What should be included in a comprehensive disaster management plan for a district hospital?

Comprehensive Disaster Management Plan for a District Hospital

Command Structure and Incident Management System

Every district hospital must establish a formal Incident Management System (IMS) with clearly defined Emergency Executive Control Groups operating at facility, local, and regional levels to exercise authority over resource allocation and communications during disasters. 1

Organizational Hierarchy

• Establish a five-functional-area command structure including: command, operations, planning, logistics, and finance/administration 1
• Designate an ICU Emergency Executive Control Group (EECG) reporting directly to hospital administration, with clearly identified ICU Director, Deputy, Head Nurses, and support staff 1
• Create a Central Triage Committee of experts with broad situational awareness to develop protocols, monitor outcomes, and coordinate responses across the region 1
• Define trigger events that activate the disaster plan, such as patient volume exceeding 120% of capacity or infrastructure failure 1

Infrastructure and Utilities Planning

Critical Utilities Assessment

Hospitals must conduct comprehensive assessments of emergency generator capacity, water supply needs, and backup systems before disasters occur, as most emergency generators cannot power all patient rooms sufficiently for critical care equipment. 1

• Map which electrical outlets and systems are included in emergency power circuits and determine maximum load capacity 1
• Arrange pre-disaster contracts with jurisdictional emergency management for temporary generators with appropriate adaptors to wire into hospital systems 1
• Calculate water requirements for critical care activities including large volumes for hemodialysis, and identify suppliers with operating procedures 1
• Ensure emergency power circuits include heating, air conditioning, ventilation systems, and negative flow isolation rooms 1

Oxygen and Medical Gas Systems

• Install oxygen ports or extra ports in meeting rooms and non-traditional patient care areas during any remodeling projects to facilitate conversion to patient care spaces 1
• Stockpile multi-patient regulators that can serve multiple patients on variable oxygen flow rates from a single wall port for cohort care 1
• Maintain ventilation of >10 air changes per hour in areas using high-flow oxygen to prevent oxygen enrichment 2, 3
• Establish oxygen shut-off valve locations and train staff on their operation during emergencies 3

Surge Capacity and Space Conversion

Patient Care Area Expansion

Identify and pre-designate alternative clinical areas for patient care expansion, including which units can be separately ventilated with 100% exhaust to outside for infectious disease cohorting. 1

• Create temporary anterooms for staff changing and donning personal protective equipment (PPE) in units designated for airborne-transmitted pathogens 1
• Designate contingency spaces with plans for oxygen, suction, and compressed air availability; activation of these spaces for >6 hours should prompt consideration of patient evacuation to less-affected facilities 1
• Ensure compressed air and suction lines are available in any spaces where mechanical ventilation is planned 1
• Cohort patients with infectious illness in single units treated as 'isolation areas' with separate ventilation 1

Coordination and Communication Systems

Internal Hospital Coordination

Develop a detailed communication system between the ICU and all key departments including emergency department, operating rooms, laboratory services, radiology, housekeeping, and medical supplies before any disaster occurs. 1

• Establish coordination protocols with clinical departments (internal medicine, surgery), nursing, infectious diseases, and supporting services 1
• Create systems for smooth inter-departmental patient transfers with clearly defined processes 1
• Identify key functions requiring coordination: manpower utilization, resource re-allocation, equipment distribution, and physical space management 1
• Develop communication plans that recognize telephone and Internet services will likely be disrupted 1

External Agency Coordination

• Establish liaison protocols with Bronze (Operational), Silver (Tactical), and Gold (Strategic) commanders in conjunction with senior Fire and Rescue officers 1
• Coordinate with regional critical care networks to establish systems for emergency bed identification and patient transfer services 1
• Create rapid communication methods between critical care network lead consultants (e.g., WhatsApp or secure messaging groups) 1
• Involve local Fire and Rescue Services in planning and awareness of evacuation processes 1

Evacuation Planning and Procedures

Evacuation Decision-Making

Hospitals must develop evacuation policies that balance the harm of premature transfer against the risk of delayed evacuation, with clear decision-making authority defined before incidents occur. 1

• Identify suitable alternative clinical areas within Business Continuity and Incident Response Plans where evacuated patients can be temporarily cared for 1
• Establish evacuation triage protocols to determine patient priority for movement 4
• Store appropriate evacuation equipment in easily accessible locations at each bed space 2, 3
• Ensure sufficient trained staff are working on each shift to enable emergency evacuation at any time 3
• Practice evacuation procedures with "walk-through" training every 2 years and aim to complete evacuations within 30 minutes when necessary 2, 3

Fire Safety Protocols (RACE)

Implement the RACE protocol: Rescue people in immediate danger, Alarm by activating fire alarms, Contain by closing doors and operating oxygen shut-offs, and Extinguish or Evacuate as appropriate. 3

• Ensure fire alarms are audible throughout the ICU unless specifically turned off by clinicians 2
• Use carbon dioxide extinguishers for electrical fires and operating theater fires 3
• Make dynamic risk assessments weighing responsibilities to patients against risk to staff life 3

Specialized Patient Population Planning

Dialysis-Dependent Patients

All dialysis units must have clear evacuation plans for patients and staff, with identification of partner renal units and alternative dialysis facilities established before disasters. 1

• Provide patients with copies of medical documents outlining dialysis treatments and medications 1
• Educate patients about renal emergency diet and early evacuation plans 1
• Plan for back-up power and water specifically for dialysis operations 1
• Anticipate staff shortages simultaneous with influx of new patients 1
• Coordinate with national agencies for patient evacuation in massive-scale disasters 1

Medication Management

• Establish protocols for patients who lose essential medications (insulin, antihypertensives, immunosuppressants) in destroyed homes 1
• Stockpile critical medications for at least 48 hours of mass casualty care 5
• Recognize increased cardiovascular mortality risk associated with natural disasters due to effects on blood pressure, blood viscosity, and psychological stress 1

Infection Control and Bioterrorism Preparedness

Isolation Capacity

Hospitals must develop pre-event plans to augment airborne infection isolation capacity and stockpile sufficient PPE to care for mass casualties of a bioterrorist attack for at least the first 48 hours. 5

• Prioritize establishment of isolation precautions before victims arrive to prevent cascade of additional casualties among healthcare workers and patients 5
• Provide initial and periodic training to all clinical staff on principles of healthcare delivery using PPE 5
• Establish decontamination protocols as part of pre-event planning 5
• Develop phased plans to accommodate larger numbers of patients with highly infectious diseases 1

High-Risk Procedures

• Develop protocols for safe performance of high-risk procedures including appropriateness criteria, personnel qualifications, site selection, PPE requirements, and equipment needs 1
• Ensure adequate training of personnel in high-risk procedures 1
• Perform procedures at bedside whenever possible 1
• Use safe respiratory equipment with adequate filters and closed suctioning to avoid aerosols 1

Staffing and Personnel Management

Modified Staffing Models

Plan for modified staffing models when critical care needs exceed available specialized staff, including identification and training of non-ICU personnel for predetermined tasks. 1, 6

• Identify staff to participate in training programs and verify participation annually 1
• Train co-opted staff in new roles as soon as possible with demonstrations followed by supervised practice 1
• Implement strategies to mitigate fatigue from shift work, including proper lighting during night shifts (at least 2500 lux) 2
• Establish double-check systems at nursing shift changes to prevent medication errors 2

Staff Welfare and Psychological Support

All staff involved in disasters must be screened for acute trauma-stress symptoms and supported using a recognized, protocol-based critical incident procedure. 1

• Conduct short operational debriefs immediately after events 1
• Provide "psychological first aid" and information about normal reactions following potentially traumatic events 1
• Screen all staff regardless of how peripheral their involvement may seem, as pre-morbid experiences can be significant 1
• Assess all involved staff by occupational health before re-starting work 1, 3
• Recognize that psychological reactions may be severe during bioterrorism events and ensure mental health support is available 5

Training and Education Programs

Comprehensive Training Requirements

Begin training and education as soon as possible, covering medical management, personal protection techniques, environmental contamination, laboratory specimens, ethical issues, and dealing with deceased patients and families. 1

• Train hospital command structure in crisis management procedures 1
• Provide multidisciplinary training in fire management and evacuation procedures as part of annual mandatory training 3
• Conduct simulated evacuations every 2 years 3
• Train staff on principles of the Hospital Incident Management System (HIMS) and specific emergency procedures 6
• Educate staff about specific diseases, their ramifications and treatment during infectious disease outbreaks 1

Resource Management and Logistics

Equipment and Supply Stockpiling

• Stockpile sufficient equipment for IV fluid resuscitation for hemodynamically unstable victims 5
• Maintain adequate PPE supplies for at least 48 hours of mass casualty care 5
• Ensure proper oxygen cylinder storage according to supplier instructions 2
• Pre-position evacuation equipment in easily accessible locations 2, 3

Service Prioritization

• Engage laboratory, radiology, and nutrition departments in prioritization of support services 1
• Minimize tests ordered and restrict to essential tests during disasters 1
• Determine criteria for cancelling and/or altering elective procedures 1
• Plan for ongoing infrastructure protection including power, water, oxygen, suction, and compressed air provisions 1

Medical Records and Information Management

The Health Information Service must have a planned response for retrieving medical records and allocating new ones during disasters, with problems identified and mitigation responses included in the disaster plan. 7

• Develop strategies for continuing patient care when healthcare infrastructure has been damaged or destroyed 7
• Plan for substantial patient volumes including those injured during acute phase, recovery attempts, and chronically ill displaced patients without access to medications 7
• Ensure timely activation of medical records disaster plan 7

Business Continuity and Post-Incident Planning

Continuity of Operations

Develop comprehensive business continuity plans that address maintenance of operating infrastructure including lighting, communications, information technology, fire suppression, HVAC, and nutrition services during outages. 1

• Plan for disengagement and return of responsibility to local services after external assistance 1
• Establish protocols for resuming routine operations while maintaining disaster response capabilities 8
• Ensure hospital fulfills two goals: sustaining against sudden demand increases and continuing essential routine duties for existing patients 8

Safety and Quality Monitoring

Critical Incident Reporting

Implement a voluntary, anonymous, non-punitive critical incident reporting system to identify potential errors before major incidents occur. 2

• Formalize handovers between clinicians with standardized checklists to prevent communication failures 2
• Organize undisturbed ICU rounds allowing intensivists to concentrate on patient inspection 2
• Monitor both complications and critical incidents to identify system issues before patient harm 2
• Encourage open communication across all team members, recognizing hierarchical structures can negatively impact safety 2

Testing and Simulation

All emergency procedures must be tested through simulation exercises, as evidence-based practice from disaster response research demonstrates that repeated preparation ensures teams function seamlessly when transitioning from theoretical plans to real-time execution. 6, 9

• Conduct regular drills to ensure stakeholders understand the disaster plan 9
• Test communication systems and clearly defined roles during exercises 9
• Update disaster plans frequently with input from multiple stakeholders 9
• Ensure all personnel understand their specific roles and responsibilities 6

Common Pitfalls to Avoid

• Failing to recognize that most stakeholders do not know or understand existing disaster plans despite their existence 9
• Underestimating infrastructure needs, particularly emergency generator capacity for critical care equipment 1
• Delaying isolation precautions while focusing on treatment supplies during bioterrorism events 5
• Inadequate pre-disaster coordination with external agencies and regional networks 1
• Neglecting staff welfare planning, leading to inadequate psychological support after traumatic events 1
• Assuming telephone and Internet will remain functional during disasters 1
• Overlooking specialized populations such as dialysis-dependent patients who require specific evacuation planning 1
• Creating overly complex plans rather than simple, well-communicated protocols with clearly defined roles 9