HOSPITAL PREPAREDNESS IN CBRN DISASTER

  1 HOSPITAL PREPAREDNESS IN CBRN DISASTER

  

_{Top Referral Hospital and Main Teaching Hospital that The Military Personnel}

_{To be a Presidential Hospital with International Standard,}

  VISION and Communities to be proud of

_{1. The function of the central level and the highest reference for Indonesia National}

_{Army Hospital} MISION

_{3. Organizing health services for the President, Vice President, State officials, State}

  

2. Organizing health services and professional and health support as well as

_{comprehensive quality 5. Scientific research and develop continuously 4. Improve the ability of health workers through continuing education} Guests and other VVIP.

  10/4/16

HOSPITAL MAP

  

_{Number of building : 33 units}

Land area : 13,5 HA

  _{2) Internal Medicine 3) Pediatrics} 4) Cardiology _{5) Pulmonology 6) Opthalmology} 7) Dermatology _{8) Obstetry Gynaecology 9) Neurology Department} 10) Ear

  12 DEPARTMENT ^{9 INSTALLATION/ CENTER 10 UNITS} SCOPE OF SERVICES

1) Surgery

• – Nose – Throuth / ENT
_{11) Psychiatry 12) Dental} ^{1) Medical Rehabilitation 2) Nuclear Radiology 3) Pathology 4) Emergency 5) Operating Theatre 6) Outpatient 7) Inpatient}

^{8) Anesthesia & Reanimation}

^{9) Pharmacy CENTER :} _{1) Cerebrovascular Center 2) Indonesia Army Cellcure Center} ^{1) Military Medicine 2) Medical Check Up 3) Food Service 4) Material Warehouse 5) Health Environment 6) Engineering 7) Training & Education Health Workers 8) Special Support : Laundry,} _{Morgue, Forensic}

  HOSPITAL STAFF 304 1124

  248 1555 MEDICAL STAFF NURSE AND MIDWIFE _{OTHER PROFESSIONAL HEALTH SUPPORTING STAFF} ^{(9,41%) (34,79%) (48,13%) (7,68%)}

NUMBER OF VISIT

  EMERGENCY 2,786 12,843 _Medik Bedah

  Vs.

  Emergency Disaster A SUDDEN & MASSIVE A SUDDEN HAPPENING HAPPENING WHICH WHICH REQUIRES REQUIRES PROMPT AND HUGE PROMPT ACTIONS ACTIONS

  Medical/CBRN Disasters » Medical/CBRN Disaster occurs when the destructive effects of natural or manmade forces overwhelm a community’s ability to properly allocate existing resources. in this case, the causative agents are : Chemical, Biological, Radioactive, and Nuclear agents

  » For example, Terorism impact on the medical Infrastructure : World Trade Center and Pentagon attack costs 3000 people dead and hundreds injured.

COMPONENTS OF HOSPITAL PREPAREDNESS

  » Incident Command System » Communication » Continuity of essential health services and patient care » Surge Capacity » Human Resources » Logistic and Supply Chain Management

  » Essential Support Services » Infection Prevention and Control » Case Management » Surveillance Early Warning and Monitoring » Laboratory Services

  Hazards Human-made  Fires 

  Explosive devices  Firearms 

  Structural collapse 

  Transportation event Air, Rail, Roadway, Water

   HAZCHEM / HAZMAT  WMD

   CBRN events etc…

  Natural 

  Earthquake

  

  Landslides

  

  Floods

  

  Fires etc…

  Biologic Nuclear/ Radn Chemical Onset Slow Rapid Rapid Transmission

  / infectivity Slow, Agent dependant

  Particulate only, Fast Fast, Agent dependant

  Detection Difficult Easier Easier Resource consumption

  Gradual, long term Rapid, short and long term

  Rapid, short term Some long term Public Health involvement

  Short & long term Short & long term Short term Bed use Mixed Hospital Hospital Decon. requirements

  Agent dependant Critical for particulate Critical for all

  Antidote Agent dependant None Class Dependant

  

CBRN Agent Detection

» By Signs & Symptoms » By Detectors/Monitors (Consider the sensitivity and the environmental conditions)

» The purposes of detection : Hazard Assesment, the Level of PPE required

for the case and consideration for Decontamination process.

  » Standard Lab Procedures for Biological Agent usually require 12 to 48 hours to yield results and treatment should be based on index of suspicion.

  » Instruments like G.M. Survey Meter, Neutron meter and Personal

Dosimeters like film badge are required in Radiation Agent Detection

process.

  CBRN Hazards Effects

  » Chemical, Heat & Radiation Burns » Injuries » Infections » Poisoning » Psychological vulnerability » Panic Syndrome

  Chemical Agents Classification

  1. Nerve Agents (Organophosphate based, insecticides)

  2. Blister Agents

  

3. Pulmonary/Choking agents (Phosgene, Chlorine)

  4. Blood Agents (Cyanide)

  5. Other Agents (Pepper Spray, Tear gas, CS, OC) The agents mentioned above is parts of Toxic Industrial Chemicals (TICs) and considered Hazardous Materials

  Reponse to Chemical Agents

  » Decontamination » Antidotal Therapy

• – 2PAM/Pralidoxime
• – Atropine – Benzodiazepines

  Chemical Incident Types

  1. Small, Localized Hazmat Incident : commonly a liquid contamination, and greater need for showering

  2. Chemical Mass Casualty Incident : commonly a gas or vapor exposure, clothing removal is the focus of decontamination

  Biological Agents

  1. Bacterial

  2. Viral

  3. Toxins Characteristics : Low visibility, high potency, latency, easy accesibility, simple delivery, good sustainability and propagation, does not affect structures

  Entry Modes : Inhalation, Ingestion, Injection, Absorption

  

Bioterorism Agents

  

1. Category A : Risk to national security (easily disseminated

and transmitted from person to person, high mortality

rates) ex : Anthrax, Botulism, Plague, Smallpox, Tularemia, Ebola

  (Filovirus), Lassa (Arenavirus)

  2. Category B : moderately easy to disseminate, low mortality rates ex : Brucellosis, Psittacosis, Q fever, Salmonella & E.colli, Viral Encephalitis, Cholera

  3. Category C : Emerging pathogens (could be engineered

for mass dissemination in the future, potential for high

morbidity and mortality) ex : Nipah virus, Hanta Virus

  Management of Potential Biological Casualties » Maintain index of suspicion » Protection of the Healthcare Providers » Assessment of the patient » Decontamination » Diagnosis establishment » Prompt treatment » Alert the Authorities » Assist in Epidemiologic investigation » Maintain Proficiency

  Patient Isolation Precaution on Biological Threats » Standard Precaution » Transmission Based Precaution » Contact Precaution » Droplet Precaution » Airborne Precaution

» Conventional Disease Requiring Airborne Precaution

  (ex : Measles, Varicella, TB) » Bio Threat Disease Requiring Airborne Precaution (ex : Smallpox) » Discontinuation of Transmission Based Precaution

  

Radiation Exposure Health Effects

» Lethal at high doses » Mutagenic » Carcinogenic » Other biological effects at high doses How to avoid the negative effects :

  1. Time : Decrease Time spent near the radioactive source

  

2. Distance : Increase Distance between you and the source

  3. Shielding : Increase the physical shielding between you and the source. (Wood Frame building is the lowest dose reduction factors only around 10%)

  Categorization of Radiological Exposure

  » External Contamination (Patient become radioactive, clothes removal is part of decontamination)

  » Irradiation (exposure to radiation but the patient is not radioactive and pose no risks to others)

  » Ingestion (patient body fluids may radioactive) » Combination of the above

  

Potential Terrorist Scenarios

  » Radiological : Radiological dispersion device (ex : dirty bomb), malicious use of radioactive substances

  » Nuclear : attack on nuclear facility, nuclear weapon, IND (Improvised Nuclear Device) which the casualties count could reach more than 100.000 patients which require evaluation and treatment.

  Preparedness

» State of Readiness [Always Ready]

» Supplies & Equipment for :

• – Antidote – PPE
• – Decontamination » Training & Equipment for :
• – Agent Recognition – Patient Management – Patient Decontamination

  

Training

  » Hospital everyday preparedness for HAZMAT Contaminated patients

  » Training for Nuclear, Biological, Chemical (NBC) Incidents

  » Training with realistic scenarios » Field Hospital Training » Public education should also be considered

  

Command, Control & Communication

» Coordinated Response at The Incident Scene & at

the Healthcare Facility » Accurate Notification & Communication :

• – Local Community to the Disaster Scene

  – from the Disaster Scene to the Hospital and

  from the Hospital to the Disaster Scene – Within the Hospital » Media Coordination : Updates & Public Relation

  _{» Mandated for all personnel who have substantial risk of exposure to hazardous}

Personal Protective Equipment (PPE)

_{» PPE on Biological Threats : Treats every patients with respiratory complaints and}

materials (According to the Regulations by OSHA, NIOSH, EPA, JCAHO) _{where aerosols coulld be generated (lab, autopsy facilities, etc) plague/smallpox/hemorhagic fevers, Precaution Upgrades in areas of the hospital} open wounds as an “infectious source”, HEPA filter mask upgrade for pneumonic » PPE on Radiological Threats : Particulate Maks (Level C is the minimum _{requirements), Shielding and Dosimeter} » Levels of PPE :

• – Level A = for Immediate Dangerous to Life and Health (IDLH) environments, _{fully encapsulated, requires SCBA (Self Contained Breathing Apparatus)}
• – Level B = for Chemical or Substance with inhalation hazards environments, _{requires SCBA or SAR (Supplied Air Respirators)}
• – Level C = for Known Contaminants Environment, requires air purifying _respirator

  

Decontaminations

» For Casualties arriving at the healthcare facilities which exposed to

harmful substances » Differentiate between Vapor & Liquid Exposure of hazardous materials »

Don’t forget to Decontaminant the exposed Healthcare Providers

» Considerations for Mass Casualty Incidents :

• – Ambulatory vs non-ambulatory victims
• – Decon methods
• – Water vs bleach methods
• – Location of decon area

DECONTAMINATION CHAMBER RSPAD GATOT SOEBROTO

  » Inventorial of current capabilities & rectify any deficiencies » Personnel training for realistic scenarios » Plan for :

  

Readiness Phase

• – Triage “Do the greatest good for the greatest number of disaster victim in the light of limited resources”
• – Decontamination

NEGATIVE PRESSURE ISOLATION ROOM

  Planning Phase » Incorporate responsible people in planning process » Plan must be Cost-Effective » Plan for Problems that may occurred (Traffic jam, Hospital Access, Communication, Security, Staff ID,

  

Triage, Decontamination, Information Management)

» Joint Planning with Law Enforcement, Local EMS, & Fire Brigade (Mutual Aid Agreement with the Policies & Procedures)

  » Stockpile antidotes & medications, purchase PPE and

decontamination equipment, make sure the facilities

keep open & viable at any time

  

Recovery Phase

» Focus shifted from Acute injury to the everyday needs

of the population » Consider the Hospital Staff needs for rest and shift changes » Increased need for :

• – Medication – Shelter – Food, water, clothing
• – Emotional support

  CBRN Disaster Management Overview » Preparedness » Training » Command, Control, Equipment » PPE » Decontamination » Detection » Triage » Staff Preparedness » Logistics/Supplies » Hospital Space Utilization » Evidence Preservation » Exercising the Plan

  

CBRN casualties pathway

» Triage : prioritization patients based on clinical condition » Resuscitate and treat patients as per triage » Decontaminate the victim and prevent the spread of contamination

» Transport victims on priority as per triage classification

  » Re triage constantly as a dynamic process throughout the phases of the management » Move the dead body of the casualties » Training theoretical and practical periodically

  GOAL Presidential Hospital Preparedness

  CBRN Disaster Management ^{CBRN Threats Good Outcome}

  _Algorithm

Presidential Hospital Triage

  

_{Decontamination Algorithm}

Presidential Hospital

  _Algorithm

CBRN Waste Treatment

INTERNATIONAL RELATIONSHIP

  _{PRESIDENTIAL HOSPITAL FRANCE} KEYNOTE LECTURE IN ₂₀₁₆

_{VISIT OF DIRECTOR OF THE CEDARS SINAI}

_{HOSPITAL LOS ANGELES}

_{KEYNOTE LECTURE DI ST. PETERSBURG RUSIA IN MILITARY MEDICINE ASIA PASIFIC COOPERATION WITH THE PRESIDENTIAL HOSPITAL THAILAND A SHORT BRIEF}

_{MEDICAL FACULTY CADET IN BANGKOK}

_{– ROYAL THAI ARMED FORCES} PARTNERSHIP AND INTEROPERABILITY IN _{FRAMING A NATIONAL PLAN FOR RISK MANAGEMENT PANDEMIC INFLUENZA PREPAREDNESS}

  

THE BEST SERVICE

_{EXCELLENT HOSPITAL 2017}

THE HEAD OF THE HOSPITAL RECEIVE

  _{ACHMAD BAKRIE XV AWARD in the FIELD of MEDICINE 2017} ^{The head of the hospital was awarded the Museum Rekor Indonesia namely the award as "the inventor of the therapy of Brainwashing" and "Workmanship DSA (Digital Subtraction} Angiogram) most“ 2017 ^{INDONESIA CHAMPION} _{MARKETING AWARD 2014} GOLDEN PERSONNALITY _{AWARD 2017} ^{VARIOUS AWARD RECEIVED RSPAD GATOT SOEBROTO}