Nik Ahmad Shaiffudin Bin Nik Him MMC: 35241

MD, MMed (Emerg.Medicine, USM), AM(Mal)

nikshaiffudin@unisza.edu.my

Disaster Management II:
Hospital Activation Phase &
Incident site Mx
Develop the understanding of disaster medicine and mass casualty
incident management

Subject contents : Disaster management II
1. Field triage and on site management
2. Hospital activation phase

Performance criteria :
Discuss the principles of disaster management
Perform on site management
Coordinate evacuation of casualities
Initiate effective communication skills during disaster
Documentation data and proceedings during disaster management
Objective

1. Able to discuss the principles of incident site
management and hospital activation phase.
2. Coordinate evacuation of casualities at site
3. Initiate effective communication skills during disaster
4. Documentation data and proceedings during disaster
management
Learning Outcome
Presentation Outlines

1. Introduction
2. Hospital activation phase
3. Field triage & Incident site
management
4. Summary/Conclusions
Introduction
~American College of Emergency Physicians~
Both medical and public health disaster
response activities shall incorporate the MCI
response whose main objective is to reduce the
morbidity (injury/disease) and mortality (death)
associated with the disaster and shall be
coordinated through one organizational structure
i.e. the Incident Command System.
Always-be-ready concept
Anytime anywhere
Activation and Response phases
In any mass casualty or disaster, the role of the
medical team deployed includes....
Primary ambulance response
Disaster triage
Control of Medical Operations at site of incident
On-scene/site management
Transfer decisions
Hospital activation
Receiving of in-coming patients
Disaster/MCI Preparedness
The Impact of a Mass-Casualty / Disaster
Event on the Hospital service
Disruption of on-going and routine services
Overwhelming of ED resources
Mobilisation of staff and resources
Unaccustomed working environment
Event stress leading to post-traumatic stress
Adverse effect on quality of care
Control of situations with patients, relatives, press, other
hospital staff
Information control
Event disrupts ability of hospital to respond or mobilise
Disaster Plan
2 main phases
Emergency Dept activation phase
Hospital Activation phase

3-stage Alert system
Yellow Alert
Red Alert
Green stand-down
Phases of Medical Response
Activation
event is first discovered
Scene assessed
Command established
Implementation
Search and rescue
Triage
Stabilization
Transport
Definitive management of
patients and scene
Forensic activities
Psychological support


Recovery
Withdrawal from scene
Resume normal
operations
Debriefing
Analysis of event
Mitigation
Lessons learnt
Risk Mapping
Contingency Planning
Save life
Prevent escalation of the incident
Relieve suffering
Protect the environment
Protect property
Rapidly restore normality
Assist any criminal investigation @ enquiry
Perform the above in a coordinated, and safe way
Recovery and lessons learnt
Emergency Medical
response
Establishment of Chain of Command
1. Intrahospital

2. Interhospital
- Primary responding hospital

- Secondary responding hospital



MEDICAL RESPONSE
AT HOSPITAL
Alert / Activation System
NSC
999
Direct Calls to facilities KK or Hospitals

ALERTING PROCESS
Notification & verification.
To evaluate the extent of the problem.
To ensure that appropriate resources are
informed & mobilized.
MOBILE/FLYING/ASSESSMENT TEAM
COMMUNICATIONS!!!!!
Carta Aliran Panggilan
ke MECC
MECC
RC 999
Berinteraksi dengan pemanggil
Tenangkan Pesakit/pemanggil
Dapatkan Maklumat Lanjut Kejadian
Hospital / Klinik
Pasti Lokasi Kejadian?
Aktifkan PRA(ART)
PRA Sampai di
Lokasi Kejadian
Tidak
Ya
Hubungi agensi
bertanggungjawab
Memberi rawatan
Talian
Hospital
Cuba dapatkan lokasi
yang berhampiran
dan maklum kpd
PRA(ART)
PRA : PASUKAN RESPON AMBULAN
ART : AMBULANCE RESPONSE TEAM
RC 999
Call Taker MECC
Professional Emergency
Dispatcher (PED)
HOSP
(MECC)
KK
HOSP
DAERAH
AGENSI
SOKONGAN
LOKASI
KEJADIAN
PROSES PENGURUSAN PANGGILAN DI-MECC
TALIAN
HOSPITAL
Memastikan Jenis
Kecemasan
Medical Emergency Coordination Centre
Mengarahkan PRA ke lokasi
berdasarkan Event Code
Memberi
Arahan Pra Tiba /
Arahan Umum
PRA : PASUKAN RESPON AMBULAN
ART : AMBULANCE RESPONSE TEAM
Carta Aliran Panggilan
ke Hosp tanpa MECC
Maklum kpd
MECC Prima
RC 999
Berinteraksi dengan pemanggil
Tenangkan Pesakit/pemanggil
Dapatkan Maklumat Lanjut Kejadian
Ikut SOP Site Management
Pasti Lokasi Kejadian?
Aktifkan PRA(ART)
Respon ke-
Lokasi Kejadian
Tidak
Ya
Hubungi agensi
bertanggungjawab
Talian
Hospital
Cuba dapatkan lokasi
yang berhampiran
dan maklum kpd
PAR(ART)
PRA : PASUKAN RESPON AMBULAN
ART : AMBULANCE RESPONSE TEAM
MECC Prima
ambilalih sebagai
Coordinating Hosp
Primary MECC is to take over
coordination of incident once informed/
call card transferred

Primary MECC shall be the
Coordinating Hospital for the incident
INFORMATION FLOW: PRESENT MALAYSIAN SCENARIO
INCIDENT SITE
Informer/Caller : Provide the following Info:
Identification of Caller
Time of Incident
Type of Incident
Location
999
99
9
999
Police
Fire &
Rescue
Civil Defence
Hospital
Deployment of
Rescue Team
Analysis of
Information
Stand
Down on
Yellow
Alert
Yellow
Alert
Standby
Red Alert
Declaration of
Disaster
Activate
Hospital
Alert
System
Deployment of Search
& Rescue Team
INCIDENT SITE
Emergency Dept Activation
Notification and Activation sequences
Chain of Command
Setting up the Emergency Operations Centre
Initiation of Field Operations
Mobilising resources and staging area
Triage and patient flow systems
Control of area and traffic flow
Re-designated treatment areas
Specialized areas for family, media, mortuary,
forensics
Emergency Operations Centre
Bilik Gerakan
Coordination and Control centre
Dispatch centre for all field operations
Development of networks between
agencies
Communications centre
Control of resources and resource matrix
Information control centre
Responder check-in and check-out centre
Hospital Activation
Preplanned Response
Documented & accessible
Tested & analysed
User challenged
Dynamic
Table top exercise
Disaster drill


Hospital Activation Phase


A Hospital Response NOT Emergency Dept.
Response
A Hospital Strategy
Handled by Hospital Authority
A Mandatory requirement by Ministry of Health,
Malaysia
ALL Hospital personnel must be AWARE of the
Response Plan.
MANAGEMENT OF MAJOR INCIDENT IN MALAYSIA
HOSPITAL ACTIVATION PHASE
PRIMARY RESPONDING HOSPITAL

The Main Hospital Leading The Management
Fulfill Criteria Of A Leading Hospital
Coordinating Role
Closest & Most Well Equipped Hospital
Identified & Selected By Authorities
Resource Development
Skill Training

SECONDARY RESPONDING HOSPITAL

- Other Hospitals Involved In The Management Of
Victims

- Activated Only When Called By Primay Responding
Hospital

ROLE:

1.Provide logistic support , Eg. Manpower, Equipment, Wards For Admission

2. Managed & Accommodate Victims etc
MANAGEMENT OF MAJOR INCIDENT IN MALAYSIA
HOSPITAL ACTIVATION PHASE
ORGANISATIONAL ASPECT
HOSPITAL ACTIVATION PHASE
COORDINATOR
HOSP. DIRECTOR
ADMIN.
COORDINATOR
DEP. DIRECTOR OF
HOSP.
MATRON SECURITY SUPERVISOR
DIETICIAN
ADMIN
PERSONNEL
PHARMACIST
CLINICAL
COORDINATOR
SENIOR
CLINICIAN
HODs Senior AMO
OF ED
SISTER ED
PHARMACIST
ADMINISTRATIVE COORDINATOR
Resource & Logistic Management
Resource & Logistic Deployment
Continous Requirement Assessment
Patient Accomodation
Inventory Management
Transport Requirement
SETTING UP OF VARIOUS Mx AREAS
Relative Areas
Control Centre


CLINICAL COORDINATOR
Organize Clinical Team
o Critical, S. Critical, Non Critical
Deploy On Site Management Team
Deploy Sar Team
Set Up Clinical Management Area
Set Up & Manage Triage Centre
Coordinate The Forensic Service Team
o Pathologist & Maxillofacial
Coordinate Psychiatrist & Counselor Service
Liaise With Admin Coordinator For Bed
Requirement, Pharmacist etc
In Close Liaison With OMC
MEDICAL RESPONSE
AT SITE
INCIDENT SITE MANAGEMENT
1. Zoning and coding
2. Work matrix
3. Medical Base Station Layout
4. Role & responsibilities
5. Human resource management
6. Triage
- Primary
- Secondary
7. Forensic activities
8. Public Health
9. Psychological Management
10. Evacuation
Management of the Event itself is as important as the management of the
individual patient
WORK PROCESS FOR ON- SITE MEDICAL SERVICES
S.A.R MEDICAL TEAM ARRIVES AT THE SITE
REPORT TO COMMAND CENTRE
(ON SCENE COMMANDER)
ESTABLISH STATION AT THE YELLOW ZONE
TRIAGE SIEVE
AT CASUALTY
COLLECTING POINT

TAG & TRANSFER
EVACUATION
TREATMENT AREA
RED
YELLOW
GREEN
ESTABLISH TEMP BODY AREA
(POLICE)
MGT.OF INJURED RESCUER
ORGANISE SEARCH &
RESCUE TEAM
DETERMINE ABILITY TO
CONTINUE WORKING
COORDINATION OF TEAM
MEMBERS WITH OTHER
RESCUE PERSONEL
TRIAGE SORT

Principles of FIELD MCM
Action for 1
st
team on-site
1. Report to OSC at PKTK
Introduce yourself
Ask for brief situational report
Safety hazards
2. Situation evaluation
3. Inform Hospital
Actual situation
Estimated number of casualties
Type of casualties
Back-up required
1
st
team. (cont)
4. Set-up Base Station
5. Communication
6. Temporary Zoning
7. Temporary morgue
8. Logistics
9. Head count duty
10. Get other agencies to aid if/ when reqd
11. Operative until stand down declared by OSC
S-S-S-S-S
S Safety
S Scene Size-Up
S Send Information
S Set-up
S START
Incident Area
High Risk
Zone
Police Base Station
Fire Base
Station
Medical
Base
COMMAND CENTRE
(TACTICS ZONE)
PRESS
Family &
Relative
Ambulance
HQ
Transportation
STRATEGY ZONE
On Scene Commander
POLICE ( OSC )
On Site Medical
Commander
( OMC )
Forward Field
Commander
BOMBA (FFC)
ZONING CONCEPT AT THE INCIDENT SITE
OSC
OMC
FFC
YELLOW ZONE
RED ZONE
Access Road
Guard Post Guard Post
PKTK
Operating zone for Specialised
Search And Rescue Units
INCIDENT SITE
SMART
PDRM
Emergency
Medical
Services
JBPM
PKTK
Pertahana
nAwam
ATM
YELLOW ZONE
RED ZONE
Access Road
Guard Post
Operating zone for Specialised
Search And Rescue Units
SMART
PDRM
Emergency
Medical
Services
JBPM
PKTK
Pertahana
nAwam
ATM
YELLOW ZONE
RED ZONE
Access Road
Guard Post Guard Post
Operating zone for Specialised
Search And Rescue Units
GREEN ZONE
Aid Agencies and NGOs
Family
Bereavement
Centre
Counseling
Centre
Temporary
Mortuary
Media
Centre
Rest Area
Food Store
SAFETY MEASURES
IMPACT ZONE (red): strictly restricted to
professional rescuers.
SECONDARY AREA (yellow): restricted to
authorized staff involved in the rescue operation
TERTIARY AREA (green): restricted to press
officials & public
Safety First !
ON SITE MANAGEMENT
YELLOW ZONE
OSC
(POLICE )
COMMAND POST
F.F.C. - BOMBA
SAR TEAM
RED ZONE
WORK MATRIX
P.K.T.K.
O.M.C.
BOMBA
MEDICAL
BASE
STATION
RED
YELLOW
FORENSIC
M.E.L.O.
QUARTER
MASTER
M.E.S.A.R.O.
SAR
SAR

FORWARD
MEDICAL
POST

SJAM
MRCS
JPAM
BOMBA
GREEN
WHITE
SEARCH & RESCUE
Safety first
Locate & remove victims
from unsafe locations to
collecting point, if necessary
On site triage
First aid, if necessary
Transfer victims to the AMP,
if necessary
Disaster Triage
Our goal is to maximize the number (of
people) who will survive the incident.
Some patients will live no matter what medical are they
receive, and some will die regardless of the care they
receive. Others will die UNLESS they receive medical
care immediately (but have a good chance of survival if
they do).
We Dont want to utilize valuable resources on people
who are certain to die, nor on people who will survive
without medical care.
Our goal is to identify those who will survive
the event with immediate care, and get it for
them as soon as possible.
from Prehospital Triage by Matthew R. Streger, BA, NREMT-P from EMS
Magazine, The Journal of Emergency Care, Rescue, and Transportation.
TRIAGE SIEVE
First look triage
Decision undertaken at
Incident Site
Rapid, simple, safe &
reproducible
Not perfect
Walking wounded to leave
danger area under their own
power
Critical patients carried to
casualty clearing station
TRIAGE SORT
Retriage at
Casualty Clearing
Station
Right patient to the
Right place at the
Right time
TRIAGE SYSTEM
-Disaster Field Triage
ON SITE MANAGEMENT TRIAGE SYSTEM
TO NEAREST APPROPRIATE HOSPITAL
GREEN
Disaster Triage Tags
Most effective
Internationally recognized Color codes
Defines severity of injury and also defines urgency
of transport
Useful to incorporate ID codes here

Red: critically injured (need immediate specialty
care)
Yellow: less critically injured
Green: no life/ limb threatening injury
White/Black: fatal injuries or dead

ADVANCE MEDICAL POST
AREA-Medical Base Station
Location: safe area, direct access to the evacuation
road, short distance from the Command Post, clear
communication zone.
Good triage capacity.
Specifically trained medical teams.
Good communications between the field & the
hospital.
Good coordination of all involved sectors.
Design of Basic AMP-Medical
Base Station
Medical management
3 T Principle
TAG
TREAT
TRANSFER
TREATMENT
AREA


MEDICAL
BASE STATION

CASUALTIES FLOW AND EVACUATION
I
N
C
I
D
E
N
T

S
I
T
E

TRIAGE

Critical
Semi-Critical
Non-critical
DEAD
BODY HOLDING
AREA
TEMPORARY
MORTUARY


HOSPITAL
Ambulance
Loading Area
Designated
medical
facility
Triage
Triage,
Immediate
Evacuation
FIELD ORGANIZATION EVACUATION SCENARIOS
1
3
2
Advance Medical Post
Triage
Stabilization
Controlled Evacuation
Non-Triage
Immediate
Evacuation
Triage
Triage
Stabilization
Immediate
Evacuation
4
Triage
Triage
Stabilization
Immediate &
Delayed Evacuation
5
Scoop & Run
Stay & Play
Mass Casualty
Management System
Search
Rescue


Medical Post
Triage
Stabilization
Evacuation
Traffic Control
Regulation of
Evacuation
Command
Post
Emergency
Department
MASS CASUALTY MANAGEMENT SYSTEM
A Multi-Sectoral Rescue Chain
Impact Zone
PRE-HOSPITAL ORGANIZATION
HOSPITAL
ORGANIZATION
Hospitals Disaster
Response Plan
TRANSFER ORGANIZATION
A. DEFINITION
Procedures implemented to ensure victims of MCI will be
safely, quickly and efficiently transferred by appropriate
vehicles to appropriate and prepared healthcare facilities

B. PREPARATION FOR EVACUATION
1. General Procedures for Evacuation
Single Receiving Facility
Multiple Receiving Facilities
2. Preparation for Transport
Evacuation Officer
Assess stability
Assess security of equipment
Ensure efficiency of immobilization measures
Ensure triage is securely attached & clearly visible
C. Evacuation Procedures
1. Regulation of Evacuation
Victim is in most stable condition
Victim is adequately equipped for transfer
Receiving health care facility is correctly informed and ready to
receive the patient
Best possible vehicle and escort is available
2. Control of Victim Flow
The Noria Principle one way, no crossing
Ambulance Traffic Control
Radio Links
- Transport Officer at AMP, A/E, Command Post,
Ambulance HQ
Responsibility of Ambulance Drivers
Road Control
D. Evacuation of Non-Acute Victims
At end of field operation or if primary healthcare facilities
available, non-medical transport available and no
interference
VICTIM FLOW
Conveyor Belt Management
Transport Resource Flow Victim Flow
TRANSFER
ADVANCE
MEDICAL POST
Triage
Impact
Zone
Collecting
Point
Triage
Treatment
Treatment
HOSPITAL
Evacuation
THE NORIA PRINCIPLE
Victim movement - one way direction, without
crossings.
Victim movement - organized as conveyor belt
(from basic first aid care level to sophisticated
levels)
each transport level will have to use its own
limited resources in a rotating system.

RULES OF EVACUATION

NO VICTIM MAY BE REMOVED FROM AMP TO THE
HOSPITAL BEFORE:

the victim is in the most stable possible condition
the victim is adequately equipped for the transfer
the hospital is correctly informed & ready to receive the
victim
the best possible vehicle & escort are available
GOOD
COMMUNICATION
GOOD
DOCUMENTATION

GOOD DOCUMENTATION GOOD COMMUNICATION

1. Registry of all victims admitted to medical triage
2. Records:
- name or identification number
- age where possible
- sex
- time of arrival
- injury category assigned
3. Evacuation process

MEDICAL TRIAGE OFFICER
1. Receives victims at the entrance
2. Examine and assesses the condition of each victim
3. Categorize and tags patients as follows:
Red immediate stabilization necessary
Yellow close monitoring care can be delayed
Green minor delayed treatment or no treatment
White deaths
1. Directs victims to appropriate treatment area
2. Reports to the commander ( MESARO)

MEDICAL TEAM LEADER
1. Supervise triage & stabilization of victims
2. Establish internal organisation
3. Manage the staff
4. Ensure effective victim flow
5. Ensure adequate equipment & supplies are available in each
treatment area
6. In collaboration with Transport Officer, organize the transfer of
patients to healthcare facilities
7. Decide on the order of transfer victims, the mode of transport,
escort and place of transfer
8. Ensure staff welfare
9. Reports to MESARO in the Command Post

RED TEAM LEADER
1. Receives patients from medical triage
2. Examine and assesses the medical condition of the victim
3. Institutes measure to stabilize the victim
4. Continuously monitors victims condition
5. Reassesses and transfers victims to other treatment
areas
6. Prioritizes victims for evacuation
7. Request evacuation in accordance with priority list
8. Reports to the OMC

Rescuing the rescue team ??
Summary

1. Alerting Process
2. Situation Assessment & Field Area Identification
3. Safety measures
4. Command Post
5. Communication Tools
6. Search & Rescue
7. Triage & Stabilization
8. Controlled Evacuation
9. Hospital disaster preparedness plan !!!
CONCLUSIONS

1. Coordination
2. Familiarization
3. Abide By The Directive From The National
Security Council Of Pm Dept., MALAYSIA (
Arahan 20, MKN )
Thank you.. 1Malaysia Boleh