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January 2005, Volume 55, Issue 1

Short Communication

Disaster Drill at a University Hospital

Introduction

The literature of disaster planning and management makes frequent reference to disaster drills and exercises as a fundamental training tool.1 By paying attention to educational principles, disaster exercises are likely to meet their potential as an educational tool.2 The place of drills in disaster management is well recognized,3 and it has proved valuable in cases of real disasters.4,5 The drills identify potential problems in real emergencies, and provide us an opportunity to correct flaws in planning long before they cause catastrophes in real life.6

The disaster drills are not done regularly in our hospitals. However it is of great relevance in Pakistan, as there is a lack of disaster plans in hospitals and increased risk of disasters due to terrorist attacks.

As part of its continuing efforts to (a) test and update the hospital Emergency Plan, (b) assess the level of awareness of emergency preparedness among staff, and (c) educate/train staff on emergency preparedness, AKU develops, arranges and conducts Emergency Mock Drills. Under the prevailing situation in the international/ national/local scenario, the need to carry out one such mock drill is evident. For this reason, an exercise was arranged to meet the above-described objectives and to streamline the emergency procedures as outlined in the AKU Emergency Plan and departmental Emergency Sub-Plans.

The aim of this exercise was to test and train hospital employees in the event of an external disaster under controlled/non threatening conditions.

The objectives of the mock drill were to:

§ Test plans and procedures.

§ Create teamwork within AKU

§ Be better prepared to respond to an actual emergency.

The hospital civil disaster contingency plan

It would be difficult for a single unit to manage a major disaster when the demand for life-saving and emergency services exceeds its normal capacity of routing operations. Both supplementary human and material resources must be ready at all times so that quick and effective response is possible. The number of contingency staff and logistics required from other units also have their own contingency plan so that they can respond to ER\'s demand effectively in case of disaster.

Disaster Drill

Preparation
A series of seminars for both hospital personnel and clinicians in the hospital were arranged in order to make everyone familiar with the Plan as well as their role in disaster management.
The hospital volunteer group was contacted for recruiting \'victims\', with encouraging response. About 30 volunteers participated in the exercise. They were briefed by the disaster drill coordinator on how to cooperate with hospital staff and their roles in the exercise. Then \'fake wounds\' of various severities ranging from open fractures to superficial abrasions were created on volunteers using cosmetic materials.
The Disaster Drill Process
The Disaster was a full-scale man-made mock drill and man-made, and held on October 23, 2001. A 747 jumbo jet with 200 passengers has crashed at the end of the runway at Quaid-e-Azam International Airport while taking off in a thunderstorm. Fifty casualties were sent to Emergency Room by ambulance. Most of them required transporting devices, for example stretchers or wheel chairs, while some were ambulatory. The Drill hindered the patient care activities     avoid rush/disturbance in ER. Some patients were transferred inappropriately.
ER : Emergency Room
ECC: Emergency Control Center
designer/coordinator decided to activate the Disaster Plan in response to the accident. Relevant parties of the hospital were mobilized according to the Plan. The trauma team was activated, and the nurses and doctors from different parts of the hospital were mobilized to support Emergency Room. A total of 42 hospital staff including doctors, nurses, supporting and security staff gathered in Emergency Room, as per plan.
Prompt consultations and treatment were delivered to all victims. The overview of the drill timetable and different scenario is illustrated in Table 1.


All the disaster patients were initially screened at the triage station that was manned by a nurse and a physician. All the victims had to stop a while in triage station, regardless of their injury, for priority determination and patient identification. Individual patients would receive a special bracelet and a clinical record sheet that carries pre printed special stickers for identification purpose. Patients with life-threatening injuries were managed in the "Resuscitation Room," while the non-ambulatory victims were transferred to examination cubicles for consultation and treatment in the main area of Emergency Room. The patients who could manage to walk were treated in the "Fast Track" that was away from the main ER stream. After being seen by doctors, patients underwent X-ray investigation and other interventions, like applying plasters, wound dressing, and suturing.
It was anticipated that there would be a huge demand on patient transportation. Those activities were centrally organized by transportation. Porters were in stand-by position at vital places where patient movement was expected, for example triage station, main treatment area, X-ray department, etc. The supply of logistics, handling of media and security services were provided by the Hospital Administration so that clinical personnel could concentrate on the major task of patient care.
It took 2 hours to complete the exercise resulting in 5 victims certified dead on arrival at ER; 12 hospitalized;and the rest allowed home after treatment.
Debriefing Session
Immediately after the drill, the drill Coordinator chaired a debriefing session with an aim to review operational difficulties encountered and to discuss possible remedies. The majority of drill controllers and evaluators attended the meeting. The discussion was summarized (Table 2).

Discussion

The disaster exercise was found to be useful in making clinicians understand their roles during disaster management. The debriefing critique reviewed problems encountered. In fact, we identified some more difficulties that did not occur in the drill.

It was planned to summon back off-duty ER staff to support the service in managing catastrophes. One may anticipate that severe traffic jams will result due to traffic control of the roads near the hospital. Off-duty staff may not be able to reach the hospital at the critical moment.

There would be many people crowded in the ER including anxious victims, stressed relatives and friends, hard working hospital staff (some may not be familiar with disaster management), journalists and relevant government officials. Different parties pose a different focus of concern. No matter how good a plan is, a certain degree of chaos in the ER is inevitable.

It was also noticed that some helping hands (those staff summoned from other units) found it difficult to identify the ER staff because numerous nurses and doctors were crowded into the department. The strangers may need help in some way, for example to access the store of intravenous fluids. The problem will no longer exist because there will be specially designed uniforms for ER staff in the near future.

During the exercise, patients bottlenecked at different areas. To solve the problem in the future, frequent visit of ER staff was suggested amongst the various functional areas in order to enhance flexible staff and logistics deployment. The use of a walkie-talkie is necessary as to enhance communication between functional stations and disaster coordination center.

Some problems were also noticed in the Communication department; such as the announcement was not properly heard at different areas and announcements were made only in English. It was also found that the Emergency Control Center was not getting the information in time. These problems will be rectified in future.

The exercise took 2 hours to complete. It seems that everything went uneventfully and smoothly. This efficiency may be due to successful staff pre-briefing. Some delay and chaos would be inevitable due to unanticipated environmental factors during disaster management.

On the other hand, a real disaster will happen anytime of the day or night and will be of different nature, type and magnitude. Hospitals should prepare more than one contingency plan, for example civil disaster plan, radiation emergency contingency plan, etc., so as to enhance effective crisis management. Disaster exercises of dirvers nature should be carried out at least once a year,7 even though disaster drills are also considered as time-wasting activities.8

Conclusion

A disaster drill is more than an isolated event. It should be an integral part of a comprehensive disaster-training program. Our experience revealed that it would be important for hospitals to test their contingency plans regularly. Organizing practice drills may provide clinicians with the opportunity to anticipate possible operational difficulties and find remedies to tackle them. This may also help to develop effective coordination and cooperation among various departments of the hospital in disaster management. Only trials run together with real life experiences could make improvement and refinement of the plan possible. Besides, continuous review of the plan against latest developments of the hospital is essential.

Acknowledgements

We would like to thank all the volunteers for their participation to make the drill as realistic as possible. We are deeply grateful to Col (R) Salim-ur-Rehman, Manager Security and Administration for his assistance and all the staff who participated in the drill on that day.

References

1. Walz BJ. Disaster training exercises: an educationally based hierarchy. Prehospital Disaster Med 1992;7:386-8.
2. Tyler RW. Basic principles of Curriculum and Instructions. Chicago: Univ of Chicago Press, 1949, pp. 83-103.
3. Rutherford WH. The place of exercises in disaster management. Injury 1990;21:58- 60.
4. Merz K, Colo L. The Columbine High School Tragedy: one ED experience. J Emerg Nurs 1999;25:526-8.
5. Theoret JJ. Exercise London: a disaster exercise involving numerous casualties. CMA 1976;114:697-9.
6. Rekus JF. Disaster drills identify potential for problems in real emergencies. Occup Health Saf 1989;58:126-30.
7. Anteau CM. The Oklahoma bombing-lesson learned. Crit Care Nurs Clin North Am 1997 9:231-6.
8. Kelin JS, Weigelt JA. Disaster management: lessons learned. Surg Clin North Am 1991;71 257-66.

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