ Guidelines on Biological, Chemical, Radio-Nuclear and Explosives ■ Others

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Table 4. 10 P’s of Health Emergency Management (Based on A.O. 168 and A.O. 155)

> All Health Care Facilities (HCF) have HEM Offi ce/Unit under the head of offi ce> All HCF have HEM Coordinator/Assistant Coordinator> All HCF have Crisis Management Com - mittee> All HCF have Offi cial Spokesperson

Standards Targets10 Ps

Systems on: > Logistics Management > Logistics Management > Public Information > Public Information > Information Management > Information Management > Communication > Communication > Crisis Management > Crisis Management > Code Alert > Code Alert > HEICS/REICS > HEICS/REICS > HEARS > HEARS > MCM and MDM > MCM and MDM > Documentation of lessons learned > Documentation of lessons learned

> All HCF have support systems for effi cient and effective emergency management

> Resource Mobilization> Public Information and Media Management> Information Management> Communication> Code Alert and Early Warning> HEICS/REICS> HEARS> Networking and Referral> MCM and MDM> Documentation

> All HCF have written, accessible, available, applied, and tested HEPRR Plans> HEPRRP approved and disseminated> HEPRRP reviewed and updated at least once a year after a drill

> Hospital Response Teams composed of Trauma and Mental Health personnel

> Resource Mobilization> Public Information and Media Management> Information Management> Communication> Code Alert and Early Warning> HEICS/REICS> HEARS> Networking and Referral> MCM and Management of Dead and Missing (MDM)> Documentation

HEPRR Plan or Risk Reduction Plan■ Emergency Preparedness Plan - Hazard Prevention Plan - Vulnerability Reduction Plan - Capacity Development Plan■ Emergency Response Plan - Search and Rescue/Recover - Evacuation/Temporary Shelter - MCM and MDM - Security■ Emergency Recovery Plan

Human Resource DevelopmentHuman Resource

Protocols Procedures Guidelines

2. Plans

3. People

Organizational Structure > HEM Offi ce/Unit > HEM Offi ce/Unit > HEM Coordinator > HEM Coordinator > HEM Coordinator > Crisis and Consequence > Crisis and Consequence > Crisis and Consequence Management Committee > Offi cial Spokesperson > Offi cial Spokesperson > Offi cial Spokesperson

1. Policies

The hospital should not be limited to developing/adapting its policies and guidelines to the aforementioned existing ones. It should be continuously vigilant in identifying con-cerns that can be addressed by policies/standard procedures.

Overall Framework for the Health Emergency Management System: 10 P’s

The ten essential elements known as 10P’s derived from the two landmark administra-tive orders A.O. 168 and A.O. 155 provide an overall framework for the hospital in the establishment and enhancement of the Health Emergency Management System. The standards and targets set for each element are shown in Table 4.

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Continuation of Table 4

> Organized Response Teams

> Organized Response Teams

Capability Building (Training)> Basic Training on HEM> BLS-CPR> ACLS> PCLS> EMT-B> MCM> PHEMAP> HOPE/ HEART

Responders’ Welfare/Safety> Proper identifi cation and uniform> Proper personal protective equipment > Orientation before deployment

> Physical & psychological fi tness

Recognition of Outstanding Performance> Rewards and incentives

Knowledge and Skills Enhancement

Inventory of Expertise

> Establishment of HE Network

> Networking Activities

> Referral System

> Development/integration of programs in support of HEM

> Regional Response Team composed of Public Health Personnel from Surveillance, Nutrition, Environmental, Water and Sanitation

> All health workers> All health workers> All ER medical staff> All ER medical staff> All responders> All responders> All emergency managers (Public Health)> All emergency managers (Hospitals)

> All responders have Identifi cation docu ments and uniform> All responders have personal protective equipments (PPE’s)> All responders have orientation on risks and hazards involved in the operation> Simulation exercises, stress management, respite care for all responders

> Given to all responders for outstanding perfor mance

> Mechanism for certifying, updating and con ducting refresher courses

> Developed inventory of available human resources based on expertise

> Establishment of internal network (within DOH)> Establishment of external network (Health Sector)> Established national and regional health, water and sanitation and hygiene (WASH), and nutrition clusters> Established national and regional health sector> Established hospital network including blood network in emergency> Conduct of regular coordination meetings, forums> Conduct of sectoral activities like drills, skills bench-markings, Post- Incident Evaluation (PIE)> Establishment of Network Referral System

> Risk Reduction Programs 1 Mental Health and Psychosocial Support 2 Nutrition Program 3 Environmental Sanitation Program 4 Hospital Poison Control Program 5 Weapons of Mass Destruction (WMD) Program, etc.> DOH Health Programs related to HEM - Safe Hospital Program - Blood Network in Emergency> Research and Development Program> Advocacy Programs

4. Partnership Building

5. Program Develop- ment

Standards Targets10 P’s

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Continuation of Table 4Standards

> Upgrading of health facilities > Upgrading of health facilities

> Documentation of HE experiences, good and innovative practices

> Allocation of funding for HE activities

> Communication equipment

> Transport

> Supplies/materials

> Drugs and medicines

> Advocacy/IEC> Public information

Targets

> All HCF have 24/7 OpCen> All HCF have HEMS Offi ce> All hospitals have equipped emergency rooms > All hospitals have equipped emergency rooms

(ER’s)> Tertiary hospitals have special units based on > Tertiary hospitals have special units based on

designation: - Burn Unit - Trauma Unit - Psychosocial Care Ward - Infectious Ward (Isolation Ward) - Decontamination Area - Ward for Biological, Chemical, Radio- nuclear and Explosives (BCRNE) cases - Laboratories to support designated functions - Blood Banks to address needs for MCI> All responding hospitals equipped with > All responding hospitals equipped with

ambulances> Receiving hospitals have equipped ER to > Receiving hospitals have equipped ER to

respond to at least 5 red-tagged patients

> Case Reports> Research Studies> Publications> Post-Incident Evaluation

> Allocation for Preparedness activities from > Allocation for Preparedness activities from annual budget

> Allocation of fund for emergency operations> Available petty cash for emergency purchase of drugs, medicines, supplies, etc.> Developed DOH Emergency Health Kit> Buffer stocks of medicines (10%) of available > Buffer stocks of medicines (10%) of available

stocks

> HEM Coordinators entitled to cell card al lowance> HEM Coordinators in Metro Manila and > HEM Coordinators in Metro Manila and

nearby regions have hand-held radios/base

> Hospitals have designated ambulance for > Hospitals have designated ambulance for emergencies with equipment, supplies and emergencies with equipment, supplies and communication

> All CHDs/hospitals have mannequins and training manuals for training

> All HCF have stockpile of drugs and medicines for emergencies

> Pre-positioned medicines, drugs, medical > Pre-positioned medicines, drugs, medical supplies, and DOH Emergency Health Kits

> HE-related posters, fl yers, advisories, stickers prototypes

> HEM orientations and trainings for leaders, managers, responders, OpCen staff, trainers, community and media

> Radio plugging> TV interviews> Speakers’ bureau and kit with key messages> Audio-visual presentations> Celebration of National Disaster Conscious- ness Month (July)> Disaster Prevention Week (December)

10 P’s

6. Physical Infra- structure Development

7. Practices

8. Peso and Logistics

9.Health Promotions

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Targets

> Developed/adapted packages > Developed/adapted packages

10 P’s

10. Package of Services

Standards

> Identifi ed package of services for the > Identifi ed package of services for the

community, evacuation centers, re gions, hospitals, etc.; direct service/

technical assistance - Patient care> Public health services delivered

Continuation of Table 4

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3 Activities During the Response PhaseGuided by the hospital HEPRR plan, the Response Phase deals with resource mobili-zation for the consequences of the hazard that has occurred or will occur (impending typhoon, civil disturbance, etc). It is aimed at the following (WHO, ADPC, 2006c):

• Preventing or reducing the exposure of the hospital staff and patients to the con-sequences of the hazard (e.g., isolation measures).

• Enhancing the resistance of the casualties and general population to a hazard after exposure (e.g., immunization).

• Promoting healing of mass casualty incident victims and the general population from the consequences of a hazard (e.g., provision of defi nitive care, mental health and psychosocial services).

• Providing culturally acceptable care of the fatalities and the bereaved.

The mobilization involves a sequence of activities for the activation and termination process and a dynamic interplay of activities for the management of operations and cor-responding support. Some examples of Standard Operating Procedures are provided in selected activities.

A. Activation

1. Activation of the Alerting Process

1.1 Declaration

As provided in the Integrated Code Alert System, 2008 (See Section 6.1), the Hospital Code Alert shall be declared by the Secretary of Health or by the Director of HEMS in cases of external emergencies; and by the Medical Cen-ter Chiefs, Chiefs of Hospital or Hospital HEMS Coordinator, for emergencies within their catchment area. The alert level is raised, lowered or suspended by these authorities or their designates. The designates who receive and give the initial notifi cation have been pre-assigned on a 24-hour basis per day to en-sure notifi cation during the evening hours, weekends and holidays.

Conditions to raise or suspend the alert level• Raise - arrival of patients in the hospitals to warrant raising; increase in

threat. • Suspend/terminate – when threat is no longer present; when no signifi -

cant incident is monitored and the hazard or condition (typhoon, elec-tion, bombing, etc.) is fi nished and/or contained

1.2 Notifi cation

Notifi cation is carried out within the hospital following the prescribed process, which specifi es the chain of command in notifying those on duty and other appropriate hospital staff of the hospital’s status. In case of problems in the system, the alternative system of notifi cation, which is adapted to the hospi-tal’s realities of people, equipment and procedures, is activated. Example: In the case of fi re, any person with knowledge of the situation immediately activates the fi re alarm system of the hospital. Although there are guideline

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for the code alert, each hospital shall develop their own procedures for activating, elevating and suspending the code.

2. Activation of the Plan

With the declaration of the code alert, the plan is activated. Depending on the alert level status, corresponding human resource and other requirements are mobilized.

3. Activation of the Hospital Operations Center

For the Operations Center, the earliest response mechanism is established at the lowest alert level – Code White. Non-permanent centers are activated within one hour and secured. This serves as the Command Post when Code Blue is raised.

The Hospital Operations Center continuously reports and coordinates with the Regional and National HEMS Operations Center and with Regional/Provincial Disaster Coordinating Councils. In the event of failure of existing communication system, the alternatives are activated.

4. Activation of the Hospital Emergency Incident Command System (HEICS)

Under Code Blue, the HEICS is immediately established using the six-step response for critical incident management.

Step 1. Assume command. Someone should immediately assume command. Step 2. Assess situation. Assess magnitude of the incident from sources and the network. Step 3. Identify critical areas. These include emergency rooms, decontamination, triage, treatment, security, media, etc. Step 4. Activate or identify the Operations Center. Coordinate with HEMS Opcen; assign staff and ensure communication system is in place. Step 5. Identify the Safety Offi cer. The Safety Offi cer is the one to go around the compound to ensure safety of the staff, the hospital, and patients. Step 6. Secure the hospital and critical areas. Identify area for ambulances, points of ingress and egress.

Job actions sheets are distributed to designated offi cers. The Incident Commander initiates the incident management process which describes an ordered sequence of actions that (WHO, ADPC, 2006):

• Establishes incident goals (where the system wants to be at the end of response). • Defi nes incident objectives (how to get there) and strategies to meet the de - fi ned goals. • Adequately disseminates information, including the following, to achieve co - ordination throughout the incident: – Response goals, objectives and strategies – Situation status reports – Resource status updates

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– Safety issues for responders – Communication methods for responders • Evaluates strategies and tactics for effectiveness in achieving objectives and monitors ongoing circumstances. • Revises the objectives, strategies and tactics as dictated by incident circumstances. The outputs of these actions are: • Incident Action Plan • Establishment of: - Gold or Strategic Command – These are the people managing the event, providing strategic direction as well as policy direction. In the hospital, this is the Incident Commander together with the heads of the Operations, Planning and Administration. Their role is to plan, assess and give directions, respond to media, etc. They should not micromanage. - Silver or Tactical command – These are the people receiving orders from the gold. They carry out the orders by supervising their people. In the hospital setting this could be the heads of the emergency room, the Logistics Offi cer, the Administrative Offi cer, etc. They ensure that the needs and requirements are met. - Bronze or Operational Command – In the hospital setting, these are the doctors treating the patients, the social workers listening to the relatives, the psychosocial worker doing debriefi ng, etc.

B. Operations/Support Management

5. Implementation of the Response Standard Operating Procedures/Protocols for Internal and External Emergencies

These procedures/protocols include (WHO, ADPC, 2006):

5.1. Callback/management of staff

The notifi cation process of staff mobilization – deployment or stand-by – is carried out as prescribed according to the alert status level. The staff should have the proper identifi cation to gain access to the hospital when called back on duty.

5.2. Management of fi eld/on-site activities

a. Deployment of on-scene response team (SOP I: Standard Operating Procedure on Information and Dispatch) b. Predetermination of fi eld areas by the fi rst responding team c. Assessment of scene using Rapid Health Assessment d. Establishment of Command Post or linkage with Command Post through Field Medical Commander as Incident Medical Commander (Unifi ed Medical Command); assignment of a Field Medical Commander in cases of multiple on-scene response teams e Conduct of measures for site safety f. Establishment of Advance Medical Post

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(SOP II: Site Selection, Signage and Logistics) g. Evacuation and transport h. Establishment of Field Hospital/evacuation site or temporary shelter i. Triage (second at Advance Medical Post, third during evacuation/transport) j. Evaluation, care (fi rst aid, medical care, etc) and stabilization of casualties at impact site, Advance Medical Post, and during evacuation/ transport (SOP III: Handling of Equipment Attached to Patient)f Equipment Attached to Patient)f Equipment k. Continuing coordination/monitoring with Regional/ DOH Central Opera- tions Center and receiving hospital l. Extension of services/termination of operations m. Post-mission debriefi ng n. Accomplishment of reporting forms – HEARS Field Report, Rapid Health Assessment Forms, Inventory Checklist, List of Casualties, Patient List, Mass Casualty Case Record, Health Situation Updates, Post-Mission Reports, Final Reports

5.3. Management of Emergency Department /Unit

This includes designation of area and provision of skilled personnel and logistics for handling multiple casualties.

5.4. Management of casualties

• Availability of Emergency Unit/ Department at short notice to receive multiple casualties who are identifi ed, registered, triaged and treated in designated treatment areas, and admitted or transferred (SOP III: Handling of Equipment Attached to Patient) • Implementation of procedures for: - clearance of all non-emergency patients and visitors from the emergency department; - cancellation of all elective admissions and elective surgery; - determination of rapidly available or open beds; and - determination of the number of patients who can be transferred or discharged

5.5. Timely provision of 24-hour services by the following:

• Administration • Emergency • Nursing • Radiology • Laboratory including Blood Bank • Pharmacy • Critical Care • Central Supply • Maintenance and Engineering • Security • Dietetics • Housekeeping and Laundry • Psychosocial/Pastoral

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• Mortuary

These services are for mass casualties, patients, hospital staff and responders.

5.6. Maintenance of 24-hour supply of drugs, medical supplies, diagnostic supplies (e.g., X-ray fi lms, laboratory reagents), and equipment; also including management of donations

5.7. Management of logistic and personnel support by concerned units for:

• Beds • Retention and safekeeping of personal items removed from casualties • Isolation of victims with communicable diseases • Segregation/isolation of victims contaminated with hazardous materials

5.8.Management and use of ambulance

5.9. Assessment and maintenance of security services, particularly the protec tion of critical services

5.10. Assessment and maintenance of communication services, including the activation of an alternative communication system

5.11. Management of Internal and External Traffi c Flow and Control, including secured traffi c access to the Emergency Department and controlled access to allow timely ambulance turnaround 5.12. Management of Hospital Evacuation/Relocation of Patients and Staff, in cluding use of alternative sites when original area is unavailable

5.13. Management of volunteers for medical and other services

6. Provision of the Public Health Services of the hospital which includes:

6.1. Damage Assessment and Needs Analysis/Rapid Health Assessment 6.2. Establishment and maintenance of Epidemiologic Surveillance System 6.3. Immunization 6.4. Therapeutic Nutrition Services 6.5. Laboratory Services (diagnostic) 6.6. Provision of Blood Services 6.7. Communicable Disease Prevention and Control 6.8. Management of the Dead (Identifi cation of the dead/Mortuary) 6.9. Health Promotion and Advocacy/Risk Communication in Public Informa- tion and in Media Management

7. Initiation and maintenance of coordination and networking for referral of cases

8. Initiation and maintenance of Mental Health and Psychosocial Support Services for casualties, patients, hospital staff, other responders, and the bereaved Services for casualties, patients, hospital staff, other responders, and the

Services for casualties, patients, hospital staff, other responders, and the

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9. Management of information – Monitoring of Plan

- Recording and reporting procedures, e.g., accomplishment of reporting forms (Inventory Checklist, Health Situation Updates, Post-Mission Reports, Final Reports) - Documentation of processes

10. Activation of plan in the event of complete isolation of hospital for auxilia ry power, water and food rationing, medication/dressing rationing, waste and garbage disposal, staff and patient morale

C. Extension/Termination

11. Declaration and Notifi cation Process for:

- Continuation of or change in alert status (extension of services) - Termination/closedown of Command Post/Operation Center

12. Conduct of Post-Incident Evaluation

13. Review and Updating of Plan including amendments to policies and procedures

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4 Activities During the Recovery/Reconstruction Phase

The recovery phase is aimed at the return of the response personnel and the hospital to normal operations the earliest time possible. The activities for this phase are described below.

A. Activation

1. Activation of the Recovery Plan. There is no identifi ed time for the activation of the Recovery Plan. It may start immediately after the response. Unlike the recovery plan for the communities, the hospital can initiate activation as soon as possible. Hence the recovery plan can be activated right away.

B. Operations/Support Management B. Operations/Support Management

2. Suspension of the HEICS. This is done as soon as possible as the code alert is lifted, then the hospital returns to its pre-disaster situation.

3. Implementation of the Recovery Standard Operating Procedures/ Protocols for Internal and External Emergencies. These include (WHO, ADPC, 2006e):

3.1. Assessment – Damage Assessment and Needs Analysis

3.2. Provision of services

a. Provision of mental health and psychosocial services for both acute and long-term physical and mental health effects sustained by mass incident casualties and hospital staff during the response. b. Continuing provision of hospital medical services. c. Continuing surveillance – water and sanitation, food safety, emergent and re-emergent endemic diseases, nutritional status.

3.3. Management of hospital facilities/logistics

a. Evaluation, clean-up and/or repair of damages to the hospital building/facilities/equipment; may include, where necessary, relocation of hospital site/facilities. b. Accounting and recording of available and utilized materials, medicines, supplies and equipment, indicating also their respective sources. c. Estimating cost of damages and response. d. Requisitioning and replenishment of utilized materials and logistics. e. Decontamination of areas, ambulance and equipment.

3.4. Management of Human Resource

a. Awarding and recognition rites for responders. b. Provision of overtime compensation for responders. c. Provision of assistance to hospital staff.

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d. Re-training of hospital on technical and administrative procedures.

3.5. Maintenance of Coordination

Continuing coordination with HEMS and with the Regional Offi ce is maintained to report the return of hospital to normal operations and the completion of its recovery.

3.6. Information Management

a. Monitoring of Plan b. Recording and reporting procedures c. Documentation of processes

C. Termination

4. Conduct of in-depth evaluation of how the response system functioned under stress. Based on the identifi ed strengths and weaknesses, strategies are proposed to improve the hospital’s capacity to respond to future emergencies and disasters, particularly in hazard-prone regions.

5. Review and update of the Hospital HEPRR plan and procedures. The modifi - cation refl ects the application of the lessons learned.

Part

III

Guid

elin

es

65

66

67

SECTION 1 Policy Formulation Guide

Policy ensures that common goals and practices are followed within and across orga-nizations and activities. It provides the legal basis for actions and protects people from liability. Policies may vary in form, from legislations to decisions by the executive gov-ernment to inter-organizational agreements, depending on the scope of the policy and the level of authority required.

There are certain requirements in policy development, such as: the legal mandate of the institution; the authority (national, regional, hospital, local) of the agency; manage-rial and technical competence (as in technical writing, etc); political will and support from the head of the agency; and acceptability and doability of the policy (WHO and ADPC, 2006).

POLICY CONTENT

The parts of a policy are described below. To illustrate, examples from Administrative Order No. 168 s. 2004: “National Policy on Health Emergencies and Disasters” are given for some parts.

• Background/Rationale – the present situation or condition of the country, region, community or hospital-relevant emergencies or disasters, leading to the reasons that triggers the development of the policy • Defi nition of Terms – list of words or terminologies seen in the policy which are not commonly used, or which are highly technical, and merit explanation • Objectives – itemized reasons why this policy is being developed; everything stated in the policy must address or attain the objectives • Scope and Coverage – the extent and limitations of who will implement and the application of the policy • Framework of Health Emergency Management – includes the vision, mission, goals/objectives • Strategies – detailed scheme for reaching a goal or intention which will be the basis for making activities • Policy Statements – broad statements that express a set of goals, the priorities within those goals, and the preferred strategies for achieving those goals; give direction in achieving the goal

Example:

A.O. 168 policy statements cover: ■ Organizational Structure ■ Human Resource Development (Capability Building) ■ Support System (Logistics, Media Management, MIS, Communication, System of Documentation, etc) ■ Program Development ■ Program Components ■ Networking and Collaboration ■ Finance

• Implementing Mechanism – includes the roles and responsibilities of the imple menters in achieving the goal

Example:

A.O. 168 s. 2004 implementers consist of: ■ Department of Health ■ Hospitals ■ Centers for health development ■ Other government agencies ■ Nongovernment organizations ■ DOH central offi ces

PROCESS PROCESS

The policy development process may be a sectoral task, i.e., within the Department of Health, as the crafting of Administrative Order 168 s. 2004. Or it may be a multi-sectoral undertaking with key partner agencies of the Department of Health, such as the formu-lation of Administrative Order No. 2007- 001B: “National Policy on the Management of the Dead and Missing Persons During Emergencies and Disasters.”

These two policies, milestones in the country’s Health Emergency Management work, are used as policy prototypes to guide the hospital in formulating its own policy. Table S1.1 compares the content of these two policies where A is A.O. 168 s. 2004 and B is A.O. 2007-001B. Policy A, providing the overarching policy, is focused on roles and responsibilities, while B, an amplifi cation of one element in Health Emergency Manage-ment (i.e., management of the dead) provides details of guidelines and procedures.

Note that the policy identifi cation number follows the existing standard within the Depart-ment of Health. Earlier practice had the year indicated as the series, e.g., Series 2004. The sequence was modifi ed in 2007 with the fi rst four fi gures representing the year of issuance.

While seven elements are constant (namely, Background, Objectives, Scope and Cov-erage, Defi nition of Terms, Separability Clause, Repealing Clause and Effectivity), the number of sections representing the main body (e.g., Sections V to VI in A.O. 168 and Sections V to VIII in A.O. 2007-001B) varies depending on the subject of the policy. An-other difference is the description of details for a given section. To illustrate, the eighth section on Implementing Mechanism may contain a general description of a structure established by the policy (A.O. 2007-001B) or if there is no new structure, the roles and responsibilities of specifi c units/groups (A.O. 168).

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Table S1.1. Table S1.1. Comparison of Policy Content of A.O. 168 s. 2004 and A.O. 2007-001B

NATIONAL POLICY A B A B

Administrative Order No. 2007- 001B: “National Policy on the Management of the Dead and Missing Persons Dur-ing Emergencies and Disasters”

I. Background and RationaleII. ObjectivesIII. Scope and CoverageIV. Defi nitions of TermsV. Guiding Principles and Operational Framework - Guiding Principles - Operational Framework - Emergency Preparedness, Re- sponse and Recovery PlanVI. Key ComponentsVII. Guidelines and Procedures

VIII. Implementing Guidelines -Structure - Roles and ResponsibilitiesIX. Separability ClauseX. Repealing ClauseXI. Effectivity

Administrative Order 168 s. 2004: “National Policy on Health Emergen-cies and Disasters”

I. Background and Rationale II. Defi nitions III. ObjectivesIV. Scope and Coverage V. Framework of Health Emergency Management - Vision - Mission - Goals/Objectives - Strategies V. Policy Statements VI. Implementing Mechanism - Roles and Responsibilities VII. Separability Clause

VIII. Repealing Clause IX. Effectivity

ELEMENTS

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70

SECTION 2 Guide to Formulation of Hospital HEPRR Plan

The planning committee formulates and documents the HEPRR plan guided by the fol-lowing outline (Go,2007; WHO and ADPC, 2006). Detailed instructions on how to pre-pare each part of the plan, as well as illustrative examples, are provided throughout the outline.

I. I. BACKGROUND

Write a narrative on the background of your hospital and its catchment area, location with reference to national geography, and location of the facility in the community/ LGU, using the template below. Present the qualitative or quantitative data/infor mation either as narratives or as tables, graphs, illustrations and maps for easy, fast and better understanding of the reader.

1. Name of the hospital, category and address

2. Geographic description of the hospital and its catchment area ■ Description of the community/catchment area – total land area ◆ Along the coastal area ◆ Location in relation to a fault line (e.g., West Valley) ◆ Low-lying area ◆ Location in relation to other hazardous elements like oil depot, industrial establishments, military camps, etc. ■ Distribution and concentration of vulnerable populations (squatters area, land-locked or water-locked area, etc.) ■ Characteristics of the location of the hospital – total area, terrain, built

on a hill, along the river bank, along the railroad, etc.

3. Demographic profi le ■ Of the hospital’s catchment area – provinces, municipalities and cities ◆ Population ◆ Population density ◆ Number of households ◆ Number of barangays ◆ Number and names of health emergency-related agencies in the

catchment area (e.g., BFP, private EMS, DSWD, other government agencies, and NGOs)

■ Of the hospital ◆ Category of the hospital (primary, secondary, tertiary) ◆ Authorized bed capacity ◆ Government or private ◆ Services delivered ◆ Other relevant information to refl ect capacity of the hospital to manage emergencies

4. Health statistics ■ Of the catchment area - provinces, cities, municipalities

◆ Leading causes of morbidity and mortality ◆ Infant mortality rate ◆ Maternal mortality rate ◆ Malnutrition rate ◆ Vaccination coverage ◆ Indicators for basic hospital services, basic health services and preventive health programs ■ Of the hospital ◆ Leading causes of morbidity and mortality ◆ Leading causes of consultation ◆ Leading causes of discharge ◆ Infant mortality rate ◆ Maternal mortality rate ◆ Malnutrition rate ◆ Vaccination coverage ◆ Indicators for basic hospital services ◆ Indicators for basic health services and preventive health programs

5. Health facilities ■ In the catchment area – provinces, cities, municipalities indicating if government or private

◆ Hospitals (private, LGU; category – primary, secondary or tertiary) ◆ Lying-in clinics, birthing places ◆ Laboratories ◆ Blood banks ◆ Halfway houses ◆ Health centers, etc.6. Health facilities (hospitals) with special areas/services ◆ Burn unit ◆ Trauma unit ◆ Isolation rooms ◆ ICU, CCU, NICU ◆ Decontamination area ◆ Reference laboratories

■ Inventory of resources or assets of hospital in all various services ◆ Emergency Room ◆ Operating Room ◆ Nuclear Medicine ◆ Radiological Service ◆ Laboratory ◆ Others 7. Health human resource

■ Of the catchment area by facility and administrative area – province, city, mu nicipality

◆ Physicians ◆ Nurses ◆ Midwives ◆ Sanitary engineers ◆ Sanitary inspectors ◆ Nutritionists/dieticians 71

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◆ Health promotion offi cers ◆ Dentists ◆ Laboratory technicians ◆ X-ray technicians ◆ Psychologists ◆ Barangay health workers ■ Of the hospital ◆ Physicians ◆ Nurses ◆ Midwives ◆ Institutional workers ◆ Engineers ◆ Nutritionists/dieticians ◆ Health promotion offi cers ◆ Social workers ◆ Dentists ◆ Medical technologists ◆ Laboratory aides ◆ Radiologic technologists ◆ Psychologists

8. Disasters that have occurred, including the lessons learned and the gaps in re - sponse ■ In the hospital ■ In the catchment area

9. Legal basis whereby the hospital is authorized to act in disaster situations ■ Law creating the existence of the hospital (R.A.; E.O.) 10. Legal issuances detailing the roles and functions of the hospital in managing all phases of emergencies or disasters (i.e., A.O. 168, A.O. 155, D.O. for Critical Infrastructure, etc.)

II. PLAN DEFINITION

Briefl y describe the content of the plan, the particular intent relevant to set goals and objectives, coverage, scope and limitations. Include the legal basis, the authority for the hospital to act in disaster situations, with the legal issuances detailing the roles and functions of the hospital in managing all phases of emergencies or disasters (i.e., A.O. 168, A.O. 155, etc.)

EXAMPLE: PLAN DEFINITION

The (Name of Hospital) Health Emergency Preparedness, Response and Recov-ery Plan defi nes the direction of the hospital in preparing for effective and effi -cient response and recovery in any event of emergency or disaster within its facilities and/or its catchment area. This embodies a set of strategies and activi-ties based on the hazards and vulnerabilities or risk analysis of the hospital and its catchment area.

Content of the Plan

The (Name of Hospital ) Preparedness Plan contains strategies and activities that the hospital will carry out to build and enhance its capacity to respond to emergency or disaster, whereas its Response Plan lays down the strategies and activities in utilizing hospital resources for effective and effi cient response during an emergency or disaster. Policies, protocols, guidelines and procedures pertaining to various emergency management systems for more effi cient re-sponse are included. The third plan, the Recovery or Rehabilitation Plan contains the strategies and activities in mainstreaming and/or restoring the facility and its services back to its prepared position for any forthcoming eventuality.

The (Name of Hospital) Health Emergency Preparedness Response and Recov-ery Plan contains the inventory of its internal and external resources, in the form of inventory lists and directories, in the context of human resources, logistics, fi nancial sources, existing systems and services. These are all in the annexes of the plan.

Scope of the Plan

This Plan shall be implemented by (Name of Hospital) together with, but not lim-ited to, all the members of the health sector concerned with emergency or disas-ter management in the catchment area.

III. GOALS AND OBJECTIVES

Write a statement of the purpose of the plan from broad to more specifi c perspec- tives. A hierarchy of the intent is described through goals and objectives. Well-written objectives are simple, measurable, attainable, realistic and time-bound (SMART).

EXAMPLE: GOAL AND OBJECTIVES

Goal:

To enhance the hospital’s capacity for prompt and effective attendance to the largest possible number of people requiring medical and health care in a health emergency or disaster ultimately reducing mortality, morbidity and disability and promoting their recovery.

Objectives:

• To provide policy for effective response to both internal and external disaster situations that will affect the operation of the hospital and its staff, patients and the community.

• To identify the hospital’s capability to handle mass casualty.

• To identify responsibilities of individuals and departments in a disaster situation.

• To identify Standard Operating Guidelines for emergency activities and responses.

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• To document best practices and lessons learned during simulation exer cises, emergencies and disasters.

IV. PLANNING GROUP/COMMITTEE

Describe the composition of the Planning Group/Committee and its functions, considering the realities of the existing committees and available human resources. This part is one of the initial steps in the planning process.

V. MANAGEMENT STRUCTURES

Conduct a review of the existing committees and their performance of functions to fi nalize the appropriate structure, i.e., use existing structures or develop new ones for the Crisis and Consequence Management Committees and the Hospital Incident Command System (HEICS).

VI. ROLES AND RESPONSIBILITIES

Describe adequately the capacity of the hospital either as a responding facility, a receiving facility or both, indicating the bases for such capacity.

VII. HEALTH EMERGENCY PREPAREDNESS PLAN VII. HEALTH EMERGENCY PREPAREDNESS PLAN

A. HAZARD

A1. HAZARD ASSESSMENT

A1.1. Defi nition

Hazard assessment is the process of identifying all the possible hazards with the potential to affect the community. This is done in order to have an idea of the possible areas to be affected, to predict the vulnerabilities of such areas, and to anticipate the possible consequences or risks of such hazards in these areas. There are four types of hazards that may affect the community and the hospital:

• Natural: Typhoon, earthquake, fl ood, landslide, tsunami, drought, etc.

• Biological: Disease outbreak (dengue, cholera, SARS, avian infl u-enza, red tide, etc.)

• Technological: Chemical spill, food poisoning, fi re, gas explosion, mercury poisoning, etc.

• Societal: Rallies, stampede, war, armed confl ict, etc.

Prioritizing the hazards is important for the purpose of equitable utilization or distribution of existing meager resources in doing hazard prevention activities. Hazards can be prioritized based on the following considerations:

• Severity• Frequency• Extent• Duration• Manageability

A1.2. Mechanics of Hazard Assessment

1. Identify the all possible hazards that have affected or have the potential to affect the catchment area and the hospital facility. Catchment area data

can be taken from the Center for Health Development. The hospital pro - vides details based on observations of the locality.

2. Prioritize the hazards based on severity, frequency, extent, duration and manageability. (A1.3.1.)

Example:

On a scale of 1-5 with 5 as the highest, rate each hazard by Severity, Frequency, Extent, Duration, and Manageability. To get the total score for each hazard, get the sum of the scores for Severity, Frequency, Extent and Duration minus the score for Manageability [(A+B+C+D) – E]. Arrange

the hazard scores from the highest to the lowest. The highest score repre- sents the highest priority, least manageable, and highest risk-developing hazard while the lowest refl ects the more manageable and least priority

hazard.

3. Prepare a hazard map. Indicate all the hazards that can possibly affect all the areas. (A1.3.2.)

- Of the catchment area (CHD data) - Of the hospital

A1.3. Format

A1.3.1. Hazard Assessment Matrices

Hazard Severity Frequency Extent Duration Manageability Total

Natural Biological Technological Societal

Hazard Severity Frequency Extent Duration Manageability TotalHazard Severity Frequency Extent Duration Manageability TotalHazard Severity Frequency Extent Duration Manageability TotalHazard Severity Frequency Extent Duration Manageability TotalHazard Severity Frequency Extent Duration Manageability TotalHazard Severity Frequency Extent Duration Manageability Total

Hospital Catchment Area and Hospital Facility

Hospital Service Areas

Fire

Earthquake

Volcanic eruption

Hazards Vulnerable Hospital AreasHazards

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A1.3.2. Hazard Map

• Layout/map all service areas of the hospital. • Identify areas likely to be exposed to hazard. • Pinpoint areas exposed to specifi c hazards. • Place the code of hazard in each service area (numbers or color codes). • Place a legend.

EXAMPLE 1: HOSPITAL HAZARD MAP (NUMBER-CODED)

Legend:1. Fire 2. Earthquake 3. Disease outbreak 4. Typhoon 5. Mass action 6. Food poisoning 7. Radio-nuclear incident

MEDICAL WARD1,2,4

PEDIA WARD1,2,4

SURGICAL WARD1,2,4

OB-GYNE WARD1,2,4

NUCLEAR MED. DEPT.1,2,7

MAINTENANCE2

HOSPITAL LOBBY2,5

OPD1,2,4,5

EMERGENCY ROOM1,2,3,4

RADIOLOGY DEPT. 2,4,7

DIETARY1,6

LAB1,2,3,4

EXAMPLE 2: HOSPITAL HAZARD MAP (USING SYMBOLS)

Legend:✪Legend:✪Legend:

Fire ✸ Earthquake ■ Disease outbreak ❍ Typhoon ❖ Mass action ✦ Food poisoning ✰

Food poisoning ✰

Food poisoning Radio-nuclear incident

MEDICAL WARD✪,✸,❍

PEDIA WARD✪,✸,❍

SURGICAL WARD✪,✸,❍

OB-GYNE WARD✪,✸,❍

NUCLEAR MED. DEPT.✪,✸,✰

MAINTENANCE✸

HOSPITAL LOBBY✸,❖

OPD✪,✸,❍,❖

EMERGENCY ROOM✪,✸,■,❍

RADIOLOGY DEPT. ✪,❍,✰

DIETARY✪,✦

LAB✪,✸,■,❍

A2. HAZARD REDUCTION/PREVENTION PLAN

A2.1. Defi nition

A Hazard Reduction/Prevention Plan contains strategies and activities meant to reduce or prevent the occurrence of hazards in the community and in the hospital. The plan targets the hazard. To check if the plan is done correctly, one must be able to answer this question: “If you carry out the strategy/activ-ity you planned, will the hazard no longer occur in your community? In your hospital?”

A2.2. Mechanics of Hazard Reduction/Prevention Planning:

Using the Hazard Prevention Plan Matrix below (A2.3): 1. List the identifi ed hazards. 2. Identify the prevention strategies and the activities. 3. Write the time frame – when the activities will be carried out and fi nished. 77

78

4. Specify the resource requirements – the required resources, those available, and the gaps or defi cits, if any. Indicate the sources to fi ll the gaps. 5. Assign the person responsible to carry out each activity and to source out the lacking resource requirements. 6. Write the performance indicators, i.e., outcomes or evidences that activities have been carried out or done successfully. These are the areas for monitoring.

A2.3 Format

B. VULNERABILITY

B.1. VULNERABILITY ASSESSMENT

B1.1. Defi nition

In vulnerability assessment, it is important to identify the factors that increase the risks arising from specifi c hazards. The presence of vulnerable areas decreases the ability of the hospital to cope with the hazards. This process determines the likely harm to the hospital. It determines the health needs before, during, and after an emergency or disaster.

Example:

The Laboratory Room is vulnerable to fi re with the use of volatile and fl ammable gases or reagents in the routine examinations.

HazardVulnerable areaVulnerability of property

Vulnerability of people

Vulnerability of servicesVulnerability of environment

FireLaboratory RoomUse of volatile and fl ammable gases or re-agents in routine laboratory examinationLack of knowledge on proper storage of reagentsNo alternate place of service deliveryLack of proper waste management

Hazard Reduction/Prevention Plan Matrix

Hazards Preventive Strategies/Activities

IndicatorsTime Frame

Resource Requirements

Person Responsible

Required Available Source

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The details of a vulnerability assessment are provided in WHO-WPRO, A Field Manual for Capacity Assessment of Health Facilities in Responding to Emergen- cies, 2006. Vulnerability is categorized as:

• Structural – Related to construction of the facility. • Non-structural – The non-structural elements of a building include ceilings, windows, doors, mechanical, electrical, plumbing equipment and instal - lations. • Functional – There are three aspects: (1) deals with general physical layout of facility, including location, accessibility and distribution of areas within the facility; (2) individual services: medical (supplies and equipment) and non-medical (utilities, transportation and communication vital to continuous operation of facility); and (3) public services and safety measures. • Human Resources – Includes: organization of the health facility (e.g., emergency planning group, subcommittees); inventory and mobilization of personnel; and preparedness activities for the personnel (e.g., hazard and vulnerability analysis, drills and training, community involvement and evacuation).

The guide provides an assessment of preparedness for specifi c emergencies such as industrial emergency preparedness, infectious disease outbreak, etc.

B1.2. Mechanics of Vulnerability Assessment

Using the Vulnerability Assessment Matrix below (B1.3): 1. List the hazards that may affect the hospital, based on the hazard map made. 2. Identify the vulnerabilities of the hospital (See earlier matrix).

B1.3. Format

B2. VULNERABILITY REDUCTION PLAN

B2.1. Defi nition

The Vulnerability Reduction Plan is developed purposely to reduce the conse-quences of exposure to hazards. The vulnerabilities specifi c to the four elements of the facility and of the hospital catchment area are identifi ed and this serves as the basis for building the resilience of the hospital to withstand the impact and consequences of a hazard.

Vulnerability Assessment Matrix

Hazard VulnerableAreas

Vulnerabilities

PeopleStructural Non-structural Functional

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B2.2. Mechanics of Vulnerability Reduction Planning:

Using the Vulnerability Reduction Plan Matrix below (B2.3):1. List all the identifi ed hazards of the catchment area and the hospital.2. State all the areas vulnerable to the hazards.3. Spell out all the vulnerabilities of the facility – structural, non-structural,

functional, and the assessment of human resources.4. List the strategies/activities to reduce the vulnerabilities.5. Specify the time frame, when the activities will be carried out and done.6. Identify the resource requirements, what is required, what is available in

the community, and the gaps or defi cits. Identify sources to fi ll the gaps. 7. Indicate the person responsible for carrying out each activity and for

looking for the source of defi cient hospital requirements.

B2.3. Format

Vulnerability Reduction Plan Matrix

Hazards Vulnera-bility

PreventionStrategies/ActivitiesStrategies/ActivitiesStrategies/

Person Responsible

Required Available Source Earth-quake

TimeFrame

Resource Requirement

Structural

Non-struc-tural

Functional

Human Resources

C. RISK ASSESSMENT

C.1. Defi nition

Risk assessment is a process of analyzing or anticipating the possible consequences of hazard once it has affected the hospital and the catchment area. This is the basis in developing the capacity development plan of the hospital.

C.2. Mechanics of Risk Assessment

1. Identify the risks or probable consequences to public health and safety of the catchment area and of the hospital being exposed to hazard: ● Probability of death ● Probability of disease or injury (mental, physical) ● Probability of secondary hazard (fi re, disease, etc.) ● Probability of contamination ● Probability of displacement ● Probability of loss of lifelines ● Probability of loss of income or property

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● Probability of breakdown in security ● Probability off damage to infrastructure

● Probability of breakdown in essential services

2. Describe why the risks or consequences of the hazard happen.

D. HEALTH EMERGENCY CAPACITY DEVELOPMENT PLAN

D1. Defi nition

From the risk assessment, problems may surface why the risks or consequences of the hazard happen. These must be addressed in the Capacity Development Plan, commonly referred to as Preparedness Plan. This is a plan with strategies and activities geared towards building the capacity of the hospital to effectively or effi ciently respond to emergency or disaster in terms of the 10 P’s Elements of Successful Health Emergency Management. The 10 P’s are: Policy, Procedures, Protocols and Guidelines; Plans; People; Health Promotion; Partnership Building; Physical Infrastructure Development; Program Development; Practices; Peso and Logistics; and Package of Services. As in the other plans, a resource analysis is done and written in the plan.

• What resources are required for response and recovery • What are available in the hospital? In the catchment area? • What are the differences between the required and available resources or what are lacking? • Where can one get the resource to fi ll the defi cit • Who is responsible for acquiring these resources

D.2. Mechanics of Capacity Development Planning

Using the Capacity Development Planning Matrix below (D.3): 1. List all identifi ed risks. 2. Identify the capacity of the hospital needed to manage the risk. 3. Develop strategies and activities to come up with these needed capacities. 4. Write the time frame when to carry out such activities. 5. Identify the required resources, what are available in the hospital and in the catchment area, the defi cit and the source of the resources to fi ll the defi cit. 6. Assign the responsible person to carry out the activities and to source out the defi cient resources. 7. Identify the indicators to prove that the activities have been carried out.

D.3. Format

Hospital Health Emergency Capacity Development Plan Matrix

Risks Capacityneeded

Prepared-ness Strate-Prepared-ness Strate-Prepared-

gies/Activi-tiesgies/Activi-tiesgies/Activi-

Person Respon-sible


TimeFrame

Resource Requirement Indica-tors

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VIII. HEALTH EMERGENCY RESPONSE PLAN

A. POLICIES, GUIDELINES, PROTOCOLS FOR ACTIVATION OF THE DEVELOPED SYSTEMS B. JOB ACTION SHEETS

C. HOSPITAL EMERGENCY RESPONSE PLAN

C.1. Defi nition

An Emergency Response Plan is meant to utilize the existing capacities to deliver relief or response. Using the developed systems for emergency management, it entails resource mobilization. It involves the actual imple-mentation of guidelines for the developed systems.

Basic conditions that the Emergency Response Plan must satisfy:

1. Internal Emergency/Disaster

a. Assignment of personnel with a system for notifi cation and recall. b. Use of alarm and sign systems, including availability and accessibility of instructional materials/protocols on response to all types of hazards. c. Rapid assessment of extent of damage to buildings and structures and threat to safety of patients and personnel. d. Protection of critical facilities and lifelines. e. Evacuation procedures and routes (include patients and facilities). f. Quick restoration of facilities and lifelines (maintain service operation). g. Maintaining communications and security of hospital and patients. h. Firefi ghting methods and directions (location of equipment). i. Networking and coordination. j. Search and rescue operations.

2. External Emergency a. Evaluation of hospital’s autonomy in terms of its services, source of electricity, gas, water, food and medical supplies. b. Effi cient systems of alerts and staff assignments. c. Unifi ed command. d. On-scene response team (team leader, surgical resident, internal medicine resident, aides/helpers and driver) e. Conversion of usable space into clearly defi ned areas ((triage, observation and immediate care) f. Prompt removal of casualties when necessary (after preliminary medical and surgical services have been performed) to the places where medical care facilities are more appropriate and defi nitive. g. Special medical census – disaster-related cases. h. Procedures for prompt transfer within hospital. i. Security arrangement. j. Prior establishment of Emergency Operation Center, Public Infor- mation System and for Media/VIP’s

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3. Internal/External Emergency

Apart from planning for Mass Casualty, the hospital has to deal with the continuity of operations- essential functions of the hospital, regardless of size, during internal or external emergencies that may disrupt usual, nor-mal operations. This is critical in hazard prone regions of the country. It focuses on the recovery of critical and essential operations including security and evacuation concerns on either: • Short-term basis, like a power failure, where having a backup capabil-

ity (systems, personnel, processes, fi les, and etc.) can quickly resolve the situation.

• Long- term such as in typhoons, fi re or earthquakes where services are affected for several days, weeks or even months. In this case, the hospital needs to plan for relocation to an alternative facility – tempo-rary hospital or construction of new facility or change of hospital site.

C2. Mechanics

Using the Emergency Response Plan Matrix below (C3):1. For the following response time – fi rst 2 hours, 2-12 hours, 12- 24 hours,

Expanded Response – identify the capacity of the hospital to address spe-cifi c concerns.

2. Develop strategies and activities to come up with these needed capaci-ties. The activities during the response phase as discussed in Part II are the ones actually carried out in an emergency response operation.This becomes part and parcel of the Emergency Plan which is activated in the event of an emergency or a disaster.

3. Write the time frame when to carry out such activities.4. Identify the required resources, what are available in the hospital, the defi -

cit and the source of the resources to fi ll the defi cit.5. Assign the responsible person to carry out the activities and to source out

the defi cient resources.6. Identify the indicators to prove that the activities have been carried out.

C3. Format

Emergency Response Plan Matrix

Re-sponse time

Capacity Strategies/Activities

Person Respon-sible


TimeFrame

Resource Requirement Indica-tors

0-2 hour 0-2 hour 0-2 hour 2 – 12 hours hours hours 12 – 24 hours hours hours Expanded Response

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IX. HEALTH EMERGENCY RECOVERY AND RECONSTRUCTION PLAN

A. Defi nition

A Recovery and Reconstruction Plan in Health for a facility or a defi ned geograph-ical area, as in the other sectors of Public Works, Education, and Agriculture, lays down the activities needed to restore services and replace damaged elements.

The hospital recognizes that an updated plan is implemented to repair the dam-ages and/or reconstruct facilities so as to ensure the return of health services to pre-disaster status or advancement to a better level of access and/or perfor-mance. This underscores the importance of the damage assessment and needs analysis. The following activities are planned for:

• Damage Assessment and Needs Analysis to include cost (including manpower). This is very important especially if you are asked to estimate the fi nancial cost of the event, but it is also an opportunity to request funds. • Psychosocial interventions for direct/indirect/hidden victims • Repair of damaged hospital facilities and lifelines • Relocation of hospital site/construction of new facility • Post-mortem evaluation • Documentation of lessons • Research and development • Review and update of Hospital Health Emergency Preparedness and Response Plan • Inventory, return and replenishment of utilized health resources • Awarding and recognition rites for the major key players • Provision of overtime compensation, as well as respite, to the responders

B. Mechanics

Using the Recovery/Reconstruction Planning Matrix below (C): 1. List all recovery/reconstruction activities. 2. Write the time frame when to carry out such activities. 3. Identify the required resources, what are available in the hospital/community, the defi cit and the source of the resources to fi ll the defi cit. 4. Assign the responsible person to carry out the activities and to source out the defi cient resources. 5. Identify the indicators to prove that the activities have been carried out.

C. Format

Recovery/Reconstruction Planning Matrix

Recovery/ReconstructionRecovery/ReconstructionRecovery/

Activities

Person Responsible


TimeFrame

Resource Requirement IndicatorsDam-ages and needsages and needsages and

X. Annexes

● Glossary ● Abbreviations ● Hazard maps ● Flow charts ● Directory of contact persons ● Inventory of resources or assets of hospital and partner agencies ● Hospital/Regional/Offi ce orders for health emergency management

85

86

Mission

Qualifi cations

Functions & Responsibili-ties

Identifi cation

Perform overall direction for the fi eld and/or facility operations and if needed, authorize evacuation.

● Must be an Emergency Manager for Field; CHD Director, Hospital Director for Facilities or his designate.● Preferably has experience in handling “on-scene” Mass Casualty Incident for Field; has experience in management situations for facilities.● Must possess good communication skills.● Must have leadership qualities. ● Must be a good coordinator; must have good command and control abilities

● Initiate the Incident Command System (ICS) by assuming the role of the Incident Commander and put any identifi cation mark.● Designate a Command Post to include required logistical needs.● Carefully assess the situation and the magnitude of the casualties.● Secure the area, preventing entry of unauthorized people and designate staging and transport area for Field Operations.● Depending on the number of responders and the magnitude of the emergency, fi ll up the organization assignment list, the needed positions relevant to the situation. In major MCI, the following should be fi lled up: Safety Offi cer, Liai- son Offi cer, Public Information Offi cer, Operations Manager, Triage Offi cer, Treatment Offi cer, Staging Offi cer, Transport Offi cer and Morgue Offi cer. The Planning Offi cer, Logistic Offi cer and Administrative Offi cer complements and completes the positions in severe MCI neces- sitating the support of major agencies and requiring long period of operations. ● Announce an action plan meeting and identify the general objective of the operations including alternatives, and the incident communication plan.● Assign someone as Documentation Recorder/Aide.● Authorize resources as needed or requested by managers.● Designate routine briefi ngs with managers to receive status reports and update the action plan regarding the continuance and termination of the action plan.● Communicate status to higher authority.● Approve media releases.

● Proper signages (hard hat with mark of Incident Commander or a vest)

SECTION 3Job Action Sheets:

Incident Command System Organization

A - INCIDENT COMMANDER(Field or Facility)

87

Mission

Qualifi cations

Functions & Responsibilities

Identifi cation

Monitor and have authority over the safety of rescue operations and hazardous conditions. Organize and enforce scene/facility protection and traffi c security.

● Knowledgeable on safety precautions, procedures.● Preferably with various training in emergencies relating to bombing, fi re, hazardous materials, structural assess ment, security procedures and safety of responding personnel.● Has had experiences in emergencies and disasters.● Good decision-making abilities.● Has sound knowledge in evacuation procedures.

● Obtain appointment and briefi ng from the Incident Com- mander.● Implement the emergency lockdown policy and personnel identifi cation policy.● Establish Security Command Post.● Remove unauthorized persons from restricted areas.● Establish ambulance entry and exit route in cooperation with Transportation and Staging Offi cers.● Secure the Command Post, Advance Medical Post, Triage and Treatment Areas including the Morgue Area and all other sensitive or strategic areas from unauthorized access.● Fully understand the importance of his roles especially in the safety of the responders.● Secure and post non-entry signs around unsafe areas. ● Always alert to identify and report all hazards and unsafe conditions to the Incident Commander.● Secure areas evacuated to and from, to limit unauthorized personnel access.● Initiate contact with fi re, police agencies through the Liai- son Offi cer, when necessary.● Advise the Incident Commander and others immediately of any unsafe, hazardous or security-related conditions.● Confer with Public Information Offi cer to establish areas for media personnel.● Establish routine briefi ngs with Incident Commander.● Provide vehicular and pedestrian traffi c control.● Secure food, water, medical, and blood resources.● Document all actions and observations.● Can order stoppage of operation if unsafe.

● Use of any identifi cation hat or vest.

B - SAFETY AND SECURITY OFFICER

Position assigned to:

You report to: _____________________________________ (Incident Commander)

Command Post: ______________________________ Telephone: ______________

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Provide information to the public and the media.

● Knowledgeable on communication aspects especially in collating relevant information needed.● Knowledgeable in media handling.● Preferably with experience in emergencies and disasters.● Preferably with understanding of Mass Casualty Management.● Good communication skills and interpersonal relationships.● Sensitive on restrictions in contents of news and patient care activities.

● Obtain appointment and briefi ng from the Inci- dent Commander.● Ensure that all news releases have the approval of the Incident Commander.● Responsible for collating relevant information needed to inform the public and for media releases; obtain progress reports from respective areas as appropriate.● Issue an initial incident information report to the news media especially on the casualty status and the actions being done.● Schedule press conferences on a regular basis.● Inform on-site media of the physical areas that they have access to, and those which are restrict - ed. Coordinate with Safety and Security Offi cer.● Contact other scene agencies to coordinate released information. ● Direct calls from those who wish to volunteer to Liaison Offi cer. Contact Operations to determine requests to be made to the public via the media.

● Proper signages (hard hat with a mark of Public Information Offi cer or a vest).

C - PUBLIC INFORMATION OFFICER (P.I.O)

Mission

Qualifi cations


Identifi cation

89

Mission

Qualifi cations


Identifi cation

D - LIAISON OFFICER

Function as incident contact person for representatives from other agencies (government or private).

● Preferably with experience in liaison procedures and coordination.● Good or excellent public relations skills.● Preferably with understanding of Mass Casualty Management.● Understands the bureaucracy and working relationships of the different government as well as private agencies responding to emergencies and disasters.● Good grasp of patient care and management in mass casualty situations; informed on inter-hospital emergency communication network, municipal operation centers and/or province, region or national as appropriate.● Knowledge on the inventory of resources available in the area/ country.● Understands municipal (provincial, regional, national) organizational charts to determine appropriate contacts and message routing.

● Obtain appointment and briefi ng from the Incident Commander.● In coordination with the Public Information Offi cer should always be knowledgeable on the following: ■ The number of “Immediate” and “Delayed” patients that can be received and treated immediately (Patient Care Ca- pacity); also the status of all other victims, especially in mass dead situations. ■ Any current or anticipated shortage of personnel, supplies, etc. ■ Number of patients transferred to hospitals. ■ Any resources which are requested by each area (i.e., staff, equipment, supplies).● Establish contact with liaison counterparts of each assisting and cooperating agency.● Keep appropriate agency Liaison Offi cers updated on changes and development of response to incident.● Request assistance and information as needed through the different networks of government and private organizations responding to emergencies and disasters.● Respond to requests and complaints from incident personnel regarding inter-organization problems.● Prepare to assist Labor Pool with problems encountered in the volunteer credentialing process.

● Use of any identifi cation (hat or vest).




90

Mission

Qualifi cations


Identifi cation

E - LOGISTIC SECTION CHIEF

Organize and direct those associated with maintenance of the physical environment, and adequate levels of food, shelter, supplies and other resources needed to support the objectives of the incident.

● Preferably with experience in logistics management.● Preferably with experience in emergencies and disasters.● Understands the bureaucracy and working relationships of the different units in government especially in procurement and emergency purchases.● Good grasp of procurement procedures; knowledgeable in accessing supplies, medicines and equipment needed during emergencies.● Good coordination with pharmaceuticals, companies and suppliers and knowledgeable on database of available resources in the market.

● Obtain appointment and briefi ng from the Incident Commander.● Establish Logistics Section Center in proximity to the Command Post.● Brief all his staff on current situation; outline action plan and designate time for next briefi ng.● Attend damage assessment meeting with Incident Com- mander.● Coordinate with companies regarding stock level, available supply and equipment.● Anticipate needed logistical requirements.● Obtain information and updates regularly; maintain current status of all areas; communicate frequently with Emergency Incident Commander.● Obtain needed supplies with assistance of the Finance Section Chief and Liaison Unit Leader.

● Proper signage (hat or vest).




91

Mission

Qualifi cations


Identifi cation

Organize and direct all aspects of Planning Section operations. Ensure the distribution of critical informa-tion/data. Compile scenario/resource projections from all areas and effect long-range planning. Document all activities.

● Preferably a senior offi cial with adequate knowledge in planning and decision-making.● Has had experiences in emergencies and disaster situations in addition to crises management.● Adequate knowledge of the government bureaucracy and the role of the different government entities responding to emergencies and disasters.● Good coordination and networking skills.

● Obtain appointment and briefi ng from the Incident Com- mander; have regular updates as appropriate.● Brief members of the staff after meeting with Incident Commander.● Provide for a Planning/Information Center.● Recruit a documentation aide from the Labor Pool. Ap- point Planning Unit Leaders, Situation Status Leader, Labor ● Pool and other appropriate positions as needed. Ensure that all appropriate agencies are represented in this section.● Ensure the formulation and documentation of an incident-specifi c action plan. Distribute copies to Incident

Commander and all areas.● Call for projection reports (Action Plan) from the Plan- ning Unit Leaders for scenarios 4, 8, 24 and 48 hours from time of incident onset. Adjust time for receiving projection reports as necessary.● Instruct staff to document/update status reports from all areas for use in decision-making and for reference in post-disaster evaluation and recovery assistance applications.● Schedule planning meetings to include Planning Sec- tion Unit Leaders, Section Chiefs and the Incident Com- mander for continued update of the Action Plan.● Coordinate with the Liaison Offi cer and Labor especially with regards to manpower requirements.





F - PLANNING SECTION CHIEF

92

Mission:

Qualifi cations


Identifi cation

G - FINANCE SECTION CHIEF

Monitor the utilization of fi nancial assets. Oversee the acquisition of supplies and services necessary to carry out the objective of the incident. Supervise the documentation of expenditures relevant to the emergency incident.

● Preferably a senior offi cial with adequate knowledge in fi nancial management.● Had experiences in emergencies and disaster situation● Adequate knowledge on the government bureaucracy and the role of the different government entities responding to emergencies and disasters.● Good resource manager; knowledgeable on tapping other resources

● Obtain appointment and briefi ng from the Incident Com- mander. ● Appoint members of his staff preferably the following: Time Unit Leader, Procurement Unit Leader, Claims Unit Leader, Cost Unit Leader and other appropriate positions as he de- sires.● Establish a Financial Section Operations Center. Ensure adequate documentation/recording personnel. His station need not be within the area of incident.● Confer with Unit Leaders after meeting with Incident Com- mander and develop an action plan.● Approve a “cost-to-date” incident fi nancial status report eight hours summarizing fi nancial data relative to personnel, supplies and miscellaneous expenses.● Obtain briefi ngs and updates from Incident Commander as appropriate. Relate pertinent fi nancial status reports to appropriate chiefs and unit leaders.● Schedule planning meetings to include Finance Section unit leaders to discuss updating the section’s incident action plan and termination procedures.

● Proper signage (hat or vest)




Mission

Qualifi cations


Identifi cation

Organize and direct aspects relating to the Operations. Carry out directives of the Incident Commander.

● Knowledgeable on Operation Procedures; understands well the organizational chart in MCI.● Preferably has experience in handling “on-scene” Mass Casualty Incident with varied knowledge of all types of operations (Search and Rescue, Fire, Medical etc.)● Must be a crisis manager and with leadership skills.● Good communicator and can stand pressures.● Must know capabilities of people for proper assignments.

● Obtain appointment and briefi ng from the Incident Com- mander.● Responsible for all specifi c sections of the operations (ex. Medical, Search and Rescue, Fire Suppression and others) depending on the incident.● Establish Operations Section in the Command Post preferably with the Incident Commander.● Brief all Operations Offi cers on current situation and develop the section’s initial plan.● Designate times for briefi ngs and updates with all Opera- tions Offi cers to develop/update section’s action plan.● Ensure that all areas are adequately staffed and supplied.● Brief the Emergency Incident Commander routinely on the status of the Operations Section especially on the status of all patients, problems encountered, resources needed, etc.● Ensure that all actions and decisions are documented.● Observe all staff and personnel for signs of stress and inappropriate behavior and report concerns to Psycho- social Supervisor. Ensure rotation of all personnel to prevent burnout among personnel.


H - OPERATIONS SECTION CHIEF




93

94

Mission

Qualifi cations


Identifi cation

I - TREATMENT TEAM LEADER

Responsible for the management of the Treatment Area and assigning of responsible supervisor for specifi c areas (Red, Yellow and Green subsections). Assure treatment of casualties according to triage categories. Provide for a controlled patient discharge and transfer to appropriate hospitals.

● Preferably a general surgeon/trauma/emergency/anesthesia/ family medicine physician.● Knowledgeable on Mass Casualty Management and the organization chart.● Should have “on-scene” experience in MCI; knowledgeable on triaging and skilled in fi eld care and fi eld operation.● Skilled in emergency procedures, especially in life sustaining and stabilization of patients.● Good in personnel management, especially in stress situations.

● Receive appointment and briefi ng from Incident Commander/ Operations Chief/ Field Medical Commander. ● Organize the treatment area assigning all members to their specifi c assignments and responsibilities. In cases of WMD, treatment area should be at the cold zone.● Appoint unit leaders for the following treatment areas in pre-established locations: Second Triage; Immediate Treatment (Red); Delayed Treatment (Yellow); Minor Treatment (Green); Discharge.● Supervise the receiving of patient from the Initial Triage from the site, re-triage the victims and institute measures to stabilize the victims; ensure that all victims are continuously monitored.● Assess problems and treatment needs, and customize the staffi ng and supplies in each area.● Receive, coordinate and forward requests for personnel and supplies to the Field Medical Commander and/or Staging offi cer.● Contact the Safety and Security Offi cer for any security needs in the area.● Establish 2-way communication (radio or runner) with Field Medical Commander, Triage, Transport and Staging Offi cers.● Coordinate with Transport Offi cer, decide on the order of transfer of victims, the mode of transport, escort and place of transfer. ● Document everything with regards to every individual patient brought to the area using the individual treatment form. ● Regularly report to the Field Medical Commander.● Observe and assist any staff that exhibits signs of stress and fatigue. Report any concerns to Psychological Supervisor. Provide for staff rest periods and relief.





Mission:

Qualifi cations

Duties & Responsibilities

Identifi cation

Sort casualties at the site according to priority of injuries, and transfer (according to tagging priorities) to the treatment area.

● Any of the following: ✔ Doctor of Medicine preferably trained in emergency

medical care and triaging. ✔ Nurse, paramedic with appropriate training in emergency,

medical care and basic triaging.● Knowledgeable on mass casualty management and has had

experience in “on-site” mass casualty incident; skilled in fi eld care and fi eld operations.

● Receive appointment and briefi ng from the Field Medical Com- mander or previously designated by the Incident commander.

● Assess fi rst the safety in entering the incident area; note abnor-malities in the surrounding, any untoward manifestations of the victims and approximate number of casualties and the type of injuries.

● Protect self by using the appropriate Personal Protective Equipment (PPE).

● In cases of WMD, ensure that decontamination is present before entering the incident site.

● Report fi rst to authority and request for additional help before proceeding to actual triaging.

● Quickly brief members of the Triage Team and assign areas for triaging.

● Tag the appropriate color to every patient as follows: ✔ RED – immediate stabilization necessary ✔ YELLOW – close monitoring, care can be delayed ✔ GREEN – minor; delayed treatment or no treatment ✔ BLUE – near or almost dead ✔ BLACK – dead ● Document important things to consider in the site for purposes

of evidence by use of camera, by mapping or sketching, etc. especially in WMD.

● Ask fi rst all walking wounded to go to an identifi ed place.● Provide and administer life sustaining support to the patient in

extreme cases (only for bleeding and respiratory problems).● Bring patients to the Treatment Area according to priority.● Assess problem, triage treatment needs relative to specifi c

incident. ● Identify a Morgue Manager and a Morgue Area for black-coded

patients.● Coordinate with Field Medical Commander and Treatment Team

Leader to report number and types of casualties, including equipment needs.

● Contact the Safety and Security Offi cer regarding security and traffi c fl ow needs in the Triage Area.

● End his services once all patients are out of his area and receive another assignment from the Field Medical Commander.


J - TRIAGE (INITIAL) TEAM LEADER




95

96

Mission

Qualifi cations


Identifi cation

K - TRANSPORT GROUP SUPERVISOR

Coordinate the transfer of patient received from the Treat-ment Area to the appropriate hospitals

● Preferably a paramedic, nurse or doctor with basic training in Basic Life Support.● Experienced and knowledgeable in Mass Casualty Man- agement.● Skilled in ambulance traffi c control; skilled in radio communications.● Sound knowledge of country’s transportation resources.● Sound knowledge of access routes to health care facilities.● Familiar with terrain, road maps, alternate routes.● Has suffi cient knowledge in the return time of the ambulance.

● Receive appointment and briefi ng from the Incident Com- mander/ Field Medical Commander.● Establish immediately an ambulance loading zone, observing principles on way traffi c fl ow; identify access routes and communicate traffi c fl ow to drivers.● Coordinate and supervise transport of victims from the Treatment Area.● Ascertain all information relating to receiving hospital (as to type of facility, bed availability, hospital capability, contact ER medical offi cer, etc.).● Supervise all available ambulance drivers; assign appropriate vehicle in accordance with status of patients.● Receive requests for transportation; Maintain a log of the whereabouts of all vehicles under his control.● Ensure all patients transferred are tagged and with their treatment form.● Brief ambulance crew as to the condition of the patient, care required, access routes, traffi c fl ow, location of the receiving hospital and the procedures in the endorsement of the patient. ● Coordinate regularly with the Treatment Team Leader/ Staging Offi cer and report all patients transferred and when the last person is transported.● Document all activities in his area, including a complete record of all patients.





97

Mission

Qualifi cations

Duties and Responsibilities

Identifi cation

L - STAGING OFFICER

Coordinate all resources arriving at the scene. For manpower resources, referring them to appropriate area of assignment. For transportation resources, organizing them and dispatching them as required.

● At least a paramedic or an EMT.● Preferably with knowledge in Mass Casualty Manage- ment and understands the organizational chart.

● Receive appointment and briefi ng from the Incident Commander/ Operations Section Chief.● Identify suitable place for the Staging Area usually away from the incident.● Organize, classify all transportation resources.● Coordinate with Transport Supervisor.● Dispatch appropriate vehicle as requested by Trans- port Supervisor.● Coordinate with appropriate agencies with regards to traffi c fl ow and access routes within the site.● Direct all incoming responding teams to the Field Medical Commander.● Document all resources.

● Any identifi cation mark (hats or vests).




98

Mission

Qualifi cations


Identifi cation

M - FIELD MEDICAL COMMANDER

Organize, prioritize and assign offi cers under it’s jurisdiction to areas where medical care is being delivered. Advice the Op-erations Section Chief/Incident Commander on issues related to handling of the victims.

● Must be a Doctor of Medicine.● Must possess managerial skills in disaster.● Preferably with training and experience in MCI management situations.● Knowledgeable in the hospital capability and networking; having sound knowledge of country’s health resources.● Skilled in pre-hospital care; skilled in radio communications.● Skilled in staff management; skilled in logistical operations.● In the absence of the above the fi rst who arrives at the scene preferably one of the following: a. Municipal Health Offi cer, City Health Offi cer, any Emer- gency Health Physician b. Emergency Critical Nurse (in the absence of an MD) c. Private MD with experience in emergency care● Can fi rst assume the position and later endorse (face to face) providing an orderly transfer of command to the next incoming qualifi ed medical personnel.

● Receive appointment from the Incident Commander/Operations Section Chief.● Identify the suitable site for the Advance Medical Post and in form everybody. ● Responsible for the different members of his team (if not yet identifi ed): Triage Offi cer, Treatment Offi cer, Transport Offi cer, Mortuary Offi cer.● Responsible that all the needed medical resources be mobilized and available. ● Report and coordinate with the Operations/Incident Command- er; likewise attend meetings and press conferences.● Ensure the welfare and safety of the medical team, including relief and sustenance (decking, scheduling, pullback, etc.)● Conduct regular meetings with his designated offi cers in the area.● Anticipate other concerns and regularly confer with the Opera- tions Offi cer/Incident Commander.● Responsible that all the necessary recording of the events be done and all required reports to all the authorities be submitted on time.● Evaluate the whole activity and make the necessary recommendations to improve future responses.● Coordinate and regularly report to the Medical Controller of the DOH Operations Center/Regional Operation Center.

● Proper signages (hat or vest).




99




Mission:

Qualifi cations

Duties & Respon-sibilities

Identifi cation

N - MORGUE MANAGER

Collect, protect and identify deceased patients

● Doctor of Medicine aided by a social worker, a psychosocial support offi cer.● For medico-legal cases forensic experts from the PNP Crime Laboratory or the National bureau of Investigation will be part of the team.

● Receive appointment and briefi ng from the Triage Offi cer/Field Medical Commander.● Identify and establish the Morgue Area; coordinate with the Tri- age Offi cer and Treatment Offi cer.● Maintain master list of deceased patients with time of arrival. ● Assure that all personal belongings are kept with deceased patients and are secured.● Assure that all deceased patients in Morgue Area are covered, tagged and identifi ed when possible.● Provide a system or procedures for identifying and endorsing the body of the deceased to authorized members of the family.● In medico-legal cases consult with PNP and NBI with regards to procedures necessary for proper identifi cation and for evidence collection and preservation.● Keep Triage/Treatment offi cers appraised of number of deceased.● Contact the Safety and Security Offi cer for any morgue security needs.● Arrange for frequent rest and recovery periods as well as relief for staff.● Schedule meetings with the Psychological Support Unit Lead- er to allow for staff debriefi ng.● Observe and assist any staff that exhibits signs of stress or fatigue. Report any concerns to the Treatment Area Supervi- sor.● Review and approve the area documenter’s recording of actions/decisions in the Morgue Area.


100

Mission:

Qualifi cations


Identifi cation

O - MEDICAL CONTROLLER

Coordinate all activities of the Department of Health/Health Sector in response to the Mass Casualty Situation

● Doctor of Medicine/Nurse familiar with the Operation Center (Central, Regional and Hospital).● Good knowledge of the DOH organization as well as members of the Health Sector responding to emergencies and disasters.● Good resource mobilizer.● Knowledgeable on the manpower resources, hospital capabilities, dispatching and radio communications.● Articulate and good spokesperson.● Excellent coordinator.

● Designated by the offi ce and assume the position in case of Mass Casualty Situations.● Supervise the Operation Center and make all decisions in relation to the dispatch and subsequent fi elding of additional teams.● Assist in the scheduling of rotation of the medical teams at the site in the event of prolonged operations in coordination with the Field Medical Commander.● Coordinate with the different receiving hospitals to prepare their facilities.● Coordinate with other agencies, DCC agencies, response units, etc.● Review resources not only within the DOH OPCEN but of the other facilities of the DOH; likewise mobilize resources if needed.● May respond to queries by offi cials, media in relation to DOH response.● Update superiors especially the Secretary of Health.● Document and record the event.● Evaluate the proceedings and make some necessary input for policy amendments or recommendations.● Schedule and lead postmortem evaluation within one week of the event for the Health Sector.





101

Mission

Qualifi cations


Identifi cation

P - INCIDENT MEDICAL COMMANDER

Represent the Department of Health in the Field Command Post and coordinate all health activities/requirements in cases of Regional Emergencies/Disasters.

● Highest offi cial designated by the Regional Health Offi ce.● Good knowledge of the DOH organization as well as mem bers of the Health Sector responding to emergencies and disasters; sound knowledge of the region’s health resources.● Knowledgeable in Mass Casualty Management and its organization.● Skilled in logistical operation and staff management.● Knowledgeable in both public health and pre-hospital care.

● Designated by the CHD and assume the position in case of Mass Casualty Situations.● Report to the Incident Commander in the Command Post. ● Usually will be part of the Planning Committee.● Keep constant coordination with the Field Medical Com mander and the Medical Controller.● Anticipate other concerns such as public health concerns (sanitation, nutritional needs, needs of evacuees) or psy chosocial concerns, especially in situations of Mass Dead.● Lead in public health information and the provision of needed IEC materials.● Organize all reports coming from the Field Medical Com mander and attend all press briefi ngs and conferences.● Document and make his own evaluation of the incident.





102

SECTION 4Deployment of Response Teams

CONDITIONS BASED ON A.O. 155 SEC. VI-B: IMPLEMENTING GUIDELINES, OPERATIONS AND DISPATCH CENTER

a. All hospitals and Regional Operation Centers shall dispatch teams within their catchment area upon monitoring or receiving a call confi rming a Mass Casualty Incident.

b. Any hospital and/or CHD team can also be dispatched even outside their catch ment area upon a request of help from neighboring facilities or upon instruction of the HEMS Central Operation Center.

c. The HEMS Central Operation Center, upon instruction of the HEMS Director, can dispatch teams from any hospital and CHD offi ces upon monitoring events that necessitate response from the Department of Health or upon request of agencies of government with authority over certain events (NDCC, NSC, etc).

While the initial team is dispatched, the Operation Center anticipates the scenario and alerts additional teams that might be needed and nearby hospitals, especially the receiv-ing hospitals, and starts to review the logistics.

COMPOSITION AND FUNCTIONS OF THE TEAM/S

From the Integrated Code Alert System 2008, the teams for dispatch from the hospital and CHD are shown in Table S4.1.

Table S4.1. Table S4.1. Human Resource Requirements by Alert Level Status in Hospital and CHD for On-scene Response CHD for On-scene Response

CHD

One Rapid Assessment Team ready for dispatch to include the following:• DOH representative • Nurse• DriverMay coordinate with Regional Hospitals for backup teams.

Mobilize Rapid Assessment Teams (RAT) and other appropriate teams. Three (3) teams on standby. (environ-mental/ surveillance/ medical)Health Promotions Offi cer as necessaryDriverAll DOH REPS in the affected area should be available at the LGU.All other regional staff on standby for immediate mobilization.

ALERT LEVEL STATUS

Code White

Code Blue

HOSPITAL

First response team ready for dispatch to include the following:• 2 doctors preferably surgeon, internist, anesthesiologist• 2 nurses• First aiders/ EMT• Driver Second response team should be on call

On-Scene Response Team

COMPETENCIES

For responders, the HEMS Training Needs Assessment identifi ed the competency re-quirements and the required training course/package, as shown in Table S4.2.

Table S4.2. Competency Requirements and Required Training Course/Package for Responders

Responders’ Position, Roles/Functions

a. Pre-hospital • Responds to emergencies (patient management) • Decontamination • Triage

• Ambulance care (patient management)

b. Hospital • Decontamination/ isolation • Patient manage ment/triage • Specifi c case management - Burns - Weapons of Mass Destruction (WMD) - Radiological, Biological & Chemical (RBC) - Poisoning

Competency Requirement(Functional)

• Rapid Assessment skills• Basic knowledge in hospital system; Basic Life Support (BLS); Stan- dard First Aid; Medical First Responder (MFR)• Emergency Medical Tech- nician (EMT)• Advanced Cardiac Life Support (ACLS)• Mass Casualty Incident (MCI)• Health Emergency Man- agement• Decontamination skills• Incident Command Sys- tem (ICS) skills

• Ambulance traffi c control• Radio communication• Sound knowledge of access routes to health care facilities• Networking/coordination• Safe driving skills

Knowledge and skills in:• Basic Life Support & Stan- dard First Aid• Advanced Cardiac Life Support (ACLS)• Advanced Trauma Life Support (ATLS)• Triage• Mass Casualty Incident , Incident Command System & Weapons of Mass Destruction (MCI-ICS- WMD)• Specifi c Case Manage- ment

Required Training Course/ Package

• Basic Life Support (BLS), Standard First Aid • Medical First Responder (MFR)• Emergency Medical Technician (EMT)• Advanced Cardiac Life Support (ACLS)• Advanced Trauma Life Support (ATLS)• Mass Casualty Incident- Incident Command Sys- tem & Weapons of Mass Destruction (MCI- ICS- WMD)• Basic Health Emergen- cy Management (HEM)

• Basic Life Support (BLS), Standard First Aid

• Medical First Responder (MFR)• Emergency Medical Technician (EMT)• Advanced Cardiac Life Support (ACLS)• Advanced Trauma Life Support (ATLS)• Mass Casualty Incident, Incident Comman Sys- tem & Weapons of Mass Destruction (MCI-ICS- WMD)• Radiological, Biological & Chemical (RBC) Courses• Basic Health Emergen- cy Management(HEM) 103

104

Depending on the available human resources, the response team may have the full human resource complement or may have few health staff but with multiple functions. Upon dispatch, the teams are equipped with the following: • Emergency kits and equipment (Refer to Sec 4.1. Ambulance Services) • Communication equipment • Food and water • Personal protective equipment (PPE), mask, goggles (A.O. 155) • Flashlight, whistle • Writing supplies – report forms/pens/clipboard • Reference materials, e.g., Directory, Pocket Emergency Tool 2nd edition, etc. • Contingency Funds

Emergency Manager Deployment Checklist

YES NO YES NO 1. Did you receive your orders? 1. Did you receive your orders? 2. Is/are the mission objective/s clear? 2. Is/are the mission objective/s clear? 3. Did you inform your family? 3. Did you inform your family? 4. Do you have with you 4. Do you have with you a. Mission order? a. Mission order? b. Identifi cation card? b. Identifi cation card? c. Emergency call number directory? c. Emergency call number directory? d. Mission area map? d. Mission area map? e. List of contact persons/ numbers? e. List of contact persons/ numbers? f. Communication equipment? f. Communication equipment? g. Cell phone? Mobile phone? g. Cell phone? Mobile phone? h. Handheld radio and accessories? h. Handheld radio and accessories? i. Pocket notebook and ballpen? i. Pocket notebook and ballpen? j. Laptop computer? j. Laptop computer? k. Transistor radio (with extra batteries)? k. Transistor radio (with extra batteries)? l. Basic PPE (cap, mask, gloves)? l. Basic PPE (cap, mask, gloves)? m. Cash and reimbursement vouchers? m. Cash and reimbursement vouchers? n. Water canteen? n. Water canteen? o. Food provisions? o. Food provisions? p. First aid kit? p. First aid kit? q. Backpack with clothing and blanket? q. Backpack with clothing and blanket? r. Flashlight/candles and matches? r. Flashlight/candles and matches? s. Portable tent (if available)? s. Portable tent (if available)? t. Mosquito repellant? t. Mosquito repellant? u. Pocket knife? u. Pocket knife? v. Digital camera? v. Digital camera? w. Pocket Emergency Tool? w. Pocket Emergency Tool?

Source: Pocket Emergency Tool, 2nd edition. Department of Health -Health Emergency Management Staff, Emergency Humanitarian Action, World Health Organization Regional Offi ce for Western Pacifi c. p. 78.

SECTION 4.1 Ambulance Services for Emergencies and Disasters

The hospital must be ready at all times to immediately dispatch the emergency medical response team with an ambulance to the disaster site, in accordance to: Administrative Order No. 13 s. 1997: Policy and Guidelines on the Management and Use of Ambulanc-es; Memorandum No. 120 s. 2003; and Administrative Order 155 s. 2004: Implementing Guidelines for Managing Mass Casualty Incidents During Emergencies and Disasters.

An update of the ambulance team composition lists the following:

1. Licensed physician – trained and certifi ed in Advance Cardiac Life Support2. Licensed nurse – trained and certifi ed in Basic Life Support, Advanced Cardiac Life and Standard First Aid Ambulance driver – trained and certifi ed in Basic Life Support and First Aid; and as proposed: Basic Emergency Medical Technician, Emergency Vehicle Driving Course3. Utility workers – trained in handling and transport of patients

According to A.O. 155, the responding medical team must be properly equipped to treat a minimum of 10 serious casualties and the responding team in their ambulance must have the capability for treating and transporting a minimum of 3 to 5 serious patients. These policies affi rm the need for an assigned ambulance for easy dispatch with equip-ment, medicines, supplies and necessary communication devices for coordination. The hospital can be guided by the steps in the request for use of the ambulance provided in A.O. 13 Section 4.4 and the Memo 120 amendment which includes the HEMS-Stop Death Coordinator as a dispatch authority.

The Hospital needs to examine the authorization of any member of the HEMS team with a driver’s license in case there is no available driver, given the implications of the GSIS insurance coverage.

All ambulance vehicles must be cleaned and decontaminated after every response ac-tivity by the response team, particularly the driver. It is the assigned driver’s responsibil-ity to keep the ambulance always clean, in good running condition with enough gasoline, and properly equipped at all times for prompt response.

Due to reemerging diseases as SARS and avian fl u, there is a need to review the pro-cedures in the use of ambulances, especially in transporting patients who are suspected cases. Furthermore, each hospital should come up with its procedure in requesting or assigning ambulances for emergency response.

Following is the list of equipment that the assigned ambulance for emergency response must have:

Evacuation/Transport 1. Wheel type stretcher with straps 2. Scoop stretcher 3. Spine board with straps 105

106

Medical Equipment/Supplies and Monitoring Devices 4. Cardiac monitor, portable 5. Automated external defi brillator (AED) with ECG, portable 6. Portable pulse oximeter with monitor 7. Sphygmomanometer and stethoscope 8. Diagnostic set (otoscope, opthalmoscope) Other equipment 9. Portable suction machine 10. Portable emergency case – 3 layers 11. Emergency kit containing drugs 12. Medical supplies and equipment 13. Manual resuscitators/bag valve mask 14. Portable oxygen tank with regulator and oxygen meter 15. Tracheostomy set with disposable tracheostomy tube 16. Splints and bandages 17. Cervical-collar (adult and pediatric) 18. Minor surgical set 19. Flashlights 20. Personal Protective Equipment (PPE) for Response Team, including appropriate HEMS identifi cation (e.g., vests, etc.) Communication 21. Handheld radio 22. Public address communication system

107

SECTION 5Hospital Operations Center

The hospital designs the Operations Center (OpCen) location, facility and size based on the level at which it will function, the nature of its activities, and the size of the staff needed for its effective operation. The activities include activation of the plan, coordina-tion of hospital activities with those at the disaster site, and adjusting the plan as neces-sary. A good communication system must be in place to ensure smooth coordination and execution of operational activities.

A. FUNCTIONS OF A HOSPITAL OPCEN

Administrative Order 155 describes the functions of an Operations and Dispatch Center as follows: 1. Receives all warning messages via connections with all major offi ces/services that are monitoring and responding to emergencies through telephone, fax machines, radio, etc. 2. Serves as dispatch center in times of emergencies. 3. Anticipates scenarios and alerts additional teams needed by receiving hospitals. 4. Reviews required logistics.

In an update of these functions, the following were added: 1. Monitors ongoing operations. 2. Mobilizes resources as needed by the On-scene Response Team or Emer- gency Room. 3. Coordinates with DOH-OpCen. 4. Documents events and responses and submits reports. 5. For Code Blue and Code Red, runs as the Center of Control, Command and Coordination of the hospital (Command Post).

B. PHYSICAL FACILITIES

• Hospital identifi es a dedicated space within its offi ces as the Operations Center (OpCen) which is periodically checked for serviceability and readiness. • However, if the hospital decides for a non-permanent OpCen, when Code Blue is raised, the facility should be easily converted within one hour and easily secured. • An alternative OpCen should be earmarked for use in the event the original Op Cen is affected or damaged. • The Operations Center must have the following: ❍ Adequate communication facilities, with a message center with the telephone numbers of all agencies responding to emergencies/disasters (e.g., RDCC, hospitals, Central Offi ce, fi re, police, etc.) ❍ Arrangements for receiving, collating and assessing information and for facili- tating decision-making. ❍ Display facilities (e.g., maps and wall facilities) for presenting an “information picture” of the disaster situation, resources, available tasks being undertaken, tasks to be undertaken, etc. ❍ Working space with offi ce furnishing and supplies for OpCen staff. ❍ Designated area for conference/briefi ng room(s) for briefi ng offi cials and other important persons and for progress meetings and discussions.

108

❍ Information room (preferably separate from the main OpCen) for briefi ng media representatives and releasing information to the public. ❍ Designated areas for rest facilities. ❍ Emergency power supplies and back-up facilities/supplies. ❍ Other aspects, such as storage space, vehicle access and parking facilities, and any other requirements to meet specifi c circumstances.

The considerations for the design are described in detail in the Manual of Guide- lines for the Operations Center.

C. HUMAN RESOURCES

With the raising of Code Alert White, the hospital should activate the Operations Center and assign Emergency Offi cers on Duty (EOD) to manage the coordination and monitoring activities of the Hospital OpCen on a 24/7 basis. The hospital may refer to the Manual on Operations Center for the competency requirements and training of the EOD.

D. COMMUNICATIONS

For adequate and effective communication facilities necessary for any emergency/ disaster setting, the considerations are as follows: • Provide adequate facilities for the normal day-to-day functioning of the organization. • Be capable of extending from the day-to-day role into the wider and more demanding functions of response operations. • When necessary, provide a mobile capability. • Have adequate reserve or back-up capacity to meet emergency demands.

Given fi nancial and other constraints, the provision of a special communications facility to fulfi ll the above needs may not be possible. This may mean utilizing the most profi cient available network (e.g., a police communication system and other communications networks) and supporting this with other networks for back-up or standby emergency purposes.

E. STANDARD OPERATING PROCEDURES

The matrix in Table S5.1, which is suitable for a non-permanent type of Operations Center, provides an overview of the standard operating procedures for the activation, operation and closing-down of a Hospital Operations Center. Of these procedures that of opening and closing are not applicable for a 24/7 OpCen. The hospital may adapt the written procedures and protocols in the Manual of HEMS Operations Center.

Table S5.1. Standard Operating Procedures for Emergency Operations Centers (EOCs)

ActivationOpen EOCOpen EOCMobilize staffActivate communication systemsPrepare/post up maps and display boardsDraw up support staff roster

OperationMessage fl owMessage fl owInformation displayInformation processingControl of resource mobilization and deploymentDrafting of situation reportsDecision-makingBriefi ngsReporting to higher authority

Closing-downFile messages and other docu- mentsRelease staffClose down communicationsClose down EOCOrganize operational debriefi ng

Source: Stop Death Program. Department of Health. Guidelines on Hospital Preparedness and Response Planning. Manual of Operations for Hospital, 1st edition, July 2000.

Key Information : Readily Available and Regularly Updated

Hospital Catchment Area Maps • Topography • Population size and distribution • Hazard • Disaster profi le • Location of o Health facilities and services provided o Potential evacuation areas o Stocks of food, medicine, health and water treatment and other sanitation supplies in government stores, commercial warehouses and international agencies and major NGO’s

Directory • Key people and organizations responsible for Response Phase (names, contact phone numbers and addresses) • Individuals with special competencies and experiences who may be mobilized on secondment from their institutions or as consultants in case of need (names, contact phone numbers and addresses) • Regular resource persons ready to translate technical information into local dialects (e.g., traditional healers, indigenous health workers, barangay cap- tains, etc.)

Resources Available for Use at All Times • Vehicles • Communications equipment • Back-up power supplies • Computers, printers, facsimiles and photocopying machines • Water-testing sets • Food supplements • Temporary shelter capacities • Funding requirements • Personal protective equipment

Suggested Guidelines for the Hospital Operations Center

The Hospital Operations Center shall be organized with the following arrangements:

• All Hospital Operations Centers should be ideally manned by at least two Emer- gency Offi cers on Duty (EO1 and EO2) under the supervision of the Hospital HEM Coordinator/Assistant Hospital HEM Coordinator or Supervising Nurse.

• During emergencies and disasters (alert codes), all Hospital Operations Center staff should be on a 24/7 duty. The Hospital HEMS Coordinator can mobilize all other members of the health emergency disaster team to augment OpCen staff.

• All hospitals must ensure that hazard protocols, fl ow charts, SOPs and guide lines on health emergency and disaster are available and such are strictly

109

(Source: Adapted from the Pocket Emergency Tool, 2nd edition, Department of Health -Health Emergency Management Staff, Emergency Humanitarian Action, World Health Organization Regional Offi ce for Western Pacifi c. pp. 9- 10)

110

followed/observed and implemented by all staff.

• Hospitals must ensure that it has established communication links with DOH- OpCen, Centers for Health Development (Regional Offi ce), and other members of the health networks for prompt response to emergencies and disaster.

• All hospitals must ensure that data, information, and reports coming from the hospital (internal emergencies) and fi eld (external emergencies) are received, collected and verifi ed promptly and are analyzed and evaluated for correctness and completeness before transmission and submission to the Regional Director, DOH-HEMS and other health partners when needed.

• All reports submitted to the HEMS OpCen should follow the HEMS forms. Fur- thermore, all responses, such as sending response teams to the site, assisting the LGU and other hospitals, should be documented and submitted.

111

SECTION 6Early Warning and Alert Systems

CODE ALERT SYSTEM

The Code Alert System of the Department of Health is a mechanism for the provision of health services during emergencies and disasters which describes the conditions that govern the expected levels of preparation and the most suitable responses by all con-cerned, particularly during mass casualty situations.

The fi rst code alert system provided by A.O. 182 s. 2001 was directed to the Depart-ment of Health hospitals given that “most emergencies and disasters are unpredictable but are not totally unexpected.” The tri-color system has been revised to expand beyond the hospital, paving the way for the harmonization of the code alert of the hospitals, regional offi ces, key central offi ces and the HEMS Central offi ce. The code starts its lowest level of alert at Code White, then Code Blue and Code Red.

The Integrated Code Alert System of 2008 (Administrative Order No. 2008 - 0024) describes the conditions for adopting the alert status, the human resource requirements and other requirements (e.g., logistics) with the procedure in implementing the Code Alert.

ALERT SIGNALS

It is a known fact that the occurrence of all hazards cannot be predicted. • Earthquakes may occur without warning. • Some hazards can be predicted as to ❍ Occurrence ❍ Impact on the community ❍ Outcome whether emergency or disaster ❍ Consequences or risks • Hazards such as typhoons, volcanic eruptions, or threats of civil disorders, can be anticipated several hours before they occur, giving at least ample time to get ready to respond before emergencies or disasters are foreseen and/or declared.

Guidelines for Effective Early Warning and Alert Systems

Basic considerations in understanding a warning and alert system are described below (Carter, 1991; SDP, 2000).

Timely warning of an imminent or probable hazard with a potential to cause an emer-gency or a disaster will possibly prevent the occurrence or lessen the severity of its consequences. The extent of such reduction depends upon the interaction of three ele-ments, namely:• Accuracy of warning• Length of time between the warning being raised/declared and the expected onset of the event• State of Emergency/Disaster Preparedness

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Requirements for Effective Warning include the capability to: • Receive international warning Example: cyclone warnings from Tropical Cyclone Warning Centers in various locations; meteorological indications from weather satellites of possibly developing threats • Initiate in-country warnings necessary in cases such as fl oods, landslides, volcanic eruptions, earthquake• Transmit warning from national level and other key government levels; mostly done by radio links or broadcast systems• Transmit warning at local community level; may be done by local radio stations, sirens, loud hailers, bells, messengers• Receive warning and act upon it. This requires: ❍ possession of or access to a radio receiver or similar facility ❍ being in hearing/seeing distance of signals ❍ knowing what various warnings mean

Alerting consists of a number of response phases, namely:

Alert Alert

Standby Standby

Call-out Call-out

Stand-down Stand-down

The period when it is believed that resources may be required to enable an increased level of preparedness

The period normally following an alert when the controlling or-ganization believes that deployment of resources is imminent – personnel are placed on standby to respond immediately

The command to deploy resources

The period when the controlling organization has declared that the emergency is controlled and that resources may be recalled

To implement these phases, there needs to be:

• A protocol of which organizations to alert for which emergencies and what tasks; • A contact list for all organizations;• Duty offi cer rosters in all organizations to ensure that the organization can be contacted during off hours; and• A description of the type of information that should be supplied in the various phases of alerting.

Warnings should be transmitted using as many media as available. These may origi-nate from: • The scene or the potential scene of the emergency and passed upwards; or

• The national government and passed down to the scene of the impending emergency.

A community warning should cause appropriate public responses to minimize harm.

Warning messages should:• Provide timely information about an impending emergency.• State the action that should be taken to reduce loss of life, injury and property damage.• State the consequences of not heeding the warning.• Provide feedback to response managers on the extent of community compliance.• Be short, simple and precise.• Have a personal context. • Contain active verbs.• Repeat information regularly.

The different alert signals for typhoons, earthquakes, tsunami, fl oods, lahar and volca-nic eruptions are given in Section 6.2.

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SECTION 6.1ACode Alert System for DOH Central Offi ces

CODE WHITE CODE WHITE

1. Conditions for adopting Code White:

● Strong possibility of a military operation, e.g., coup attempt/armed confl ict which has a national implication

● Any planned mass action or demonstration which has a national implication● Forecast typhoons (Signal No. 2 up)● National or local elections and other political exercises● National events, holidays or celebrations with potential for MCI● Notifi cation of reliable information of terrorist/attack activities ● Any other hazard that may result in emergency ● Unconfi rmed report of reemerging diseases, e.g., bird fl u, SARS

2. Human resource requirements for responding to the code:

● Concerned directors or designates of the following offi ces should be on standby:

• Material Management Division• Finance Service• Administrative Service• Procurement and Logistics Service• National Epidemiology Center• National Center for Health Promotion• Media Relations Unit• National Center for Disease Prevention and Control• National Center for Health Facilities and Development• Bureau of Quarantine & International Health Surveillance• Bureau of Food and Drug

CODE BLUE CODE BLUE

1. Conditions for adopting Code Blue

● Any condition mentioned in Code White plus any of the two below: • Mobilization of DOH resources is needed (manpower, materials, etc.) • 30-50% health facilities in the area affected or damaged. • No capability of the LGU and/or lack of resources of the region to respond to the affected area. • Magnitude of the disaster based on geographic coverage and number of affected population (more than 30%). • Any Mass Casualty Incident (MCI) with 50-100 casualties (mortalities plus injuries) irrespective of color code. • High case fatality rate for epidemic or confi rmed/documented report of reemerging diseases (SARS, human to human Avian fl u).

2. Human resource requirements for responding to the code:

● Director or designate to be present at the respective offi ces: • Material Management Division • Finance Service • Administrative Service • Procurement and Logistics Service • National Epidemiology Center • National Center for Health Promotion • Media Relations Unit • National Center for Disease Prevention and Control • National Center for Health Facilities and Development • Bureau of Quarantine & International Health Surveillance • Bureau of Food and Drug

3. Other requirements:

Activate the following offi ces:

● Material Management Division • Ensure availability of staff to prepare all medicines and supplies needed. • Ensure that the medicines and supplies be transferred to the affected area via NDCC arrangement or other means. • Ensure the presence of the inspection team (DOH and BFAD Teams).

● Finance Service • All unit heads must be available to facilitate release of funds. • Petty cash must be in place. • Facilitate travel arrangements and other requirements in case of local or international teams to be sent. ● Administrative Service • Should ensure availability of vehicles with drivers, gasoline/diesel, etc. • Should ensure the provision of electricity/ generator in all services responding to the emergency/disaster at the Central Offi ce. • Should ensure availability of other communication lines specially PABX. • Security Force to institute measures and stricter rules at the DOH Compound. • Assist MMD in the preparation of medicines and supplies and transfer of these to airports, etc. • Facilitate arrangement with the airport for the travel of medical teams. ● National Epidemiology Center • Ready surveillance and outbreak investigation team and experts to be deployed as needed.

● Procurement Division • Should ensure the availability of list of qualifi ed & responsible pharmaceutical companies and other suppliers for emergency procurement of drugs and medicines. • Should facilitate procurement of emergency drugs/supplies as needed. ● National Center for Health Promotion (NCHP) • Should ensure their availability to assist and provide technical assistance to HEMS and Regional Offi ces in the conceptualization and development of behavioral messages and IEC materials. • Should assist Regional Offi ces in the conduct of health education activities. • Assist in documentation of events.

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● Media Relations Unit (MRU) • Anticipate any untoward media reports and recommend necessary response. • Prepare press releases and/or press statement. • Recommend and organize press conference and other media blitz like radio and television appearances. • Coordinate with HEMS/NCDPC and other offi ces for technical inputs. ● National Center for Disease Prevention and Control (NCDPC) • All Program Managers with concerns in disaster should be available for their technical support, such as those for communicable disease, environmental, nutrition, sanitation, psychosocial concerns, etc. • Provide treatment protocol as necessary. • Standby experts to be mobilized to affected area. ● National Center for Health Facilities Development • Technical support for hospitals should be readily available especially for infrastructure concerns. • There should be protocols in the movement of blood requirements for emergencies especially for Mass Casualty Incidents. Blood intended for elective cases can be realigned for the use of victims. • Provide technical support, especially for hospital management. ● Bureau of Food and Drug • Ensure the presence of the inspection team to issue certifi cate of clearance for drugs and medicines. • Facilitate requirements and certifi cation for donated medicines, etc.

● Bureau of Quarantine and International Health Surveillance • Will only be activated in the presence of cases of reemerging diseases such as SARS and Avian Flu which needs international surveillance in all ports of entry and other emergencies related to incoming and outgoing transporta- tions.

All offi ces/bureaus to have regular coordination with DOH-HEMS.

CODE RED

1. Conditions for adopting Code Red:

Any natural, man-made, technological or societal disaster where all of the fol lowing are present:

● Declaration of disaster in the affected area.● 100 or more casualties in one area.● Health personnel in the region not capable of handling entire operation.● Mobilization of health sector needed.● Mobilization of key offi ces of Department of Health. ● Uncontrolled human to human transmission of SARS/avian fl u in any region.

2. Human Resource requirements for responding to the Code:

All services should ensure the availability of staff for 24 hours to address all requests for technical as well as other logistical support.

3. Other requirements

● Each offi ce to deploy one personnel to augment HEMS Central Operations

Center and NDCC Operations Center.● DOH Crisis Committee to convene and provide overall support, direction and

policy directions to affected regions. Likewise, they can call on any other offi ce for technical and management support.

● All directors or designates mentioned above to report 24/7 to operations until Code Red is lifted.

● Other offi ces/units shall be on call or required to report to the Operations Center as identifi ed or needed by the Crisis Committee.

Guidelines in implementing the Code

● The Central Code Alert shall be declared by the Secretary of Health upon the recommendation and evaluation of the Director of HEMS for natural and man-made emergencies with national implications; and for epidemics and reemerging diseases by the directors of NEC and NCDPC.● This will be disseminated through a Department Memorandum. HEMS OpCen may call through a telephone brigade all offi ces concerned. This will also be followed in lifting the code alert.

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SECTION 6.1BIntegrated Code Alert System for the Health Sector

as per A.O. 2008-0024CODE ALERT LEVEL

CODE WHITE

CODE WHITE

HEMS CENTRAL OFFICE

1. Conditions for adopting Code White: • Strong possibility of a military operation, e.g., coup attempt/ armed confl ict which has a national implication • Any planned mass action or demonstration which has a national implication • Forecast typhoons (Signal No. 2 up) • National or local elections and other political exercises • National events, holidays or celebrations with potential for MCI • Any emergency with potentially 10-50 casualties (deaths, injuries) • Notifi cation of reliable information of terror ist/attack activities • Any other hazard that may result to emergency • Unconfi rmed report of re-emerging diseases, e.g., bird fl u, SARS

2. Human Resource requirements for responding to the Code:• Emergency Offi cer on Duty (EOD) 1 and 2• Driver and Security Guard to assist at the Operation Center• Reliever 1 and 2 (next day EOD’s) on standby• Response Division Chief or alternate on continu - ous monitoring and will

HOSPITAL

1. Conditions for adopting Code White:• Strong possibility of a military operation within the area/region, e.g., coup attempt• Any planned mass action or demonstration within the catchment area• Forecast typhoons (Signal No. 2 up) the path of which will affect the area• National or local elections and other political exercises• National events, holidays, or celebrations in the area with potential for MCI• Any emergency with potentially 10-50 casualties (deaths, injuries)• Any other hazard that may result in emergency • Unconfi rmed report of reemerging diseases, e.g., bird fl u, SARS

2. Human Resource requirements for responding to the Code:• First response team ready for dispatch to include the following:

✔ 2 doctors preferably Surgeon, Internist, anesthesiologist, etc.

✔ 2 nurses

CENTER FOR HEALTH DEVELOPMENT

1. Conditions for adopting Code White:• Strong possibility of a military operation, e.g., coup attempt within the region• Presence of hazards that pose a public threat such as epidemics, chemical, biological and radiological threat, etc.• Notifi cation of ongoing epidemic by LGU, with adequate measures by local health personnel• Any planned mass action or demonstration in the area• Forecast typhoons (Signal No. 2 up) the path of which will affect the region• National or local elections and other political exercises• National events, holidays or celebrations with potential for MCI• Any emergency with potential 10-50 casualties (deaths, injuries)• Any other hazard that may result in emergency• Unconfi rmed report of reemerging diseases, e.g., bird fl u, SARS

2. Human Resource requirements for responding to the Code:• 2 Emergency Offi cers on Duty• Driver• Regional HEMS Coordi- nator on call and on proactive monitoring• One Rapid Assessment Team ready for dispatch to include the following:

✔ DOH Representative

CODE ALERT LEVEL

CODE WHITE

CODE WHITE

HEMS CENTRAL OFFICE

serve as Medical Con- troller for Mass Casualty Incident

3. Other requirements:• EOD 1 to check all medicines, supplies available. • EOD 1 & 2 to do proactive monitoring.• EOD to alert the region, hospitals and other facilities that might be affected or needed to respond- or receive patients.• Response Division Chief or HEMS Director to alert key offi cials as needed.• EOD to inform National Epidemiology Center regarding outbreaks for confi rmatory report.

HOSPITAL

✔ First Aider/EMT✔ Driver

• Second response team should be on call• The following should

be available for immediate treatment of incoming patients: ✔ General Sur- geons ✔ Orthopedic Sur- geons ✔ Anesthesiolo- gists ✔ Internists ✔ O.R. Nurses ✔ Ophthalmologists ✔ Otorhinolaryngolo- gists ✔ Infectious Special - ists• Emergency service personnel, nursing personnel and administrative personnel residing at the hospital dormitory shall be placed on call status for immediate mobilization.

3. Other requirements:• The Hospital Operations Center should be activated. It should continuously report and coordinate with the Regional and DOH Central Opera- tions Center.■ Medicines and Supplies• Ensure that emergency medicines (especially for trauma needs) be made available at the emergency room.• Medicines and supplies in the operating rooms should likewise be reviewed and in creased to meet sudden requirements.• Other needs such as X-ray plates, laboratory requirements, etc. should be made avail-


✔ Nurse✔ Driver

3. Other requirements:• The Regional Operations Center should be activated on 24 hours and continuously report and coordinate with HEMS Operations Center.• Do proactive monitoring for any development.• Report to HEMS-OpCen daily and as necessary.• Require update from fi eld as necessary.• Finance division to ensure availability of funds in cases of emergency purchases and the like.• Supply section to coordinate with possible suppliers for additional re - quirements.• Transport section to ensure availability of ve-

Continuation of Integrated Code Alert System for the Health Sector

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HEMS CENTRAL OFFICE

1. Conditions for Adopt- ing Code Blue■ Any condition mentioned in Code White plus any of the two below:• Mobilization of DOH resources is needed (manpower, materials, etc.).• 30-50% health facilities in the areas affected or damaged. • No capability of the LGU and/or lack of resources of the region to respond to the affected area.• Magnitude of the disaster based on geographic coverage and number of affected population (more than 30%).• Any Mass Casualty Incident (MCI) with 50-

HOSPITAL

able and not required to be purchased by victims.• Personnel department to prepare for mobilization of additional staff.• Finance department to ensure availability of funds in cases of emergency purchases and the like.• Logistics department to coordinate with possible suppliers for additional requirements.• Dietary department to open and meet the need of the victims as well as the health personnel on duty. • Security force to institute measures and stricter rules in the hospital.• Activate Bird Flu Plan/ SARS Plan, etc.• Enforce and monitor use of personal protective equipment (PPE) for all health personnel. • Triage system should be activated.

1. Conditions for Adopt- ing Code Blue: ■ Any of the following conditions:• When 20-50 casualties (red tags) are suddenly brought to the hospital.• Any internal emergency/disaster in the hospital which brings down their operating capacity (i.e., vital areas) to 50% or which would require evacuation of patients and setting up of a Field Hospital.• For conditions other than MCI, the infl ux of patients is beyond the capacity of the hospital to handle.• Confi rmed/documented report of reemerging


hicles.• Monitor and assess continuously for require ments of other teams (medical, surveillance, environmental, health promotion, psychosocial etc.). These teams are on standby/on call for immediate mobilization.• Intensify IEC campaign through health advisories. • Coordinate regularly with affected LGUs.• Coordinate with regional hospitals for back-up teams.• Monitor stock level of needed drugs/supplies, pre-position as needed.• Activate Bird Flu Plan.• Mobilize RESU team to conduct investigation for outbreaks.

1. Conditions for Adopt- ing Code Blue: ■ Any of the following conditions: • 50-100 casualties irrespective of tags for MCI.• Declaration of epidemic.• Declaration of calamity in any province in the region.• Presence of evacuation centers estimated to last for more than a week which has public health implications.• Magnitude of the disaster based on geographic coverage and number of affected population (more than 30%).• Any conditions that would require mobilization of resources of the entire region.

Continuation of Integrated Code Alert System for the Health SectorCODE ALERT LEVEL

CODEBLUE

CODE ALERT LEVEL

CODE BLUE

CODE BLUE

HEMS CENTRAL OFFICE

100 casualties irrespective of color code.• High case fatality rate for epidemics. • Confi rmed human to human for avian fl u or SARS.

2. Human Resource requirements for responding to the Code:• Response Division Chief or HEMS Director should be physically present at OPCEN.• EOD 1 and 2• Driver and security guard to assist at the Opera tions Center.• Incoming EODs on call for immediate mobilization.• Logistics Offi cer or alternate to go on duty.• At least one DOH representative to go on duty to NDCC if required and/or requested.

3. Other requirements:• Coordinate with the following: ✔ Implementing agencies (hospitals, region, central

HOSPITAL

diseases (SARS, human to human avian fl u) within the catchment area.

2. Human Resource requirements for responding to the Code:• HEMS Coordinator to be physically present at the hospital.• On-scene Response Team• Medical Offi cer in charge of the Emergency Room• All residents of the De- partment of Orthopedics• Medical Offi cer in charge of the Operating Room• Surgical Team on duty for the day• Surgical Team on duty the previous day• Mental health professionals• All anesthesiology residents• Toxicologist, chemical experts for poisoning and/or chemical cases (if available)• All third and fourth year residents• Administrative Offi cer or designate• Nursing supervisor on duty• All OR nurses• Social workers• Dietary personnel• Offi cer in charge of supplies at the CSR• The entire security force • Institutional workers on duty

3. Other requirements: All those mentioned in Code White plus:• Activate Hospital Emer- gency Incident Com-



2. Human Resource requirements for responding to the Code:• RHEMS Coordinator to be physically present at OPCEN.• Rapid Assessment Teams and other appropriate teams (RAT) • Three (3) teams on standby (environmental/ surveillance/medical)• EOD 1 and 2• Logistics Offi cer• Finance Offi cer as necessary• Health Promotions Offi cer as necessary• Driver• All other regional staff on standby for immediate mobilization• All DOH REPS in the affected area should be available at the LGU.

3. Other requirements: All those mentioned in Code White plus:• Activate the Regional

Emergency Incident 121

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CODE ALERT LEVEL

HEMS CENTRAL OFFICE

offi ce) for possible dispatching of teams or experts ✔ NDCC and other sectors for other concerns, e.g., transportation, etc. ✔ MMD regarding supplies available at DOH ✔ Different DOH Cen- tral Offi ces for per sonnel augmentation to the Operations Center and for other technical support• Prepare possible drugs and medicines needed for movement to affected area.• If needed drugs/medi - cines not available, prepare emergency purchase.• Check all possible means of transportation, e.g., with NDCC, air cargo, etc.• Anticipate need of medical teams and other experts.• Prepare all needed reports and presentations required, especially for emergency NDCC meetings.• Orient staff to be deployed to NDCC and those additional staff to augment the OpCen.• In cases of long term emergencies, plan for support to the affected region.• Activate Code Blue for HEMS and prepare necessary documentation. • Initiate the conduct of coordinative meet ing of the national clusters: Health, Nutri- tion and WASH.

HOSPITAL

mand System (HEICS). • Other needs of victims apart from medicines and supplies depending on the disaster should as much as possible be made available.• The Chief of Hospital/ Medical Center or his designate should make proper coordination with other hospitals for networking and/or possible transfer of patients.• Incident Commander should assign a Safety Offi cer, Liaison offi cer to coordinate with other agencies, and Public Information Offi cer to serve as the spokesperson of the hospital.• Social Service section should prepare assistance to victims in coordination with mental health professionals of the hospital, if available, and the Depart- ment of Social Welfare; in addition they should lead in providing information to relatives of victims. • Mortuary section should anticipate dead victims brought to the hospital for proper care and identifi cation.• The security team, in anticipation of possible infl ux or patients, relatives, responders, police, press, etc. should ensure smooth fl ow of traffi c inside the compound especially for the ambulances.• Should report regularly to HEMS OpCen and as much as possible have regular press releases or briefi ngs.


Command System (REICS).• Operations Center on 24/7 with adequate personnel and logistical support to receive, evaluate and analyze all reports.• Mobilize teams to affect ed areas for Rapid As- sessment in coordination with the DOH Rep.• Regional Director or his designate to make proper coordination with RDCC and other agencies like DSWD, DepEd, etc. for networking and other requirements.• Incident Commander should assign needed staff in Operations, Lo- gistics, Planning and Administrative sections to assist affected LGUs.• Public Information Of - fi cer to prepare and have regular media conferences or press releases.• Continuous IEC campaign through health advisories, especially in evacuation centers.• May need to activate also a Field EOC as needed to coordinate health activities.• Oversee operation of Management of Mass Dead together with the health unit of the LGU concerned.• Lead in coordinative meetings of the cluster under the DOH: Health, Nutrition and WASH.• Provide technical support to LGUs.• Mobilize other requirements as needed, such as psychosocial team, etc.• Regularly coordinate with DOH-HEMS OpCen for reports and other needs.


CODE ALERT LEVEL

CODERED

CODERED

HEMS CENTRAL OFFICE

1. Conditions for Adopt- ing Code Red:

Any natural, manmade, technological or societal disaster, where all of the following are present: • Declaration of disaster in the affected area. • 100 or more casualties in one area. • Health personnel in the region not capable of handling entire operation. • Mobilization of the health sector needed. • Mobilization of key offi ces in DOH. • Uncontrolled human to human transmission of SARS/avian fl u.

2. Human Resource requirements for responding to the Code: The HEMS Offi ce personnel and staff augmentation from other offi ces shall be divided into 3 teams to go on a 24-hour duty rotation every 3 days. The team is composed of the following: • Team Leader • 2 Data Collectors/ Encoders • Logistics • Communication • Administrative Of fi cer • Support Staff/Clerk • Driver • At least 1 staff to be assigned at OCD

HOSPITAL

1. Conditions for Adopt- ing Code Red: Any of the following is present:

• When more than 50 (red tag) casualties are suddenly brought to the hospital. • An emergency wherein the services of the hospital is paralyzed since 50% of the manpower are themselves victims of the disaster. • Hospital is structur- ally damaged requiring evacuation and/or transfer of patients. • Conditions requiring mandatory quarantine of hospital and its personnel (e.g., SARS, avian fl u); uncontrolled human to human transmission of SARS/avian fl u within the catchment area.

2. Human Resource requirements for responding to the Code: All personnel enumer- ated under Code Blue All medical interns and clinical clerks All nurses • All nursing attendants • All institutional work ers • All administrative staff


1. Conditions for adopting Code Red:

Any of the following is present: • Conditions resulting in mass dead and missing. • Disaster declared in 2 or more provinces in the region or 30% of the cities in Metro Manila. • Major facilities or hospitals, such as the provincial/city hospital, in area are not able to provide optimal services due to damages or 50% of staff are affected. • Mobilization of entire regional resources not enough thus requiring external support. • Uncontrolled epidemic/outbreak. • Uncontrolled human to human transmission of SARS/avian fl u.

2. Human Resource re quirements for responding to the Code: Mobilize all regional staff as needed on rotation basis. Establish surveillance system in all evacuation centers. All other teams deployed in affected area.


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CODE ALERT LEVEL

CODERED

HEMS CENTRAL OFFICE

OpCen on 24-hour duty

3. Other requirements: • HEMS to represent the Department of Health to NDCC and other agencies. • Lead in the coordination with international partners in the health, nutrition and WASH clusters. • Lead in the coordination with all members of the health sectors. • Lead in the coordination with donor agencies, both international and local. • Prepare updated reports for use of Sec- retary and other partners. • Assist in the preparation of the rehabilitation and recovery plan; represent the DOH in the national DANA team. • HEMS-OpCen to serve as DOH Com- mand Post.

• Recommend the activation of the Crisis Committee which serves as the techni-cal operations arm and prepares recom-mendations to the Executive Committee of DOH to be chaired by the Undersecretary for Policy Develop-ment Team for Service Delivery and to be assisted by the Direc-tors of HEMS, NEC, NCDPC, NCHFD, Finance, Administra-tive and MMD.

HOSPITAL

3. Other requirements: All those mentioned in Code Blue plus: • The Chief of Hospi- tal/Medical Center Chiefs can cancel all types of leaves and can order all personnel to report to the hospital. • The Chiefs of Hospital/ Medical Center Chiefs can temporarily stop all elective admissions and surgeries and network with other hospitals. • The Chief of Hospi- tal/Medical Center Chiefs should anticipate requests for additional manpower and specialists not available in his hospital. He is further authorized to accept medical volunteers and other professionals to augment the hospital’s manpower resources rather than transferring patients based on some agreements. • Networking with other hospitals for augmentation of resources and transfer of patients in special cases. • Answer all queries of the media pertaining to patients in the hospital. • Anticipate evacuation and/or use of fi eld hospital; closure and/ or quarantine of the hospital. • The Chief of Hospi - tal/Medical Center Chief to specifi cally be concerned with safety and security, not


3. Other requirements: All those mentioned in Code Blue plus: • The CHD Director can cancel all types of leaves and can order all personnel to report to the CHD. • The CHD Director can stop all operations not related to the disaster. • The CHD Director should anticipate requests for additional manpower and specialists not available in his CHD. He is further authorized to accept volunteers and other professionals to augment the CHD’s manpower based on some agreements. • Continue networking with RDCC and its clusters (Health, Nutri - tion, WASH). • Public information campaign. • Handles queries from media. • For reemerging dis - eases, to provide leadership together with the LGU in decisions like quarantine of the area and other decisions in preventing spread of the epidemic. • Provide updated report to HEMS Central OpCen.


CODE ALERT LEVEL

CODERED

HEMS CENTRAL OFFICE

✔ Guidelines in implementing the Code Alert• The HEMS Code Alert shall be declared by the HEMS Director or by the Division Chief (Response or Preparedness).• Announced through telephone brigade.• Administrative Offi cer to prepare Offi ce Or der/Department Personnel Order.• HEMS Director or the Division Chief (Response or Pre- paredness) lifts the Code Alert and make the necessary announcement.

HOSPITAL

only of the patients but of the personnel as well.

✔ Guidelines in implementing the Code Alert• The Hospital Code Alert shall be declared by the Secretary of Health or by the Director of HEMS for external emergencies; by the Medical Center Chiefs; Chiefs of Hospi- tal; HHEMS Coordinator; or Head of the Disaster Committee of the Hospital emergencies within their catch ment area. • Chiefs of hospital/medical center to automati cally declare Code White during national events and activities especially with the potential of an MCI.• Each hospital shall prepare its own proce dures in declaring and lifting the Code.

✔ The alert level is raised, lowered or suspended by the Secretary of Health, Director of HEMS for

external emergencies and national events; the respective Medical Center Chiefs/Chiefs of Hospital or their designates for emergencies within their catchment area.

✔ Conditions to raise or suspend the alert level depends on the threat pends on the threat pends – whether it is increased or is no longer present.

✔ Arrival of patients in the hospitals warrants the raising of the alert level; likewise alert can be suspended when no signifi cant incident is monitored and the hazard or condition (typhoon, election, bombing, etc.) is fi nished and/or contained.


✔ Guidelines in implementing the Code Alert• The Regional Code Alert shall be declared by the Secretary of Health or Director of HEMS for emergencies with national implications; Re- gional Director and RHEMS Coordinator for internal (regional) emergencies.• Regional Directors to automatically declare Code White during national events and activities especially with the potential of an MCI.• The alert is raised, lowered or suspended by the Secretary of Health, HEMS Director for emergencies with national implications, or by the respective Re- gional Director or RHEMS Coordinator for internal (regional) emergencies.• Each region shall prepared its own procedures in declaring and lifting the Code.

✔ Conditions to raise or suspend the alert level depends on the threat depends on the threat depends – whether it is increased or is no longer present.


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SECTION 6.2Alert Signals

1. PUBLIC STORMSWHAT ARE THE DIFFERENT PUBLIC STORM WARNING SIGNALS, THEIR MEANINGS AND THE THINGS TO BE DONE?

MEANING

A Tropical Cyclone will affect the locality.

Winds of 30-60 KPH may be expected in at least 36 hours or intermittent rains maybe expected within 36 hours*.

Disaster preparedness plan is acti-vated to alert status.

A Moderate Tropical Cyclone will affect the locality.

Winds of more than 60 up to 100 KPH may be expected in at least 24 hours*.

Disaster preparedness agencies/organizations are in action to alert their communities.

A Strong Tropical Cyclone will affect the locality.

Winds of more than 100 up to 185 KPH may be expected in at least 18 hours*.

Disaster preparedness agencies/organizations are in action with appropriate response to actual emergency.

A Very Intense Typhoon will affect the locality.

Winds of more than 185 KPH may be expected in at least 12 hours*.

The National Disaster Coordinating Council and other disaster re-sponse organizations are now fully responding to emergencies and in full readiness to immediately respond to possible calamity.

WHAT TO DO

• Listen to the radio for more information about the weather disturbance.• Check the capacity of the house to withstand strong winds and strengthen the house if necessary.• The people are advised to listen to the latest severe weather bulletin issued by PAGASA every six hours. In the meantime, business may be carried out as usual except when fl ood occurs.

• Special attention should be given to the latest position, the direction and speed of movement and the in tensity of the storm as it may inten sify and move towards the locality. • The general public, especially people travelling by sea and air, are cautioned to avoid unnecessary risks. • Secure properties before the signal is upgraded. • Board up windows or put storm shut ters in place and securely fasten them.• Stay at home.

• Keep your radio on and listen to the latest news about the typhoon.• Everybody is advised to stay indoors.• People are advised to stay in strong buildings.• Evacuate from low-lying areas.• Stay away from coastal areas and river banks.• Watch out for the passage of the “Eye wall” and the “Eye of the Ty phoon.”

• Stay in a safe house or evacuation centers!!!• The situation is potentially very de structive to the community. • All travels and outdoor activities should be cancelled. • In the overall, damage to affected communities can be very heavy.

PUBLIC STORM WARNING

SIGNAL # 1

SIGNAL # 2

SIGNAL # 3

SIGNAL # 4

* Times are valid only the fi rst time the signal number is raised.

DESCRIPTION

Scarcely Perceptible - Perceptible to people under favorable circumstances. Delicately bal-anced objects are disturbed slightly. Still water in containers oscillates slowly.

Slightly Felt - Felt by few individuals at rest indoors. Hanging objects swing slightly. Still water in containers oscillates noticeably.

Weak - Felt by many people indoors especially in upper fl oors of buildings. Vibration is felt like the passing of a light truck. Dizziness and nausea are experienced by some people. Hanging objects swing moderately. Still water in containers oscillates moderately.

Moderately Strong - Felt generally by people indoors and by some people outdoors. Light sleepers are awakened. Vibration is felt like the passing of a heavy truck. Hanging objects swing considerably. Dinner plates, glasses, windows and doors rattle. Floors and walls of wood-framed buildings creak. Standing motor cars may rock slightly. Liquids in containers are slightly disturbed. Water in containers oscillates strongly. Rumbling sound may sometimes be heard.

Strong - Generally felt by most people indoors and outdoors. Many sleeping people are awak-ened. Some are frightened, some run outdoors. Strong shaking and rocking felt throughout building. Hanging objects swing violently. Dining utensils clatter and clink; some are broken. Small, light and unstable objects may fall or overturn. Liquids spill from fi lled open containers. Standing vehicles rock noticeably. Shaking of leaves and twigs of trees are noticeable.

Very Strong - Many people are frightened; many run outdoors. Some people lose their balance. Motorists feel like driving with fl at tires. Heavy objects or furniture move or may be shifted. Small church bells may ring. Wall plaster may crack. Very old or poorly built houses and man-made structures are slightly damaged although well-built structures are not affected. Limited rockfalls and rolling boulders occur in hilly to mountainous areas and escarpments. Trees are noticeably shaken.

Destructive - Most people are frightened and run outdoors. People fi nd it diffi cult to stand in upper fl oors. Heavy objects and furniture overturn or topple. Big church bells may ring. Old or poorly built structures suffer considerable damage. Some well-built structures are slightly dam-aged. Some cracks may appear on dikes, fi sh ponds, road surface, or concrete hollow block walls. Limited liquefaction, lateral spreading and landslides are observed. Trees are shaken strongly. (Liquefaction is a process by which loose saturated sand lose strength during an earth-quake and behave like liquid).

Very Destructive - People panic. People fi nd it diffi cult to stand even outdoors. Many well-built buildings are considerably damaged. Concrete dikes and foundation of bridges are destroyed by ground settling or toppling. Railway tracks are bent or broken. Tombstones may be dis-placed, twisted or overturned. Utility posts, towers and monuments may tilt or topple. Water and sewer pipes may be bent, twisted or broken. Liquefaction and lateral spreading cause man-made structures to sink, tilt or topple. Numerous landslides and rockfalls occur in mountainous and hilly areas. Boulders are thrown out from their positions particularly near the epicenter. Fissures and faults rupture may be observed. Trees are violently shaken. Water splash or stop over dikes or banks of rivers.

Devastating - People are forcibly thrown to ground. Many cry and shake with fear. Most build-ings are totally damaged. Bridges and elevated concrete structures are toppled or destroyed. Numerous utility posts, towers and monument are tilted, toppled or broken. Water sewer pipes are bent, twisted or broken. Landslides and liquefaction with lateral spreadings and sandboils are widespread. The ground is distorted into undulations. Trees are shaken very violently with some toppled or broken. Boulders are commonly thrown out. River water splashes violently on slops over dikes and banks.

Completely Devastating - Practically all man-made structures are destroyed. Massive land-slides and liquefaction, large-scale subsidence and uplifting of land forms and many ground fi ssures are observed. Changes in river courses and destructive seiches in large lakes occur. Many trees are toppled, broken and uprooted.

2. EARTHQUAKESPHIVOLCS EARTHQUAKE INTENSITY SCALEINTEN-SITY SCALE

I

II

IV

III

X

IX

VIII

VII

VI

V

127

128

INTERPRETATION/RECOMMENDATION

No eruption in foreseeable future. Entry in the 6-km radius Permanent Danger Zone (PDZ) is not advised because phreatic explosions and ash puffs may occur without precursors.

No eruption imminent.Activity may be hydrothermal, magmatic or tectonic in origin.No entry in the 6-km radius PDZ.

Unrest probably of magmatic origin; could eventually lead to eruption.6-km radius Danger Zone may be extended to 7 km in the sector where the crater rim is low.

RICHTER MAGNITUDE SCALEMagnitudeScale Description

1 Earthquake with M below 1 are only detectable when an ultra sensitive seismometer is operated under favorable conditions.

2 Most earthquakes with M below 3 are the “hardly perceptible shocks” and are not felt. They are only recorded by seismographs of nearby stations.

3 Earthquake with M 3 to 4 are the “very feeble shocks” and only felt near the epicenter.

4 Earthquakes with M 4 to 5 are the “feeble shocks” where damages are not usually reported.

5 Earthquakes with M 5 to 6 are the “earthquakes with moderate strength” and are felt over the wide areas; some of them cause small local damages near the epicenter.

6 Earthquake with M 6 to 7 are the “strong earthquakes” and are accompanied by local damages near the epicenters. First class seismological stations can observe them wherever they occur within the earth.

I

II

III

IV

V

VI

Earthquake with M 7 to 8 are the “major earthquakes” and can cause considerable damages near the epicenters. Shallow-seated or near-surface major earthquakes when they occur under the sea, may generate tsunamis. First class seismological stations can observe them wherever they occur within the earth.

Earthquake with M 8 to 9 are the “great earthquakes” occurring once or twice a year. When they occur in land areas, damages affect wide areas. When they occur under the sea, considerable tsunamis are produced. Many aftershocks occur in areas approximately 100 to 1,000 kilometers in diameter.

Earthquakes with M over 9 have never occurred since the data based on the seismographic observations became available.

VII

XI

VIII

3.1 MAYON VOLCANO ALERT LEVELS

MAIN CRITERIA

Quiet. All monitored parameters within background levels.

Low level unrest.Slight increase in seismicity. Slight increase in SO2 gas output above the background level. Very faint glow of the crater may occur but no conclusive evidence of magma ascent. Phreatic explosion or ash puffs may occur.

Moderate unrest. Low to moderate level of seismic activity.Episodes of harmonic tremor. Increasing SO2 fl ux.

3. VOLCANIC ERUPTIONS

ALERT LEVEL

0No Alert

1 Abnormal

2 Increasing Unrest

129

INTERPRETATION/RECOMMENDATION

Magma is close to the crater.If trend is one of increasing unrest, eruption is possible within weeks.Extension of Danger Zone in the sector where the crater rim is low will be considered.

Hazardous eruption is possible within days. Extension of Danger zone to 8 km or more in the sector where the crater rim is low will be recommended.

MAIN CRITERIA

Faint/intermittent crater glow. Swelling of edifi ce may be detected. Confi rmed reports of decrease in fl ow of wells and springs during rainy season.

Relatively high unrest. Volcanic quakes and tremor may be come more frequent. Further increase in SO2 fl ux. Occurrence of rockfalls in summit area. Vigorous steaming/sustained crater glow.Persistent swelling of edifi ce.

Intense unrest. Persistent tremor, many “low frequency”-type earthquakes. SO2 emission level may show sustained increase or abrupt decrease. Intense crater glow. Incandescent lava fragments in the summit area.

ALERT LEVEL

3 Increased Tendency Towards Eruption

4 Hazardous Eruption Imminent

Continuation of 3.1 MAYON VOLCANO ALERT LEVELS

Pyroclastic fl ows may sweep down along gul- lies and channels, especially along those fronting the low part(s) of the crater rim. Additional danger areas may be identifi ed as eruption progresses.Danger to aircraft, by way of ash cloud encoun- ter, depending on height of eruption column and/or wind drift.

INTERPRETATION

No eruption in foreseeable future.

Magmatic, tectonic, or hydrothermal disturbance; no eruption imminent.

Probable magma intrusion; could eventually lead to an eruption.

Increasing likelihood of an eruption, possibly explosive, probably within days to weeks.

Magma close to or at the earth’s surface. Hazardous explosive eruption likely, possibly within hours or days.

Hazardous eruption ongoing.Occurrence of pyroclastic fl ows, tall eruption columns and extensive ashfall.

CRITERIA

Background, quiet.

Low level seismic, fumarolic, other unrest.

Moderate level of seismic, other unrest with positive evidence for involvement of magma.

Relatively high and increasing unrest, including numerous low frequency volcanic earthquakes, accelerating ground deformation, increasing fumarolic activity.

Intense unrest, including harmonic tremor and/or many “long-period” (i.e., low frequency) earthquakes and/or dome growth and/or small explosions.

5 Hazardous Eruption

ALERT LEVEL

No Alert

1

2

3

4

3.2 BULUSAN VOLCANO ALERT SIGNALS

130

INTERPRETATION

INTERPRETATION

No eruption in foreseeable future.

Magmatic, tectonic or hydrothermal distur-bance; no eruption imminent.

A) Probable magmatic intrusion; could eventually lead to an eruption. B) If trend shows further decline, volcano may soon go to level 1.

MAIN CRITERIA

Hazardous eruption in progress. Hazards in valleys and downwind.

CRITERIA

Background, quiet.

Low level seismicity, fumarolic, other activity.

Low to moderate level of seismicity, persistence of local but unfelt earth quakes. Ground deformation measurements above baseline levels. Increased water and/or ground probe hole temperatures, increased bubbling at Crater Lake.

ALERT LEVEL

5

ALERT LEVEL

No alert(NORMAL) 1(ABNOR- (ABNOR- MAL)

2(ALARM- ING)

3.3 TAAL VOLCANO ALERT SIGNAL

Continuation of 3.2 BULUSAN VOLCANO ALERT LEVELS

A) If trend is one of increasing unrest, eruption is possible within days to weeks. B) If trend is one of decreasing unrest, volcano may soon go to level 2.

Hazardous explosive eruption is possible within days.

Hazardous eruption in progress. Extreme hazards to communities west of the volcano and ashfalls on downwind sectors.

Relatively high unrest manifested by Relatively high unrest manifested by seismic swarms including increas- seismic swarms including increasing occurrence of low frequency ing occurrence of low frequency earthquakes and/or harmonic tremor (some events felt). Sudden or increasing changes in temperature or bubbling activity or radon gas emission or Crater Lake pH. Bulging of the edifi ce and fi ssuring may accom- pany seismicity.

Intense unrest, continuing seismic Intense unrest, continuing seismic swarms, including harmonic tremor swarms, including harmonic tremor and/or “low frequency earthquakes” and/or “low frequency earthquakes” which are usually felt, profuse steam- which are usually felt, profuse steaming along existing and perhaps new vents and fi ssures.

Base surges accompanied by eruption Base surges accompanied by eruption columns or lava fountaining or lava columns or lava fountaining or lava fl ows. fl ows.

3 3 (CRITICAL) (CRITICAL)

4 4 (ERUPTION (ERUPTION IMMINENT) IMMINENT)

5 5 (ERUPTION)

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4. HURRICANES HURRICANE CATEGORIES

BAROMETRIC BAROMETRIC STORMPRESSURE WIND SPEED SURGE DAMAGE POTENTIALPRESSURE WIND SPEED SURGE DAMAGE POTENTIAL

Category One (1): Weak

> 28.94 in 74-95 mph 4-5 ft Minimal damage to vegetation. No real damage to other (980 mb) (64-82 kt or (980 mb) (64-82 kt or structures. Some damage to poorly constructed signs. Low-

119-153 km/hr) lying coastal roads inundated, minor pier damage, some small craft in exposed anchorage torn from small craft in exposed anchorage torn from moorings.

Category Two (2): Moderate

28.50-28.94 96-110 mph 6-8 ft Considerable damage to vegetation; some trees blown 6-8 ft Considerable damage to vegetation; some trees blown in (965-980 (83-95 kt or down. Major damage to exposed mobile homes. down. Major damage to exposed mobile homes. (83-95 kt or down. Major damage to exposed mobile homes. (83-95 kt or Moderatemb) 154-177 km/hr) damage to houses. Considerable damage to damage to houses. Considerable damage to piers; marinas

fl ooded. Small craft in unprotected an fl ooded. Small craft in unprotected anchorages torn from moorings. Evacuation from some shoreline residences and moorings. Evacuation from some shoreline residences and low-lying areas required. low-lying areas required.

Category Three (3): Strong 27.91-28.50 111-130 mph 9-12 ft Large trees blown down. Mobile homes destroyed. Ex- 9-12 ft Large trees blown down. Mobile homes destroyed. Ex- in (945-965 (96-113 kt or tensive damage to small buildings. Poorly constructed tensive damage to small buildings. Poorly constructed (96-113 kt or tensive damage to small buildings. Poorly constructed (96-113 kt ormb) 178-209 km/hr) signs blown down. Serious coastal fl ooding; larger signs blown down. Serious coastal fl ooding; larger

structures near coast damaged by battering waves and structures near coast damaged by battering waves and fl oating debris. fl oating debris.

Category Four (4): Very Strong 27.17-27.91 131-155 mph 13-18 ft All signs blown down. Complete destruction of mobile 13-18 ft All signs blown down. Complete destruction of mobile in (920-945 (114-135 kt or homes. Extreme structural damage. Major damage to homes. Extreme structural damage. Major damage to (114-135 kt or homes. Extreme structural damage. Major damage to (114-135 kt or lower mb) 210-249 km/hr) fl oors of structures due to fl ooding and battering fl oors of structures due to fl ooding and battering by waves

and fl oating debris. Major erosion of beaches. and fl oating debris. Major erosion of beaches.

Category Five (5): Catastrophic < 27.17 in > 155 mph > 18 ft Catastrophic building failures. Devastating damage to roofs > 18 ft Catastrophic building failures. Devastating damage to roofs (920 mb) (135 kt or 249 of buildings. Small buildings overturned or blown away. of buildings. Small buildings overturned or blown away. km/hr) km/hr)

132

5. LAHAR LAHAR ALERT

ALERT SIGNAL INTERPRETATIONALERT SIGNAL INTERPRETATIONLEVEL

Alert I “Get ready” People residing near the river channels and low lying areas Alert I “Get ready” People residing near the river channels and low lying areas Alert I “Get ready” People residing near the river channels and low lying areas - Get ready - Get ready - Get ready - Tune in to their national/local radio station for further announce- - Tune in to their national/local radio station for further announce- - Tune in to their national/local radio station for further announcement ment

Alert II “Get Set “ Residents in the endangered areas Alert II “Get Set “ Residents in the endangered areas Alert II “Get Set “ Residents in the endangered areas - Secure their houses and pack basic item and belonging - Secure their houses and pack basic item and belonging - Secure their houses and pack basic item and belonging - Prepare to leave to higher grounds/safer places or to the predesig- - Prepare to leave to higher grounds/safer places or to the predesig- - Prepare to leave to higher grounds/safer places or to the predesig- nated evacuation center nated evacuation center

Alert III “Go” People in the endangered areas Alert III “Go” People in the endangered areas Alert III “Go” People in the endangered areas - Leave their homes - Leave their homes - Leave their homes - Proceed to safer places, higher grounds, designated pick-up - Proceed to safer places, higher grounds, designated pick-up - Proceed to safer places, higher grounds, designated pick-up points for evacuation to designated evacuation centers. points for evacuation to designated evacuation centers.

Source: Department of Health – Health Emergency Management Staff. A compilation on Natural Hazards Accessedom Philippine Athmospheric, Geophysical and Astronomical Services Administrastion Website http://www.pagasa.dost.gov.ph/wb

133

SECTION 7RAPID HEALTH ASSESSMENT/ASSESSMENT FOR RECOVERY

DEFINITION

Rapid Health Assessment is the “collection of subjective and objective information to measure damage and identify those basic needs of the affected population that require immediate response within 24 hours.”

OBJECTIVES

1. To determine the magnitude of the emergency.2. To defi ne the specifi c health needs of the affected population.3. To establish priorities and objectives for action.4. To identify existing and potential public health problems.5. To evaluate the capacity of the local response, including resources and logistics.6. To determine external resource needs for priority actions.7. To set up the basis for a health information system.

INFORMATION

The assessment involves the collection of two key categories of information:• Classifi cation of the victims• Classifi cation of damage to infrastructure and/or interruption of services Classifi cation of Victims

To prioritize the allocation of scarce resources in the soonest possible time, it is es-sential to classify the victims. The following are considered essential to survival and are called lifelines:

o Watero Foodo Sheltero Energy

Victims can be classifi ed according to their access to lifelines. The following is used to describe the severity of the impact on people:

o Affected - all those living within the geographical area involvedo Severely affected - those who have lost one or more of their lifelineso Critically affected - those who have lost all of their lifelines or who have been

displaced (and therefore are totally dependent on others to supply them)

Therefore, a report describing the impact of a hazard provides the number of:o Casualties (killed, injured, sick)o Affected (total, severe, critical)

Classifi cation of Damages in Emergency Situations

The following are the physical elements that require assessment by the health

134

sector after a disaster:o Integrity of infrastructureo Capacity of service deliveryo Access to serviceso Essential supplies – water, energyo Capacity for distribution of essential health supplies

For each facility or service in the affected area, the assessment grades function ac-cording to a predefi ned scale. The following is an example of a grading scale:

o Destroyed or unavailableo More than 50% reduction in capacityo Less than 50% reduction in capacityo Undamaged

Determining Magnitude of Emergency and Health Needs of Affected Population

The health impact to the community along the fi ve elements is considered:a. People – number of injuries, number of deaths, number of missing, and num-

ber of affected populationb. Properties – number of affected/ damaged health facitlites such as hospitals,

rural health centers, laboratoriesc. Environment – description of changes in land, soil, air, waterd. Services – type of disruption of specifi c servicese. Livelihood – damage to sources of livelihood, etc.

The hospital focuses on the four elements (people, properties, environment and ser-vices) and derives the health needs of the affected population.

Determining Response Priorities

The health sector carries out the following activities according to priorities identifi ed in the assessment:

1. Priority Relief Needs• Assistance in search and rescue (not a DOH role, except when requested for

in special circumstances)• First aid• Acute medical and surgical care• Care of the displaced and vulnerable• Security of water supply• Assistance in provision of shelter, warmth and clothing

2. Secondary Relief Needs The health sector acts to improve the capabilities of services where defi cien-

cies are indicated. This is accomplished by: (a) increasing stocks of materials and supplies; (b) developing auxiliary power sources, and providing supplies of fuel, and acquiring additional repair equipment, and (c) recruiting and brief-ing personnel, volunteers, retired professionals, and other similar workers.

• Control of communicable disease• Mental Health and Psychosocial services

135

3. Management of Logistics, Transport, Communications

4. Epidemiological Surveillance• Morbidity – number of illnesses – priorities include trauma, diarrhœa , ARI,

measles, notifi able diseases• Mortality – number of dead• Laboratory support• Water quality• Nutrition• Vectors

5. Public Information and Community Participation

6. Monitoring, Evaluation and Reporting

7. Rehabilitation and Reconstruction (for internal disasters)• Replacement and repair• Restocking• Review of emergency plan, local policy and administrative procedures• Overall development policy and planning review• Retraining – technical and administrative

Recommended Tools

The Hospital should accomplish and submit appropriate Rapid Health Assessment Forms Prototype; for an MCI, for an outbreak and for a natural disaster within 24 hours upon the occurrence of the event using the appropriate forms of HEMS.

Corresponding Health Situation Updates for Natural Disasters, MCI and Outbreak are submitted twice a week for the fi rst two weeks and once a week thereafter until termina-tion of response activities. The forms are in the section on Information Management.

Rapid Assessment Surveys (RAS) Rapid Assessment Surveys (RAS)

Aim

Decide on the fi rst priority to: Decide on the fi rst priority to: 1. Prevent or reduce the adverse health consequences of the health 1. Prevent or reduce the adverse health consequences of the health emergency. emergency. 2. Optimize the decision-making process associated with management of 2. Optimize the decision-making process associated with management of the relief effort. the relief effort. 3. Avoid the so-called “second disaster” which is a result of arrival on the 3. Avoid the so-called “second disaster” which is a result of arrival on the disaster scene of outdated or inappropriate drugs, medical and disaster scene of outdated or inappropriate drugs, medical and surgical teams without proper support, and relief programs that do surgical teams without proper support, and relief programs that do not address local needs. not address local needs.

Time Time

Conducted during the fi rst 24 hours of the disaster. Conducted during the fi rst 24 hours of the disaster.

136

Process

Keep in mind the “Keep It Simple and Short (KISS)” principle. This helps lessen the burden of the fi eld workers.

Content

1. Presence/nature of disaster (all hazards) 2. Emergency or disaster 3. Impact of disaster: magnitude and lifelines

• Area affected by the disaster - location and size• Impact on human lives

o Number of population/individuals/families affected o Number of deaths and injured o Types of injuries and illnesseso Characteristic and condition of the affected population

• Damage to Facilities/ Services / Material Resourceso Emergency medical, health, nutritional, water and sanitation situation.o Infrastructure and critical facilities; homes and commercial buildings.o Economic resources, and social organization

• Level of continuing or emerging threats (natural/human caused); vulnerability of the population to continuing or expanding impacts of the disaster over the coming weeks and months.• Level of response

o By affected area/community/internal capacities to cope with situationo Needed from outside the community

- Central Offi ce- Private voluntary organizations, nongovernment organization, International organizations and donor countries

Basic Key Questions Required Within 24 Hours of the Event

1. Is there an emergency or not? (If so, indicate type, date, time and place of emergency, magnitude and size of affected area and population.) 2. What is the main health problem? 3. What health facilities or services have been or may be affected? 4. What is the existing response capacity (actions taken by the local authorities, by DOH HEMS)? 5. What decisions need to be made? 6. What information is needed to make these decisions?

ASSESSMENT FOR RECOVERY

Assessment during the recovery phase is part of the Damage Assessment and Needs Analysis (DANA), a process that is usually undertaken by a multidisciplinary team. While

Continuation of Rapid Assessment Survey

137

the Health Sector is not responsible for the overall process, it contributes actively to the process with its own assessment (HEMS, June 2007).

The concept of DANA is complex for it covers the fi rst initial reports, the succeeding reports, as well as the macro assessment of the damages in the long-term perspective.

The hospital assesses the impact of the health emergency/ disaster in terms of damages and losses created by the new situation, identifying the future areas where risks may evolve.

Primary damage assessment involves rapid appraisal of deaths, injuries and disease and identifi cation of damage to infrastructure, material resources and services. Sec-ondary damage assessment, on the other hand, is concerned with the impact of the primary damage on the economic, social and cultural life of survivors. Since sustainable livelihood security is the goal of both recovery and sustainable development, the as-sessment is concerned with three kinds of losses or disruption – loss of livelihood, loss of social cohesion, and loss of cultural identity. (HEMS, June 2007)

These losses can create new vulnerability to future disasters or make existing vulnera-bility worse. Failure to recover or partial recovery makes it more likely that people will be more vulnerable to the next stressful situation. The assessment at this stage is known as secondary vulnerability assessment.

The secondary damage assessment and secondary vulnerability assessment provide the information base for the recovery planning.

The sources of information are:• Response Operations• Post-Incident Evaluations• Development Programs• Special Teams• Previous Disasters

The assessment and analysis of information for this phase supports the development of the hospital recovery program which contributes to an overall strategy of the Community or the Hospital Catchment Area recovery program (Carter, 1991). The latter include:

Government aspects •Government aspects •Government aspects National infrastructure (roads, ports, etc.)• Government administrative facilities• Education facilities• Health Care Systems – Hospital etc,• Resettlement of displaced persons and communities

Private Sector• Industrial systems• Commercial buildings, stores

Community•Community•CommunityRe-establishment of Social Services System• Long-term rehabilitation of communities and individuals

138

SECTION 8Mass Casualty Management System

The planning of the hospital response in emergencies and disasters inevitably revolves around its surge capacity and the development or enhancement of its Mass Casualty Management System (HEMS, June 2007; WHO and ADPC, 2006). For this reason, the Department of Health issued Administrative Order No. 155 s. 2004 on the Implementing Guidelines for Managing Mass Casualty Incidents During Emergencies and Disasters as basis for establishing systems procedures and mechanisms, including the develop-ment of an integrated comprehensive action plan for fi eld management and hospital reception.

DEFINITIONS DEFINITIONS

Mass Casualty Incident is an event resulting in a number of victims large enough to disrupt the normal course of emergency and health care services. The event affects several victims which could be as few as three or as many as several hundreds. Manag-ing the victims, however, entails resources greater than those of the initial responders.

Mass Casualty Management is the handling of victims of a mass casualty incident, Mass Casualty Management is the handling of victims of a mass casualty incident, Mass Casualty Managementaimed at minimizing loss of lives and disabilities. There is a need to initiate fast, timely, coordinated and adequate response to reduce morbidity, mortality and disability among the victims. The management of the incident spans from the disaster or impact site (pre- hospital care) to the transport of the last victim to the emergency room of the receiving

SEARCHRESCUE

FIRST AID

COMMAND POST

TRIAGESTABILIZATIONEVACUATION

RESCUE CHAIN -- MULTI-SECTORAL

PRE-HOSPITAL ORGANIZATION HOSPITAL ORGANIZATION

IMPACT ZONE

Traffi c Control

Regulation of Evacuation

CP/AMP

Establishing a Mass Casualty Management System

Source: Sixth Inter-regional Course in Public Health and Emergency Management in Asia and the Pacifi c (PHEMAP), WHO (WPRO, SEARO) and ADPC, 2006.

Figure S8.1. Rescue Chain in a Mass Casualty Management System

or A&ED

hospital. It is directed at prompt and effi cient bringing back of disrupted emergency and health care services to routine operation. The fi rst fi ve minutes response will determine the response for the next fi ve hours.

Mass Casualty Management System refers to groups of units, organizations, sectors and agencies which work jointly through institutionalized procedures to minimize dis-abilities and loss of lives in a mass casualty event through the effi cient use of all existing resources.

139

As shown in Figure S8.1, the rescue chain starts at the disaster site with activities like initial assessment, command and control, search and rescue, and fi eld care, and contin-ues up to the transfer of victims to the appropriate health care facility for defi nitive care.

DIFFERENT APPROACHES TO MASS CASUALTY INCIDENTS

1. “Scoop and Run” • Most common • Does not require specifi c technical ability from rescuers • Justifi ed for small numbers occurring near a hospital • May just transfer the problem to the hospital

2. Classical Approach • First responders are trained in basic triage and fi eld care • Disregards the receiving hospitals from the fi eld • Quickly results in chaos

3. Mass Casualty Management System Approach • Most sophisticated approach; includes: o Pre-established procedures for: - Resource mobilization - Field management - Hospital reception o Training of various levels of responders o Incorporation of links between fi eld and health care facilities o Command Post o Multisectoral response • Dependent on the availability of large amounts of human and material resources

GENERAL CONSIDERATIONS IN THE ESTABLISHMENT OF THE MASS CASUALTY MANAGEMENT SYSTEM

1. Preparation for Mass Casualty Management • Pre-planning and training are critical. • Guidelines and procedures are established. • Incident Command should be implemented early. • First fi ve minutes will determine the next fi ve hours.

140

2. Conditions to anticipate and address in developing a Mass Casualty Management System (MCMS):

• Limited human resources • Limited material resources – facility, transport, communication • Poor communication o Topography o Isolation • Political environment

In the development of a Mass Casualty Management System appropriate for the setting and consistent with available resources, an understanding of the MCMS components is essential. For upgrading the system in a step-wise manner, assessments through drills and/or actual emergency events will provide valuable insights and lessons.

As shown in Figure S8.2, a Mass Casualty Management System entails sequence of activities at various levels of responses:

1. Pre-hospital a. Mass casualty incident site • Search and rescue • First triage b. Collection Point for unstable MCI c. Advance Medical Post (AMP) • Tag - Second triage (entrance to AMP) • Treat • Transport - Third triage

2. Evacuation Site or Temporary Shelter From the Advance Medical Post, the following victims are placed in evacuation sites or temporary shelters: • Uninjured victims who have no relatives/place to go • Victims who need shelter, not treatment

3. Hospital a. Field Hospital will be established if there is no hospital around or the hospital is too far from the impact site b. Fourth triage at the Emergency Room c. Defi nitive treatment

4. Emergency Medical Service (EMS) These are the medical services rendered from the impact site to the Emergency Room of the hospital; these are centered on evaluation, care and stabilization of victims at the impact site, and transporting them to the nearest appropriate health care facility.

SPECIFIC CONSIDERATIONS IN THE ESTABLISHMENT OF MASS CASUALTY MANAGEMENT SYSTEM

I. Field Organization (On-site/Pre-hospital)

Field organization encompasses procedures used to organize the disaster area to facilitate the management of victims. Its components are the following. A. Alerting Process

The alerting process is the sequence of activities implemented to achieve the effi cient mobilization of adequate resources. It aims to: • Confi rm the initial warning. • Evaluate the extent of problems. • Ensure that appropriate resources are informed and mobilized.

Dispatch Center • Core of the alerting process (Operations Center) • Functions o Receives all warning messages (radio/ phone) o Mobilizes a small assessment team from police, fi re or ambulance services • Types of alert o Pre-confi rmation alert o Confi rmation report from the fi eld o Post-confi rmation alert

Figure S8.2. Role of the Hospital in the Mass Casualty Management System (MCMS)

Mass Casualty Incident Mass Casualty Management

PRE - HOSPITAL

EMERGENCY MEDICAL SERVICE (EMS)

Advance Medical Post

CollectionPoint (for unstableMCI)

2nd TRIAGE Treatment

3rd TRIAGE Transport

Source: Banatin & Go, 2007

FIELD HOSPITALHOSPITAL or

Impact Site

1stTRIAGE

Search &Rescue

Hospital

4th TRIAGEEmergencyRoom

141

142

B. Initial Assessment

Initial assessment should obtain the following information: • Precise location of the event • Time and type of event • Estimated number of casualties • Added potential risk • Exposed population • Resources needed

This involves the deployment of an On-scene Response Team composed of individuals skilled in assessment, triage, treatment and surveillance . When human resources are limited, one individual may perform multiple tasks

C. Pre-identifi cation of Field Areas

The identifi cation of fi eld areas for various purposes prior to dispatch and operations will allow various incoming resources to reach their intended places rapidly and effi ciently. This is the fi rst part of deployment. This should consider the topo- graphical area, wind direction and access roads. Maps could be used initially and will help in the management of restricted areas; potential risks to victims and the population are graphically determined, including boundaries. The following should be mapped out and identifi ed: • Impact Zone • Command Post • Collecting Area in unstable location • Advance Medical Post Area (Tag, Treat, Transfer: 3-T Principle) • Evacuation Area • VIP and Press Area (Information Offi cer) • Access Roads (Geographical presentations if available) • Checkpoint for Resources (Staging Area)

D. Safety/Security

This component calls for the best practice technique to protect victims, respond ers and exposed population, and determine immediate/potential risks.

Measures

1. Direct Actions • Reduce risk – fi re fi ghting. • Contain hazardous materials. • Evacuate exposed population.

2. Preventive Actions: Establish fi eld areas. Primary : Impact Zone/Ground Zero - Strictly restricted to professional rescuers who are adequately equipped, such as HAZMAT teams, WMD teams, etc. - Known in WMD as “Hot Zone”

Secondary - Known in WMD as the “Warm Zone,” it is intended for decontamination. Tertiary - Command Post, Advance Medical Post, Evacuation Center and parking for various emergency and technical vehicles will be set up in this area which is approximately 100 meters from impact zone and appropriately positioned depending on the wind direction. - Accessed by press offi cials and serves as “buffer zone” to keep onlookers out of danger - approximately 50-100 meters from warm zone and approximately positioned depending on the wind direction. - Known in WMD as “Cold Zone”

3. Minimum Personal Protective Equipment (PPE) for any medical responder who is in contact with a patient: gloves, goggles, mask

4. For suspicion of Weapons of Mass Destruction incidents, medical responders are allowed only at cold zone with proper protective clothing. Only those with appropriate protective clothing and with proper training will be allowed entry into the hot and warm zone.

Personnel • Fire services • Specialized units • Hazardous Materials and Explosives (bio-nuclear and radioactive material) Experts, etc • Airport manager • Chemical plant expert

Security Measures • Non-interference of external elements; Crowd/Traffi c Control • Contribute to safety: o Protect workers from external infl uence – additional stress. o Ensure free fl ow of victims and resources. o Protect general public from risk exposure. - Ensured by police offi cer/special units/security force of airport/build ing/hospital/establishment, etc.

E. Command Post (CP) or Incident Command Post (ICP)

This is a multisectoral control unit tasked to: • Coordinate sectors involved in fi eld/ scene management • Linked with backup system: provide information and mobilization of resources • Supervise victim management

A requisite for the unit to be effective is the Radio Communication Network, which serves as a coordination/communication hub of people who do not work routinely (pre-hospital setting).

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Personnel • High-ranking offi cer (government police, fi re, health, defense) o Plant manager/airport manager/chief security, etc. o Fire offi cer/police offi cer skilled in Incident Command System/Mass Casualty Management o Highest representative of the Department of Health, or Local Health Offi ce or Center for Health Development in regional disasters o Two positions for medical concerns based on A.O. 155 s. 2004: - Medical Controller, a designated senior DOH offi cer appointed to assume the overall direction of the medical response to mass casualty incidents and disasters. Control is established from a designated Operations Center either in the Central Operations Center or the Regional Operations Center. Main responsibility is to coordinate all the services of the Sector. - Incident Medical Commander, the highest representative of the DOH or Local Health Offi ce as designated by the local executive depending on the extent of the disaster. Serves as the liaison offi cer of the Health Sector to the Command Post headed by the Incident Commander. For regional disasters, it should be the highest representative from the DOH-CHD.

• Identifi ed by name/position, coordinator/commander. • May depend on the type of incident. • Must be familiar with each other’s roles during previous meetings/drills/simulation exercises (policy). • Core group cooperates with volunteer organizations.

Method • Communication/coordination hub of the pre-hospital organization. • By constant reassessment, Command Post will identify needs to increase/ decrease resources: o Organize timely rotation of rescue workers exposed to stressful or exhausting conditions in close coordination with backup system. o Ensure adequate supply of equipment/ manpower. o Ensure welfare/comfort of rescue workers. o Provide information to backup system, other offi cials and trimedia through an Information Offi cer. o Release as soon as situation allows emergency (“E”) staff and reestablish normal operations. o Determine termination of fi eld operations.

F. Management of Victims

1. Search and Rescue (MCI)/Search and Recover (MDM) • Locate victims. • Remove victims from unsafe locations – collecting area. • Assess victim’s status (On-site Triage). • Provide fi rst aid, if necessary (No CPR on-site in a Mass Casualty Incident). • Transfer injured victims to Advance Medical Post

• Transfer of dead victims by MDM group • May, in special situations, require medical personnel (trained) to stabilize/

resuscitate/amputate (trapped) victim before extrication.

This activity will be handled only by skilled teams, such as those coming from the Bureau of Fire, Coast Guard, 501 Engineering Brigade, CSSR, 505 Fighter Wing, etc. In situations where there might be a need for on-site assistance of medical personnel to commence stabilization of the patients dur ing evacuation or extrication of victims, only DOH personnel with training in Search and Rescue should involve themselves (especially in high-risk situations like collapsed buildings or in mountainous areas), except in

exceptional situations and with the company of trained rescuers.

The Department of Health is not into Search and Rescue except in the condition described earlier.

2. Field Care • Pre-established capabilities/inventory: Pre-planning • Integrated community plan: Practiced with policy support • “Golden Hour” Principle

Trimodal Distribution of Death in Trauma (Advanced Trauma Life Support or ATLS) 1st Peak: within seconds to minutes 2nd Peak: golden hour versus golden 24 hours 3rd Peak: days to weeks/months

Recent progress in pre-hospital emergency/disaster medicine: Establish Ad- vance Medical Post with specially skilled/trained “disaster fi eld medical teams.” • Good triage/stabilization capacity • Specifi cally trained/upskilled medical teams • Good (radio) communications between the fi eld scene and medical facility Don’t transfer chaos in the scene to the hospital.”

2a. Triage Defi nition: French word meaning “to sort”; is a system used to identify treatment priorities in a multiple-victim situation.

Basis: Urgency (victim’s status) Survival (chance or likelihood) Care resource availability and capability

Objective: Quick identifi cation for immediate stabilization, life-saving measures and surgery.

START System • Meaning: Simple Triage and Rapid Treatment • Most commonly used by fi rst responders. • Assessment focuses in three areas: respiration, pulse rate and quality, and mental status. (RPM) 145

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Table S8.1 shows the levels of triage in the fi eld and in the hospital, location of conduct, and categories used.

Table S8.1. Triage Levels by Period, Location and Categories

Triage

First

Second

Third

Fourth

Period

During Search and Rescue

Stabilization or Treatment

Evacuation

Defi nitive Care

Location

Impact site(Ground Zero)

Advance Medical Post

Transport

Emergency Room

Categories

AcuteNon-acute

RedYellowGreenBlueBlack & White



FIELD CARE

HOSPITAL CARE

Color Tagging

The basic colors used for triage include: red for fi rst priority cases; yellow for second priority cases; green for third priority cases; blue for fourth priority cases; and black/white for last priority cases. In the Philippines, the prescribed tag is the ribbon for practical reasons.

Categories

Red – Transferred as soon as possible to tertiary facilities in an equipped ambulance with medical escortYellow – After evacuation of Red, without life threatening problemGreen – “Walking wounded’ to Admitting Section/Outpatient DepartmentBlue – To be returned for Re-triageBlack and White – To Morgue, Forensic Services, Public Health and psychosocial interventions to relatives/kin

Determining Priority for Case Management

Patient classifi cation is based on the severity of the injury and need of Emergency Medi-cal Service and evacuation.

Table S8.2. Use of Color Tag for Prioritization of Care

COLOR TAG

RED

YELLOW

GREEN

BLUE

BLACK and WHITE

Priority for evacuation

1st

2nd

3rd

3rd or 4th

Not a priority

Medical needs

Immediate care

Need care, injuries not life-threatening

Minor injuries

Near dead

Dead

Priority

1st

2nd

3rd

4th

Last

Conditions

Life- threatening

Urgent

Delayed

After the red and yellow

Dead

ON SCENE HOSPITAL CARE

Priority for In-Hospital Care (Retriaging in the Hospital)

RED – Immediate: Priority One (Life-threatening Conditions) The condition is life-threatening and the patient requires immediate attention and transport. The following conditions should be present for a Mass Casualty Incident (MCI) victim to be classifi ed Priority One: a. Obstruction or damage to airway. b. Disturbance of breathing – respiration above 30/min. c. Disturbance in circulation – capillary refi ll greater than 2 seconds or carotid pulse weak , irregular or absent, radial pulse absent. d. Does not follow commands or altered level of consciousness. e. Need for life-saving measures (BLS and ATLS) and urgent hospital admission. f. Victims whose injuries demand defi nitive treatment in the hospital but which treat ment may be delayed without prejudice to ultimate recovery.

YELLOW – Urgent: Priority Two Patient has passed primary survey, but with major system injury, may delay transport to one hour. Any one of the following conditions could place a victim into a Priority Two category:

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a. Needs to be treated within one hour; otherwise they will become unstable. b. Severe burns; burns involving hands, feet or face (not including the respiratory tract); burns complicated by major soft tissue trauma. c. Hospital admission is required. d. Moderate blood loss; back injuries; head injuries with a normal level of consciousness.

GREEN – Delayed: Priority Three An injury exists but treatment can be delayed for four to six hours. Generally, anyone who can walk (walking wounded) to a designated area for treatment will be a Priority Three. The following injuries are examples:

a. Minor injuries not threatened by airway, breathing and circulatory instability. b. Minor fractures, minor soft tissue injuries, minor burns. c. May or may not be admitted.

BLUE – Near Dead: Priority Four Victims who are clinically dead. Those tagged blue in the fi eld are to be returned for re-triaging when time and physical conditions of area allow, e.g., collapsed structure, etc.

BLACK and WHITE – Dead: Last Priority a. Patient is dead. b. Those who die while awaiting treatment, and those in cardiac arrest following trauma. For Moslem communities, white tag will be used for dead Moslems. 2b. First Aid

Personnel: Volunteers, fi re, police, staff, special units, EMT and Medical Personnel

Location • On-site, before moving victim • At collecting point/area in an unstable environment • “Green Area” of “Advance Medical Post” • Ambulance in transit to facility Action: Primarily to transfer with consideration of the RPM order of priority.

2c. Advance Medical Post Purpose: Reduce loss of life and limb: Save as many as possible in the context of existing and available resources/situation (e.g., Field Hospital). Location • 50-100 meters from Impact Zone (walking distance) • Direct access to Evacuation Road/Command Post • Clear Radio Communication Zone and SAFE (Upwind)

Role • Provide “entry” medical triage. • Effectively stabilize victims of an MCI through:

o Intubation, tracheostomy, chest drainage. o Shock management, analgesia, fracture immobilization. o Fasciotomy, control of external bleeding, and dressing. • Convert red to yellow as possible.. • Organize patient transfer to designated care facility/ies. • Advance Medical Post principle: Tag-Treat-Transfer (3-T) Personnel • Emergency Room, Admission and Emergency Department (A and ED): Physicians/nurses (trained/skilled) • Support – Anesthesiologists/surgeons/EMT’s/nurses/aiders, etc. 2d. Field Hospital (FH)

• Tent/building/open/mobile • Established if there is no hospital around or the hospital is too far from the Impact site.

2e. Evacuation Site or Temporary Shelter

From the Advance Medical Post, these victims are placed in evacuation sites: o Victims who need shelter, not treatment. o Uninjured victims who have no relatives or place to go.

3. Evacuation

3a. Transfer Organization

This consists of procedures undertaken to ensure that victims of a mass casualty situation are safely, quickly and effi ciently transferred by appropriate vehicles to the appropriate and prepared facility.

Preparation for Evacuation • Single Reception Facility • Multiple Reception Facilities o Type of vehicle required o Type of escort required o Destination

Preparation for Transport Transport Offi cer should be responsible for: • Assessing patient’s status, vital signs, ventilation/hemostasis. • Checking security of equipment and accessories. • Ensuring effi ciency of immobilization measures. • Ensuring triage tags: secure/clearly visible. Evacuation Procedures: Principles • Not to overwhelm care facility. • Avoid spontaneous evacuation of unstable patients.

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Rules • Victim is in most possible stable condition. • Victim is adequately supported by appropriate equipment during transfer and transport • Receiving facility is correctly informed and ready. • Best possible vehicle and escort are available.

3b. Victim Flow

■ Based on the “Noria Principle” used during World War I, Battle of Chemin de Dames, Verdun, France. (‘Noria” is the Spanish word for the Arabic water wheel)

■ Simulates that of a “conveyor belt” fl ow where the victims are relayed from fi rst aid to the most sophisticated care level shown in Figure S8.3.

Figure S8.3. Victim Flow: “Conveyor Belt” Management Diagram

Impact Zone

Collecting Point

Triage

AMP

Triage

3-TTagTreatandTransfer

Evacua-tion

TRANS-FER HOSPITAL

Treatment

Victim FlowTransport Resource Flow

3c. Ambulance Traffi c Control Radio Links • Transport Offi cer at AMP • Hospital Admission and Emergency Department/Emergency Room • Command Post • Ambulance Headquarters Ambulance Driver takes orders from Transport Offi cer 3d. Road Control Police offi cers are in charge of Crowd and Traffi c Control. 3e. Evacuation of Non-acute Victims

• Use available mass transport. • As much as possible, transport to primary care center.

Field Organization Checklist

■ Situation Assessment■ Report to Central Level■ Work Areas Pre-identifi cation■ Safety■ Primary Area – Impact Zone■ Secondary Area units: Command Post,/Advance Medical Post/ Evacuation/Transfer■ Radio Communications■ Crowd and Traffi c Control■ Search and Rescue■ Triage and Stabilization■ Controlled Evacuation

II. Hospital Organization

A. Hospital Disaster Plan

• Hospital Mass Casualty Management (MCM) Plan • Dissemination and regular drills among the hospital staff and multisectoral groups

B. Activation of Hospital MCM Plan

Alerting Process

Dispatch/Opcen/Unqualifi ed Observer • Emergency Room/Admission & Emergency Department (ER/A&ED) • Operator to activate System Recall

Mobilization • Hospital Scene Response Team • Hospital Staff o Hospital Senior Management Staff o Reinforcment Staff - Internal: ER/A&ED staff leaves, replacement - Centripetal Mobilization: Avoid burnout o Coordination: other sectors - Police - Red Cross/NGO/Paramedics/Volunteers - Radio Groups

• Hospital Command Post o Clearance of receiving facility: beds and designated areas - Care Facility Capacity and Capability Rating 151

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C. Management of Victims

1. Reception of Victims

Location: Accessible/suitable/suffi cient Equipped/manned *Chaotic scene overwhelms care facility. Personnel: Triage offi cer (4th triage) – Confi rms Evacuation Triage; may recategorize patients

Links with fi eld, especially Command Post.

2. Hospital Treatment Area

Red Treatment Area: Follow Trauma Flow Chart. Yellow Treatment Area: Monitored/reassessed/stabilization maintained/re- categorized – Red area Green Treatment Area: Holding area “walking wounded” Hopeless Victim Area: Supportive Care Bodies Morgue/mortuary “Activate Mental Health Team”

3. Hospital Defi nitive Treatment Units 4. Secondary Evacuation • When hospital facility is overwhelmed • Highly specialized care – neurosurgery • Domestic and overseas evacuation • Hospital Command Post requests: district/regional level

D. Support Requirements

Various departments are mobilized in support of patient care. As highlighted in the Integrated Code Alert System, this is done by alert status: Code WHITE • Emergency Department, Surgery (Operating Room), Pharmacy, Laboratory and Radiology to: - Ensure that emergency medicines (especially for trauma needs) are made available at the emergency room. - Review and increase medicines and supplies in the operating rooms to meet sudden requirements. - Ensure that other needs such as X-ray plates, laboratory requirements, etc. are made available and not required to be purchased by victims. - Ensure and monitor use of personal protective equipment (PPE) for all health personnel. • Personnel Department - Prepare for mobilization of additional staff. • Finance Department - Ensure availability of funds in cases of emergency purchases and the like. • Logistics Department - Coordinate with possible suppliers for additional requirements.

• Dietary Department - Open for and meet the needs of the victims as well as the health personnel on duty. • Security Force - Institute measures and stricter rules in the hospital.

Code BLUE • Activation of Hospital Emergency Incident Command System (HEICS) • Chief of Hospital or his designate - Make proper coordination with other hospitals for networking and/or transfer of patients. • Incident Command - Assign a Safety Offi cer, Liaison Offi cer, (to coordinate with other agencies), and Public Information Offi cer (spokesperson of the hospital). • Social Service Section - Prepare assistance to victims in coordination with mental professionals of the hospital if available, and with the Department of Social Welfare; lead in providing information to relatives of victims. • Mortuary Section - Anticipate dead victims brought to the hospital for proper care and identifi cation. • Security Team - In anticipation of possible infl ux or patients, relatives, responders, police, press, etc., should ensure smooth fl ow of traffi c inside the compound especially for the ambulances.

Code RED All those mentioned in Code Blue and highlighting the key role of the Chief of Hospital as follows: • The Chief of Hospital/Medical Center Chiefs: - Can cancel all types of leaves and can order all personnel to report to the hospital. - Can temporarily stop all elective admissions and surgeries and network with other hospitals. - Should anticipate request of additional manpower and specialists not available in his hospital; authorized to accept medical volunteers and other professionals to augment the hospital’s manpower resources rather than transferring patients based on agreements. - Networks with other hospitals for augmentation of resources and trans - fer of patients in special cases. - Be concerned with security and safety of patients, hospital personnel and the infrastructure. - Answers all queries of the media pertaining to patients in the hospital. - Provides leadership especially in decision-making on matters like evacuation and/or use of fi eld hospital, closure and/or quarantine of the hospital.

Special conditions such as emergencies related to Weapons of Mass Destruc tion entail modifi cation of responses appropriate to the hazard identifi ed, e.g. chemical, radiological, etc.

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Requirements from DOH Hospitals in MCM

1. Upgrading of hospital capability that shall include the ability to handle trauma victims, burn patients, poisoning cases, etc.

2. Ensuring the readiness of the Emergency Rooms in terms of equipment, manpower and systems to answer to Mass Casualty Incident especially for general hospitals.

3. Availability of suffi cient emergency medical kits containing equipment and supplies for treating a minimum of 10 serious casualties. The number should increase depending on the capability of the hospitals. A responding team should have the capability for treating a minimum of 3-5 serious patients.

4. Ready availability at all times of at least one ambulance for emergencies/ disasters equipped with all the necessary emergency supplies and equip ment including communication equipment to establish coordination.

5. Activating Hospital Emergency Plan, observation of the Code Alert Sys tems and Hospital Emergency Incident Command System (HEICS) in such situations.

-- AO 155. Section VII B Responsibility of all DOH Hospitals

SECTION 9 Management of the Dead and Missing Persons

During Disaster

This section draws largely from Administrative Order No. 2007-0018. National Policy on the Management of the Dead and the Missing Persons During Emergen-cies and Disasters. The Department of Health (DOH) was mandated to lead the multisectoral process of formulating the policy in response to the mass fatality events in recent years 2004 to 2006.

Mass Fatality Incident refers to any event resulting in number of deaths large enough to disrupt the normal course of health care services, usually a result of natural and/or hu-man-generated disasters, including terrorism or the use of Weapons of Mass Destruc-tion. As a consequence, there would be numerous deaths and missing persons.

In emergency or disaster management, most efforts are being concentrated on the man-agement of the living victims while the least considerations are being given to the dead and the missing, to the extent that there are a lot of problems cropping up from the side of the bereaved families, to the community at large, to the leaders, and most especially to the media when not properly managed. Management of the Dead and Missing Per-sons during Emergencies or Disasters (MDM) in disasters must be a major component of the overall management of the consequences of disasters. MDM has fi ve domains, namely: Search and Recovery; Identifi cation of the Dead; Final Arrangement of the Dead; Handling the Missing Persons; and Assistance to the Bereaved Families. MDM is not the sole responsibility of a single agency but rather requires concerted efforts of the various sectors of the society.

In the Philippines, the lead agency in managing the dead and missing persons during disasters is the Department of Health. It serves as the coordinating body responsible for all the MDM operational activities of the various key players in the fi ve domains men-tioned.

Figure S9.1. MDM Functional Structure

Management of the Dead, the Missing, and the Bereaved (DOH)

Search andRecovery

DND – AFP/PNPBFP-SRUPCGDILGPNRCLGU Leagues

Identifi cationof the Dead

NBI/PNP-CLForensic ExpertsAcademeLGU Leagues

Final Arrangement

DILGLGU LeaguesMortuaryCemeteryReligious Organizations

Handlingthe Missing

DSWDDILGPNRCNBIPNPLGU Leagues

Assistance toBereaved Families

DSWDDOH, PNRCDILGInsuranceCompanies/CommissionSocial Security GroupsLGU Leagues 155

156

The activities related to the management of the dead and the missing persons are the responsibility of the DOH, the Armed Forces of the Philippines (AFP)/Philippine National Police (PNP), National Bureau of Investigation (NBI), Department of the Interior and Lo-cal Government (DILG) and Department of Social Welfare and Development (DSWD). The functions of search and recovery, identifi cation of the dead, fi nal arrangement, handling the missing, and assistance to bereaved families have to be coordinated and harmonized at various sites at all levels, from the national, regional and local levels.

GUIDING PRINCIPLES

1. All efforts shall be exerted for proper retrieval, identifi cation and disposition of the remains in a sanitary manner and cautions to prevent negative psychological and social impact on the bereaved and the community, including the responders. 2. Every person has the right to be found, to be identifi ed, and to be buried according to a culturally acceptable norm. 3. Rights to privacy of the dead shall be observed at all times. 4. The dead shall be treated with utmost respect. 5. When death is the result of disaster, the body does not pose a risk for infection. 6. Victims shall never be buried in common graves. 7. Mass cremation of bodies shall never take place when this goes against the cultural and religious norms of the population. 8. Every effort must be taken to identify the bodies. As a last resort, unidentifi ed bodies shall be placed in individual niches or trenches, which is a basic human right of the surviving family members.

NB: Section IV. Defi nition of Terms. Distinction is made regarding the following:

Collective Grave shall refer to the burial of two (2) or more dead bodies/body parts in an orderly process, preserving the individuality of every body, and maintaining individual characteristics of each body.

Mass Grave or common grave shall refer to the indiscriminate burial of more than two (2) unidentifi ed bodies/body parts in the same excavated site.

Temporary Burial shall refer to shallow burial of two (2) or more dead bodies/body parts in an orderly process, preserving the individuality of every body and maintaining individual characteristics of each body pending proper identifi cation and disposition.

OPERATIONAL FRAMEWORK OPERATIONAL FRAMEWORK

1. A coordinated body shall be established under the National Disaster Coordinat- ing Council (NDCC) primarily for the management of the dead, the missing, and the bereaved families during an emergency or disaster, to be led by the Depart- ment of Health. 2. Recovery/Retrieval Operation will commence simultaneously with the Search and Rescue Operation and will end upon the declaration of the NDCC as per recommendation of the Local Disaster Coordinating Council. 3. In any event of disaster, the Local Health Offi cer of the concerned local government unit (LGU) shall lead/coordinate the activities in the management of the dead, the missing and the bereaved families. 4. If two (2) or more municipalities/provinces are involved, the concerned Provincial Health Offi cer shall lead in the MDM.

5. If two (2) or more provinces are involved, the concerned Regional Health Director shall lead in the MDM. 6. In providing assistance to the bereaved, the Social Welfare Offi ce of the concerned LGU shall be primarily in charge, to be supported by other concerned agencies. 7. In every agency at all levels, the MDM shall be incorporated as a component of the agency’s Disaster Management Program.

MDM OPERATIONAL GUIDELINES AND PROCEDURES MDM OPERATIONAL GUIDELINES AND PROCEDURES

A. Search and Recovery Operation

Dead Body Recovery shall be done spontaneously and simultaneously, led by the Armed Forces of the Philippines of the Department of National Defense (AFP-DND) and supported by the following agencies and groups: the Philippine National Police (PNP), Search and Rescue Unit of the Bureau of Fire Protection (BFP-SRU), Philippine Coast Guard (PCG), Philippine National Red Cross (PNRC), Private Rescue Personnel, Local Rescue Unit and Civilian Group Volunteers. For the National Capital Region (NCR), the Search and Recovery Operation shall be led by the PNP supported by other agencies.

In the event of disaster, the initial site commander shall be the Chief of Police (COP) who shall turn over the responsibility to AFP upon the arrival of the AFP task group except for that in NCR.

1. The Search and Rescue Operations Commander shall establish and disseminate a unifi ed and standardized tagging system of the bodies and body parts recovered. 2. All body parts and dead bodies retrieved on-site shall be placed in cadaver bags or any appropriate means during transport to identifi ed collection point or storage area which are preferably refrigerated, for examination or proper identifi cation. 3. The Local Health Offi ce shall look after the health conditions and needs of the responders and volunteers. In the event that the Local Health Offi ce cannot cope, it can request support from the DOH. 4. Protection and safety of responders and volunteers must be observed in the retrieval, handling, transport and disposition of body parts and dead bodies and shall be the primary considerations of sending agencies. There should be proper coordination among the agencies on this matter. 5. The local chief executive through the local health offi ce shall coordinate all processes related to the management of corpses, including the retrieval, handling, transport and disposition of body parts and dead bodies.

B. Identifi cation of the Dead Operation

1. The LGU shall request the NBI and/or PNP Crime Laboratory for disaster vic tim identifi cation. 2. The NBI and/or PNP shall proceed to the disaster site upon the request of the LGU to assess the situation and shall establish mortuary operations in coordination with the LGU. 157

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3. In case of a mass fatality incident caused by natural disasters, the NBI shall primarily be in charge of identifi cation of the dead. The NBI shall coordinate with the PNP-CL and other related experts. 4. In case of a mass fatality incident caused by human-generated activities, the PNP shall primarily be in charge of identifi cation of the dead. The PNP shall coordinate with the NBI and other related experts. 5. The Medico-Legal Offi cers of the NBI and/or PNP shall issue a Certifi cate of Identifi cation for all examined/processed and identifi ed bodies. 6. The NBI and/or PNP shall provide the Local Health Offi cer an offi cial list of identifi ed and unidentifi ed disaster victims. 7. The Local Health Offi cer shall issue a Death Certifi cate based on the Certifi - cate of Identifi cation issued by the NBI/PNP. 8. The LGU shall provide the NBI and/or PNP with a list of missing persons. 9. The LGU through the NDCC shall provide the Department of Foreign Affairs (DFA) a list of identifi ed and unidentifi ed foreigners. 10. The LGU shall identify and put up areas for temporary collection or storage of retrieved body parts and corpses as per local health offi ce recommendations. 11. The Local Health Offi ce shall monitor the proper sanitation of the temporary collection and storage area at all times and shall take the responsibility to maintain the sanitary retrieval and disposal of body parts and dead bodies. 12. All retrieved body parts and corpses waiting for examination and identifi cation in the collection points or storage areas shall be properly preserved by any appropriate and available means. 13. Refrigeration of bodies and body parts is preferable. In its absence, temporary burial will be resorted to. Chemical preservatives (such as quicklime, formol and zeolite, as well as commonly used disinfectants such as hypochlorite) may be applied only after the examination and identifi cation of the bodies and body parts. 14. The NBI and/or the PNP may request the fi ngerprints, dental and medical records of the missing/dead in the custody of other government agencies (GSIS, SSS, or other offi ces) for the purpose of identifying dead bodies only. 15. The Interpol Identifi cation System for the Antemortem (Dead/Missing Persons Form) and Postmortem (Dead Bodies Identifi cation Form) forms may be used in generating the data relative to MDM. These forms may be made available (posted in the NDCC Website) and accomplished by all agencies concerned. 16. The NBI and/or PNP shall ensure scientifi c identifi cation of the all recovered bodies using all possible available technologies in conformity with national and international standards. 17. The LGU shall, in coordination with the NBI, PNP, DOH, DILG, and other agencies involved in managing the dead/missing shall conduct trainings and seminars regarding the proper handling of the missing/dead. 18. All concerned agencies shall undertake Forensic Research regarding Disaster Victim Identifi cation (DVI).

C. Final Arrangement for the Dead

1. Legitimate claimants shall be responsible for the ultimate disposal of identifi ed cadavers. 2. The respective embassies of identifi ed dead foreigners shall be informed and the repatriation of their bodies shall be their responsibility. 3. The LGU shall be responsible for the fi nal disposition of the unidentifi ed bodies.

4. The unidentifi ed bodies shall be buried in the collective or individual graves, marked with their unique case numbers. 5. Cremation of unidentifi ed bodies will not be allowed. 6. The LGU shall consult the community and religious leaders of the disaster site regarding the fi nal disposition of the unidentifi ed bodies. 7. Religious and ethnic considerations shall be considered in the fi nal disposition of bodies. 8. Exhumation of unidentifi ed remains shall be done in the presence of local health offi cials. 9. Necessary decontamination or disinfection of the dis-interment areas must be done. 10. All body parts and corpses that remain unidentifi ed after examinations shall be buried immediately according to the prescribed procedures. 11. No embalming procedures for identifi ed dead bodies shall be done without permission from the nearest of kin of the dead (bereaved). 12. The Local Health Offi ce should take the responsibility of maintaining the sanitary retrieval and disposal of body parts and dead bodies. 13. All identifi ed body parts and corpses shall be turned over to the rightful/legitimate claimant accordingly. 14. Burial of bodies in mass graves or the use of mass cremation/burning shall be avoided in all circumstances. 15. All unidentifi ed bodies and body parts shall be turned over to the LGU for fi nal disposition after thorough postmortem examinations have been fi nished. 16. MDM related to infectious diseases and Biological, Chemical, Radiological, Nuclear, and Explosives Emergencies (BCRNE) shall be done in accordance with the existing DOH guidelines/procedures.

D. Management of the Missing Persons Operation

1. Provincial/City/Municipal Social Welfare Offi ce (P/C/MSWDO) shall: a. Establish the Social Welfare Inquiry Desks for data generation/information management of missing persons and the surviving families; b. Manage information regarding the Identifi cation of Retrieved Bodies/Body Parts using the Interpol identifi cation System; c. Validate and process documents of the missing persons for the issuance of the Certifi cate of Presumptive Death; and d. Submit to the Local Chief Executive (LCE) processed and validated documents. 2. The LGU shall submit to the NBI and/or PNP an updated list of missing and dead persons. 3. The DOH, PNRC and DSWD shall provide technical and resource augmentation/assistance for the medical, psychological and physiological needs of the families of the missing persons. 4. The NDCC through the Offi ce of Civil Defense (OCD) as per the recommendation of the LGU shall issue Certifi cates of Missing Persons Believed to Be Dead During Disaster.

E. Management of the Bereaved Families

1. P/C/MSWDO is the lead agency in the overall management of the bereaved families. 159

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2. The DSWD shall provide technical and resource augmentation/assistance to the P/C/MSWDO on the overall management of the bereaved families.

3. The DSWD, PNRC and NGOs shall provide technical and resource augmeta-tion/assistance to P/C/MSWDO for the physiological needs of the bereaved in terms of : Food Assistance; Financial Assistance; Livelihood Assistance; Clothing Assistance; Shelter Assistance; Management of the Orphans; and Food/Cash for Work.

4. The DSWD, PNRC and NGOs shall provide technical and resource augmen-tation/assistance to P/C/MSWDO for the social needs of the bereaved in terms of: Family/Peer Support System; Social Welfare Inquiry Desk/Informa-tion Center; Educational Assistance; and Legal Needs.

5. The DSWD, PNRC and NGOs shall provide technical and resource augmen-tation/assistance to P/C/MSWDO for the psychological needs of the bereaved in terms of: Mental Health and Psychosocial Support approaches such as Psychosocial First Aid.

6. The DOH and PNRC shall provide the technical and resource augmentation/ assistance for the medical and psychological needs of the families of the missing persons, and provide a support system from among volunteers for the families of the missing persons, respectively.

7. The DOH shall provide services for Mental Health Management.

F. Reporting Protocol

1. The LGUs concerned shall submit to the NDCC-OCD, through the DOH, an initial report on the MDM containing the background of the disaster, initial fi nd ings, and initial actions taken. 2. LGUs shall, from time to time, submit an update or situation report to the NDCC-OCD, through the DOH. 3. Final report and documentation shall be submitted by the LGUs concerned to the NDCC-OCD, through the DOH. 4. LGUs and NDCC-OCD shall be guided by proper protocol on confi dentiality of reports. 5. NDCC-OCD shall be the repository of all information/reports, which could be shared and/or accessed by concerned agencies.

G. Communication

1. In time of disasters, the established communication networks within the NDCC member agencies shall be used in the dissemination of information and other updates at all levels. 2. The NDCC shall be designated as the clearinghouse for information dissemination. 3. The NDCC-OCD, DOH, National Telecommunication Commission (NTC), and the Movie Television Review and Classifi cation Board (MTRCB) shall coordinate/collaborate in drawing the guidelines for the proper coverage of MDM activities. 4. The Local Health Offi ce shall conduct Information, Education and Communica- tion (IEC) services to the public on proper sanitation and hygiene practices, emphasizing that, in general, the presence of exposed corpses poses no threat of epidemics.

H. Information Management

1. All information obtained about the dead/missing person and from relatives shall be held confi dential. 2. The right of the public to information shall be respected subject to the existing rules and regulations. 3. NDCC-OCD shall be the repository of all information/reports, which could be shared and/or accessed by concerned agencies. 4. There shall be a list/database of all accredited search and rescue volunteer groups available at the NDCC. 5. LGUs and NDCC-OCD shall be guided by proper protocol on confi dentiality of reports. 6. The issuance of the Certifi cate of Missing Person Believed to Be Dead During Disaster shall be supported by required proofs, and in certain cases (such as those with respect to informal undocumented wage earners, transients and passersby), shall be issued after the lapse of one year in accordance with the resolution on the issuance of Certifi cate of Missing Person Believed to Be Dead.

I. Logistics Management

1. All foreign donations (food and non-food) intended for disaster relief shall be free from any customs taxes and duties. 2. There shall be established norms and guidelines in receiving/accepting and managing donations for disasters from DSWD – relief goods and cash; DOH – medicines and cash; and NDCC – checks and cash (fully receipted) 3. All concerned agencies shall formulate a logistics management system to include the preparation of a list of logistics needed on MDM for submission to NDCC/DOH. 4. All agencies shall have a stockpile good for 200 victims and that would last for at least three (3) days of operations (for replenishment by the NDCC). 5. NDCC shall invest in cold storage for the dead bodies. 7. The LGUs shall include in their Disaster Management Plan all possible logistical arrangements such as burial sites, etc.

J. Monitoring and Evaluation

1. The Local Health Offi ce shall monitor the entire MDM operation. 2. The Local Health Offi cer shall monitor the proper sanitation of the temporary collection and storage area at all times. 3. The DOH shall initiate the conduct of Post-Incident Evaluation (PIE).

ROLES OF THE DEPARTMENT OF HEALTH IN MDM

The roles and responsibilities of DOH in general include:

1. Serves as lead agency in the Management of the Dead and the Missing Persons During Disaster. 2. Leads the Health Sector in the formulation of policies, protocols, guidelines, and standards related to MDM. 3. Gathers, clears, and releases information regarding mortalities together with 161

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causes of mortalities in coordination with all the stakeholders in the Health Sector. 4. Provides technical advice to and coordinates with the NDCC as well as international agencies regarding MDM. 5. Conducts public information, health education/promotion, and other social mobilization or advocacy activities related to MDM. 6. Monitors and evaluates existing policies and initiates revision or update, or even formulation of new policies and guidelines pertaining to MDM. 7. Provides and publishes the general information in handling and transferring of remains. The information should include the characteristics and environment of a right place that will serve as temporary work camp for holding area.

ROLE OF THE HOSPITAL IN MDM

The hospital may need to adapt and/or formulate policies and procedures not covered by existing policies and standard operating procedures (SOPs) related to the following concerns:

1. Provision of Mental Health and Psychosocial support to direct and indirect victims including the responders.

2. Procedure in confi rmation of the dead brought to the hospital (4th triage)3. Identifi cation of the dead (dress and personal materials, etc.)4. Provision of technical assistance in terms of expertise and laboratory services in

the identifi cation of the dead (pathologists, DNA testing, etc.)5. Mortuary: Refrigeration/care of the body (cadaver bags, etc.)6. Public information7. Ambulance use – discourage its use as transport for the dead.

SECTION 10 Public Health Roles of the Hospital

in Emergency Management

The hospital plays crucial roles in emergency management. It is the receiving end of victims and it can be a responding agency to any type of emergency or disaster at in the disaster site. It is well-known for its life-saving roles during emergencies.

The role of the hospital as a receiving health care facility has public health implications (ADPC, WHO/WPRO, 2006) and it is expected to function as follows: 1. Provides not only curative but preventive services as well. 2. Contributes to the diagnosis, prevention and control of diseases. 3. Signals early warning of communicable diseases. 4. Hosts public health reference laboratories. 5. Serves as a resource center for public heath education. 6. Provides Psychosocial and Mental Health Services. 7. Undertakes Management of Mass Dead brought to hospitals. 8. Acts as center for research.

A. PROVIDES CURATIVE SERVICES DURING EMERGENCIES

1. Treats trauma injuries with infections. 2. Treats communicable diseases resulting from outbreaks. 3. Provides treatment to victims belonging to vulnerable segments of the population (children, pregnant women, elderly, disabled, etc.) 4. Provides therapeutic nutrition to victims with malnutrition. 5. Provides intervention to direct and indirect victims with organic psychological affl ictions due to trauma. 6. Provides drugs and medicines for treatment.

B. PROVIDES DISEASE-PREVENTIVE SERVICES

1. Provides immunizations for vaccine-preventable diseases. 2. Maintains cold chain management. 3. Provides chemo-prophylaxis to the exposed/contacts of highly communicable diseases. 4. Provides safe water to prevent water-borne diseases. 5. Provides isolation rooms in the hospital for communicable diseases. 6. Provides necessary PPEs to care providers. 7. Provides treatment protocols. 8. Conducts health education.

C. SIGNALS WARNING FOR COMMUNICABLE DISEASES

1. Conducts disease surveillance among the victims and the health workers/re sponders. 2. Conducts advocacy and early warning activities regarding impending outbreak of communicable diseases based on surveillance results.

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3. Develops and disseminates IEC materials in the form of health advisories, key health messages, etc.

D. HOST TO PUBLIC HEALTH LABORATORIES

1. Provides laboratory services such as water analysis, culture and sensitivity of disease pathogens, etc. 2. Provides diagnostic laboratory examinations. 3. Provides blood banking laboratory services. 4. Provides facility to store blood and blood products.

E. RESOURCE CENTER FOR HEALTH EDUCATION

1. Available resource persons for health education initiatives. 2. Source of materials for health education and promotion activities.

F. MENTAL HEALTH AND PSYCHOSOCIAL SUPPORT SYSTEMS

Develops and/or adapts the hospital minimum responses to mental health and psy-chosocial support services arbitrarily categorized into:1. Designation of mental facilities2. Establishment and activation of referral systems3. Identifi cation, training and mobilization of health workers including local indig-

enous traditional health care providers4. Provision of treatment protocols5. Provision of reporting and assessment forms6. Provision of selected psychotropic drugs7. Provision of information on availability of mental health services

G. MANAGEMENT OF DEAD BODIES 1. Health Sector Action 2. Health Considerations in Cases of Mass Fatalities 3. Practical Approach to a Multiple Fatality Accident (12 points) • Initial concerns • Personnel • Handling of the bodies at the scene • Evidence and property • Removal and transport of remains • Temporary mortuary facility • Examination of remains • Preservation of body • Dealing with claimants • Death certifi cation and release of bodies • Disposal of the dead • Other concerns

H. CENTER FOR RESEARCH 1. Rich materials for research purposes in terms of cases and patients 2. Abundant data/information for research studies

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SECTION 11Mental Health and Psychosocial Support

POLICY BASE POLICY BASE

Administrative Order No. 168 s. 2004 Section V-E: Policy Statements on Program Com-ponents states that “1. Mental Health in Disaster should be a major component and should be institutional-ized in all phases of disaster. Likewise, mental health services should be provided to the victims, relatives of victims, as well as the responders.”

DEFINITION

Mental Health and Psychosocial Support (MHPSS) is a composite term used to de-scribe any type of local or outside support that aims to protect or promote psychosocial well-being and/or prevent or treat mental disorder.

“These close-related terms refl ect different, yet complementary approaches. Agencies outside the health sector tend to speak of supporting psychosocial well-being. People… in the health sector tend to speak of mental health but have also used the terms psy-chosocial rehabilitation and psychosocial treatment to describe non-biological interven-tions for people with mental disorders.” (IASC, 2007)

CURRENT STATE

The Health Emergency Management Staff is in the process of reformulating guidelines on Mental Health in collaboration with the Department of Social Welfare and Develop-ment, the agency earlier responsible for providing psychosocial support through Criti-cal Incident Stress Debriefi ng (CISD). The guidelines will now follow the Inter-Agency Guidelines on Mental Health and Psychosocial Support in Emergency Settings 2007 of the Inter-Agency Standing Committee (IASC).

The IASC guidelines center on six core principles, namely: 1. Human rights and equity 2. Participation 3. Do no harm 4. Building on available resources and capacities 5. Integrated support systems 6. Multi-layered supports: a. Basic services and security b. Community and family supports c. Focused, non-specialized supports d. Specialized services

Health service is one of the four areas in the Core Mental Health and Psychosocial Supports. The other three are Community Mobilization and Support, Education, and Dis-

166

semination of Information. For health, the minimum response covers fi ve points, namely: 1. Include specifi c psychological and social considerations in the provision of general health care. 2. Provide access to care for people with severe mental disorders. 3. Protect and care for people with severe mental disorders and other mental and neurological disabilities living in institutions. 4. Learn about and, where appropriate, collaborate with local, indigenous and traditional health systems. 5. Minimize harm related to alcohol and substance use.

Given this context, the DOH-HEMS/DSWD Technical Working Group agreed to a set of health service minimum responses, i.e., essential high-priority responses that should be implemented as soon as possible in an emergency.

AREAS FOR HOSPITAL ACTION AREAS FOR HOSPITAL ACTION

With the above IASC framework, the HEMS coordinator, in consultation with the psy-chiatrist, psychologist and social worker, needs to draw the hospital minimum responses in mental health and psychosocial support services to cover internal and external emer-gencies.

As shown in Table S11.1, the country’s minimum responses may serve as a checklist to guide the development and/or adaptation of appropriate hospital responses given its geographical and socio-cultural setting:

Philippines Minimum MHPSS Responses Philippines Minimum MHPSS Responses

1. Designate mental facilities at strategic loca- 1. Designate mental facilities at strategic locations in the area.

2. Establish access to mental hospital networks 2. Establish access to mental hospital networks (government and private).

3. Establish referral system. 3. Establish referral system. 4. Identify/tap personnel trained on Psychiatric 4. Identify/tap personnel trained on Psychiatric

Emergencies. 5. Mobilize health workers trained in identifi ca- 5. Mobilize health workers trained in identifi ca-

tion and management of alcohol and other substance use substance use (AOSU). 6. Provide treatment protocols. 6. Provide treatment protocols. 7. Provide screening procedure/guidelines incor- 7. Provide screening procedure/guidelines incor-

porated in Treatment Protocols. 8. Provide reporting forms and assessment 8. Provide reporting forms and assessment

tools. 9. Utilize existing monitoring/assessment tools 9. Utilize existing monitoring/assessment tools

for alcohol and other substance use (AOSU) in emergency settings.

Hospital Minimum MHPSS Responses

Adapt Develop RemarksAdapt Develop RemarksAdapt Develop Remarks

Table S11.1. Checklist of Minimum Mental Health and Psychosocial Services

SOCIAL CONSIDERATIONS SOCIAL CONSIDERATIONS

The social considerations in the fi rst minimum response relate to an equitable, appropri-ate and accessible health care, such as: • Maximizing participation of both genders in the design, implementation, monitor ing and evaluation of any emergency health services. • Maximizing access to health care, geographically and culturally. Aim to balance gender and include representatives of key minority and language groups among health staff to maximize survivors’ access to health services. Use translators if necessary. • Protection and promotion of patients’ rights to: o Informed consent for both sexes before medical and surgical procedures (clear explanations of procedures are especially necessary when emergency health care is provided by international staff, who may approach

Philippines Minimum MHPSS Responses

10. Include selected/limited psychotropic drugs 10. Include selected/limited psychotropic drugs in a separate “E” kit based on previous in a separate “E” kit based on previous reports and identifi ed need with necessary reports and identifi ed need with necessary precautions/guidelines on its use. precautions/guidelines on its use. 11. Identify and designate MHPSS workers in- 11. Identify and designate MHPSS workers including psychiatrists to be included in the cluding psychiatrists to be included in the DOH emergency response team. DOH emergency response team. 12. Submit list of response teams to HEMS- 12. Submit list of response teams to HEMS- OpCen for proper staffi ng, scheduling of de- OpCen for proper staffi ng, scheduling of deployment. ployment. 13. Ensure proper orientation and supervision of 13. Ensure proper orientation and supervision of traditional health care providers, traditional health care providers, 14. Mobilize local indigenous traditional health 14. Mobilize local indigenous traditional health care providers. care providers. 15. Provide area in health facilities and on-site for 15. Provide area in health facilities and on-site for mental health consultations and management. mental health consultations and management. 16. Provide information on the availability of men- 16. Provide information on the availability of mental health services/facilities, e.g., distribution tal health services/facilities, e.g., distribution of IEC materials and basic mental health edu- of IEC materials and basic mental health educational activities. cational activities. 17. Ensure adequate stock pile of resources for 17. Ensure adequate stock pile of resources for basic biological needs. basic biological needs. 18. Mobilize hospital network to take over psychi- 18. Mobilize hospital network to take over psychiatric facility/local MH facility operations or for atric facility/local MH facility operations or for referral/distribution of patients to their respec- referral/distribution of patients to their respective hospitals. tive hospitals. 19. Activate collaborative services. 19. Activate collaborative services. 20. Activate referral system. 20. Activate referral system.

Continuation of Checklist of Minimum Mental Health and Psychosocial Services

Hospital Minimum MHPSS Responses

Adapt Develop Remarks

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medicine differently) o Privacy (as much as possible, e.g., put a curtain around the consultation areas) o Confi dentiality of information related to health status of patients. Caution is especially needed for data related to human rights violation (e.g., rape). • Use of essential drugs consistent with the WHO Model List of Essential Medi- cines. • Recording and analysis of sex- and age-disaggregated data in the health infor - mation system.

PSYCHOLOGICAL CONSIDERATIONS

A. A half-day to one-day orientation for health staff on the psychological components of emergency health care may include the following contents:

• Psycho-education and general information o Importance of treating survivors with respect to protect their dignity. o Basic information on what is known about mental health and psychosocial impact of emergencies, including understanding of local psychosocial responses to an emergency. o Avoiding inappropriate pathologizing/medicalization (i.e., distinguishing non-pathological distress from mental disorders requiring clinical treatment and/or referral). o Knowledge of available mental health care in the area to enable appropriate referral for people with severe mental disorders. o Knowledge of locally available social supports and protection mechanisms in the community to enable appropriate referrals. • Communicating to patients, giving clear and accurate information on their health status and on relevant services, such as family tracing. Communicating in a supportive manner include: o Active listening o How to deliver bad news in a supportive manner o How to deal with very angry, very anxious, suicidal, psychotic or withdrawn patients o How to respond to sharing of extremely private and emotional events such as sexual violence • How to support problem management and empowerment by helping people clarify their problems, brainstorming together on ways of coping, identifying choices, and evaluating the value and consequences of choices. • Basic stress management techniques, including local (traditional) relaxation techniques. • Non-pharmacological management and referral of medically unexplained somatic complaints, after exclusion of physical causes.

B. Make available psychological support for survivors of extreme stressors (also known as traumatic stressors).

Most individuals experiencing acute mental distress following exposure to extremely stressful events are best supported without medication. All aid workers, and especially health workers, should be able to provide very basic psychological fi rst aid

(PFA). PFA is often mistakenly seen as a clinical or emergency psychiatric intervention. Rather, it is a description of a humane, supportive response to a fellow human being who is suffering and who may need support. PFA is very different from psychological debriefi ng in that it does not necessarily involve a discussion of the event that caused the distress. PFA covers: • Protecting from further harm. (In rare situations, very distressed persons may take decisions that put them at further risk of harm.) Where appropriate, inform distressed survivors of their right to refuse to discuss the events with other aid workers or with journalists. • Providing the opportunity for survivors to talk about events but without pressure. Respect the wish not to talk and avoid pushing for more information than the person may be ready to give. • Listening patiently in an accepting and non-judgmental manner. • Conveying genuine compassions. • Identifying basic practical needs and ensuring that these are met. • Asking for people’s concerns and trying to address these. • Discouraging negative ways of coping, (specifi cally, use of alcohol and other sub- stances), explaining that people in severe distress are at much higher risk of developing substance use problems. • Encouraging participation in normal daily routines (if possible) and use of positive means of coping (e.g., culturally appropriate relaxation methods. • Accessing helpful cultural and spiritual supports. • Encouraging, but not forcing, the company of one or more family members or friends. • As appropriate, offering the possibility to return for further support. • As appropriate, referring to locally available support mechanisms (e.g., rituals, festivals, discussion groups) or to trained clinicians.

- In a minority of cases, when severe acute distress limits basic functioning, clinical treatment will probably be needed. If possible, refer the patient to a clinician trained and supervised in helping people with mental disorders. - In most cases, acute distress will decrease naturally over time, without out side intervention. However, in a minority of cases, a chronic mood or anxiety disorder (including severe post-traumatic stress disorder) will develop. If the disorder is severe, it should be treated by a trained clinician as part of the minimum emergency response. If the disorder is not severe (e.g., person is able to function and tolerate suffering), the person should receive appropriate care, i.e., from trained and clinically supervised health workers such as social workers and counselors attached to health services.

Moreover, there is increasing inter-agency consensus that psychosocial concerns in-volve all sectors of humanitarian work, because the manner in which aid is implemented (e.g., with/without concern for people’s dignity) affects psychological well-being. Mor-tality rates are affected not only by vaccination campaigns and health care but also by actions in the water and sanitation, nutrition, food security and shelter sectors. Similarly, psychosocial well-being is affected when shelters are overcrowded and sanitation facili-ties put women at risk of sexual violence.

In most emergency situations, signifi cant numbers of people exhibit suffi cient resilience to participate in relief and reconstruction efforts. Many key mental health and psychoso-cial supports come from affected communities themselves than from outside agencies. 169

170

From the earliest phase of an emergency, local people should be involved to the greatest extent possible in the assessment, design, implementation, monitoring and evaluation of assistance.

HOSPITAL STAFF

The Hospital HEMS Coordinator considers the following concerns in support of hospital staff including volunteers (HEMS, June 2007):

1. Recognition of the sources of stress for Health Emergency Workers a. Health Emergency/Disaster Event Stressors • Personal injury • Personal loss • Traumatic stimuli – gruesome sights/activities b. Occupational Pressures • Time pressure • Work overload • Physical demands • Emotional demands c. Organizational Pressures • Role confl ict • Role ambiguity • Confusing chain of command • Organizational confl ict

2. Identifi cation of Health Emergency Workers at Greatest Risk for Severe Stress Symptoms

Those who directly experience or witness any of the following during or after the disaster: • Life threatening danger or physical harm (especially to children) • Exposure to gruesome death, bodily injury, or dead or maimed bodies • Extreme environmental or human violence or destruction • Loss of home, valued possessions, neighborhood or community • Loss of communication with or support from close relations • Intense emotional demands (such as searching for possibly dying survivors or interacting with bereaved family members) • Extreme fatigue, weather exposure, hunger, or sleep deprivation • Extended exposure to danger, loss, emotional/physical strain • Exposure to toxic contamination (such as gas or fumes, chemicals, radioactivity)

Those with history of: • Exposure to other traumas (such as severe accidents, abuse, assault, com- bat, rescue work) • Chronic medical illness or psychological disorders • Chronic poverty, homelessness, unemployment or discrimination • Recent or subsequent major life stressors or emotional strain (such as single parenting)

3. Development of mechanisms (e.g., training, fast track administrative procedures, staff rotation) to ensure that health workers have the following before, during and after disaster work:

■ Health emergency preparedness before disaster work/assignment

• Have a good training on disaster work.• Have a factual information on the disaster situation.• Have ample emergency and regular supply packed.• Have communication lines with family, superiors and authorities.• Have a personal/family emergency and contingency plan.• Have mutual aid system with neighbors.• Secure well-being of family.

■ Health emergency response at disaster work/assignment

Health worker • Make working conditions as comfortable as possible.• Try to get enough food, fl uids, rests, breaks, relaxation, exercise,

sleep.• Develop a buddy system with co-worker.• Encourage and support each other.• Be aware of stress reactions and signs of burnout.• Have communication lines with family, co-workers, superiors, authori-

ties.• Have defusing/debriefi ng sessions.

Hospital Staff (HEMS/WHO/WPRO, 2nd edition)• Rotation of work assignments to allow time away from the daily routine

of disaster work for those in the fi eld.• Rest and recreation program for those in active duty.• Conduct of debriefi ng sessions regularly.• Provision by superiors and hospital for situations to give credit, ex-

press appreciation and recognition of their disaster workers at regular intervals.

• Provision of appropriate assistance to those who might require coun-seling and/or specialist psychiatric attention.

■ Health emergency recovery after disaster work/assignment

• Attend defusing/debriefi ng sessions.• Anticipate problems at home/at work.• Be aware of the effects of disaster to self.• If with children, help them understand work without frightening them.• Catch up on sleep, rest, relaxation, exercise.• Take time to introspect, learn, grow from experience.

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NEED FOR RESEARCH NEED FOR RESEARCH

At present, there is scarcity of scientifi c evidence regarding the kind of Mental Health and Psychosocial Support that proves to be most effective in emergencies. Most re-searches have been conducted months or years after the end of the acute emergency phase. The survivors, communities and health workers will benefi t from appropriate documentation and analysis of the experiences of practitioners in a hospital setting.

Mental

Mental confusionSlowness of thoughtInability to make judg- ments & decisionsLoss of objectivity in evaluating own function

Emotional

DepressionHyper-excitabilityIrritabilityExcessive rage reactionsAnxiety

Physical

ExhaustionLoss of energyGastrointestinal disturbancesSleep disorders

Behavioral

Feeling of excessive fatigueHyperactivityInability to express self

These pointers are aimed at minimizing the occurrence of the burnout syndrome to which health workers, particularly in health emergency/disaster work are prone to. Burn-out syndrome is a state of exhaustion, irritability, and fatigue which markedly decreases worker’s effectiveness and capability. Its symptoms consist of:

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SECTION 12Networking and Coordination

POLICY BASE

Administrative Order No. 168 s. 2004 contains the following provisions.

In Section V-C: Policy Statements on Support Systems: “2. Resource pooling/sharing of resources (including manpower and materials) among the various stockholders in the health sector shall be institutionalized.”

In Section V-F: Networking and Collaboration:“1. Response to emergencies and disasters is not a monopoly of any institution. Hence there should be an active desire to coordinate with all agencies, other government agencies, nongovernment organizations, private organizations and also international organizations.2. Collaboration with the Health Sector responding to emergencies and disasters will ensure a more comprehensive, integrated and coordinated response to maximization of resources. Hence, a system for coordination/collaboration should be developed.”

DEFINITIONS

1. Networking is an exchange of information or services among individuals, groups or institutions. It is a purposive engagement of individuals and groups in a process of collaboration to achieve common goal. (HEMS, June 2007)

2. Coordination is an ongoing process. The nature of the relationship depends on what is acceptable to the participating agencies. No single model can be provided. It is important to forge linkages not only during emergencies, but also more importantly before the disaster.

Coordination ensures: (HEMS, June 2007)

• Information sharing • Working together with a common goal • Avoidance of overlapping of services • Regular communication of relevant data

IMPORTANCE OF NETWORKING AND COORDINATION

Networking enables the health facility to: 1. Coordinate and guide the activities of the members of the response teams. 2. Maximize resource utilization and minimize waste of resources. 3. Facilitate referrals of cases from one facility to another. 4. Facilitate transmission and receipt of information and instructions.

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Coordination enables the health facility to: 1. Understand each other’s operations, roles and responsibilities. 2. Integrate views, capabilities and options. 3. Ensure cooperation. 4. Determine the strategic direction. 5. Maximize resources. 6. Achieve synergy.

Coordination of the action taken in response operations is very important. Good co-ordination ensures that resource organizations are utilized to the best effect, therefore avoiding gaps or duplication in operational tasks.

OBJECTIVES OF NETWORKING AND COORDINATION

In a broader context, networking aims to exchange information and services to broaden resources and thus achieve goals while supporting others to achieve theirs (HEMS, June 2007). Similarly, coordination also involves information sharing and working to-gether with a common goal to avoid overlapping/duplication of tasks and facilitate the maximization of resource utilization.

Specifi cally, networking and coordination enable the health facility to: 1. Improve effi ciency, effectiveness and speed of response. 2. Provide a framework for strategic decisions. 3. Unify the strategic approach. 4. Reduce gaps and duplication in services. 5. Ensure appropriate division of responsibilities.

PRECONDITIONS TO COORDINATION PRECONDITIONS TO COORDINATION

To establish good working relationship with other groups or entities, consider the following: 1. Have all agencies commit to a common goal. 2. Develop clear, detailed group goals and a mission statement from the start of the project or engagement. 3. Defi ne the parameters of coordination. 4. Enlist and maintain the support of top-level management with decision-making authority. 5. Identify role/s of own organization and in relation to other participating organizations. 6. Identify priorities of the whole group. Recognize that each agency has a different set of priorities to take into consideration, but maintain a set of equal importance for each agency on the team. 7. Identify points of complementation, integration and collaboration.

REQUIREMENTS AND TECHNIQUES FOR COORDINATION REQUIREMENTS AND TECHNIQUES FOR COORDINATION

Requirements: • Perceived need for coordination • Mutual understanding and respect • Agreed parameters and responsibilities • Common vocabulary and concepts

Figure S12.1. The Spectrum of Coordination Activities

Information Sharing (What is at hand)

Points of Integration (Strategies, etc.)

Points of Collabora-tion

Collaborative Planning and Programming

Points of Comple-Points of Comple-mentation (Avoid duplication)

Least diffi cult Most diffi cult“The degree of coordination possible will depend on the circumstances”

Coordination techniques: • Use a neutral facilitator. • Build consensus before meetings/proposals. • Document agreements and arrangements with memoranda of understanding. • Identify strengths and capabilities before dividing work and responsibilities. • Respect organizational mandates. • Establish and maintain effective communications. • Take fi nal decisions in plenary. • Include partners and benefi ciaries. • Provide mechanisms for timely action, especially during crises. • Ensure responsibilities for follow-up and follow-through on decisions. • Provide personal and organizational incentives to coordinate. • Make use of the news media to strengthen coordination.

Possible Information-sharing activities: • Provide rosters, points of contacts, and alternative means of communication. • Initiate, maintain, and share early warning systems and information. • Clarify general roles and responsibilities. • Identify the specifi c resources each organization brings to the emergency.

Potential shared resources and divisible work: • Identify the affected population and jointly assess local capacity and needs. • Identify gaps and overlaps in assistance. • Agree on standards of assistance and services. • Collaborate in preparation of appeals. • Negotiate as a group for access and resources. • Conduct common training.

STAGES IN NETWORKING Networking is a continuum of three stages namely : 1. Stakeholders analysis • Clear statement of the mission or objectives of the agenda or activities being planned. • List of individuals and groups who may share the agenda and its vision. • Identifi cation of possible stakeholders from the list who will provide the needed support. 175

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2. Social mobilization • Is about people taking action for the common good. • Key steps involved in planning social mobilization activities: i. Situation analysis of the need to conduct such activities. ii. Formation of team or committees/technical working groups that will be involved in a participatory planning and will sustain the strategic part nership. It is important that the team will be able to overcome any obstacles along their implementation of the activities.

3. Sustained interaction

WHEN TO APPLY NETWORKING AND COORDINATION

Networking and coordination cut across all the activities in each of the three phases of health emergency management, particularly for these areas of concern: • Organization• Systems implimentation• Resource mobilization • Tasking and responsibility sharing of partners and sectoral workers 1. Health Emergency/Disaster Preparedness • Do collaborative planning (e.g., preparation of preparedness and contingency plan, plans for shared use of facilities, investments in infrastructure, evacuation and transportation) • Organize emergency response teams in hospitals, clinics and other health institutions. • Prepare and stockpile medicines and supplies. • Pre-identify, pre-designate and prepare potential evacuation centers. • Conduct sanitary and environmental inspections to designated evacuation centers. • Conduct inventory of all available resources: clinics, hospitals and medical institutions in the area; services, logistics. • Establish Regional Epidemiology Surveillance Unit/Local Epidemiology Surveillance Unit. • Organize the health sector in the region and establish a regional network. • Act as the cluster focal points at the regional level. • Develop a functional referral system.

2. During Health Emergency/Disaster Response • Activate emergency response teams. • Provide medical care/assistance to victims during evacuation operations. • Initiate and coordinate evacuation operations. • Monitor occurrence of epidemics in evacuation centers and undertake the necessary measures to control and prevent spread of diseases. • Provide warning to the public on occurrence of epidemics. • Conduct daily inspection on the state of sanitation in the evacuation center. • Submit periodic reports to the council.

3. Post Health Emergency/Disaster Recovery • Provide psychological debriefi ng to victims and bereaved families. • Continue to provide direct service and/or technical assistance on sanitation. • Submit after operation reports to the council.

NETWORKS/ORGANIZATIONS AND RESPONSIBILITIES: NETWORKS/ORGANIZATIONS AND RESPONSIBILITIES: NETWORKING WITH THE HEALTH SECTOR NETWORKING WITH THE HEALTH SECTOR

Networking in the Catchment Area (DOH-SDP, 2000a)

Networking for the hospital is imperative. Every hospital integrates its hospital health emergency preparedness, response and rehabilitation plan with those of community dis-aster management agencies for better inter-operability during emergencies or disasters. This is critically important in disaster notifi cation and communication, transport of casu-alties, and provisions for dispatch of hospital response teams to a disaster site. Strong relationships with community agencies (e.g., fi re department, the local EMS/emergency management, the civil defense agency, volunteer agencies) ensures a more compre-hensive, integrated and coordinated disaster and emergency response in addition to maximization of resources.

The hospital HEPRR plan has to incorporate measures to respond to identifi ed hazards commonly occurring in the community (e.g., typhoons, landslide, volcanic eruptions, etc.). These include the pre-identifi cation of expert personnel (e.g., poison control) and special supplies (e.g., antidotes) which may not readily be available in a particular dis-aster situation, and the formulation of appropriate procedures to ensure rapid access to these resources. For consideration in the plans are acquisition of additional shelter, food and water.

Below is a list of partners and agencies who are members of the network in the different catchment areas of hospitals. DOH Hospitals and Offi ces Philippine Hospital Association (Local Counterpart) Philippine Medical Association (Local Counterpart) Specialty Groups (Local Counterpart) Philippine National Red Cross (Local Counterpart) Respective Local Chief Executives Respective Disaster Coordinating Councils and member agencies - Local Health Counterparts (PHO, MHO, CHO) and LGU Hospitals Department of the Interior and Local Government -Bureau of Fire Protection (Local Counterpart) -Philippine National Police (Local Counterpart) Department of National Defense -Armed Forces of the Philippines -Philippine Navy -Philippine Army -Philippine Air Force Department of Transportation and Communication - Philippine Coast Guard Local Emergency Medical Services groups Academe/Universities Local Private Hospitals Pharmaceutical Companies Local Laboratories Local Ambulance Service Providers Local Funeral Parlor and Morgue

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Local Transportation Group/Trucking Services Local Business Sector Group Local Nongovernment Agencies International Organizations with local counterparts Local Private Organizations and Civic Organizations Community (Community/Barangay Leaders, Church, Youth) Local Volunteers Local Blood Bank Local TV/Radio stations/Press Cluster Approach

A recent development in networking and coordination is the institutionalization of the Cluster Approach in the Philippine Disaster Management System. The Cluster Approach aims to ensure a more coherent and effective response by mobilizing groups of agen-cies, organizations and NGOs to respond in a strategic manner in support of the exist-ing government coordination structure and emergency response mechanism.

The cluster lead at National Level is DOH-HEMS with the Center for Health Develop-ment at the regional level for four clusters: Nutrition; Water, Sanitation and Hygiene (WASH); Health, and Psychosocial Services.

Roles and Responsibilities • Inclusion of humanitarian partners in the cluster taking stock of their mandates and program priorities • Establishment and maintenance of appropriate humanitarian coordination mechanisms • Attention to priority cross-cutting issues • Needs assessment and analysis • Emergency Preparedness • Planning and strategy development • Application of standards • Monitoring and reporting • Advocacy and resource mobilization • Training and capacity building

The regional counterpart of the members of the three (3) clusters at the national level can be tapped by the hospital. These include among others:

Nutrition Cluster • CHD-HEMS as Government Lead Agency in the region • United Nations Children’s Fund as the Inter-Agency Standing Committee (IASC) Country Team Counterpart/Co-Lead • DOH-National Nutrition Council • DOH-National Center for Disease Prevention and Control • Department of Social Welfare and Development • Department of Science and Technology-Food and Nutrition and Research Institute • World Health Organization • Philippine National Red Cross

• Save the Children • Accion Contra El Hambre

Water, Sanitation and Hygiene (WASH) Cluster • CHD-HEMS as Government Lead Agency in the region • United Nations Children’s Fund as the IASC Country Team Counterpart/Co-Lead • DOH-National Center for Disease Prevention and Control • Department of Public Works and Highways • Department of the Interior and Local Government • OXFAM Great Britain-Philippines • World Health Organization • Philippine Center for Water and Sanitation/International Training Network Foundation • Plan International • Manila Water Company, Inc.

Health Cluster • CHD-HEMS as Government Lead Agency in the region • World Health Organization as the IASC Country Team Counterpart/Co-Lead • DOH-National Center for Disease Prevention and Control • DOH-National Epidemiology Center • DOH-National Center for Health Promotion • Department of Social Welfare and Development • United Nations Children’s Fund • United Nations Population Fund • International Federation Red Crescent • Philippine National Red Cross • Plan International • Save the Children • Handicap International • International Organization for Migration

For providing mental health and psychosocial support to direct and in direct victims, as well as responders, during emergencies and disasters, the CHD is responsible in coordinating with DSWD and other GOs and NGOs.

Hospital Networking and Referral System (DOH-SDP, 2000a)

The hospital network is a sharing arrangement among several hospitals of different levels and specialties in a given area to work together. It is aimed at managing medi-cal emergencies more effi ciently. The hospital network can readily be mobilized during disaster operations. This implies that the hospital develops its external disaster plan in conjunction with other emergency facilities in the community. For example, there may be a pre-arranged memorandum of agreement with hospitals outside the immediate area should hospital capacity be exceeded. Hospitals, both private and government, need to work as a network irrespective of specialty and capability. With a clear system of refer-rals, pre-planned and pre-arranged to tertiary medical centers and special units of gov-ernment and private institutions (e.g., burn, spinal, pediatric trauma centers), continuous appropriate patient care is assured.

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One example is the Hospital Zoning System in Metro Manila, where DOH Metro Ma-nila-retained hospitals were divided into eight zones. Each zone has a lead hospital and support hospitals. This hospital zoning system identifi es easily the specifi c hospital to request support from and mobilize its resources for the appropriate emergency condi-tion.

At the policy level, Section VIII of Administrative Order FAE 007 s. 1998: Policies and Guidelines on the Transfer and Referral of Patients Between DOH Metro Manila Hospi-tals addresses the situation that during MCI, the prescribed usual rules and procedures on Emergency Referrals were unsuitable.

At the implementation level, the development of the Metro Manila Hospital Network can provide lessons to hospitals.

With a clear system of referrals, pre-planned and pre-arranged to tertiary medical cent-ers and special units of government and private institutions (e.g., burn, spinal, pediatric trauma centers), continuous appropriate patient care is assured.

Metro Manila Hospital NetworkOne example of a hospital network arrangement is that of the hospitals in Metro Manila. The arrangement is based on the rated capability of a hos-pital using the following criteria: (1) presence of specialty experts, existing training program and of available personnel in the emergency room capable at all times of handling specifi c sub-specialty problems; and (2) available equipment, therapeutics and communication facilities, infrastructure and service performance. .

The hospital capability ratings serve as a guide for networking activities in the different phases of health emergency management.

RATED 1 means that the hospital is capable of accepting all cases of this specialty. A hospital Rated 1 is an end-hospital that will not refuse patients unless the situation makes admission extremely diffi cult or impossible.

RATED 2 means that the hospital is capable of handling sub-specialty cases but has some limitations such as bed capacity, equipment, etc. and cannot be expected to offer defi nitive care. It may also mean there are not enough full-time consultants or residents available on a 24-hour basis or that there is no training program and therefore no front-line personnel in this specialty.

RATED 3 means the hospital is incapable of handling cases of this sub-specialty beyond giving primary care and resuscitation.

Per catchment area, a lead hospital (Rated 1) for the identifi ed sub-special-ty and its support hospitals were identifi ed. A two-way referral system be-tween the lead hospital and other hospitals in the network was established.

SECTION 13Human Resource Development

Human Resource Development (HRD) consists of organized learning activities arranged within an organization to improve performance and/or personal growth for the purpose of improving the job, the individual and/or the organization. A comprehensive process, it covers training and development, career development, and organizational development as well.

The goal of HRD is to improve the performance of organizations by maximizing the ef-fi ciency and performance of its people. It centers on the development of knowledge and skills, actions and standards, motivation, incentives, attitudes and the work environment.


This holistic view is refl ected in the provisions of the National Policy – Administrative Order No. 168 s. 2004, Section V-B: Human Resource Development, which states that:

1. All health workers should receive basic training on health emergency manage-ment as part of their educational preparation as it is expected that everyone

should participate in preparedness, response, rehabilitation, and mitigation activi-ties at various levels.

2. The safety/security of the health worker is of prime importance in any health emergency operation. Before deployment, they should be provided with proper identifi cation, proper uniform, and the necessary personal protective equipment. Furthermore, they should be properly oriented and given proper guidance on the risks and hazards involved in such an operation.

3. A system for rewards, incentives, and recognition for outstanding performance should be put in place to develop a culture of excellence in health emergency management.

4. The physical and psychological integrity of health workers is an important factor in the success of health emergency management. Physical and psychological fi tness of personnel shall be maintained through drills/simulation exercises, stress management, debriefi ng sessions and respite care in long-term operation.

A mental health program for disasters should be developed and integrated in the training for health personnel.

5. A mechanism for certifying, updating, and conducting refresher courses shall be organized to ensure that all personnel involved in health emergency manage-ment are knowledgeable in current trends and state-of-the-art techniques and technology related to their area of expertise.

6. Core and functional competencies required of health emergency personnel at various levels shall be identifi ed to develop an integrated national human re-source development program addressing various types of health emergencies. Selection of health personnel for training shall be based on their roles and responsibilities. Personnel trained and developed shall be retained in areas where their expertise can be maximally utilized, e.g., emergency rooms. In the event that they are rotated there should be a system wherein they could readily be recalled for emergency operations. 181

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7. An inventory of the available human resources based on their expertise should be developed at each level.

Administrative Order No. 155 s. 2004: “Management of Mass Casualty Incidents” Section V: General Guidelines provides that:

D. Training sessions and drills relative to MCI shall be institutionalized and organ-ized annually in all DOH Hospitals and Centers for Health Development to con-tinually upgrade levels of knowledge and maintain a state of readiness. All physicians, nurses and other emergency responders shall be required to under-go MCM training.

Section VI: Implementing Guidelines of the same Administrative Order further provides:

2. Capability Building a. Basic Life Support (BLS) training shall be mandatory for all health personnel. b. Advance Cardiac Life Support (ACLS) and Pediatric Cardiac Life Support (PCLS) shall be a requirement for all medical personnel assigned in the Emergency Rooms. c. All Response Teams shall have additional training in Emergency Medical Technician’s Course – Basic and Mass Casualty Management. d. Regular simulation exercises shall be done at least once a year.

TRAINING TRAINING

The HEMS Coordinator is responsible for the training of its members, as well as their communities, relative to health emergency skills and management while the Assistant Coordinator acts as the Training Offi cer.

Training Process

The development of appropriate, effective and effi cient training programs is a fi ve-step training process that includes: Training Needs Assessment, Preparation of a Training Design, Development of Instruction Methodology, Conduct of Training, and Validation of Training. The activities and outputs of each step are in Table S13.1.

Table S13.1. Training

STEPS

1. Training Needs Assessment (TNA)

2. Design training

3. Develop instruction/methodology

4. Conduct instruction/methodology

5. Validate training

ACTIVITIES

Analyze the job.• List the task performances, task conditions and standards.• List the training needs and their priorities.

• Design training to suit the results of job analysis. • Defi ne and arrange the training objectives and assessment in logical sequence within the framework of training design.

• Choose the instructional methods and media.• Compile the course program and content .• Trail and amend the instruction content and methods.

• Conduct the course.• Administer the test.• Monitor the progress of the course.• Apply remedial measures to problems met.

• Identify the problem areas from Steps 4 and 5 by analyzing: - effectiveness - appropriateness - effi ciency • Modify or update the training as necessary.

OUTPUTS

List of task performances, conditions, and standards

Schedule of training & priorities

• Sequenced set of training objectives and tests

• A program of instruction which has been successfully trailed

• Trainees who have achieved course objectives• Course modifi ed as necessary

• Validated and successful conduct of training

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Functional Core Competencies

The HEMS coordinator can be guided by the results of the Training Needs Assessment (TNA) conducted for the identifi ed six groups of trainees namely: Health Emergency Managers, Leaders, Responders, OpCen Staff, Trainers, and General Public. The func-tional competency requirements and required training courses for each group are shown in Table S13.2.

Table S13.2.Table S13.2. Competency Requirements and Required Training Course/Package by Roles

PositionRoles/Functions

1. Health Emergency Managers - Leader - Policymaking, budget, etc - Standard formulation - Capability building - Advocacy - Coordination/collabo - ration - Management of event - Monitoring & evaluation (M/E)

2. Leaders (Chief of Hospital)- Decision-makers- Resource mobilizers- Communicators- Advocators- Program director/supervisor

3. Responders a. Pre-hospital - Responds to emergencies (Patient management) - Decontamination - Triage - Ambulance care (patient management)

Competency Requirement (Functional)

• Technical writing for policy development• Policy development planning• Knowledge & skills in standard formulation• Training needs analysis• Analytical thinking• Evidence-based analysis• Negotiation• Public information• Social marketing• Public speaking• Power communication• Coordination/collaboration skills• Decision-making• Confl ict management• Leadership training• Training in M/E• Organizational management• Basic HEM• Information technology (IT)

• Basic HEM• Crisis & Consequence Manage- ment• Mass Casualty Incident & Inci - dent Command System (MCI & ICS)

• Rapid assessment skills• Basic knowledge on hospital system; Basic Life Support (BLS), Standard First Aid; Medi- cal First Responder (MFR)• Emergency Medical Technician (EMT)• Advanced Cardiac Life Support (ACLS)• Mass Casualty Incident (MCI)• Health Emergency Management• Decontamination skills• Incident Command System (ICS) skills• Ambulance traffi c control• Radio communication• Sound knowledge of access routes to health care facilities• Networking/coordination• Safe driving skills


• Hospital Emergency Aware- ness and Response Train- ing (HEART)• Leadership Training especially in decision-making• Management Training – Policymaking, Planning, Budgeting, Standard Formulation, TNA, Evaluation• Power and Risk communication• Coordination Skills• Crises and Consequence Management• MCI and ICS• Personnel Management• Logistics Management

• Orientation on Basic HEM • HEART

• Basic Life Support (BLS), Standard First Aid; • Medical First Responder (MFR)• Emergency Medical Techni- cian (EMT)• Advanced Cardiac Life Support (ACLS)• Advanced Trauma Life Support (ATLS)• Mass Casualty Incident , Incident Command System & Weapons of Mass De - struction (MCI-ICS-WMD)• Basic Health Emergency Management (HEM)

Continuation of Competency Requirements and Required Training Course/Package by RolesContinuation of Competency Requirements and Required Training Course/Package by RolesContinuation ofPositionRoles/Functions

Hospital- Decontamination/isolation- Patient management/triage- Specifi c case management o Burns o Weapons of Mass Desruction (WMD) o Radiological, Biological & Chemical (RBC) o Poisoning

4.Trainers

- Training needs assessment (TNA)- Training design- Actual conduct of training- Development of evaluation tool- Evaluation of training- Development of module

5. OpCen Staff- Monitoring of events

- Coordination

- Data Management


Knowledge and skills in:• Basic Life Support & Standard First Aid• Advanced Cardiac Life Support (ACLS)• Advanced Trauma Life Support (ATLS)• Triage• Mass Casualty Incident , Inci- dent Command System & Weapons of Mass Destruction (MCI – ICS- WMD)• Specifi c case management

• Presentation skills• Communication skills• TNA skills• Training design skills

• Knowledge of DOH System/Health Sector

• Knowledge of HEMS Policies, guidelines, procedures in moni-toring

• Skills in tri-media monitoring• Skills in map reading, hazard

mapping, etc.

In addition to the above:• Knowledge of the network and • Knowledge of the network and • Knowledge of

contact persons• Communication skills• Negotiation skills• Skills in decision making

• Knowledge in all HEMS reporting forms and templates

• Knowledge in data collection, data evaluation, data analysis and data dissemination

• Knowledge in epidemiology, sta-tistics and surveillance

• Skills in presparation of reports and presentation

• Skills in computer and other tech-nology


• Basic Life Support (BLS), Standard First Aid;

• Medical First Responder (MFR)

• Emergency Medical Technician (EMT)• Advanced Cardiac Life Support (ACLS)• Advanced Trauma Life Support (ATLS)• Mass Casualty Incident ,

Incident Command System & Weapons of Mass De - struction (MCI-ICS-WMD)

• Radiological, Biological & Chemical (RBC) Courses

• Basic Health Emergency Management (HEM)

• Basic Training of Trainers (TOT)

• Organization of the DOH and the Health Sector

• Health Emergency Manage-ment (HEM) Basic

• Public Health and Emer-gency Management in Asia and the Pacifi c (PHEMAP)

• Basic courses in computer including use of Internet

• Networking and Coordina-tion

• Basic Epidemiology• Data Management

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Hospitals

The HEMS Coordinator needs to classify the different hospital staff by their function in health emergency to determine the appropriate training courses for them. The recom-mended courses include the requirements from A.O. 155 for Mass Casualty Manage-ment, stated below.

1. BLS training shall be mandatory for all health personnel. 2. Advance Cardiac Life Support (ACLS) and Pediatric Cardiac Life Support (PCLS) shall be a requirement for all medical personnel assigned in the Emergency Rooms. 3. All Response Teams shall have additional training in Emergency Medical Techni- cian’s Course – Basic and Mass Casualty Management.

Specially designated hospitals should have training on their areas of expertise. Below is a list of such hospitals and their corresponding training requirement: 1. Hospital Poison Control Centers - Toxicology Training, Chemical Terrorism 2. Trauma Centers 3. Infectious Disease Hospitals – Biological terrorism, emerging and re-emerging diseases (SARS, Avian Flu, etc.)


• Knowledge of available re- • Knowledge of available resources in DOH

• Knowledge on the steps in mobilizing human (e.g., medi-cal teams, etc.) and material resources to the affected com-munity

• Knowledge and skills in MCI/ICS

• Knowledge of available IECs especially for emergencies

• Skills in media handling

• Administrative Functions such as:

- Maintaining database of con-tact persons, experts, facilities, logistics, etc.

- Filing, recording of important documents

- Updasting fi les• Performing other functions assigned• Skills in BLS/ First Aid/ EMT

Knowledge and skills on the fol-lowing:

- Basic HEM (Awareness)- BLS- First Aid- 4W’s & 1H (Who, Where,

When, Why and How)


• Logistics Mobilization• Mass Casualty Incident and Inci-

dent Command System

• Risk Communication• Basic Communication Technology

(Radio, Map Reading, GIS, etc.)

Basic HEM Training – 2-day course (training module to be developed)

PositionRoles/Functions

- Logistics Mobilization Logistics Mobilization

- Risk Communication

- Others

6. Other Hospital Personnel- Initial responder- First aider- Health education &

promotion- Reporting

Continuation of Competency Requirements and Required Training Course/Package by RolesContinuation of Competency Requirements and Required Training Course/Package by RolesContinuation of

4. Burn Centers 5. Hospitals with Radio-nuclear Management Capability – Radiological Terrorism 6. Hospitals with Chemical Management Capability – Chemical Terrorism

Similarly, designated referral hospital laboratory should have training on their areas of laboratory capability.

Apart from the training which hospital staff should have, they can serve as technical resource persons and/or trainers. As part of the Hospital Emergency Preparedness, Re-sponse and Recovery (HEPRR) Plan, the hospital can provide technical assistance on Basic Life Support, Basic First Aid, and Basic Health Emergency Management (HEM) to the community within their catchment area.

CAREER DEVELOPMENT CAREER DEVELOPMENT

A holistic approach in initiating and nurturing staff in health emergencies is crucial to human resource development. Upgrading of competencies through training should be mapped out in the context of a long-term perspective – that of a career path of the hos-pital staff, an area that needs to be defi ned and enhanced.

Health Human Resource Management

Beyond knowledge and skills, psychosocial support for the staff deserves closer at-tention, given the pressures inherent in the work including the 24-hour shifts, the quick decision-making process, and need to balance with equally important demands of their respective families.

Considering the nature of the work where speed and timeliness are of the essence, spe-cifi c concerns such as safety, incentives, compensation, and other workers’ benefi ts as covered in the second, third and fourth provisions of the A.O. 168 need to be addressed by the hospital. It should be cognizant that these areas are part of health human resource management which is a function of the Central DOH, and part of a multisecto-ral process covering the entire government workforce.

The DOH had earlier highlighted this aspect through A.O. 155 Section V-F which states that:

All DOH personnel mobilized in response to emergencies and disasters like MCI shall be entitled to overtime pay and other allowable benefi ts based on actual time ren-dered due them even during Saturdays, Sundays and holidays. This shall be support-ed through the issuance of a pertiment hospital/offi ce order which shall state funding of such overtime from savings of the hospital, HEMS-Stop Death funds or any other funds subject to the usual accounting and auditing rules and regulations.

It is crucial for the hospital to distinguish those concerns which can be responded to promptly by implementation of guidelines and procedures from those which will take some time since these require refi nement of existing systems and/or development of new policies and procedures. A timetable of having the new systems in place provides moral boost to the staff performance.

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SECTION 14Logistics Management


A.O. 168 s. 2004 Section V-C: Policy Statements on Support Systems provides:

1. Logistics Management shall be developed for health emergency with the aim of pro-viding the right requirement, with the right amount at the right time and the right place. A system for procurement and delivery shall be developed wherein the logistical needs are identifi ed at the different levels of health facilities.

PURPOSE PURPOSE

The purpose of this section is to provide an overview of logistics management system and to provide guidelines for the hospitals to be able to perform their logistic man-agement functions during emergencies and disasters.

DEFINITION DEFINITION

1. Logistics management has been described as the procurement and delivery of the right supplies, in the right quantities, in the right order, in good condition (proper packing and not expired), at the right place, at the right time (HEMS, June 2007).

Getting the appropriate emergency resources to the right place at the right time in the most effi cient means possible is a primary concern. These resources include drugs, medicines, supplies, equipment and materials needed in response to emergencies and disasters.

2. Logistics management is the process of planning, preparing, implementing and evaluating all logistics functions in the provision of assistance, as well as its place in carrying out emergency management operations.

LOGISTICS MANAGEMENT PROCESS LOGISTICS MANAGEMENT PROCESS

A. Planning

• Annual Procurement Plan (APP)

The APP containing a list of all drugs/medicines, supplies, equipment and materials to be procured for the coming year shall be prepared and submitted by the HEMS Coordinator and signed by the Chief of Hospital at least one quarter prior to the start of the succeeding calendar year. Any procurement

not included in the APP will not be approved and processed.

The HEMS Coordinator of the hospital should be involved during logistics planning for emergency requirement.

In the preparation of the APP, the HEMS Coordinator of the hospital will have to consider the following: - Inventory of available stocks including the expiry date of drugs, medicines, supplies and materials including equipment. - Utilization of the past years. - Postmortem analysis of disasters specifi cally for logistics. - All drugs and medicines should be found in the Philippine National Drug Formulary (PNDF) latest edition. If not included look for an alternative or request for exemption from the drug committee. - Projected needs. - Projected emergencies and kinds of hazards in the hospital or catchment area. - Leading causes of morbidity and mortalities during the past emergencies or disasters and other relevant health indices. - Appropriate storage facilities and alternate backups.

It is important that drugs and medicines for emergency use conform to standard specifi cations and appropriateness to emergency conditions, indicating the following: - Dosage - Size - Volume - Preparation - Ingredients - Required packaging - Appropriate storage and transport (e.g., cold chain management) - Necessary supplies for administration (e.g., vaccines need syringes, needles, and special puncture-proof container for containment prior to waste treatment and disposal). - It is very important that only drugs and medicines in the latest PNDF will be considered.

• Supplemental Annual Procurement Plan

In the event of additional needs or during emergency procurement, a supplemental APP will have to be prepared and submitted.

B. Procurement

The hospital can procure emergency drugs/medicines and supplies. However, if the hospital can make arrangements with pharmaceutical companies and other suppliers during emergencies there might be no need to procure large amount of drugs and medicines.

Procurement shall follow the pertinent government rules and regulations and other DOH policies relative to procurement. 189

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Purchase request for the whole year must be submitted to the procuring entity every fi rst quarter of the year (or the hospital may have a different schedule) with the following supporting documents: • Annual Procurement Plan/Supplemental Annual Procurement Plan • Certifi cate of Clearance (medicines, drugs, medical supplies and equipment) • Certifi cate of Availability of Fund

In the event that supplies and materials are not available locally or the hospital’s supply was depleted because of the emergency and ongoing operation, they can request for augmentation from HEMS. A letter of request or just a call, especially during emergencies, will suffi ce. The request shall be supported by a report on the emergency.

C. Storage/Warehousing

There are various options for storage during preparedness, response and rehabilitation phase.

Preparedness

Look at various storage/warehouse areas in and outside the hospital. Ideal storage areas may include warehouses and other suitable buildings where storage management procedures already exist during pre-disaster phase.

Emergency/Response Phase

When ideal storage is not available, especially during emergency or response phase, available space in the fi eld can be utilized. There are ways to innovate/ modify the minimum requirement for storage. These may include among others: • Lockable transport container that can be left near the site or stricken areas • Temporary storage for stocks in transit

The following are some guidelines to be observed to ensure proper storage and to minimize wastage of drugs/medicines, compact food, medical supplies and reagents: • Store foods in a dry, well-ventilated area free from insects and rodents. • Boxes, bags and containers must not be placed directly on fl oor. Use pallets or boards underneath piles. • Keep items at least 40 cm away from the wall and do not stock them too high. • Replace damaged boxes, bags and containers. • Pile boxes, bags and containers two by two crosswise to permit ventilation. • Observe ”First in-First Out” principle and dispose of food supplies at least one (1) year, and medicines at least six (6) months, before the expiry date. • Vaccines should be stored at the cold storage with a temperature of 2-8 degrees centigrade. • Do not store food and vaccine together in one cold storage. • Keep the medicines away from sunlight.

It is necessary to categorize and record what might be termed as logistic tools to address needs for disaster situations. Commodities which are likely to be needed may include among others: • Operational support items (e.g., fuel, oil lamps/lanterns, fl ashlight, means of communication)

• Relief commodities (e.g., food, shelter materials, clothing) • Medical necessities (e.g., drugs, water purifi cation accessories) • Items likely to be required for recovery programs (e.g., building materials)

D. Distribution and Delivery

The HEMS Coordinator can request their own supply for use in the emergency room or for the use of the response teams in responding to the site. They have to make their own listings for these, considering that they should be able to handle at least 5 red victims during response. Majority of the needs of the hospitals are for trauma management, so this should be considered.

The resources are distributed to the concerned department/unit.

In the event of augmentation from CHD, emergency drugs, medicines, supplies (including BP Compact Food) shall be provided to the Response Teams so they can respond immediately during emergencies in their areas.

E. Monitoring and Reporting

To ensure that essential items are always available, incoming supplies, supplies dis-tributed, and stock levels should be closely monitored. It is important to:• Record the end destination for items in the stock records.• Monitor that they are being used appropriately.• Provide reliable reports.

The Hospital Supply Offi cer together with the HEMS Coordinator shall prepare the following:• Monthly Inventory Report of available stocks in the warehouse, the expiry date, and the location of delivery of the items every fi rst week of every month.• Annual Utilization Report of the distributed drugs and medical supplies. This should be received by DOH-HEMS on or before January 15 of the succeeding year. This is to be submitted if the funds came from HEMS.• In Postmortem Analysis of every emergency and disaster, logistical problems and issues should be discussed and evaluated. Recommendations can be used as inputs in the crafting and amendment of logistics for Hospital SOP/Protocol for Emergencies.• Monitoring of the units should be done regularly.

ACCEPTANCE AND DISTRIBUTION OF DONATIONS

Guidelines on acceptance and distribution of foreign and local donations during a disas-ter, including the roles and functions of hospitals, shall be in accordance with A.O. 2007-0017, which provides for the following:

A. General Guidelines

There shall be no donation for purposes of emergencies and disaster situations, whether from international or local sources, unless a formal acceptance for the purpose is issued by the Secretary of Health or his designated representative. 191

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B. Acceptance

Infant formula, breastmilk substitutes, feeding bottles, artifi cial nipples and teats shall not be items for donation. No acceptance for donation shall be issued for any of these items.

Acceptance of donation in foodstuffs for purposes of emergency and disaster situations should be made for foodstuffs that have a shelf life of at least three (3) months from the time of arrival to the Philippines.

Acceptance of donation in drugs/medicines for purposes of emergency and dis-aster situations should comply with the following minimum criteria: ■ Shelf life of at least twelve (12) months from the time of arrival to the Philip-

pines. ■ Labeling with English translation or in a language that is understood by Philip-

pine health professionals. ■ Packaging that complies to international shipping regulations accompanied by

a detailed packing list ■ Weight per carton does not exceed 50 kilograms. ■ Exclusive packaging with regards to other supplies. ■ Documentary proof of compliance to applicable quality standards.■ Documentary proof that the items were obtained from reliable sources.

C. Distribution

The DOH shall distribute the donated items to emergency and disaster affected areas. The distribution of such items for election purposes shall not be allowed nor the repackaging thereof in consideration of elective or appointive government offi cials.

ROLES AND FUNCTIONS OF THE HOSPITAL DURING EACH PHASE

A. Health Emergency Preparedness Phase

During this phase, the Logistic Management System shall be developed.• Proper coordination and arrangement must be established between the HEMS

Coordinators, Logistics and Supply Offi cer, Budget Offi cer and the warehouse management.

• Proper protocols and procedures likewise should be established to ensure faster accessibility to the drugs and medical supplies as needed.

• Logistics and Supply Offi cers should have data of available suppliers in the event of an emergency procurement; they can also establish special arrangements or go into an MOA (MOA) with established and credible suppliers.

• Suffi cient logistical capacity must be in place for the ambulance needs as well as for emergency room requirements.

• Ensure plans are in place.

B. Health Emergency Response Phase

• Rapid Assessment, specifi cally on logistics needs, must be conducted. Vulner-ability of logistics components (i.e., commodities, transport vehicles of various kinds, supply systems and routes) must be considered and addressed.

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• The Logistics Offi cer should take charge in supplying all the needed logistical requirements needed by the responders.

• The Finance Offi cer should ensure available fi nances and shall be responsible for sourcing out from other budgets.

• The Hospital Liaison Offi cer should be able to network with other hospitals to identify sources.

C. Health Emergency Recovery and Reconstruction Phase

• Conduct evaluation. • Update inventory of resources. • Review and update systems and plans. • Replenish utilized resources.

Hospitals should have a supply stock for two weeks to one to three months based on hazards in their region. DOH Central Offi ce will be called only for augmentation purposes.

HOSPITAL LOGISTICS HOSPITAL LOGISTICS

The hospital should be in constant state of readiness to respond to any health emer-gency/disaster in terms of logistics for patient care and for safety of workers, both at the disaster site and in the hospital.

Necessary supplies and equipment must be ready for immediate distribution to appro-priate locations in the hospital: (a) Emergency Room (e.g., stretchers and wheelchairs to the receiving area); (b) X-ray; (c) Laboratory ; (d) Blood Bank; (e) Operating Rooms; (f) Intensive Care Units; (g) Special Units – Burn, Toxicology, etc.

The essential medical facilities and support for disaster operations to on-scene and in-hospital response teams should be in place, regularly monitored and regularly main-tained. This includes: (a) ambulance facilities that enable the Scene Response Teams to conduct rescue operations at the site of the disaster (see Section 4.1); (b) transport and communication facilities; and (c) standby power generators. Apart from the supplies and equipment for patient care, the personal protective equipment (PPE) for workers is an utmost necessity.

The hospital, particularly in disaster-prone areas, has to develop logistic management procedures to support the organizational shift in times of emergencies and disaster. Prior arrangements have to be made, such as opening of credit lines with suppliers of critical supplies to ensure continuous supply of medicines and other consumables, and with maintenance service providers to ensure prompt repair and/or temporary replace-ment of critical medical equipment that break down during disasters.

One major area to consider is the procurement, transport and storage of biological sup-plies such as blood, plasma or vaccines.

Stockpiling of Equipment and Supplies at Hospital Level

Normally all hospitals have a system of procurement and stockpiling drugs, medicines and supplies usually for 2-3 months. In health emergency management, there is no

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need for the hospital to maintain stocks of drugs, medicines, supplies, equipment and materials, as long as these can be procured locally. However, arrangement and agree-ments with local suppliers must be in place.

In case these logistics are not available locally, stockpiling is suggested but has to be monitored regularly to prevent the expiration of drugs and supplies to pass unnoticed. The needs to be met may vary depending on the demand and previous experience.

The categories of logistics may include:a. Emergency Kit for the respondersb. Emergency stocks of reagents c. Emergency drugs, and medical supplies for the emergency roomd. Power generatorse. HEMS Trauma Kit (fi rst responder medical supplies)f. Others (e.g., things which are most frequently requested and needed)

Inventories should be regularly reviewed and updated. Periodic tests must be carried out to ensure that the equipment are always in good working condition.It is important to record the end distribution destination for items in the stock records, to monitor that they are being used appropriately and to provide reliable reports.

Supplies that are not usually readily available locally can be requested from the DOH Central Offi ce. These include, among others:

a. Cadaver bagsb. Water disinfectantsc. B5 compact food (donation)d. Vitamin Ae. Lime

Logistic management is one critical system that breaks or makes responses to emer-gencies and disasters. Some investments may be expensive but are most likely well worth it.

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SECTION 15Information Management

POLICY BASE

A.O. 168 s. 2004 Section V-C: Policy Statements on Support Systems provides:

4. A system for managing information during emergencies shall be developed and institutionalized for the health sector to ensure that appropriate, timely and rel-evant information are disseminated to the target stakeholders. Furthermore, fl ow of information and proper way of documentation should be established.

5. A communication system should be developed at all levels to improve monitor-ing and response to emergencies and disasters.

DEFINITION

Information Management, an iterative process of data collection, information sharing and utilization, is carried out to support decisions and activities during pre-disaster, emergency/disaster and post-disaster phases of health emergency management. (De la Peña, 2007).The tasks for a Management of Information System are the following:

1. Set policy, goals and objectives (to address identifi ed information needs), prepare guidelines.

2. Develop methodologies, procedures, indicators, etc.3. Issue guidelines and identify training needs.4. Collect data and information.5. Filter the data.6. Analyze the data.7. Disseminate information about managing risks to: • Guide decision-makers. • Inform the public. • Inform research. • Obtain feedback.

DATA COLLECTION

The Information Management Manual for Coordinating and Monitoring Health Emergen-cy and Disaster Response, Volume I, 2007 identifi es the roles and information needs of eight key players in health emergency management at the national level; the hospital is the fi fth key player. It presents seven data collection tools of DOH-HEMS which are the reporting forms of the HEMS Coordinator. Three forms have been added to the Informa-tion Manual set – the Inventory Checklist, Patient List from Field Medical Commander, and the Mass Casualty Medical Record. Table S15.1 presents the data collection forms/

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reporting forms and their timing/frequency for DOH-HEMS. (The forms are presented towards the last part of this manual.)

Reporting form

Form 1. Hears Field ReportAnnex

Form 2. Materials Utilization Report

Form 2-1. Inventory Checklist Annex

Form 3-A. Rapid Health AssessmentAnnex

Form 3-B. Rapid Health Assessment (MCI) Annex

Form 3-C. Rapid Health Assessment (Outbreak) Annex

Form 5. List of Casualties Annex

Form 5 -1. Patient List from Field Medi-cal Commander Annex

Form 5-2. Mass Casualty Medical Case Record Annex

Form 6-1. Post Mission Report Annex

Form 6. HEMS Coordinator’s Final Re-port Annex

Timing/Frequency

Within 24 hours of occurrence of event

One month after the event or as needed

Daily for fi rst two weeks, as necessary thereafter

Within 24 hours of occurrence/aware-ness of event

Within 24 hours of occurrence/awareness of event

Within 24 hours of occurrence/awareness of event



Prompt accomplishment

Within 24 hours of completion of mission

Within one week after termination of re-sponse

Table S15.1. Data Collection Tools

Data and information have three dimensions of quality in information, namely: 1. Time dimension – refers to timeliness (ready when needed), currency (up-to-

date), and frequency (available as often as needed) of the data or information being managed.2. Form dimension – refers to clarity (easy to understand), level of detail (de-

tailed vs. summary report), and order (sequence of data presentation) in which the data or information is presented in the reports.

3. Content dimension – refers to the accuracy (free from error), relevance (an swer the needs of the user), and completeness (free of omissions) of the

data or information.

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The Hospital HEMS Coordinator shall ensure the quality of data and information follow-ing these guidelines:

1. All data and information providers shall exercise due diligence in verifying ac-curacy of their reports. Doubtful data or information shall be verifi ed with reliable sources within the network of agencies involved in emergency and disaster man-agement.

2. Data collection forms and reporting templates shall be prepared and submitted within the prescribed deadline and frequency.

3. The persons responsible for fi lling out the data collection forms and preparing the reports shall ensure that the latest data and information are provided.

4. Prescribed forms shall be fi lled out as completely as possible. Templates may be modifi ed but the general format shall be followed and the minimum data/informa-tion asked for shall be provided. For data fi elds requiring descriptive information (e.g., Brief Description of Event), the person preparing the report shall provide as much relevant details as possible.

5. As much as possible, all forms and reports shall be typewritten or computer-gen-erated. Otherwise, they shall be written legibly and in black ink.

DATA COLLATION, INTERPRETATION AND ANALYSIS

Data collated with the above tools shall be assessed and interpreted to help make deci-sions related to resource mobilization and other aspects of emergency response. After verifying the reliability of data, the Hospital HEMS Coordinator shall assess the rel-evance of the data to other information, its urgent implications and signifi cance – what needs to be done in response to the information.

INFORMATION DISSEMINATION AND UTILIZATION

The reporting forms are submitted to DOH-HEMS, specifi cally OpCen, as prescribed. The utilization of information is incumbent upon the offi ces and personnel to whom it is disseminated. The following actions may be considered in planning and implementing appropriate health emergency response by the Hospital HEMS coordinator.

1. Resource Matching – allocation of personnel and resources to identifi ed tasks2. Preliminary Deployment – responding using available resources3. Activation of Support Services and Request for Outside Assistance – when the

required response cannot be addressed by immediately available resources, but which may be available from other organizations through existing planning ar-rangements

4. Logistics Support – considering: • Length of self-suffi ciency of affected area • Need to bring a small stock of high-usage items • Replenishment of consumables • Provision of operational equipment • Repair of operational equipment5. Prognosis – forecasting the potential for additional assistance or resources re-

quired for the following hours or days as appropriate

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DATA STORAGE

Hard copies of the accomplished forms shall be organized and stored into related fi les for each type of report. Where feasible, an electronic storage of data is maintained. In-formation may be retrieved from these manual and electronic databases upon clearance of highest authority as needed for use by policymakers and researchers.

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SECTION 16AHealth Promotion and Advocacy

INTRODUCTION INTRODUCTION

Behaviors conducive to health among the population is the ultimate goal of every health worker. However, behavior is greatly infl uenced by the knowledge and attitude of the people. This area is where Health Education and Promotion plays a crucial role.

Health Promotion and Advocacy is one of the 10 P’s or elements of Successful Health Emergency Management. This element advocates for behavior change towards prepar-edness and response to health emergency and disaster.

POLICY BASE

A.O. 168 s. 2004 Section V-C: Policy Statement on Support Systems states:

3. Media management and public information shall be made readily accessible in such situations. As such, there shall be a designated spokesperson in all health facilities and institutions to respond to inquiries related to health emergencies. Such person should be trained and be readily available, accessible to the media”

DEFINITIONS

Health Promotion as defi ned by the World Health Organization is the process of ena-bling people to increase control over, and to improve, their health. Health promotion is much more narrowly conceived as “the science and art of helping people change their lifestyle to move toward a state of optimal health.” To reach a state of complete physical, mental and social well-being, an individual or group must be able to identify and realize aspirations, satisfy needs, and change or cope with the environment. At the heart of the process is the empowerment of the community, their ownership and control of their en-deavors and destinies. This affi rms the earlier defi nition of the Ottawa Charter of Health Promotion in 1986, where it is implied that Health Promotion works through concrete and effective community action in setting priorities, making decisions, planning strate-gies and implementing them to achieve better health.

Advocacy is the organization of information for the purpose of persuading, convincing and motivating the target audience towards a specifi c idea or behavior. It changes the social climate within which “changes in the behavior of people about their own lives” takes place.

Health Promotion in Health Emergency and Management is educating and promot-ing for a change in lifestyle among the common people that will lead to the prevention of health emergencies and disasters.

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Advocacy in Health Emergency and Management covers all the phases of the emergency/disaster cycle (Hodgkinson and Stewart, 1991). Preparedness advocacy includes planning activities like public education and training potential service providers. Mitigation advocacy is linked to activities designed to reduce the likelihood of disaster Mitigation advocacy is linked to activities designed to reduce the likelihood of disaster Mitigation advocacyoccurring. Responsive advocacy activities include the actual provision of emergency response like evacuation and rescue services. Recovery advocacy activities are longer-term efforts to assist or rebuild the affected community. This is the rehabilitation period after the disaster which will also bring its post-disaster hazards like psychological trau-ma and diseases.

PROCESS PROCESS

1. How to Conduct Health Promotion

1.1. Develop a Health Promotion Plan.

The development of a Health Promotion Plan on Health Emergency and Man-agement is one of the tasks in the Health Emergency Management Coordinator’s roles and responsibilities – “Takes the lead in public information and awareness concerning disasters and emergencies.” There are three major steps in the development of a Health Promotion Plan. These are: (1) Conduct of Diagnosis – deals with the assessment of the different situations affecting the behavior and lifestyle of the people; (2) Development of Intervention Strategies – determining the strategies that will be done in order to achieve the desired behavior change; and (3) Development of Evaluation Tools and Parameters – assessment of the effect of the health promotion intervention.

1.1.1. Conduct of Diagnosis

a. Social Diagnosis – process of determining people’s perception of their own needs, quality of life, and aspirations for the common good, through broad participation and the application of multiple information-gathering activities designed to expand understanding of the community. Methods that can be used for Social Diagnosis are: community fora, focus groups, surveys, interviews, etc.

b. Epidemiological Diagnosis – data gathering of important statistical data related to health emergency and disaster. This step determines the health issues associated with quality of life, in particular, specifi c health problems and non-health factors related to poor quality of life. Epidemiological data include vital statistics, years of potential loss, disability, disease preva-lence and incidence, morbidity and mortality.

c. Behavioral and Environmental Diagnosis – assessment of the present behavior of the target audience and the environmental factors that affect their risk. It also includes non-behavioral causes (personal and environ-mental factors) that contribute to health problems, but controlled by behav-ior. Behaviors identifi ed should be scaled to their importance and change-ability.

Environmental Diagnosis is a parallel analysis of factors in the social and

physical environment other than specifi c actions that could be linked to behaviors.

d. Educational and Organizational Diagnosis – assessment of the causes

of health behaviors which were identifi ed in (c) Behavioral Diagnosis. Three kinds of causes are identifi ed:

1. Predisposing factors – any characteristics of a person or population that motivate the individual/s prior to the occurrence of that behavior. These include values, cultures, beliefs and attitudes of the person or population.

2. Enabling factors – characteristics of the environment that facilitate Enabling factors – characteristics of the environment that facilitate Enabling factorsaction and any skill or resource required to attain a specifi c behavior, including the knowledge, skills and resources of the population and environment.

3. Reinforcing factors – rewards or punishments following or anticipated Reinforcing factors – rewards or punishments following or anticipated Reinforcing factorsas a consequence of a behavior, which serve to strengthen the motiva-tion of behavior.

e. Administrative and Policy Diagnosis – the assessment of resources, budget development and allocation, development of an implementation time table, organization or personnel within the programs, coordination of the program with all other departments, and institutional organization within the community.

Administrative diagnosis – analysis of the policies, resources and circum- Administrative diagnosis – analysis of the policies, resources and circum- Administrative diagnosisstances prevailing, and of organizational situations that could hinder or facilitate the development of the health programs.

Policy Diagnosis – assessment of the capability of the program goals and objectives in relation to those of the organization and its administration.

1.1.2. Development of Intervention Strategies

Following the recommendations of the Ottawa Charter, the strategies should focus on the fi ve areas of health promotion in order to:

1. Develop personal skills – personal and social development of the tar-Develop personal skills – personal and social development of the tar-Develop personal skillsget audience by providing information, education and enhancing skills related to health emergency and disaster management.

2. Build health public policy – putting health emergency and disaster Build health public policy – putting health emergency and disaster Build health public policymanagement on the agenda of policymakers in all sectors and at all levels.

3. Create supportive environment - establishing network and alliance building among partner agencies. 201

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4. Reorient health service – greater attention to health research as well as changes in professional education and training. This must lead to a change in attitude and organization of health services, refocusing on the total needs of the individual as a whole person.

5. Strengthen community action – empowerment of communities, their ownership of the projects, and activities geared towards prevention of health emergency and disaster.

1.1.3. Development of Evaluation Tools and Parameters

This can be done through records review, survey, focus group discus-sion and other evaluation methods. The health promotion program can be evaluated at one or more of three levels:

Process Evaluation – evaluates the process by which the program is being implemented; assesses the planned strategies/activities versus the strate-gies/activities actually implemented.

Impact Evaluation – measures the program effectiveness in terms of inter-mediate objectives and changes in predisposing, enabling and reinforcing factors. It measures the attainment of the Behavioral and Environmental Diagnosis and Educational Diagnosis.

Outcome Evaluation – measures change in terms of overall objectives and changes in health and social benefi ts or the quality of life. This form of evaluation takes a very long time to get results. It may take years before an accrual change in the quality of life is seen.

1.2. Implement the Health Promotion Plan – refers to the execution of the strategies and activities of the plan

1.3. Evaluate the effects of the Health Promotion Plan – refers to the Process, Impact and Outcome Evaluation

2. How to Conduct Advocacy

2.1. Build oneself as an advocate. Learn to imbibe the qualities of an advocate, which include the following:

• Objectivity – degree of confi dence or suspicion you have in the system, and your belief in the potential of positive change

• Independence – uninfl uenced and informed judgment• Sensitivity and understanding – interest and empathy • Persistence and patience – determined and secure enough in your position to

weather storms, deal with setbacks, and maintain energy over time. • Knowledge and judgment – understanding what to ask for and whom to ask,

and be able to exercise judgment about what is reasonable, and what is not • Assertiveness – fi rmness with politeness; having a good working relationship

with others without letting them not control you • Ethics and respect for others – having respect for the privacy and confi -

dentiality of others, and respect for the basic rules of ethical conduct, to be effective and to maintain credibility

2.2. Develop the Advocacy Plan.

2.2.1. Assess the problem – What is the issue, idea or behavior that needs persua-sion, convincing and motivation of the target audience? Form an advocacy team.

2.2.2. Gather information and form solutions – Conduct literature review or other similar situations from other organizations, communities or institutions.

2.2.3. Choose your strategies – There are different strategies or tools that can be used. Advocacy strategies include:1. Policy reform 2. Organized community response 3. Dispute resolution

Advocacy tools that can be used are:

1. Big bang – presentation of information during national events. Big bang – presentation of information during national events. Big bang Examples: Basic Life Support Demonstration at the different malls during the obser-

vation of the National Disaster Consciousness Month Conduct of National Convention on Disaster Management by the Health

Sector in the Philippines during the celebration of the Health Emergency Week

2. Little bang – small events can become excellent venues for presenting Little bang – small events can become excellent venues for presenting Little bangyour advocacy arguments.

Example: Announcements during fl ag ceremony or community assemblies

3. Big visit – visits by leaders and decision-makers in your areas. Example: Big visit – visits by leaders and decision-makers in your areas. Example: Big visitPersonal appearance of the Secretary of Health or other executives at any community event

4. Inside man – key people in an organization can do advocacy with leaders and decision-makers with whom they have routine access and you do not.

Example: Making use of the gate keepers

5. Letter – a letter to a leader and decision-makers can provide a good Letter – a letter to a leader and decision-makers can provide a good Lettermeans to present your arguments and allow the other side time to think out their response.

Example: Issuance of Department Memorandum on the Observance of the National Disaster Consciousness Month

6. Quiet meeting – sometimes it is more effective to talk with the person Quiet meeting – sometimes it is more effective to talk with the person Quiet meetingalone.

7. Technical journal – concerns the need to make certain ideas respectable Technical journal – concerns the need to make certain ideas respectable Technical journalin professional circles before pushing them with government offi cials.

2.3. Implement the plan – actual implementation of the strategies and tools conceptualized.

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2.4. Evaluate the plan – carry out the identifi ed assessment tools and proce-dures.

OUTPUT

Following is an example of a health promotion and advocacy plan.

HEALTH EDUCATION AND PROMOTION PLAN

I. DIAGNOSIS

A. Social Diagnosis

• The World Bank study entitled “Natural Disaster Risk Management in the Philip-pines: Enhancing Poverty Alleviation Through Disaster Reduction,” published in 2004, reported that the country’s vulnerability to natural hazards cost the Govern-ment an average of PhP 15 billion annually in direct damages, or more than 0.5% of the country’s GNP.

• A study on the “Impact of disaster-related mortality on gross domestic product in the WHO African Region by Kirigia, Sambo, Aldis and Mwabu” found that: o Disaster-related deaths have a statistically signifi cant negative effect on GDP

per capita. o A unit increase in disaster mortality was found to decrease GDP per capita by

US$0.01828, which is the economic burden of a single disaster-related death. o The annual GDP lost by the Region has been estimated at US$9,713. o The undiscounted lifetime GDP lost through the death of 539,597 people was

estimated at US$242,819.

• Indirect and secondary disaster impacts lead to a greater economic burden of disease and thus lead to a poor quality of life among the Filipinos, especially those mostly affected.

B. Epidemiological Diagnosis

• Of the 124,566 total population in Real, Infanta and Nakar,Quezon affected by typhoon Yoyong and Winnie:o !9,211 families and 94, 060 persons were affected. o 530 were injured, 623 dead and 338 missing.o Leading causes of morbidity – ARI, wounds of all kinds, diarrhea, UTI. o Leading cause of mortality – drowning.

C. Behavioral and Environmental Diagnosis

Behavioral Diagnosis• Act only when disaster strikes.• Does not practice health emergency and disaster-preventive measures. • Note: No existing study has been done on the behavior of the people and

health emergency-concerned staff regarding health emergency and disaster preparedness.

Environmental Diagnosis• The Philippines forms part of the prominent volcanic chain known as the ring

of fi re.• The country experiences, on average, 887 earthquakes every year.• Out of 220 dormant volcanoes, 22 are potentially alive.• The Philippines also lies within the ‘Pacifi c typhoon belt,’ an area renowned

for hydrometeorological hazards.• According to the Philippine Atmospheric and Geophysical Services Adminis-

tration, the average tropical cyclone occurrence in the Philippines is 19 to 21 per year, of which two are super typhoons.

D. Educational and Organizational Diagnosis

Educational Diagnosis (Note: No study on the knowledge and attitude of the people and the health

emergency staff at all levels)

1. Predisposing Factors• Inadequate knowledge on the facts and concepts of health emergency

among the community• Inadequate knowledge on what to do when health emergency and disaster

occurs among the community• Passive attitude towards prevention of disasters• Attachments of people to personal property

2. Enabling Factors • Inadequate IEC campaign materials • Available health emergency trained personnel at the regional level

3. Reinforcing Factors• Presence of gate keepers in the community

Organizational Diagnosis• Existing health emergency management staff• Presence of health emergency and disaster preparedness network

E. Administrative and Policy Diagnosis

• Presence of legal mandate – P.D. 1566: Strengthening the Philippine Disaster Control Capability and Establishing the Program on Community Disaster Prepar-edness

• Existing policies on health emergency management at the DOH:o A.O. 168 – National Policy on Health Emergencies and Disasterso A.O. 155 – Implementing Guidelines for Managing Mass Casualty Inci-

dents During Emergencies and Disasters

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II. INTERVENTION

Areas of HealthPromotion

Build health public policy

Develop personal skills

Reorient health services

Strengthen community action

Create supportive environment

Strategies

Advocacy

Capability Building

IEC Campaign

Community development

Networking and alliance building

Activities

1. Review existing policies on health emergency management.

2. Draft local ordinance on health emergency management

3. Advocacy forum on health emergency management

4. Awarding of Best Practices

5. Development of HEMS video presentation

1. Conduct mandated trainings on health emergency management among regional staff.

2. Send health emergency management staff to appropriate trainings on health emergency.

3. KAP survey among the com-munity, health workers and managers on health emergency management.

4. Health Promotion Needs as-sessment on health emergency

1. Conceptualization, develop-ment, pretesting, production and distribution of IEC materials and collaterals

2. Celebration of HEMs event

3. Establishment of HEMS re-source center

1. Development of guidelines on the organization of local emer-gency brigade

1. Conceptualization of HEMS webpage

2. Establishment of health emer-gency SMS network

Evaluation Indicators

% existing policies re-viewed and recommended for amendment

% local ordinances passed at the local board

% realized among pledges of commitment made

Regional Offi ce/LGUs with best practices recognized

Level of reach

% of regional staff trained on health emergency man-dated training

% health emergency management staff sent to training

KAP on health emergency evaluated

Health promotion needs identifi ed and analyzed

% distribution reachedLevel of reach

Level of reach

Functional HEMS resource center

% functional local emer-gency brigade

HEMS webpage online and updated

Health emergency SMS network functional

III. EVALUATION

Year-end survey on Health Emergency among the community, health workers and health managers.

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SECTION 16BRisk Communication and Media Management

INTRODUCTION INTRODUCTION

The public’s yearning to learn about health, the increasing trend toward health behavior change, and the advances in information technology all contribute to the likely attain-ment of a health-informed public. Communication strategies are often done through mass distribution of information, education and communication (IEC) materials and media releases. But health providers should not only focus on health behavior in normal situations but also on communicating health risk messages. Risk communication is an area of communication strategies that is rarely practiced. It is imperative that health workers develop the habit of communicating health risks before the event, during the response and after the disaster. (Covello &Allen, 1988)

WHAT IS RISK COMMUNICATION? WHAT IS RISK COMMUNICATION?

Risk Communication is the purposeful exchange of information about the existence, nature, and form severity or acceptability of health risks between policymakers, health care providers and the public/media aimed at changing behavior and inducing action to minimize/reduce risks.

It is an ongoing process involving potentially affected “audiences” and various stake-holders to come to a common understanding about the hazards, the risks, their accept-ability, and actions needed to reduce the risks considering risk management strategies.

It is the process of bringing together various stakeholders to come to a common under-standing about the risks, their acceptability and actions needed to reduce risks.

Four Kinds of Risk Communication (Sandman, P.and Lanard, J.)

1. High hazard, low outrage Situation: When the lack of outrage increases the hazard. In this situation, the

hazard is high; however, the outrage or the response/reaction of the people is very low so there is a behavior of complacency.

Health Emergency Manager’s communicator role: Make the population con-scious of the hazard to level off the hazard and outrage.

2. Medium hazard, medium outrage Situation: When outrage and hazard need to be linked. The level of hazard and

the reaction of the public are of the same intensity. Health Emergency Manager’s communicator role: Take advantage of the situ-ation to develop communication and behavioral strategies.

3. Low hazard, high outrageSituation: When outrage is the problem. The outrage is largely of the audience, but the actual hazard is low. In this situation, the public has overreacted to the hazard which is at its manageable level or of minimal consideration. The reaction of the public is manifested in their attitude and their behavior.

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Health Emergency Manager’s communicator role: Calm the public and inform them of the real hazard scenario.

4. High hazard, high outrage Situation: Crisis occurs when hazard is high but outrage is even higher.

Health Emergency Manager’s communicator role: Help the public bear its fear and misery while avoiding reassurance.

What Is the Purpose of Risk Communication?

• It is the fundamental right of the population to access information about the risks they face.

• Organizations are seen to be more legitimate and effective when they are trans-parent and open with information.

• The risk is shared by the organization and the population.• Risk Communication serves as an avenue for information and education to the

communities, health personnel and decision-makers. It gives a better chance to explain risks to the population more effectively.

• Populations can make better choices when they are better informed.• The emergency information can stimulate behavior change.• It prevents misallocation and wasting of resources.• It can decrease illness, injuries and deaths.

How Do We Explain Risks?

• Find out what information people want and in what form.• Anticipate and respond to people’s concerns about their personal risk.• Take care to give adequate background when explaining risk numbers.• Acknowledge uncertainty.

HOW DO WE CONDUCT RISK COMMUNICATION?

The steps are:

1. Identify risks to be addressed. • Identify risks of the hazard using the risk management process. Refer to the Health Emergency Preparedness Plans. • Determine the knowledge and the behavior(s) to be learned and adopted to prevent the risk(s). These will be the basis for the development of the communication plan.

Example: Hazard: Disease Outbreak, Measles

Risk: DeathKnowledge:

• Prevention of measles• Signs and symptoms of measles• Measures to prevent complications from measles• Home management of measles

Behavior:• Bring eligible children for measles immunization.

What NOT to Do During a Crisis

DON’T speculate on the causes of the emergency.DON’T speculate on the resumption of normal operations.DON’T speculate on the outside effects of the emergency.DON’T interfere with the legitimate duties of news people.DON’T permit unau-thorized spokesper-sons to comment to the media.DON’T attempt to cover up or mislead the press.DON’T place blame for the emergency.

• Bring children with early signs and symptoms of measles to health workers.

• Proper care and management of measles.

2. Develop a communication strategy. • Identify communication strategy based on the identifi ed risk(s). Strategies should

focus on the prevention and/or management of the identifi ed risk(s).

Examples:1. Development of IEC materials2. Media mix campaign

3. Design a Risk Communication Plan.

The communication plan should contain the following:

• Target group – To whom the Risk Communication will be addressed or the recipient of the message. One important target group could be the people responsible for creating risk situations through human activities. Target audience can be grouped according to the following classifi cations:• Social – refers to the age, gender, educational status, religion and eth-

nicity of the target group. Example: Productive age group or 15-44 years old, mothers, Muslims,

Aetas• Economic – refers to the economic status of the target group. Exam-

ple: Below poverty line, underpriveleged • Political – refers to the political affi liation of the target group. Example:

Mayors, businessmen, farmers

• Message – Informs the target group - what is happening (eg., to know the dangers they are exposed to) - what it means to them (potential impacts to understand the risk)- what the target group can do (to know how to respond when the haz-

ard strikes and protect lives and minimize damage)

Risk Communication messages may contain information on the following:• The nature of the risk

- Characteristics and importance of the hazard concern- Magnitude and severity of risk- Urgency of the situation- Probability of exposure to the hazard and its distribution- Nature and size of the population at risk

• The nature of the benefi ts- Actual or expected benefi ts associated with each risk- Who benefi ts and in what ways- Where the balance point is between risks and benefi ts- Total benefi t to all affected populations combined

• Risk management options- Actions taken to control or manage the risk- Action individuals may take to reduce personal risk

209

210

- Justifi cation for choosing a specifi c risk management option- Effectiveness and benefi ts of a specifi c option- Cost of managing the risk, and who pays for it- Risks that remain after a risk management option is implemented

• Source – Who will be the sender of the message.

• Communication channel – Medium through which the message will be conveyed. The use of media mix is highly recommended to achieve the maximum intended result. The types of media commonly used are:• Print – Newspapers, magazines• Broadcast – Radio, TV• Electronic – Internet, SMS, MMS• Folk – Street play

Other channels of communication are: • Interpersonal communication• Group communication• Telecommunication (including cable TV)• Printed IEC materials (posters, brochures, fl yers, billboards, etc.)• Special events• Showcases and exhibits

• Intended results – Expected impact of the Risk Communication; change in the Intended results – Expected impact of the Risk Communication; change in the Intended resultsknowledge and behavior of the target group as infl uenced by the Risk Communi-cation.

The intended result leads to the expected outcome which is either the prevention or reduction of the risk(s), although this may take a longer period of time to be measured.

4. Pre-testing

Check or verify the content, design and mode of communication for appropriateness as perceived by the target group. Conduct the pretest with a group that matches the characteristics of the intended audience. The most common methods used in pre-testing are Focus Group Discussion and Survey.

5. Program implementation

Execution of the communication strategies identifi ed.

6. Program evaluation and impact assessment

Program evaluation refers to the process evaluation or assessment of what strate-gies/activities had been implemented as against the plan.

Impact assessment refers to the change in the knowledge and behavior of the target group/audience.

Figure S16B.1 presents a fl ow chart summing up the entire process of communicating health risks (Dr. Sulaiman Che Rus).

Figure S16B.1. Flow Chart: Steps in Communicating Health Risk (Dr. Sulaiman Che Rus)

START

Identify and prioritize issues

Analyze communication situation

Set communicataion objectives

Analyze and select audience

Design, develop and pretest

Redesign Accept

Communicate Message

No Yes

Evaluate

OK

End

211

212

REMEMBER!!!

Seven Cardinal Rules of Risk Communication

1. Accept and involve the public as a partner. Your goal is to produce an informed public, not to defuse public concerns or

replace actions.

2. Plan carefully and evaluate your efforts. Different goals, audiences, and media require different actions.

3. Listen to the public’s specifi c concerns. People often care more about trust, credibility, competence, fairness, and

empathy than about statistics and details.

4. Be honest, frank, and open. Trust and credibility are diffi cult to obtain; once lost, they are almost impossi-

ble to regain.

5. Work with other credible sources. Confl icts and disagreements among organizations make communication with

the public much more diffi cult.

6. Meet the needs of the media. The media are usually more interested in politics than risk, simplicity than

complexity, danger than safety.

7. Speak clearly and with compassion. Never let your efforts prevent your acknowledging the tragedy of an illness,

injury, or death. People can understand risk information, but they may still not agree with you; some people will not be satisfi ed.

MEDIA MANAGEMENT MEDIA MANAGEMENT

Role of Media During Risk Communication

Media plays a very important role in Risk Communication and handling media is very crucial in health emergency management. Understanding them is one of the signifi cant tasks of a health emergency manager.

Handling Media

1. Familiarize yourself with what media wants.

■ Know what kind of information media wants. ■ Consider that media runs after information to sell their story and in return

merit needed ratings for their newspaper and radio or TV station.

2. Be prepared for what media will ask.

• Make available for media consumption information on the nature, effect and other vital facts about the risk.

• Consider that information should be brief and concise so that it will not create misinformation. Below are some of the important data/information that media wants:

a. Casualties• Number killed or injured• Number who escaped• Nature of the injuries received• Care given to the injured• Disposition of the dead• Prominence of anyone who was killed, injured or escaped• How escape was handicapped or cut off

b. Property Damage• Estimated value of loss• Description – kind of building, etc.• Importance of the property, e.g., business operations, historic value, etc.• Other property threatened• Insurance protection• Previous emergencies in the area

c. Causes• Testimony of participants• Testimony of witnesses• Testimony of key responders • How emergency was discovered • Who sounded the alarm• Who summoned aid• Previous indications of danger

d. Rescue and Relief• The number engaged in rescue and relief operations• Any prominent persons in the relief crew• Equipment used• Handicaps to rescue• How the emergency was prevented from spreading• How property was saved• Acts of heroism

e. Descriptions of the Crisis or Disaster• Spread of the emergency• Blasts and explosions• Crimes or violence• Attempts at escape or rescue• Duration• Collapse of structures• Extent of spill

f. Accompanying Incidents 213

What does media like?

• Good stories.• Scoops.• Exclusives.• “Gut” material.• Good sources

who are ap-proachable, available, cred-ible and reliable ALL THE TIME.

• Being “fed” continuously.

214

• Number of spectators – spectator attitudes and crowd control• Unusual happenings• Anxiety, stress of families, survivors, etc.

g. Legal Actions• Inquests, coroner’s reports• Police follow-up• Insurance company actions• Professional negligence, or inaction• Suits stemming from the incident

3. Decide when to release information.

When to release information:

• If people are at risk, do not wait.• Inform people concerned of any risk you are investigating and why.• If it seems likely that media (or others) may release information, release it

yourself.• Fill in information gaps for the media.• If preliminary results show a problem, release them and explain the tentative-

ness of the data.• If the information will not make sense without other relevant information, wait

to release it all at once.• Advise community on interim actions while waiting to confi rm data.• If you don’t trust your data, don’t release it.• Consider:-

- Although the agency is vulnerable to criticism, one may be more vulner-able if information is held on to.

- The alarm caused by early release will be less than the alarm that can be compounded by resentment and hostility if information is held on to.

4. Choose how to release information.

Information can be released through:

1. Press release – follow the following basic press release structure:• Summarize the content: “In a press statement today, the Mayor called

on….”• Quote the source: “A public health emergency can only be avoided by…,”

the Secretary said.• Link the quote to an important event that is public knowledge: “The state-

ment was made referring to the recent outbreak of measles where 10 children died…”

• Acknowledge controversy but show that this is the best course of action: “Despite overwhelming resistance to…,the action is needed because …”

• Tell the public what to do: “In support of this, the public is asked to … For more information call…”

2. Press Statement – it should contain the following: • Opening remarks.

• State the action.• Link it to an event.• State other supporters of the action.• Inform people of their role.

3. Press conference

HOW TO PREPARE FOR A PRESS CONFERENCE:

A. Before a Press Conference1. Prepare (update) media directory.2. Select a location which is accessible to media.3. Make sure there are no other (newsworthy) events happening at the time of your event/press conference.4. Issue a press conference advisory.

■ Date■ Topic or agenda■ Time■ Location■ Contact information

5. Follow up calls after issuing advisory.6. In the event of other “breaking” news, try to reschedule your event

or reach out to journalists on a one-on-one basis to generate a few stories.

7. Prepare logistics needed. The ideal set-up includes a podium (or table) and microphone(s) for the speakers.

8. For indoor press conferences, leave space for TV cameras at the back of the room.

9. Provide for sign-in table where media can register their name and contact information.

10. Prepare simple signage, e.g., banner behind the speakers. Name plates for speakers may also be necessary.

11. Prepare press kit to hand out to media during the press conference.■ Press release containing key information presented at the press

conference■ Fact sheets or background information (including graphs, charts,

photos, etc.)■ Copies of prepared statements■ Brief background information and photo of speakers

12. Prepare speakers or spokespersons for the event.13. Decide the order of speakers. Ideally, no more than three speakers

per forum.14. Develop a brief statement (under 10 minutes is a good rule-of-

thumb) or provide spokespersons “talking points” and Questions and Answers (Q&As).

15. Include “quotable phrases” or “soundbites” in the prepared statement(s).

16. Prepare visual aids (e.g., easily seen from any point in the press areas).17. Anticipate questions and prepare clear, brief answers.18. Schedule a rehearsal. 19. Prepare visual aids (e.g., easily seen from any point in the press areas). 215

216

20. Anticipate questions and prepare clear, brief answers.

B. During the Press Conference1. Arrive at least an hour before the event to give time to attend to any

last-minute matters.2. Assign staff to greet media guests as they arrive and direct them to

the sign-in table.3. Start on time even if few people are in attendance.4. Review with the moderator the tasks. Moderator shall have been

prepared before the event. o Moderator welcomes the media and briefl y explains why the

press conference has been called. Also, acknowledge VIPs (speakers).

o Moderator may summarize key messages and opens the ses-sion to questions. The Q & A portion should last no more than 30 minutes.

o Moderator may ask the reporter to identify himself/herself and the name of their organization before asking a question.

o Moderator designates the appropriate speaker to answer the question (in case there is more than one speaker).

o Moderator should not let the press conference drag on or fi zzle out. He/she should step in and formally conclude the proceed-ings.

5. Consider that: o In science journalism, off-the-record, not-for-attribution, no-publi-

cation news conferences are neither unknown nor totally without merit.

o An ideal press conference should last no more than one hour.o TV reporters may still want to get speaker aside for some on-

cam comments after the conclusion of the press conference.

C. After the Press Conference 1. Consider sending thank you notes to the VIPs who attended.2. Distribute press kits to key media who were unable to attend.3. Monitor the press for coverage.

217

SECTION 16CRisk Communication in the Hospital

POLICY BASE

A.O. 168 s. 2004 Section V-C: Policy Statement on Support Systems provides:

3. Media management and public information shall be made readily accessible in such situations. As such, there shall be a designated spokesperson in all health facilities and institutions to respond to inquiries related to health emergencies. Such person should be trained and be readily available, accessible to the media.

RISK COMMUNICATION IN A HOSPITAL SITUATION

During an emergency/disaster, the hospital may be overwhelmed by more members of the media than by actual disaster victims. The presence of these individuals can impair the performance of an already stressed hospital staff if not handled properly.

The right of the public to know must strike a balance with the right of the patient to privacy and quality medical care which media should understand and consider. Doctors must have a conducive working atmosphere and enough working space in treating his/her critically ill patient without having to worry about someone seemingly looking over his/her shoulders.

The activities in the Emergency Room are so critical and urgent that any form of distrac-tion or interruption may impact on the delivery of effi cient and timely patient care.On the other hand, the hospital recognizes that news releases from media can assist in providing information to the families of victims who are looking for their loved ones. Authorities can be contacted to activate the Emergency Broadcast System which dis-seminates information on very short notice to a large number of people. Media provides a mechanism for coordination with other stakeholders.

This familiar scenario during an emergency/disaster highlights the issues confronting the hospitals during a disaster. The hospital takes a broader perspective in its health promotion and advocacy role focused on the risk communication element prior to, dur-ing and after an emergency. The sections on Health Promotion and Advocacy and Risk Communication will serve as a guide to the HEMS Coordinator and other hospital emer-gency managers in the formulation of plans and protocols. A media management protocol may include the following actions as examples. • Identifi cation/designation of a Public Information Offi cer.• Description of roles and functions. • Training for a Public Information Offi cer. • Preparation of guidelines on what information to look for and what information to

share with the Press. • Pre-designation of Press Room/Area. • Preparation of a schedule for press releases guided by the urgency of the informa-

218

tion that needs to be shared. • Clearance from the Incident Commander to release critical information.

While a protocol specifi es the conduct of the duties of the designated Public Informa-tion Offi cer, such as directing members of the press and other media representatives to a designated area of the hospital away from the patient care activities, it should also specify the corresponding role of the hospital staff (e.g., All hospital staff must leave all communications with the press to the designated public information offi cer and they should direct any member of the media to the designated public relations/press area in order to have consistency in the information given out by the hospital.)

An equally important aspect of the Risk Communication Plan is on health promotion and advocacy for behavior that will reduce risks for the patients, health workers and the general public. The hospital is a highly vulnerable area given the supplies and equip-ment used in the provision of services. Risks from internal emergencies and those from external emergencies have to be addressed with messages for staff, for neighboring hospitals and operation partners (such as ambulances, police), for victims/patients and respective families and friends, and for communities in the catchment area. The hos-pital may refer to the HEMS. November 2007, Key Health Messages for Emergencies: Philippines.

SECTION 17 Health System in Emergency or Disaster

The common health risks encountered during disasters are directed at the vulnerable elements of the community, such as the people, properties, environment, livelihood and services. Natural hazards are the most common culprit of disasters nowadays, damag-ing health care facilities and life lines, bringing about detrimental ecological changes, crippling the national economy, disrupting basic health care services, and victimizing the population, not sparing even the health care providers. Accessible, adequate, timely, equitable and orchestrated multisectoral response is deemed necessary to intervene rapidly and effectively to save life and limb.

When a mass casualty incident strikes, Mass Casualty Management is instituted from the disaster or impact site (pre-hospital care) up to the transport of the last victim to the Emergency Room of the receiving hospital for a fast, timely, coordinated and adequate response to minimize morbidity, mortality and disability. Aimed at promptly and effi cient-ly bringing the disrupted emergency and health care services back to routine operation, the MCM is based on: pre-established procedures to be adapted to meet the demands of a major incident; maximization of the use of existing resources; multisectoral prepara-tion and response; and strong pre-planned and tested coordination.

The fi rst fi ve minutes response determines the response for the next fi ve hours.

Immediate response starts with on-site or fi eld management where activities include: scene assessment; setting up of a command post; alerting process; fi eld organization; triaging of victims; establishment of command, control, coordination and communica-tion; search and rescue; and fi eld care. There will be evacuation or transport of victims from the impact site to the appropriate receiving health care facilities for defi nitive care. The green-tagged or the walking wounded victims, together with all other survivors, will be transported or evacuated to safe shelters other than the hospitals.

The safe shelter, evacuation center, or temporary shelter for the displaced population serves as another milieu for adaptation that may prove to be a safe haven or a death-bed for the disaster victims depending on its proper management. Preventive, curative and rehabilitative health services need to be established in this confi ne in support of the compromised condition of the victims and the subnormal condition of the environment. This could be in the context of organizing a suitable health system with only limited or inadequate health resources – whether logistical, fi nancial or human resources – amidst a jeopardized circumstance. This health system needs to address the variety of health needs of this confi ned population during disasters.

COMPONENTS OF A HEALTH SYSTEM DURING DISASTER

A. Organizational Component

1. Incident Command System - command, control, and coordination spearheaded by the CHD Director 2. Organized operational and management support teams a. Health Operation Team 219

220

b. Planning Team c. Logistics/Supply Team d. Administrative Team

Functions: • Operationalize health care delivery in the evacuation site, including man- ning the clinic/hospital at the evacuation center if necessary. • Perform medical management/treatment at the center based on the devel - oped treatment protocols and health program protocols. • Deliver direct health services (immunization, services, therapeutic nutrition, etc.) • Provide water and environmental sanitation services. • Take charge of setting up a surveillance system for outbreak prevention. - Early detection - Monitoring of cases - Case defi nition - Community surveillance - Effective treatment - Rapid response • Conduct health education and promotion at the center. • Provide psychosocial support services to both direct and indirect victims as well as responders. • Manage the logistics, supplies, equipment and other logistical needs at the center.

B. Organized Health Operation

Health Operation Team Composition: a. Medical Team b. Water, Sanitation and Hygiene (WASH) Team c. Food and Nutrition Team d. Surveillance Team e. Psychosocial Team f. Health Education Team

C. Health Service Delivery

1. Disease Prevention Services a. Prevention of communicable diseases such as: • Food and water-borne diseases • Vaccine-preventable diseases • Communicable diseases with epidemic potential • Respiratory diseases b. Disease prevention services • Disease surveillance • Water and sanitation services • Food and nutrition services • Environmental sanitation • Immunization services • Case segregation at the evacuation center

221

2. Disease Control Services a. Early case detection – based on disease surveillance report, and laboratory results b. Proper and appropriate treatment of cases – based on the developed treatment protocols and health program treatment protocols c. Provision of appropriate drugs, medicines and food

Figure S17.1. Strategy for Controlling Communicable Diseases

Control of Communicable Diseases

Primary Prevention

Secondary Secondary SecondarPrevention

Secondary Prevention

TertiaryPrevention

Environmental sanitationFood systemPreventive services provided by health systems

Food systemHealth services

Health system: medical care

Health system: Social services

3. Referral System

Levels of Health Care Services: a. Community-based • Health education • Community surveillance • Environmental sanitation • Feeding programs b. Primary Health Care Services • Out-patient clinic with daytime operation or 24-hour operation • Mobile hospital if necessary • Laboratory • Medical fi rst aid • Treatment/management/stabilization of selected diseases (e.g., rehydration, etc.) c. Hospital Care Services • Referral system • Established network of hospitals • Coordinated ambulance services

D. Health Care Structures

1. Health care facilities in the evacuation site in the form of: • Out-patient clinic with daytime operation • Clinic or hospital with 24-hour operation

222

• Rehydration center • Feeding center for the malnourished children 2. Established Operation Center 3. Warehouse for storage of resources

E. Provision of fi nancial and logistical needs

1. Needed medical equipment and supplies 2. Drugs and medicines 3. Transport vehicles 4. Communication equipment 5. Reporting forms 6. Financial support

F. Systems developed

1. Early Warning and Alert System2. Damage Assessment and Needs Analysis/Rapid Health Assessment 3. Emergency Operations Center4. Mass Casualty Management 5. Management of Mass Dead and Missing6. Public Health Services7. Mental Health and Psychosocial Support8. Coordination and Networking9. Human Resource Development10. Logistic Management11. Health Promotion and Advocacy/ Risk Communication in Public Information and Media Management12. Information Management13. Evaluation !4. Research

223

SECTION 18Evaluation

Once fi nalized and approved, the hospital’s Health Emergency Preparedness, Re-sponse and Recovery (HEPRR) Plan needs continuous evaluation and updating to maintain its viability. The plan should be revised frequently to refl ect changes in staff, technicians, material resources, etc., which have taken place since the plan was pre-pared.

An overall evaluation of the entire process of health emergency management in the hospital is closely interlinked with the competencies of the users of the plan, meaning the Crisis and Consequence Management Committee, HEMS coordinators, and the hospital staff. Continuous improvement of the hospital and its health emergency man-agement process through an evidence-based approach is fundamental to its function. This can be derived from an analysis of the post-incident evaluations (actual experi-ences) and evaluation exercises (hypothetical situations).

POST-INCIDENT EVALUATIONS (PIE)

Post-incident evaluations (PIE) are conducted during the debriefi ng of the deployed teams and at the end of the response phase. The debriefi ng may be done immediately at the conclusion of the event. The evaluation at the end of the response phase is often done in a structured meeting of all participants, which includes a review of events fol-lowing a timeline, analysis of strengths and weaknesses, and drawing up proposed ac-tion to improve/enhance the response work. Other documented sources of insights from actual experiences are the Post-Mission and Final Reports of deployed teams.

The learning process usually centers on the following questions: • What worked well? Why did these work well? • What did not work well? Why not? • What are the insights from these experiences in the context of the event, as well as past events? • What are the recommendations for future response work?

The results shall be included in the Hospital HEMS Coordinator’s Final Report (Form 6) as lessons learned – either as new lessons or validated ones based on previous expe-riences. A critical review of such lessons should be undertaken for “the lessons cannot be said to be fully learned until the recommendations have been implemented and new behaviors demonstrated through subsequent practice or experience.” (WHO/WPRO, 2006)

Post-Incident Evaluation needs to have a comprehensive review of the health emer-gency/disaster which will include the following aspects as modifi ed from Carter (Carter, 1991): • Status of HEPRR plans and preparedness prior to the emergency/disaster • Communications • Early Warning and Alert system including origin(s), transmission and receipt, processing dissemination, action taken (by sender, recipient), functioning of warning systems

• Emergency Operation Center, acquisition, receipt and handling of information,

224

display and assessment of disaster situation, decision-making, dissemination of decisions and information • Activation of the Hospital Emergency Incident Command System and Emergency Response Plan • Mobilization of Response Facilities/Units • Assignment of tasks to units/departments involved in the Response Operation • Operations for internal and external emergencies that carried out search and rescue/search and recovery, casualty handling, initial relief measures, clearance of vital routes/areas, evacuation, restoration of services, handling the mass dead • Mental Health and Psychosocial Support Services • Arrangements for emergency feeding, health, shelter, welfare • Assessment of Risk Communication in Promotion and Advocacy (e.g., Public Information, Media Relations) • Provision of information for recovery programs • Human Resource Development concerns of staff (e.g., Training, Welfare, etc.) • External Assistance arrangements – Central, Regional and International Donors, Community • Any special factors raised by the nature and effects of the particular disaster • Research requirements revealed by the disaster

Where appropriate, the Post-Incident Evaluations can include briefi ng from technical experts on future trends and developments to help achieve optimum utilization of post-incident experiences.

COMPREHENSIVE EXERCISE PROGRAM (DRILLS AND EXERCISES)

A continuing evaluation of the viability of a hospital’s HEPRR plans and of the training of personnel, however, requires exercises of increasing complexity through the implemen-tation of a comprehensive exercise program. Through exercises ranging from orienta-tion exercises, drills, tabletop exercises to functional and full-scale exercises, hospital personnel should be oriented on and familiarized with the plan.

The emphasis is on a comprehensive exercise program made up of progressively com-plex exercises, each one building on the previous one, until the exercises are as close to reality as possible (i.e., making use of scenarios commonly occurring in the hospitals and communities) and, more importantly, until mastery is achieved.

A progressive program has several important characteristics: ■ Involves the efforts and participation of various entities – departments, organizations or agencies. Through the involvement of multiple entities, the program allows the involved organizations to test, not only their implementation of emergency management procedures, but their coordination with each other in the process as well. ■ Is carefully planned to achieve identifi ed goals. ■ Is made up of a series of increasingly complex exercises.

In the progressive internal and external exercises, the role/function of each department/unit in the hospital during the response and recovery phases is closely examined along with their increasing commitment to work in order for the hospital to build/enhance a coordinated, effective response.

The stepwise manner of organizing the exercises ensures that weaknesses are identi-fi ed through simpler and less expensive exercises.

225

The nature of the exercise determines the participants. An orientation for key decision-makers may include a tabletop exercise while a full-scale exercise may involve one department, unit, an entire hospital or community. A functional exercise has the players and also simulators, controllers and evaluators.

The fi ve main types of activities in a comprehensive exercise program are (WHO/WPRO, 2006):

■ Orientation seminars ■ Drills ■ Tabletop exercises ■ Functional exercises ■ Full-scale exercise

These activities build from simple to complex, from narrow to broad, from least expen-sive to most costly to implement, from theoretical to realistic.

Focused on questions of coordination and assignment of responsibilities, orientation exercises are informal discussions aimed at familiarizing participants with plans, roles and procedures. These are considered the minimum requirement for validating a plan or its sections or a facility under development.

Drills are exercises used to develop, evaluate and maintain skills in specifi c proce-dures, such as alerting and notifi cation. A critique of the procedure being tested and the existing capacity of the facility for an appropriate support are parts of every drill.

A tabletop exercise is an informal process in which all the assigned personnel examine and discuss simulated emergency situations, hypothetically respond and resolve prob-lems based on the operational plan and without a tight time constraint. Group participa-tion in identifi cation of problem areas determines the success of its conduct.

An interactive process conducted under time constraints in the health facility (i.e., hospi-tal) is the functional exercise. Designed to validate policies, roles and responsibilities, and procedures of single or multiple emergency management functions or agencies, the functional exercise requires more resources.

A full-scale exercise examines the operational capability of emergency response and management systems. Used to evaluate a component of a total response system, this type requires deployment of more human and material resources for its detailed plan-ning and conduct.

It is suggested that exercises are conducted at least twice a year, such as during the Disaster Consciousness Month of July. Some practical considerations are as follows:

1. Precautionary measures should be taken so as not to alarm the patients during disaster preparedness drills. 2. Simulations are conducted preferably without announcements. 3. Prior to these exercises, training session may be conducted in a stepwise manner: - Session for individual participants to learn their functions/tasks - Separate rehearsals for each section or group of participants, particularly those on evening shift - Comprehensive rehearsal for entire hospital

226

4. Post-exercise assessments are conducted to improve the practical exercises and the components of the HEPRR plans.

Tables S18.1 and S18.2 provide a quick guide for the hospital in the planning and con-duct of a comprehensive exercise program. Table S18.1 shows the comparison of the key characteristics of the fi ve types of exercises and Table S18.2 shows the reasons for the conduct of the fi ve types of exercises.

(NOTE: While the material in these tables was intended for an Operations Center, the information may also be useful for the hospital. A detailed description of the characteristics and some guidelines on the use of the fi ve types of exercises is given in Annex S18.1.)

Table S18.1. Table S18.1. Table S18.1. Comparison of Key Activity Characteristics

Charac-Charac-teristicsteristics

Format

Leaders

Partici-pants

Facilities

Time

Prepara-tion

Orientation

Informal discus-sion in group settingVarious presen-tation methods

Facilitator

Single agency/ department, or cross-functional

Conference room

1-2 hours

Simple prepara-tion, 2 weeks

Drill

Actual fi eld or facility responseActual equip-ment

Manager, su-pervisor, depart-ment head, or designer

Personnel for the function be-ing testedMay include coordination, operations, re-sponse person-nel

Facility, fi eld, or EOC

½-2 hours

Easy to design, 1 monthParticipants need orientation

Tabletop Exercise

Narrative pre-sentationProblem state-ments or simu-lated messagesGroup discus-sionNo time pres-sures

Facilitator

Anyone with a policy, planning, or response role for the type of situation used

Large confer-ence room

1-4 hours or longer

1 month prepa-rationPreceded by orientation and 1 or more drills

Functional Exercise

Interactive, complexPlayers respond to messages (events/prob-lems) provided by simulators.Realistic but no actual equip-mentConducted in real time; stressful

Controller

Players (policy, coordination, and operations personnel)SimulatorsEvaluators

EOC or other operating center (multiple rooms)

3-8 hours or longer

Complex, 6-18 months prepa-rationPreceded by simpler exer-cisesSignifi cant allocation of resources

Full-Scale Exercise

Realistic event announcementPersonnel gather at as-signed siteVisual narrative (enactment)Actions at scene serve as input to EOC simulation.

Controller(s)

All levels of per-sonnel (policy, coordination, operations, fi eld)Evaluators

Realistic settingEOC or other operating center

2 hours to 1 or more days

Extensive time, effort, resources1-1½ years de-velopmentIncluding pre-paratory drills, tabletops, func-tional exercises

Table S18.2. Reasons to Conduct Exercise Program Activities

Orientation

No previous exercise

No recent operations

New plan

New proce-dures

New staff, leadership

New biological risk

Drill

Assess equip-ment capabili-ties

Test response time

Personnel training

Assess inter-agency coop-eration

Verify resource and staffi ng capabilities

Tabletop Exercise

Practice group problem solving

Promote execu-tive familiarity with emergency man-agement plan

Assess plan cov-erage for a spe-cifi c case study

Assess plan coverage for a specifi c risk area

Examine staffi ng contingencies

Assess interagen-cy or interdepart-mental coordina-tion

Observe informa-tion sharing

Train personnel in negotiation

Functional Exercise

Evaluate a func-tion

Observe physical facilities use

Reinforce estab-lished policies and procedures

Assess hospital preparedness

Test seldom-used resources

Assess and strengthen inter-jurisdictional or inter-organiza-tional relations

Full-Scale Exercise

Assess and im-prove information analysis

Assess and im-prove interagency cooperation

Support policy formulation

Assess negotia-tion procedures

Test resource and personnel allocation

Assess and strengthen inter-jurisdictional or inter-organiza-tional relations

Assess personnel and equip-ment locations

Test equipment capabilities

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SECTION 19Research and Development

POLICY BASE

A.O. 168 Section V-C:.Policy Statement on Support Systems states:

10. There should be a system for documentation of lessons learned from all health emergency incidents.

IMPORTANCE OF HEALTH EMERGENCY/DISASTER RESEARCH

Research is one of the Health Emergency Management strategies. Its importance can-not be overemphasized as this provides inputs to and serves as a feedback mechanism for policy and program development.

The rich amount of data and information generated by health emergency and disasters can be maximized, through research studies, in promoting evidence-based manage-ment. Health Emergency/Disaster Management is a dynamic process that varies in every event. Even the policies, systems developed, and the guidelines that go with these events have been evolving to keep pace with the changing times, technology, and degree of disaster impacts on the community.

Closely linked with operations management is the search for the “Best Practices” in all phases. Learning from the response and recovery phases has been the basis for the signifi cance accorded the preparedness phase.

The critical analysis that is central to research is not the sole prerogative of the aca-deme. The hospital can seek guidance regarding appropriate research methods and tools but it remains the key decision-maker, the principal investigator, and the benefi -ciary and immediate user of the results, either in modifying existing policies and pro-cedures or developing new ones. Moreover, the results can help in the identifi cation of new areas of concern where there is limited information and where studies have not been conducted.

Research is useful to Health Emergency/Disaster Management in the following ways: • For input to decision-making, e.g., development or revision of policies, procedures and tools • For monitoring and evaluation purposes, e.g., to test the functionality and effectiveness of health emergency policies, operations and systems • As source of data for developing teaching materials • For sharing experiences locally and internationally, e.g., success stories, lessons learned and best practices

Some sources of data or information for research activities are:

• Success stories, lessons learned, and best practices brought about during the health emergency/disaster management • Statistical data and reports gathered related to the disaster

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• Surveillance reports • Hazards, varying impacts and risks of the disaster to the community • Peculiarities, innovations, and practices of emergency operations and systems • Post-incident Evaluation Report • Rapid Health Assessment Report

TYPES OF RESEARCH ACTIVITIES THAT MAY BE CONDUCTED

Depending on the level of information available for an area of concern, the hospital may conduct research on any of the following: • Need for a program/procedure • Structure , processes and effects • Effectiveness and effi ciency concerns • Client satisfaction • Differential value of the program across populations

The choice between descriptive and analytical studies is largely dependent on the state-of-the art information for the particular intended study. Of interest to health emergency managers are the different types of researches, such as policy research, operational and methodological researches, and epidemiological researches on health conditions related to disasters.

Fundamental to the institutionalization of the documentation process is the systematic identifi cation and validation of “Best Practices.” Hospitals in hazard-prone areas are liv-ing “Experience Resource Centers” whose documentation and refl ection of experiences need to be distilled and shared to improve health care in an emergency/disaster situ-ation. The HEMS Coordinator needs to works closely with the Regional Research and Development Coordinator for the organization of such centers and the systematization of knowledge processing. An initial step is the system for documentation mandated in the National Policy. Networking with academe in the catchment area will be a valuable relationship to nurture toward this end.

Among the initiatives in the documentation process to date are the following publica-tions: 1. Health Emergency Management Staff, Department of Health (2005). Responding to Health Emergencies and Disasters: The Philippine Experience 2. Bi-annual Proceedings of the Health Emergency Management Convention (2001, 2003, 2005, 2007)

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Standard Operating Procedures in Mass Casualty IncidentSOP I: INFORMATION AND DISPATCH

(OPCEN CENTRAL, CHD OPCEN, HOSPITAL OPCEN)

PROCEDURES

For the use of the local system.Proper message handling and verifi cation (Use Form I):.1. Get details of the caller and the incident if received by telephone (type, place, magnitude).2. Verify through DOH agencies (HEMS Central, CHDs, Hospi- tals, etc.) a. If reliable, dispatch assessment teams immediately. b. If not reliable, verify by dialing the return call number, or call other reliable agencies (BFP, Police, NDCC/ RDCC/PDCC, LGU’s, etc.) 3. Set a limit as to how long to verify and decide the needed action to be taken.

1. Your superiors2. DOH Central Operations Center – for health emergencies especially MCI 3. EARNET – for ordinary emergencies/incidents (police, fi re and health)4. Respective local government units – if within their catchment area5. Region/offi ce concerned (regional catchment area)6. Respective RDCC, PDCC, etc.7. Others depending on individual local arrangements

1. Call your Medical Controller to manage the event.2. Dispatch a Rapid Assessment Team initially to the site and report to the Incident Commander.3. Depending on the report of assessment, send a medical team.4. Identify and designate a Field Medical Commander when sending more than one team.5. Always inform HEMS Central OpCen and other appropriate agencies.6. Monitor the incident and have continuous coordination with the on-site team and your OpCen.7. Send additional teams as needed and as recommended by the Field Medical Commander. 8. For anticipation of longer missions, schedule duties and shift ing of several teams considering their capability.9. Document everything; preferably have a board to put up data for easier analysis.10. Anticipate possible inquiries by press or higher offi cials; designate a spokesperson to answer all inquiries.

STEPS

1. Verifi cation of 1. Verifi cation of report (coming (coming from radio, telephone, televi- phone, television, Internet, sion, Internet, etc.)

2. Whom to inform (within (within the organiza- the organization, outside the organization)

3. What to do initially

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PROCEDURES

1. Alert other hospitals within the vicinity/catchment area for possible back-up. 2. Perform continuous regular reassessment of the situation. 3. Alert all other hospitals when the magnitude of the incident necessitates their participation.

Responding Teams1. Advanced Cardiac Life Support medicines and supplies2. Appropriate ambulance and transport vehicle with communication equipment3. Inventory of emergency drugs and supplies4. Standardized recording sheets (patients, response groups, problems actions taken, locator chart, maps, etc.5. Briefi ng of the team members6. Provisions like food, etc.Operations Center1. Inventory of resources, manpower, etc.2. Review of stock level of drugs and supplies3. Locator maps, white board, marker, eraser, etc.4. Communication equipment5. Status of traffi c and access routes in the area

Information needed:1. Precise location of the event2. Time of the event3. Type of the incident4. Estimated number of casualties, nature of injuries, disposition5. Added potential risk6. Exposed population7. Resources needed (need for public health teams, sanitation teams or psychological teams, etc.)8. List of response groups and their capabilities9. Problems encountered and actions taken10. Coordination needed especially with transporting of victims to hospitals11. Suggestions/recommendations

1. Status of incident and resources2. Activities that transpired during the tour of duty3. Problems encountered and actions taken4. Pending problems and current actions being done5. And other special concerns

STEPS

4. Alerting other hospitals/rescue teams

5. Preparations done while waiting (to include supplies to be prepared by the Operation Cen- ter and responding teams)

6. Coordination with the Field Medical Com- mander (initially during the fi rst 24 hours)

7. Endorsement of staff (data needed)

Continuation of SOP I, Information and Dispatch

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SOP II: SITE SELECTION, SIGNAGES AND LOGISTICS

PROCEDURES

Identifi ed by the Field Medical Commander with concurrence of the Incident/Scene Commander upon considering the fol-lowing criteria:1. Safety from the disaster impact and from natural factors2. Security not a problem3. Proximity, easy route access and upstream location4. Available/accessible water source (preferably potable) and provision for waste disposal5. Communication access6. Route to ingress/egress7. Spacious terrain – fl at surface preferably with protective covering8. Should not disrupt activities of other response groups

All Health Sector’s response teams/hospitals must have the corresponding signages in the following areas and must provide their own when responding. All letters must be be refl ectorized and readable at 20 feet. 1. Advance Medical Post, Field Medical Commander2. Triage Area, Triage Offi cer3. Treatment Area (red, yellow, green, black fl ags and banner), Treatment Offi cer4. Ambulance Loading Area, Transport Offi cer5. Staging Area, Staging Offi cer6. Mortuary Area, Mortuary Offi cer

1. Personnel2. Communication equipment3. Medical equipment4. Medical supplies (toxicology kit, trauma kit)5. Emergency drugs 6. Defi brillator; suction machine7. Electrical supplies/generator8. Jump and/or emergency kits9. Cot beds, intravenous stand, tents10. Food and water provision – mess area at staging/R&R area11. Personal protective equipment

STEPS

1. Selection of the Advance Medi- cal Post

2. Signages

3. Logistics needed at the site

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SOP III: HANDLING OF EQUIPMENT ATTACHED TO THE PATIENT

PROCEDURES

1. There should be proper documentation.2. Equipment should be properly labeled.3. Standard form should be used for retrieval purposes.4. There should be a standing agreement between the receiving hospital and responding units for temporary non-disposable gadgets/supplies and equipment, and for fi nal turnover at a later time.5. In case receiving hospital has no available gadgets/ equipment for exchange, proper documentation using standard form should be accomplished for easy retrieval.6. Form should be accomplished and duly signed by the nurse supervisor and by the team leader of the responding unit.7. The hospital should designate an area/person where the referring team can retrieve such equipment later.8. A person should be assigned to handle the equipment.

1. Splint a. Traction splints b. Foam-padded splints c. Cravats d. Vacuum splints e. Air splints2. Cervical collar3. Bag valve apparatus4. Thoracostomy bottle5. ET and oral airway6. Spine board7. Medical anti-shock trouser8. Kendricks extrication device9. Thoracostomy and tracheostomy tubes10. Traction device11. Vacuum mattress12. Foley catheter13. NGT14. Monitoring patches15. Bandages16. Needles

STEPS

1. Role or responsibility of the receiving hospital in the handling of medical equipment hooked/ attached or connected to the victims

2. Equipment/ gadgets that should not be removed from the patient unless advised by the doctor

Form

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ANNEX 1Considerations in Hospital Design,

Energy and Communications

INTRODUCTIONINTRODUCTION

The types of disasters that may occur during the useful life of a hospital are earth-quakes, fi res, fl oods and explosions. The frequency and intensity of these hazards will differ according to the building’s location. Owing to the highly important function per-formed by hospitals in times of disaster, the safety provisions for the protection of hu-man lives and equipment are the same regardless of the type of disaster.(PAHO, 1983). Minimum requirements to be met by all hospitals are discussed below.

STRUCTURE

The structure should be designed in accordance with the national anti-seismic regula-tions. It should follow all national regulations, such as the Building Code, the Fire Safety Code, the Sanitation Code, etc.

It will be necessary to calculate the seismic risk over the useful life of the building, using attenuation coeffi cients appropriate to the place. The structure will be designed for the highest-intensity earthquake expected during that period.

The construction materials used should be reinforced concrete or steel, depending on the availability and cost of each. In all cases, the parts of the structure should be rein-forced to attain a 180-minute resistance to fi re (RFA 180). The inner walls and partitions should be RFA 120.

Stairwells should be located so as not to produce a torque effect on the structure when it is subjected to horizontal forces.

The structure of the stairways should have the same resistance to fi re specifi ed for the structure of the building.

LOCATION WITHIN THE PROPERTY

The main façade of all the buildings of the hospital should face a public thoroughfare. Another façade should face a private street or inner court at least 10 meters wide where vehicles can enter.

ISOLATION OF AREAS

Anesthesia and pharmacy rooms and other areas used for storing dangerous supplies (such as chemical reagents, radioactive materials, fuel, etc.) should be isolated com-partments protected with fi reproof walls. In buildings four or more stories high, escape routes of bedroom areas should be compartmentalized.

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ESCAPE ROUTES

All doors should open in the direction of traffi c exiting through an escape route. Auto-matically closing doors with “antipanic” locks should be installed in places designed to accommodate 50 or more people. Hospital and infi rmary exits should be at least 1.2 meters wide.

Wards of 15 or more persons should have at least two exits, one at each end. Ward exits should open directly onto hallways.

Hallways should be at least 1.5 meters wide. A hallway along which beds or stretchers are moved should be at least 2.4 meters wide.

In buildings of two or more stories, ramps should be provided as part of the escape route so that bed patients may be evacuated.

All doors opening into an escape route should be at least 1.1 meters wide.

SIGNS

The following signs should be put in place: a. Signs indicating the escape routes b. Signs indicating equipment c. Building layout diagrams

“Exit” signs should be placed at all emergency exit doors providing access routes and leading to stairways. These signs should be placed over the door at a height 2.25 me-ters above the fl oor.

All signs should be lit as long as the building is occupied.

All buildings should contain diagrams showing the location of the various types of alarm and fi refi ghting equipment. Such diagrams should be placed on each fl oor of the build-ing in places where they are visible to building personnel.

All fi refi ghting equipment that can be used by the staff should have precise instructions beside the equipment itself.

A diagram showing a person’s location in relation to escapes routes should be installed in each area.

FIRE DETECTION, ALARM AND CONTROL EQUIPMENT

Ionic-type, linear-operation fi re detection equipment should be installed at the rate of one detector for every 50 m2 of fl oor space. The building should have an alarm center, preferably in the basement.

The building should be equipped with ABC type portable extinguisher for every 200 m2 of fl oor space and at least one per fl oor. An extinguisher should never be more than 20 meters away.

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SERVICES

Water supply

The fi re extinguishing system should consist of a tank with a capacity of at least 30 m2,,a pumping system capable of providing a pressure of 75 lbs./inch2, and iron piping. The system’s distribution line should have a built-in automatic extinguisher system with automatic sprinklers. There should be one sprinkler for every 15 m2 of fl oor space.

Drains

The drainage system should be of the separator type; if there is no connection to the public sewer system, a septic tank or seepage pit should be provided.

Contaminants and/or radioactive materials

If it is necessary to dispose of this type of contaminants or radioactive materials within the perimeters of the hospital, an underground reinforced concrete tank should be constructed as far away from the building as possible. The tank should be covered by a layer of soil at least 2 meters thick.

Electric energy

The following points should be checked with respect to:

Hospital’s electrical installations

1. Have available and up-to-date installation plans. 2. Check type of switchover to the emergency power plant. • If automatic, check to see that it is operating normally. If not automatic, determine the procedure to be followed to transfer the load. • If the switchover is normal, step-by-step instructions for transferring the load should be available in an accessible place. 3. Check the length of time the emergency plant’s fuel reserves will last. 4. Check the equipment once a month. 5. Keep the fuel tank full. 6. Identify the equipment and installations that operate with the emergency plant.

Energy source

1. Request for a generator with at least 40 percent of the transformer capacity of the hospital, if the hospital does not have an emergency plant. Know the cycles (60 or 50 Hz) of the generator required, the type of connection to the distribution line (delta or star), and the voltage of the hospital’s system

Take the following steps:

• Determine where the generator will be placed and how it will be connected. Bear in mind noise and contamination problems.

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• Determine the fuel consumption of the generator to be installed per 24- hour period. • Determine how fuel is to be supplied to the generator to keep it in opera tion. • Have a diagram showing the distribution boxes that must be disconnected in order for the generator to function correctly.

2. Know the source of electric supply for the X-ray equipment: • If it is connected to the main distribution box, it may be fed by either the hospital’s emergency plant, if one exists, or by the generator furnished for the emergency. • If the X-ray equipment has its own feeder system, it will be necessary to install a generator solely for that equipment; the generator’s capacity should be that of the X-ray equipment. The fi rst three steps in installing a generator (No. 1 above) should be considered.

3. Determine if a special system provides emergency service in operating rooms and intensive care units. This system provides uninterrupted energy supply to those areas. An emergency system refers to a direct current system and is an alternative to the systems described above.

4. Check the batteries (charge and acid) at least once a week. Know exactly how long the batteries will continue to hold the charge with all the equipment in operation. Determine the source of power for charging the batteries in the event of failure of the power distribution network.

5. Know the hospital substation’s transformer capacity.

Communication service

Have the hospital’s communications diagram available and updated. For this purpose, do the following:

1. Determine the point of origin of the telephone trunk lines feeding the hospital. 2. Determine how the communications equipment is supplied with energy in the event of a failure in the power distribution network. Determine: a. Whether it will be fed by the hospital’s emergency plant (the hospital’s own generator or a borrowed one); or b. Whether it will be fed by a generator operating exclusively for hospital communications; c. The size of the generator in relation to the communications system’s load, cycles (50 or 60 Hz), type of connection, and feeder voltage of the communication network. d. Where the generator will be placed and how it will be connected. e. The generator’s consumption of fuel in a 24-hour period and the type of fuel it uses. 3. Locate and identify all of the hospital’s secondary telephone lines. 4. Locate all the loudspeakers of the hospital’s public address system. 5. Check the operation of the telephone switchboard and the public address system, if any. Preferably, there should be a switchboard for the reserve loudspeakers and the use of the switchboards should be alternated.

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6. Check the operation of the blinker paging system or any hospital communication equipment at least once every two weeks. 7. Have in mind a place for locating and feeding a set of equipment for communication with the outside world in the event of failure of the telephone lines. Preferably, the hospital should always have equipment of this type on hand and its operation should be checked daily. 8. Keep on hand for emergencies some battery-operated portable speakers.

DRILLS

Simulation exercise for any type of disaster should be conducted at least once a year.Each member of the hospital should be assigned a specifi c function to facilitate evacuation of the building.

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ANNEX S18.1Five Types of Evaluation Exercises:

Characteristics and Guidelines

ORIENTATION SEMINARORIENTATION SEMINAR

As the name suggests, an orientation seminar is an overview or introduction. Its pur-pose is to familiarize participants with roles, plans, procedures or equipment. It can also be used to resolve questions of coordination

Format

Applications

Leadership

Participants

Facilities

Orientation Seminar Characteristics

The orientation seminar is a very low-stress event, usually presented as an informal discussion in a group setting. There is little or no simu-lation. It is for this reason that orientations are not usually recognized as exercises, but they are an important part of the cycle. A variety of seminar formats can be used, including:■ Lecture■ Discussion■ Slide or video presentation■ Computer demonstration■ Panel discussion■ Guest lecturers

The orientation seminar can be used for a wide variety of purposes, including:■ Discussing a topic or problem in a group setting.■ Introducing something new (e.g., policies, plans and resources).■ Explaining existing plans to new people (e.g., staff, newly elected offi cials or executives who need an explanation of the EOP and their role at the EOC; new employees who need an orientation to operational plans as they relate to emergencies).■ Introducing a cycle of exercises or preparing participants for success in more complex exercises.■ Motivating people for participation in subsequent exercises.

Orientations are led by a facilitator, who presents information and guides the discussion. The facilitator should have some leadership skills, but very little other training is required.

A seminar may be cross-functional – involving one or two participants from each function or service being discussed (e.g., management, pol-icy, coordination, and operations staff). Or, it may be geared to several people from a single agency or department.

A conference room or any other fi xed facility may be used, depending on the purposes of the orientation.

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Time

Preparation

Continuation of Orientation Seminar Characteristics

Orientations should last a maximum of 1 to 2 hours.

An orientation is quite simple to prepare (two weeks’ preparation time is usually suffi cient) and conduct. Participants need no previous train-ing.

Guidelines in Conducting an Orientation Seminar

There are no cut-and-dried rules for an effective orientation; its purpose will determine its format. Here are the general guidelines:

■ Be creative. You can use various discussion and presentation methods. Think of interesting classes that you have attended in other subjects, and borrow the techniques of good teachers and presenters. For example, you might call on people one by one to give ideas, plan a panel discussion, hold a brainstorming session, present case studies for problem solving, or give an illustrated lecture.

■ Get organized and plan ahead. Even though orientation seminars are less complex than other activities, it is no time to “wing it.”

■ Be ready to facilitate a successful orientation seminar. Discourage long tirades, keep exchanges crisp and to the point, focus on the subject at hand, and help everyone feel good about being there.

DRILL

A drill is a coordinated, supervised exercise activity, normally used to test a single spe-cifi c operation or function. With a drill, there is no attempt to coordinate organizations or fully activate the EOC. Its role in an exercise program is to practice and perfect one small part of the response plan and help prepare for more extensive exercises, in which several functions will be coordinated and tested. The effectiveness of a drill is its focus on a single, relatively limited portion of the overall emergency management system. It makes possible a tight focus on a potential problem area.

Format

Applications

Drill Characteristics

A drill involves actual fi eld or facility response for an EOC operation. It should be as realistic as possible, employing any equipment or appa-ratus for the function being drilled.

Drills are used to test a specifi c operation. They are also used to provide training with new equipment, to develop new policies or pro-cedures, or to practice and maintain current skills. Drills are a routine part of the daily job and organizational training in the fi eld, in a facil-ity, or at the EOC. Example of a drill conducted by the hospital is an evacuation drill.

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Leadership

Participants

Facilities

Time

Preparation

A drill can be led by a manager, supervisor, department head, or ex-ercise designer. Staff must have a good understanding of the single function being tested.

The number of participants depends on the function being tested. Co-ordination, operations, and response personnel could be included.

Drills can be conducted within a facility, in the fi eld, or at the EOC or other operating center.

One-half hour to 2 hours is usually required.

Drills are one of the easiest kinds of exercise activities to design. Preparation may take about a month. Participants usually need a short orientation beforehand.

Continuation of Drill Characteristics

Guidelines in Conducting a Drill

How a drill is conducted varies according to the type of drill – ranging from simple oper-ational procedures to more elaborate communication and command post drills. For ex-ample, a command post drill would require participants to report to the drill site, where a “visual narrative” would be displayed in the form of a mock emergency. Equipment, such as vans, command boards, and other needed supplies would be made available.

Given the variety of functions that may be drilled, there is no set way to run a drill. How-ever, some general guidelines in the conduct of drills are as follows:

■ Prepare. If operational procedures are to be tested, review them beforehand. Review safety precautions.

■ Set the stage. It is always good to begin with a general briefi ng, which sets the scene and reviews the drill purpose and objectives. Some designers like to set the scene using fi lms, slides or videotapes.

■ Monitor the action. After a drill has been started, it will usually continue under its own steam. If you fi nd that something you wanted to happen is not happening, however, you might want to insert a message to trigger that action.

TABLETOP EXERCISE

A tabletop exercise A tabletop exercise A is a facilitated analysis of an emergency situation in an informal, stress-free environment. It is designed to elicit constructive discussion as participants examine and resolve problems based on existing operational plans and identify where those plans need to be refi ned. The success of the exercise is largely determined by group participation in the identifi cation of problem areas.

There is minimal attempt at simulation in a tabletop exercise. Equipment is not used, resources are not deployed, and time pressures are not introduced.

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Format

Applications

Leadership

Participants

Facilities

Time

Tabletop Exercises

The exercise begins with the reading of a short narrative, which sets the stage for the hypothetical emergency. Then, the facilitator may stimulate discussion in two ways:

■ Problem statements. Problem statements (describing major or detailed events) may be addressed either to individual participants or to participating departments or agencies. Recipients of problem statements then discuss the actions they might take in response.■ Simulated messages. These messages are more specifi c than problem statements. Again, the recipients discuss their responses.

In either case, the discussion generated by the problem focuses on roles (how the participants would respond in a real emergency), plans, coordination, the effect of decisions on other organizations, and simi-lar concerns. Often, maps, charts, and packets of materials are used to add to the realism of the exercise.

Tabletop exercises have several important applications. They:

■ Lend themselves to low-stress discussion of coordination and policy. ■ Provide a good environment for problem solving. ■ Provide an opportunity for key agencies and stakeholders to be come acquainted with one another, their interrelated roles, and their respective responsibilities.■ Provide good preparation for a functional exercise.

A facilitator leads the tabletop discussion. This person decides who gets a message or problem statement, calls on others to participate, asks questions, and guides the participants toward sound decisions.

The objectives of the exercise dictate who should participate. The exercise can involve many people and many organizations – essen-tially anyone who can learn from or contribute to the planned discus-sion items. This may include all entities that have a policy, planning or response role.

A tabletop exercise requires a conference or meeting room where par-ticipants can surround a table.

A tabletop exercise usually lasts from 1 to 4 hours but can be longer. Discussion times are open-ended, and participants are encouraged to take their time in arriving at in-depth decisions – without time pres-sure. When the time is up, the activity is concluded. Although the facilitator maintains an awareness of time allocation for each area of discussion, the group does not have to complete every item in order for the exercise to be a success.

Preparation It typically takes about a month to prepare for a tabletop exercise. Preparation also usually requires at least one orientation and some-times one or more drills.

Continuation of Tabletop Exercises

FUNCTIONAL EXERCISE

A functional exercise is a fully simulated interactive exercise that tests the capability of an organization to respond to a simulated event. The exercise tests multiple functions of the organization’s operational plan. It is a coordinated response to a situation in a time-pressured, realistic simulation.

A functional exercise focuses on the coordination, integration, and interaction of an organization’s policies, procedures, roles and responsibilities before, during or after the simulated event.

Format

Applications

Functional Exercise Characteristics

This is an interactive exercise – similar to a full-scale exercise without the equipment. It simulates an incident in the most realistic manner possible short of moving resources to an actual site. A functional exer-cise is:

■ Geared for policy, coordination, and operations personnel – the “players” in the exercise – who practice responding in a realistic way to carefully planned and sequenced messages given to them by “simulators.” The messages refl ect ongoing events and problems that might actually occur in a real emergency.

■ A stressful exercise because players respond in real time, with on- the-spot decisions and actions. All of the participants’ decisions and actions generate real responses and consequences from other players.

■ Complex. Messages must be carefully scripted to cause participants to make decisions and act on them. This complexity makes the functional exercise diffi cult to design.

Functional exercises make it possible to test several functions and exercise several agencies or departments without incurring the cost of a full-scale exercise. A functional exercise is always a prerequisite to a full-scale exercise.

In some instances, taking part in a functional exercise may serve as a full-scale exercise for a participating organization (e.g., a hospital may conduct its own full-scale exercise as part of a community-based functional exercise).268

Leadership and Partici-pants

Facilities

Time

Preparation

Functional exercises are complex in their organization of leadership and the assignment of roles. The following general roles are used:

■ Controller: Manages and directs the exercise■ Players: Participants who respond as they would in a real emer gency (Players should include policymakers; may include coordinators and operational personnel directing fi eld activities.)■ Simulators: Assume external roles and deliver planned messages to the players■ Evaluators: Observers who assess performance

It is usually conducted in the EOC or other operating center. Ideally, people gather where they would actually operate in an emergency. Players and simulators are often seated in separate areas or rooms. Realism is achieved by the use of telephones, radios, televisions and maps.

A functional exercise requires from 3 to 8 hours, although it can run a full day or even longer.

Plan on 6 to 18 months or more to prepare for a functional exercise, for several reasons:

■ Staff members need considerable experience with the functions being tested. ■ The exercise should be preceded by lower-level exercises, as needed.■ The controller, evaluators and simulators require training.■ The exercise may require a signifi cant allocation of resources and a major commitment from organizational leaders.

Continuation of Tabletop Exercises

FULL-SCALE EXERCISE

A full-scale exercise simulates a real event as closely as possible. It is an exercise designed to evaluate the operational capability of emergency management systems in a highly stressful environment that simulates actual response conditions. To accomplish this realism, it requires the mobilization and actual movement of emergency personnel, equipment and resources. Ideally, the full-scale exercise should test and evaluate most functions of the emergency management plan or operational plan.

A full-scale exercise differs from a drill in that it coordinates the actions of several enti-ties, tests several emergency functions, and activates the EOC or other operating cen-ter. Realism is achieved through: ■ On-scene actions and decisions from Policy Groups ■ Simulated “victims” ■ Rapid Detection, Reporting and Response requirements ■ Communication devices ■ Equipment deployment ■ Actual resource and personnel allocation

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Format

Applications

Leadership and Partici-pants

Facilities

Time

Preparation

The exercise begins with a description of the event, communicated to responders in the same manner as would occur in a real event. Per-sonnel conducting the fi eld component must proceed to their assigned locations, where they see a “visual narrative” in the form of a mock emergency (e.g., a plane crash with victims, a “burning” building, a simulated chemical spill on a highway, or a terrorist attack). From then on, actions taken at the scene serve as input to the simulation taking place at the EOC or operating center.

Full-scale exercises are the ultimate in the testing of functions – the “trial by fi re.” Because they are expensive and time-consuming, it is important that they be reserved for the highest priority hazards and functions.

One or more controllers manage the exercise, and evaluators are re-quired. All levels of personnel take part in a full-scale exercise:■ Policy personnel■ Coordination personnel■ Operations personnel■ Field personnel

The event unfolds in a realistic setting (e.g., outbreak in a community, an IHR Event attack at a public venue). The EOC or other operating center is activated, and fi eld command posts may be established.

A full-scale exercise may be designed to be as short as 2 to 4 hours, or to last as long as 1 or more days.

Preparation for a full-scale exercise requires an extensive investment of time, effort and resources – 1 to 1½ years to develop a complete exercise package. This timeframe includes multiple drills and prepa-ratory tabletop and functional exercises. In addition, personnel and equipment from participating agencies must be committed for a pro-longed period of time.

Full-Scale Exercise Characteristics

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