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Monitoring and reporting of Foreign Medical teams (FMT)

arriving in the aftermath of earthquakes

Contents 1. Background ......................................................................................................................... 2

2. Introduction ......................................................................................................................... 3

2.1. Intended audience ........................................................................................................ 3

2.2. Purpose of this document ............................................................................................ 3

3. Scenarios of response .......................................................................................................... 4

3.1. The national health services are able to provide trauma care; ..................................... 4

3.2. The needs clearly exceed the national health capacity ................................................ 5

3.3. Intermediate cases ........................................................................................................ 6

4. Reporting on arrival ............................................................................................................ 6

4.1. Linkage with proposed global registry of providers .................................................... 6

4.2. OSOCC at point of entry ............................................................................................. 7

a. Principles for a FMT OSOCC ..................................................................................... 7

b. Requirements ............................................................................................................... 7

4.3. Template of on-site registration form (basic information) .......................................... 8

5. Periodic reporting ............................................................................................................. 10

5.1. Rationale for reporting ............................................................................................... 10

5.2. Modalities of reporting .............................................................................................. 10

5.1. Template for periodic reporting by FMT .................................................................. 10

6. Referral of patients to local or national health services ................................................... 12

7. Departure hand-over reporting ......................................................................................... 13

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1. Background Among the Sudden Onset Disasters (SOD), earthquakes are those producing the largest

number of traumas requiring rapid and massive medical response. Contrarily to complex

disasters (conflicts) where casualties are usually produced over days and weeks, earthquakes

do produce most if not all injuries in a matter of seconds or minutes presenting a formidable

challenge to local health services and the humanitarian community. Conditioning the initial

response to the availability of data (evidence-based) and progressively learning from ongoing

experience are ruled out for the early responders.

Large sudden onset natural disasters have historically generated a surge of generosity and

solidarity from the international community. This solidarity often expressed itself in the rapid

dispatch of medical teams and donations of health supplies.

As recognized by the UN resolution 46/182 and again in 48/57,”the affected State has the

primary role in the institution, organization, coordination and implementation of humanitarian

assistance within its territory”.On one side, the affected countries are increasingly attempting

to coordinate and assume their responsibilities, on the other side, the number of foreign

respondents, field hospital or medical teams, has rapidly increased in number. The

competence of the Foreign Medical Teams and the standard of their services are however very

variable, from the increasingly well trained and equipped facilities established by donor

governments, the Red Cross system or specialized medical NGOs down to the ad hoc teams

or individuals with no particular experience, competence or even ethical standards.

Over the decades, internal efforts were made to optimize the medical response to earthquakes.

In order to improve the medical response, WHO and PAHO developed in 2003

Guidelines on the use of Foreign Field hospitals in consultation with experts from

donor as well as disaster affected countries.1 The response to the Tsunami in 2004 and

the earthquake in Haiti (2010) suggests that those technical guidelines were mostly

ignored at the time of the decision to send those medical teams.

Aware of the need for increased sectorial coordination, the humanitarian community

launched in 2004 an independent Humanitarian Response Review of the global

humanitarian system. The review assessed the humanitarian response capacities of key

external humanitarian actors.2 Following the recommendations of the review, the

cluster approach was proposed as “a way of clarifying the division of labour among

external organizations, and better defining their roles and responsibilities within the

different sectors of the response”.3 Intended to “make the humanitarian community a

better partner for host governments, local authorities and local civil society”, the

1 http://www.who.int/hac/techguidance/pht/FieldHospitalsFolleto.pdf

2 The review was limited to external agencies and did not cover local actors and stakeholders.

3 http://oneresponse.info/COORDINATION/CLUSTERAPPROACH/Pages/Cluster%20Approach.aspx

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Clusters had often the unintended consequence to marginalize the national health

authorities and weaken their coordination role.

The results were not particularly impressive: In large disasters and in particular in the case of

Haiti, both the national and international mechanisms (respectively the Ministry of Health and

the Health Cluster under WHO leadership) failed to properly filter, monitor or coordinate the

incoming medical teams.

On the urge of the recommendations from a global Technical Consultation on Foreign

Medical Teams (FMT) held in Havana, Cuba in December 2010, the Global Health Cluster

resolved to create an international register of FMT provider organizations and established a

FMT working Group to guide and monitor the progress.

2. Introduction

2.1. Intended audience The present document is directed to:

the institutions responsible for coordinating the medical care response at national /

local level (usually the Ministry of health) as well as at international level (the health

Cluster);

the organizations likely to provide FMTs;

those providing financial support for the medical response (government agencies,

foundations or the public).

2.2. Purpose of this document This documents aims to provide guidance to improve coordination and effectiveness of the

combined national and international response to a large number of traumas caused by SOD,

especially earthquakes. It will outline realistic scenarios of deployment of this response based

on past experience.

More specifically, it provides the coordinators with guidelines for the monitoring and

coordination of FMTs and templates for locally registering those teams and monitoring their

activities. The model reports and templates include only the basic minimum actionable data

that authorities should demand and obtain from the FMTs.

Those templates are intended for severe disasters leading to a major international response,

whether or not it is required. Under other less challenging situations, the templates may

benefit from being expanded keeping in mind that frequently too much data are requested

from actors, leading to low reporting rate and lack of resources and time for their meaningful

analysis and evidence-based action.4

4 This is particularly the case when reporting requirements are designed by interagency committees.

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3. Scenarios of response The guidelines are particularly applicable to developing or emerging countries affected by a

major earthquake. It is assumed that the country is not affected by conflicts or complex

disasters and that its Government shares the humanitarian ideals and objectives to provide free

and impartial care to the affected population.

Three types of scenarios can be observed according to the balance between needs for trauma

care and local availability of services:

1. The capacity of the health services at national level is and remains clearly sufficient to

provide timely care to the number injured;

2. The number of injuries clearly exceeds the absorption capacity of the affected country

health system;

3. It is unclear whether the country has the full capacity to provide the necessary medical

care.

These guidelines will focus particularly on the latter two scenarios.

3.1. The national health services are able to provide trauma care; This situation will be particularly noted in the larger and/or more developed countries. In all

SOD, the National Health Service is mobilizing its full capacity to provide medical care long

before the first FMT can arrive. The same surge of solidarity noted internationally is indeed

taking place locally. In many countries, local teams are much better placed to provide rapid

assistance but may lack the required support (supplies, equipment, communication, transport,

personal subsistence…). Examples of local response abound: from the earthquakes in Bam

(2003, Iran) and Chile (2010) to the 2004 tsunami in India, Sri Lanka, Thailand and in lesser

extent Indonesia.

In those cases, the affected country must indicate very early that FMTs are not required or at

least should not arrive without prior specific clearance from the health sector/cluster. The

international generosity should be redirected towards the support (material or financial) of the

response of the national medical community.

Some caution should be exercised by the national MoH before concluding that no external

medical may ever be wanted.5 National pride and sense of sovereignty may occasionally

cloud the initial judgment. Even “self sufficient” countries may benefit from the experience in

health humanitarian coordination that the Health Cluster and its Lead Agency (WHO) or from

highly specialized medical expertise in themes unfamiliar to the health services

(rehabilitation, spinal injuries, crush syndrome) offered by some NGOs. Finally, although, the

experts and coordinators in the health sector may feel unnecessary or even counterproductive

the arrival of FMTs, a different decision is often taken at a higher (and more political) level.

5According to OCHA, out of 27 “Mega-cities” which are defined as having a population > 8 million: 1/3 are in

earthquake prone zones.

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Consequently, adopting procedures for registration of incoming FMT and developing a

national protocol for their monitoring and reporting remain necessary as evidenced by the

response to recent disasters.

3.2. The needs clearly exceed the national health capacity This situation is most likely to occur in smaller countries with limited resources or those with

poor health coverage and resources in normal times. The most typical and recent example is

the earthquake in Haiti. The Haiti scenario could be perceived as an exceptional event

unlikely to affect many other countries. However, few developing or emerging countries can

confidently exclude scenarios of massive destruction affecting the capital and its governance

or response capacity.

National pride and sovereignty should not impede the access to care for the affected

population. Demanding formal and detailed registry of individual teams (including for

instance the name and qualifications of all the health personnel) can only generate lengthy

delays costing lives and damaging the reputation of the country. The efforts of the affected

country authorities should concentrate on disseminating widely the criteria and standards

considered indispensable under the circumstances. Models for such criteria and standards are

being developed by the Global Health Cluster Working Group.

Some FMT will most likely arrive unsolicited or even unannounced regardless of the policy

or action of the affected government. They will need to be coordinated on site. Sorting

progressively and weeding out at the point of entry the FMTs deemed unprepared or

unsuitable for the task may be the only practical option. Under these extreme circumstances

when capacity to process information is overstretched, only the most basic data can be

realistically requested from the FMTs.

The host country is the only body with the legitimate authority for accepting or refusing a

FMT. In the event that the Health Cluster is assuming temporarily the operational

coordination of FMTs,6 a clear and public endorsement by the MoH will remain critical to

legitimize the decisions of the Cluster.

In any case, the technical support from the Health Cluster mechanism will be most useful for

an effective and coordinated response.

6 Under the transformative Agenda adopted in 2011, the agencies of the Inter Agency Standing Committee

(IASC) may declare a level 3 emergency enabling the clusters to coordinate the external response in line with the

accountability of agencies to the affected population. Level 3 emergencies are exceptional in view of their scale,

complexity, urgency, the capacity required to respond and the reputational risk to humanitarian organizations

and responders.

http://www.humanitarianinfo.org/iasc/pageloader.aspx?page=content-template-default&bd=87

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3.3. Intermediate cases Many countries will fall between the two extremes: countries that would not benefit from the

contribution of FMTs and those where the absence of those FMTs would clearly result in

considerably more deaths and suffering.

Historically, the response of the international community is determined by the available

mortality data (information of overwhelming emotional and political value but of little

relevance to the magnitude of the needs for trauma care among survivors). FMTs tend to

overestimate the value of their (often late) contribution while national authorities may do the

same regarding their own capacity to respond in time without external assistance. Needs in

specialized care are likely to emerge as was the case in most disasters. How to regulate and

tune up the flow of FMTs without imposing inacceptable delays is particularly delicate with

diplomatic and political implications.

Prior knowledge of the likely areas of deficit and of who’s who in the medical humanitarian

community is critical. Again, this is where the health cluster can provide valuable support to

the MoH in disseminating clear and adjusted guidelines on the type of services required and

criteria/procedures for rapid accreditation on arrival.

As in scenario 3.2, most of the registering and coordination will take place on the site of

arrival.

4. Reporting on arrival

4.1. Linkage with proposed global registry of providers The Global Health Cluster endorsed the set up of a global register of providers of foreign

medical teams or facilities. A classification based on capacities of those teams is being

developed.

The register, once established will provide useful information on the type of FMT that the

participating institutions may provide. Registration may not reflect the actual capacity of the

FMT offered or dispatched at the time of a given crisis.

In addition, registration will be on a voluntary basis and is unlikely to provide data on the

numerous teams set up on an ad hoc basis in highly mediatized extreme events. Universities,

groups of hospitals, associations, or sub national entities in donor countries or faith based

groups that are not usual providers of FMTs are less likely to be registered prior to the

emergency. In any given crisis, those groups may represent a significant number of medical

actors.

When the Register will be fully operational, the data will be valuable for the health

coordinator but local registration on the point of entry in the host country will remain

indispensable.

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4.2. OSOCC at point of entry The health sector would benefit from the experience gained by the International Search and

Rescue Advisory Group (INSARAG). Established in 1991 to coordinate the external response

in Urban Search And Rescue (USAR), INSARAG developed an external classification of the

USAR teams (light, medium and heavy) and formulated quality standards. Without doubt, the

medical and surgical sector is considerably more complex than USAR. The practice of

surgery and emergency medicine, normally heavily regulated, is too often not subject to any

external monitoring and quality control in the aftermath of a major disaster. The consequences

in terms of number of life lost or permanent sequels in case of malpractice are also greater.

The health cluster initiated the development of external classification /registration criteria and

standards on the model of INSARAG 20 years old initiative.

Another area of leadership of INSARAG is implemented On Site Operations Coordination

Center (OSOCC) to welcome and guide USAR teams. The next section will deal with the

establishment of a host Government led OSOCC at the key point(s) of entry of the FMTs.

a. Principles for a FMT OSOCC

A number of teams will arrive unannounced or unsolicited and will proceed to their

chosen site of activity unless registered, screened and guided at the entry point;

Some FMT do prefer carrying out their activities without seeking to approach the

national health authorities. They see themselves as accountable only to their selected

beneficiaries;

Indiscriminately turning down teams or facilities at the border that were not pre-

approved can be misinterpreted internationally and ultimately deny care for affected

population. It is most likely to be ineffective or counterproductive.

The registration of the FMTs should not delay their deployment

b. Requirements

The early presence of professionals and officials from the MoH and/or the Health

Cluster is required at the airport or other key point of entry before the first FMTs

arrival. This is a considerable challenge for a health system overwhelmed with

demands for urgent care. This presence should be on 24/h 7days basis;

The receiving/registering team should be familiar with the prior and residual health

care capacity of the host country and have access to information on pending needs

(rapid assessment).

The receiving/ registering team should have the authority to take a hold decision

should a team not presenting the minimum guarantee of competence and capacity

(lack of qualified trauma related expertise, inadequate resources, no sponsoring

agency, etc.). The FMT standards under development will guide this process.

The receiving/ registering team should have the knowledge and authority to assign

incoming FMT areas to or sites of greater priority.

A virtual OSOCC (internet based) has been used in past disasters. In the context of medical

assistance, it is no substitute to a physical presence of the MoH and/or health Cluster at the

entry point. A virtual OSOCC alone would not provide information on many FMTs and

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permit their monitoring or quality control. Those FMT not seeing the value or the need for

coordination and monitoring by the host countries health authorities are unlikely to register

electronically.

4.3. Template of on-site registration form (basic information)

Agency offering the services

Name and Acronym

Type (Government, registered NGO, Red Cross System, University, other)

Affiliation: civil , military

If NGO: registered in host Country since (year)

Name, address, phone and email of contact in host country

Name address, phone and email of contact outside the host country

Is your agency already registered in the global database/registry of FMT providers?

Are the services offered as described in the database/registry?

Operational parameters

Place, date and time of arrival at the entry point

Projected date and time for starting delivery of care (first patient seen)

How long do you plan to stay? (projected date of departure)

Place where the FMT will provide care:

Within existing health facility? Y/N if yes which one?

Classification of services (check several when relevant) (to be revised based on

forthcoming classification of FMTs)

Level of care: Primary, secondary or tertiary

o Trauma and orthopedic surgery,

o general clinical services in substitution/ support to existing damaged hospitals,

o Other specialized services (f.i. pediatry obstetric, renal dialysis, rehabilitation, …describe):

For Field Hospital:

Type of facility (tents, etc) Number of beds

Facilities:

o Operating rooms (number)

o General anesthesia

o RX (number)

o Laboratory (define complexity?) o Blood Bank

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Our team/sponsoring agency will report to the MoH and the Health Cluster in the format

and periodicity required. I received the hand-over form and my agency will collect data,

complete the form and submit it before the departure of the FMT or field hospital.

Signed: date

Approved by MoH/Cluster:

Health Personnel:

Total MD and number of female doctors

Number of orthopedic surgeons

General surgeons

Internist

Gynecology-Obstetric

Pediatrician

Other specialties

Para medical personnel:

number of nurses,

Pharmacists

Laboratory technician

Others

Quality control:

Are the credentials of the medical staff verified by your agency? Are they all licensed to provide the

same type and level of services in their country of origin?

Will proof of medical qualification be available on request from authorities?

Is the management staff speaking English?

Does the clinical staff speak local languages or have full access to translators?

Had the Team prior experience in earthquake response: Foreign? Domestic? Which ones?

Was the team trained prior to this intervention?: periodicity and duration

Which support may be required from local health authorities (facilities, personnel, equipment,

medicines translation, utilities and services)?

Will you incorporate local medical staff into your team: In clinical and / or co-managerial function?

Is the team linked to a hospital or teaching institution in your country?

(if so, note that all evacuation / referral outside the country must be formally approved by the MoH)

Handover policy:

How will you prepare the local health services to assume the follow up upon your departure?

Will you donate some equipment and supplies upon your departure? What and to whom?

Assigned ID Number:

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5. Periodic reporting

5.1. Rationale for reporting In the early aftermath of an earthquake, the routine registration of patients in public health

facilities is usually disrupted for days. Only few better organized and disciplined field

hospitals were keeping medical records following the earthquake in Haiti. Patient records

were for internal use and rarely shared.

There are several potentially competing objectives in requiring FMT to report regularly to the

health authorities:

To know what they are doing: A legitimate demand for accountability but of limited

benefit for the affected population

To identify critical areas and gaps: needs for post surgical follow up, unattended renal

failures, shortage of specific supplies (e.g. external fixators…)

To compile statistics on number and type of injuries for inclusion in situation reports

To anticipate the longer term workload for rehabilitation (amputations and spinal cord

injuries…

To save perishable information for further study (research).

In large scale mass casualties, attempting to fully meet all objectives is leading to

cumbersome request for extensive data without clear immediate benefit, overburdening the

FMT (and national health services). Detailed reporting formats, often the results of a

compromise between many stakeholders, are self defeating. Compliance rate is low, a

situation aggravated by a lack of useful feedback to those reporting.

Priority should be given to data and information that can lead to operational decisions (actions

and policies).

5.2. Modalities of reporting Ideally, reporting from FMTs should be daily. In practice, even ensuring compliance on a

twice weekly basis turns to be a significant challenge for the coordinating agencies (MoH or

Health Cluster).

For sake of convenience, the same format of reporting should be used for foreign and host

countries treatment facilities.

Dedicated personnel are required to track non-responders, analyse data and translate the

results into actionable recommendations.

5.1. Template for periodic reporting by FMT Several models of templates are available, most being used for vertical reporting within an

organization. The terminology well standardized within the provider institution is rarely

compatible between organizations

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Name and ID Number of the FMT or Field Hospital

Type:

Host country: Public or private

Foreign: Government (civilian or military), NGO, Red Cross/ Red Crescent, university or other

Location: Name, phone and email of contact:

Reporting period: from ……. to ……… Number of beds:

Activities

Total Children Adults # Condition resulting from

disaster

# pre-existing or unrelated

condition male female male female

Total patients seen

Of which new patients Anesthesia for major surgery

Minor surgery General Regional Spinal Ketamine

Major surgery/ Orthopedic

Of which # Amputations

Major surgery / General

(excluding Cesarian section)

Other interventions performed during the period

Cesarian section

Deliveries

New cases of reportable conditions

Crush Syndrome/ renal

failure

Tetanus Any unusual conditions?

Spinal Cord injury

Patients flow, outcome and operational shortcomings

New Admissions # vacant beds (at 5pm) # total of deaths (incl. DOA) # intra-operative deaths

# Post-operative Deaths (24h)

Observations (critical items in short supply, other operational problems)

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6. Referral of patients to local or national health services

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7. Departure hand-over reporting

Most of the FMT and field hospitals depart within weeks of their arrival. At that time, the

medical problems will far from being fully resolved. The national health services or local

counterparts will have to assume some of the remaining tasks such as post-op care,

rehabilitation, treatment of infections and complications.

The level of services provided by some of the most sophisticated or performing FMTs will be

difficult to sustain or emulate by local services possibly damaged by the earthquake.

The ideal solution –adding a strong component of capacity building and ongoing support to

the local hospital or services- is rarely contemplated by foreign field hospitals and medical

teams.

The hand-over procedure will involve the referral of patients to other facilities. That step is

treated in section 6. This section will cover the information required from the FMT before

they leave the disaster affected area or the host country.. It will include three sections: a) a

summary of the data on the FMT and the contact point following departure; report on

activities and conditions observed and c) a checklist on good hand over procedures.

Data on the FMT or Field Hospitals ID Number:

Name and Acronym of the agency

Type (Government, registered NGO, Red Cross System, University, other)

Affiliation: civil , military

Date of arrival: Date of departure:

Location: Date of first intervention

Number of beds

Level of care: Primary, secondary or tertiary

o Trauma and orthopedic surgery,

o general clinical services in substitution/ support to existing damaged hospitals,

o Other specialized services (f.i. pediatric,Gyn- obstetric, renal dialysis, rehabilitation, …describe):

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Report of activities, interventions and conditions

TOTAL male Female <15 Y Adult # of Conditions

related to SOD

# consultations

Of which # new patients

Total admissions

Trauma care management Major orthopedic surgery

interventions

Of which amputations

# of patients undertaking orth.

Surg.

Minor orthopedic

interventions

#o f patients undertaking those

minor interventions

# crush syndrome / renal

failure

Spinal cord injury

Tetanus

Other Major Surgery (excl

caesarian)

# of caesarian sections

Fatality Death on arrival

Death while under care

Please attach any other more detailed report or data you may have. They will be treated

confidentially and not used for scientific publication without your written permission.

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Hand-over Process Where you located and working within a

public health facility? Y/N

If yes: which one?

Did you incorporate local medical

personnel in your FMT or hospital? Y/N

If Yes, in which capacity and how many?

Interpretors #:

Clinical care #

Management/coordination #

Other function #

Did you provide formal training to the

local medical staff Y/N Describe:

Did you refer / transfer remaining

patients to another facility?

Did you complete the referral form for

each patient?

Did you share the complete medical

record?

Did you leave behind and donate some or

all of your equipment and or expandable

supplies?

Equipment: Y/N Supplies: Y/N

If yes: what did you donate and to whom

(name and title) ?

If possible, attach a copy of the handover

receipt please

Did you debrief with the local or regional

health authorities? Provide name and title

Y/N

Any observation/suggestion:

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8. Conclusions

Mass casualty management in large earthquakes is characterized by a breakdown in data

collection and information sharing. The set of templates developed on request of the Health

cluster is a very simple (too simplistic perhaps in the views of trauma experts).

However, only ensuring that this information is collected, interpreted and shared will require a

substantial investment from the national health services and the international community

(health cluster in particular). What is essential is a strong political commitment to improve the

monitoring of the process of mass casualties care and of the activities of the many valuable

(or less so) actors.

The host country has the primary responsibility to demand from forthcoming facilities and

teams that they report on a simple format. Which form is adopted by the country is up to the

health authorities to decide PRIOR to an emergency.

Donors and health cluster lead agencies (sectorial or cross sectorial) must strongly support

this move and ensure that the FMTs do participate in this process. Additional staffing from

the MoH will need to be assigned very early after the impact to this task. The health cluster

will also need additional staff to support this misleadingly simple process. The matter of

improving trauma management after large earthquakes is considerably more urgent and

critical in the immediate aftermath than the launching of communicable diseases surveillance.