Disasters and emergencies may occur in different forms like floods [26/7], earthquake [Bhuj/Gujrat], terrorism [26/11] and mass casualties in a major road traffic accident, blasts, biological warfare and nuclear attacks. Even mass food poisoning can be counted as a disaster.

When disasters strike, aid agencies, communities, media, and the government focuses immediately on the victims. But if the focus on victims is to have real meaning, we must prioritise medical care.

Traffic, flooded roads, fallen trees and roadblocks create problems in providing urgent medical attention as patients cannot be moved to a major medical centre. Going to the nearest hospital is the only saving grace.

Those who are injured need urgent medical attention and those who escape injury also require greater attention during and after the disaster. When health services and hospitals fail to provide the required help, people suffer needlessly. Even a tiny investment can make a difference between life and death; and between building a safe and an unsafe hospital.

The objectives are to effect change that helps to protect lives of patients and health workers by ensuring the structural resilience of health facilities. To build health facilities and services that function in the aftermath of emergencies and disasters—when they are most needed and improve the risk factor levels to health workers and institutions, including emergency management.

Make hospitals safe

It is important to focus on the physical structure of the health facility so that it remains standing and resists the impact of destructive natural hazards, with minimal damage. For example, hospitals need to build an earthquake-resistant structure as per the seismic zone recommendations. It is also important to prepare for an emergency, train the health workforce to improve the response time and quality of service. A hospital must also ensure that essential resources are available for a quick response during disaster.

Apart from preparing the hospital for an emergency, also share experiences with other hospitals in various cities and countries to improve the response time.

Guidelines for disaster management

• Policies and procedures for emergency care should be documented and should guide the triage of patients for initiation of appropriate care.
• The staff should be trained in the procedures for care of emergency patients.
• A hospital should have adequate number ambulances, easy access to them and space for them.
• Ambulance[s] should be appropriately equipped with emergency care equipment and medicines, and should be manned by trained staff.
• The ambulance[s] should have proper communication systems.
• The organisation should plan for fire and non-fire emergencies within the facilities.
• The organisation should plan and provide for early detection, abatement and containment of fire and non-fire emergencies.
• The organisation should document a safe exit plan in case of fire and non-fire emergencies.
• Staff should be trained for their role in case of emergencies.
• The hospital should identify potential emergencies.
• Provision should be made for availability of medical supplies, equipment and materials during such emergencies.
• Hospital staff should be trained in disaster management, which should be tested at least twice a year.

[These points are mandated by NABH—National Accreditation Board for Hospitals and Healthcare Providers].

Safety provisions in a hospital

For fire-related emergencies

A good hospital should have smoke detectors, water sprinklers, manual call points, auto glow signages, smoke sensors, emergency communication systems, and lift failure communication systems.

For non-fire related emergencies

A good hospital should have:

• Flooding sensors fitted with an sump pump in the basement of the hospital. Any rise in water level should start the pumps automatically, removing excess water from the basement.
• A spare submersible pump in the hospital premises for monsoon.
• Lifts fitted with lift failure sensors —an alarm to indicate lift failure.
• Floor plans maintained in the engineering department, for guidance in emergencies.
• Prominent exit signages on every floor for easy identification.
• Security guards who can handle emergencies adequately.
• Fire drills conducted quarterly.
• Security and engineering staff periodically trained in lift operations.
• Adequate basic and advanced training for all staff, especially one dealing directly with patient care.
• Mock drills should be held at least twice a year to test the readiness of the staff to handle emergencies.
• Crash carts and pharmacy stores stocking with life saving medicines available 24/7 in all patient care areas.
• Kitchen with a provision for storing extra raw material for 15 days.
• Trainings conducted by the engineering department.
• Updated records regarding patients, facilities and trainings maintained at the hospital.
• Trained fire wardens designated for each floor with requisite fire safety kit and protection to lead an evacuation from that floor in case of emergency.

What to do during an earthquake

• Remain calm.
• Put out any fire and shut off the main circuit breaker.
• Keep the doors open for a clear exit route.
• Move away from furniture and light fixtures that are liable to fall.
• Seek shelter under a sturdy desk or table.
• Do not rush out of the building.
• Watch out for falling objects and evacuate wearing functional clothing.
• Obtain accurate information from radio.
• Make evacuating the elderly, physically challenged and children a priority.

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A quality-conscious hospital should define all such activities internally, document the same, and impart necessary training to the staff. These documented activities include detailed job responsibilities, work instructions, checklists and quality indicators for the staff to follow.

So how will the patient know about these processes? He is not expected to inquire with the hospital whether they have these processes laid down. And how many processes could he check even if allowed to?

Accreditation is the key

Organisations like the Quality Council of India [QCI] and its National Accreditation Board for Hospitals and Healthcare providers [NABH] have designed an exhaustive healthcare standard for hospitals and healthcare providers. This standard consists of stringent 500 plus objective elements for the hospital to achieve in order to get the NABH accreditation.

To comply with these standard elements, the hospital will need to have a process-driven approach in all aspects of hospital activities – from registration, admission, pre-surgery, peri-surgery and post-surgery protocols, discharge from the hospital to follow-up with the hospital after discharge.

NABH accreditation criteria

To give an idea what NABH standard comprises of, some of the 500-plus objective elements are listed here. The requirements have been grouped for easy understanding.

Information to patients

1. The patients and/or family members are explained about the proposed care.
2. The patients and/or family members are explained about the expected results.
3. The patients and/or family members are explained about the possible complications.
4. The patients and/or family members are explained about the expected costs.

Rights of the patient and family

1. Respect for personal dignity and privacy during examination, procedures and treatment.
2. Right to refusal of treatment.
3. Informed consent before anaesthesia, blood and blood product transfusions and any invasive or high-risk procedures.
4. Information on how to voice a complaint.
5. Access to his / her clinical records.

Quality in investigations

1. Adequately qualified and trained personnel perform and/or supervise the lab investigations.
2. Policies and procedures guide collection, identification, handling, safe transportation and disposal of lab specimens.
3. Laboratory and imaging results are available within a defined time frame.
4. Critical results are intimated immediately to the concerned personnel.
5. The lab and imaging quality programme addresses verification and validation of test methods.
6. The lab and imaging quality programme includes periodic calibration and maintenance of all equipments.
7. The lab and imaging programme includes the documentation of corrective and preventive actions.

Surgical services

1. Surgical patients have a pre-operative assessment and a provisional diagnosis, documented prior to surgery.
2. Documented policies and procedures exist to prevent adverse events like wrong site, wrong patient and wrong surgery.
3. The operating surgeon documents the post-operative plan of care.
4. There is a documented policy and procedure for the administration of anaesthesia.
5. All patients for anaesthesia have a pre-anaesthesia assessment by a qualified individual.
6. During anaesthesia, monitoring includes regular and periodic recording of heart rate, cardiac rhythm, respiratory rate, blood pressure, oxygen saturation, airway security and level of anaesthesia.

Medication

1. Documented policies and procedures exist for prescription of medications.
2. The organisation defines a list of high-risk medication.
3. High-risk medication orders are verified prior to dispensing.

Infection control

1. The hospital has an infection control team.
2. The hospital has designated and qualified infection control nurse[s] for this activity.
3. Hand-washing facilities in all patient care areas are accessible to health care providers.
4. Compliance regarding proper washing of hands is monitored regularly.
5. Isolation/ barrier nursing facilities are available.
6. Adequate gloves, masks, soaps, and disinfectants are available and used correctly.

Facility and infrastructure maintenance

1. The organisation’s environment and facilities operate to ensure safety of patients, staff and visitors
2. There is a documented operational and maintenance [preventive and breakdown] plan.
3. Up-to-date drawings are maintained which detail the site layout, floor plans and fire escape routes.
4. The provision of space shall be in accordance with the available literature on good practices [Indian or International Standards] and directives from government agencies.
5. There are designated individuals responsible for the maintenance of all the facilities.
6. Maintenance staff is contactable round the clock for emergency repairs.
7. Response times are monitored from reporting to inspection and implementation of corrective actions.

Other

1. Defined procedures for situation of bed shortages are followed.
2. Ambulance[s] is appropriately equipped.
3. Ambulance[s] is manned by trained personnel.
4. There is a checklist of all equipment and emergency medications in the ambulance.

How NABH accreditation helps patients

In an NABH accredited hospital, there is a strong focus on the following:

• Patient rights and benefits
• Patient safety
• Control and prevention of infections
• Practicing good patient-care protocols e.g. special care for vulnerable groups, critically ill patients
• Better and controlled clinical outcome.

NABH now is a member of the International Society for Quality in Health Care [ISQua] and thus NABH standard is at the threshold of being recognised globally.

So, if a hospital is NABH accredited, the patient can rest assured that the hospital follows stringent standards as laid down by the accreditation body for providing best in patient care comparable to any international hospital of repute.

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