Internal Disaster Preparedness and Management in Hospitals

This presentation deals on the following
1. Disaster definition- Internal and external
2. Learning from Disasters- Case Studies- AMRI, Chennai Floods
3. Four phases of emergency management
5. Risk assessment
6. 5 steps of emergency preparedness
7. Emergency management and evacuation plan for hospitals
8. Mock drills and how to conduct them
9. Table top exercises

1. Dr. Lallu Joseph Quality Manager, Associate GS, CMC Vellore Secretary General, CAHO Internal Disaster Preparedness and Management CHRISTIAN MEDICAL COLLEGE VELLORE

2. Learning Objectives Disaster - Internal and External Learning from disasters - Case Studies Four phases of emergency management Risk assessment in hospitals Preparing the disaster management plan Mock drills 2

3. Hospitals and Disasters Disaster – “A sudden accident or a natural catastrophe that causes great damage or loss of life ”. Classified as Natural and Human-made. Disasters have uncanny ability to bring to the forefront vulnerabilities of systems, structures, processes and people. Hospitals are no exception. When hospitals are affected, the repercussions are multifold. 3

4. Types of Disaster Scenarios – Hospitals Internal Disaster Unforeseen situation Limited to the hospital facility Can cause huge damage to people and property Disrupts or shut down of hospital Eg .: Fire accidents, explosions External Disaster Unforeseen situation Hospital may/ may not be affected but is a critical part of the larger response Eg .: Earthquake, flooding, accidents, terrorism 4

5. Case Studies

6. AMRI Hospital, Kolkatta Occurrence of accident on 9 December 2011 at 2:15 AM Fire started from the basement. 3:30 AM Smoke started spreading through AC ducts 4:10 AM Fire Brigade called 4:30 AM Rescue process started 7:30 AM Firemen broke the wall of basement and started flooding the wall. Could not enter due to smoke and poisonous gas 8:00 AM Snorkel arrived and rescue by breaking the glasses of the building facade 6

7. ROOT CAUSE ANALYSIS The basement had plenty of Inflammable articles like paper, cotton, mattress, chemicals etc Alarm did not get activated as it was made inactive, due to many false alarms Fire extinguishers at the basement did not work as they were not checked. No evacuation was initiated even after 1 ½ hrs. Central AC system and electricity supply were not stopped Carbon monoxide gas started spreading through AC ducts No trained person to deal the emergencies, specially how to evacuate critically ill patients. No signage for emergency exits. No arrangement for alternate ventilation. No escape route. Set back around the building had vehicles parked . 7

8. Chennai Floods 575 patients admitted 75 in ICU 57 transferred, 18 died Basement flooding – sudden inflow No power, no oxygen, no network, no transport 8

9. Lessons Learnt Inadequate compliance to building codes and norms Absence of operational disaster management plan Lack of planning and preparedness to disasters Inadequate internal and external communication Lack of networking among hospitals 9

10. Four Phases of Emergency Management 10 To protect people and property in the wake of an emergency, disaster or crisis. To rebuild after a disaster and return back to normal. To  take actions ahead of time  to be ready for an emergency. To  prevent  emergencies and take steps to minimize their effects. Phase 1: Mitigation Phase 2: Preparedness Phase 3: Response Phase 4: Recovery

11. Five Steps to Emergency Preparedness 11 1. Know the risks 2. Build the team 3. Prepare the plans 4. Test the plans 5. Update everyone

12. 1. Know the Risks 12 Fire Bomb threat Failure of utilities Flood Earthquake Structural collapse Medical emergency

13. Risk Quantification Matrix 13

14. Risk Score 14 Threat Likelihood (L) Consequence/ Severity of Impact (S) Risk Fire 4 4 16 Floods 2 3 6 Infant abduction 2 4 8 Bomb threat 1 5 5 Risk Cut-off Values 1 - 5 Low risk 6 - 12 Medium risk 15 - 25 High risk

15. 2. Build the Team 15 Every individual may have a role as a first responder. Subject matter experts from different departments should help in overall span of the plan, including the four phases of emergency management cycle: Mitigation: Preventing emergencies and minimizing the effects if an event occurs. Preparedness: Identifying efforts to prepare for the event. Response: Planning efforts to respond safely to the event. Recovery: Identifying actions needed to return the facility to normal operations. Representatives from safety, security, HR, PR, facilities, operations and top management should be involved from the start.

16. 3. Prepare the Plans 16 Common mistake - We often think that the bigger the document, the better it is! And it is often conducted ( in vacuum), with no input from the end users. Emergency plans should be the product of an inclusive team instead of an individual or group.  It should have an outline of each emergency: Whom to call, their contact number and what should an individual do to ensure their own safety and safety of others.  It should have a description of the specific tasks of all individuals. Note: If the plans are already in place, then the team would form a good review committee.

17. Fire Evacuation Plan for COVID Areas CHRISTIAN MEDICAL COLLEGE VELLORE

18. First response protocol

19. Fire Person who sees the fire (Staff 1) Shout for help Person coming for help (Staff 2) Inform 3000 Inform Sr. Doctor on floor Inform Charge Nurse / Senior Nurse on floor Sr. Doctor & Charge Nurse / Senior Nurse rush to the fire spot) Fire Officer & Team Central Command Center (CCC) - 8800 Fire Spot Activate Electrical, Medical Gas, AC Section, Security Office & Admin Offices (MS, NS, GS, Director, Quality / Safety Cell) Announcement protocol “Attention please CODE RED LEVEL 1 in Eg. P2 Ward ( 3 Times) P2 Ward stay alert – (3 Times) Control fire with the nearest fire extinguisher Electrical Medical Gas & AC Technician Inform CCC PROTOCOL FOR LEVEL 1 FIRE RESPONSE TEAM RUSHING TO COVID WARDS Wear N95 mask and rush to the fire area (Fire response team should maintain N95 stock in their office or rush to the respective scrub counter and get N95 mask) Security (trained on fire management) posted in COVID floors round the clock should run to the spot and start fire fighting as soon as the information reaches him

20. LEVELS OF FIRE Level 1 Fire Contained fire – Fire is contained within a confined space (No evacuation) Level 2 Fire Partially controlled fire – Full evacuation of the Ward (Partial evacuation of the building) Level 3 Fire Uncontrolled fire   (Full evacuation of the building)

21. Level 1

22. PROTOCOL FOR LEVEL 1 FIRE RESPONSE TEAM RUSHING TO COVID WARDS Wear N95 mask and rush to the fire area (Fire response team should maintain N95 stock in their office or rush to the respective scrub counter and get N95 mask) Security (trained on fire management) posted in COVID floors round the clock should run to the spot and start fire fighting as soon as the information reaches him Fire Person who sees the fire (Staff 1) Shout for help Person coming for help (Staff 2) Inform 3000 Inform Sr. Doctor on floor Inform Charge Nurse / Senior Nurse on floor Sr. Doctor & Charge Nurse / Senior Nurse rush to the fire spot) Fire Officer & Team Central Command Center (CCC) - 8800 Fire Spot Activate Electrical, Medical Gas, AC Section, Security Office & Admin Offices (MS, NS, GS, Director, Quality / Safety Cell) Announcement protocol “Attention please CODE RED LEVEL 1 ……….. Ward ( 3 Times) Adjacent Wards stay alert – (3 Times) Control fire with the nearest fire extinguisher Electrical Medical Gas & AC Technician Contained fire Level 1 Uncontrollable Fire Level 2 or Level 3 Fire team to put off the fire and call off Code red Fire team to inform CCC that “Code red in …… ward is called off Announcement to Electrical, Medical Gas, AC Section, Security Office & Admin Offices (MS, NS, GS, Director, Quality / Safety Cell) Announcement protocol “Attention please CODE RED LEVEL 1 in …………… Ward called off. Continue with your work (3 Times) Level 1 Calling off

23. Level 2

24. Announcement protocol CODE RED LEVEL 2 Attention please CODE RED LEVEL 2 in Eg . P2 Ward - (3 times) P2 ward evacuate – (3 times) 3. P1 & P3 ward stay alert – (3 times) 4. Request staff from Q block, M block and E ward to rush to P2 ward for help NS / NS representative announcement protocol Affected Area Announcement protocol If COVID ICU 1. Move the patients to ……………... OR (I repeat) 2. ………………... OR be prepared to receive the patients (I repeat) If other COVID wards 1. Move the patients to………………. Ward (I repeat) 2. ………………. Ward stay prepared to receive the patient (I repeat) Note: Staff coming for help should wait outside the affected ward and accompany the patient while coming out of the affected ward If Level 2 fire Chief fire officer/ Fire officer assess and inform the level of fire to the decision making team Decision Making Team (Responsible for affirming the level of fire and order for evacuation) 1. Chief Fire Officer / Fire officer 2. Sr. Doctor 3. Sr. Nurse Order for evacuation Chief Fire Officer / Fire Officer activate Sr. Doctor and Sr. Nurse (Incident Commander for the evacuation process) Triage patients. Inform alternate care site Assign responsibilities to the staff to evacuate Guide evacuation Confirm that all the patients and staff are safely moved to their respective alternate care site Central Command Centre (CCC) Critical Incident Team Members: 1. Director, 2. Associate Director (Admin) 3. MS, 4. NS, 5. GS, 6. PRO, 7. Quality Manager, 8. Safety Officer, 9. PA system technical coordinator CSO to Activate Specially Trained Security Guards (STSG) and rush to the fire spot Chief Security Officer / Security Officer assess the situation and inform Critical Incident Team Rush to the Control Command Centre Analyse the situation based on the report by Chief Fire Officer & Chief Security Officer Inform CCC about level of fire Inform Security office Fire office Fire fighting

25. If Level 2 fire Chief fire officer/ Fire officer assess and inform the level of fire to the decision making team Decision Making Team (Responsible for affirming the level of fire and order for evacuation) 1. Chief Fire Officer / Fire officer 2. Sr. Doctor 3. Sr. Nurse Order for evacuation Chief Fire Officer / Fire Officer activate Sr. Doctor and Sr. Nurse (Incident Commander for the evacuation process) Triage patients. Inform alternate care site Assign responsibilities to the staff to evacuate Guide evacuation Confirm that all the patients and staff are safely moved to their respective alternate care site Central Command Centre (CCC) Critical Incident Team Members: 1. Director, 2. Associate Director (Admin) 3. MS, 4. NS, 5. GS, 6. PRO, 7. Quality Manager, 8. Safety Officer, 9. PA system technical coordinator CSO to Activate Specially Trained Security Guards (STSG) and rush to the fire spot Chief Security Officer / Security Officer assess the situation and inform Critical Incident Team Rush to the Control Command Centre Analyse the situation based on the report by Chief Fire Officer & Chief Security Officer Inform CCC about level of fire Inform Security office Fire office Controllable Level 2 fire Uncontrollable fire Level 3 Fire team to put off the fire and call off Code red in consultation with Decision making team Fire team to inform CCC that “Code red in …… ward is called off Announcement to Electrical, Medical Gas, AC Section, Security Office & Admin Offices (MS, NS, GS, Director, Quality / Safety Cell) Announcement protocol “Attention please CODE RED LEVEL 2 in …………… Ward called off. Continue with your work ( 3 Times) Level 2 Calling off Fire fighting

26. Level 3

27. Note: Staff coming for help should wait outside the affected ward and accompany the patient while coming out of the affected ward If Level 3 fire Chief fire officer/ Fire officer assess and inform the level of fire to the decision making team Decision Making Team (Responsible for affirming the level of fire and order for evacuation) 1. Chief Fire Officer / Fire officer 2. Sr. Doctor 3. Sr. Nurse Order for evacuation Chief Fire Officer / Fire Officer activate Sr. Doctor and Sr. Nurse (Incident Commander for the evacuation process) Triage patients. Inform alternate care site Assign responsibilities to the staff to evacuate Guide evacuation Confirm that all the patients and staff are safely moved to their respective alternate care site Central Command Centre (CCC) Critical Incident Team Members: 1. Director, 2. Associate Director (Admin) 3. MS, 4. NS, 5. GS, 6. PRO, 7. Quality Manager, 8. Safety Officer, 9. PA system technical coordinator CSO to Activate Specially Trained Security Guards (STSG) and rush to the fire spot Chief Security Officer / Security Officer assess the situation and inform Critical Incident Team Rush to the Control Command Centre Analyse the situation based on the report by Chief Fire Officer & Chief Security Officer Inform CCC about level of fire Inform Security office Fire office Fire fighting Announcement protocol CODE RED LEVEL 3 Attention please CODE RED LEVEL 3 in …………………... P block - (3 times) All floors evacuate – (3 times) 3. Request staff from Q block, M block and E ward to rush to P2 ward for help NS / NS representative announcement protocol Affected Area Announcement protocol If COVID ICU 1. Move the patients to ……………... OR (I repeat) 2. ………………... OR be prepared to receive the patients (I repeat) If other COVID wards 1. Move the patients to………………. Ward (I repeat) 2. ………………. Ward stay prepared to receive the patient (I repeat)

28. If Level 3 fire Chief fire officer/ Fire officer assess and inform the level of fire to the decision making team Decision Making Team (Responsible for affirming the level of fire and order for evacuation) 1. Chief Fire Officer / Fire officer 2. Sr. Doctor 3. Sr. Nurse Order for evacuation Chief Fire Officer / Fire Officer activate Sr. Doctor and Sr. Nurse (Incident Commander for the evacuation process) Triage patients. Inform alternate care site Assign responsibilities to the staff to evacuate Guide evacuation Confirm that all the patients and staff are safely moved to their respective alternate care site Central Command Centre (CCC) Critical Incident Team Members: 1. Director, 2. Associate Director (Admin) 3. MS, 4. NS, 5. GS, 6. PRO, 7. Quality Manager, 8. Safety Officer, 9. PA system technical coordinator CSO to Activate Specially Trained Security Guards (STSG) and rush to the fire spot Chief Security Officer / Security Officer assess the situation and inform Critical Incident Team Rush to the Control Command Centre Analyse the situation based on the report by Chief Fire Officer & Chief Security Officer Inform CCC about level of fire Inform Security office Fire office Fire fighting Fire team to put off the fire and call off Code red in consultation with Decision making team Fire team to inform CCC that “Code red in …… ward is called off Announcement to Electrical, Medical Gas, AC Section, Security Office & Admin Offices (MS, NS, GS, Director, Quality / Safety Cell) Announcement protocol “Attention please CODE RED in …………… Ward called off. Continue with your work ( 3 Times) Level 3 Calling off

29. ROLES AND RESPONSIBILITIES DURING EVACUATION

30. Role of Incident commanders (Sr. Doctor and Charge nurse / Sr. Nurse ) Sr. Doctor: Take charge of the situation Triage the patients for evacuation and pass on the list to team to prepare for evacuation Co-ordinate the evacuation process along with charge nurse Charge Nurse / Sr. Nurse Responsible for informing the ward team about alternate care site. Organise to inform the alternate care site if Level 2/Level 3 evacuation is ordered Assign responsibilities to the ICU staff to evacuate long with senior doctor Co-ordinating the evacuation process along with Sr. Doctor Confirm that all patients are safely shifted and inform NS Both can move to the alternate care site only after all patients and staff are moved out of the ICU.

31. ICU Doctors and Nurses Knows the triage status of their patient Ensure patient is transferred safely with critical equipment / Bag and Mask ventilation and Emergency medications Shifting essential pumps to the bed Make sure chest drains are on the bed-chest tubes should not be clamped Ensure patients records are transferred safely Get help from the external staff waiting outside Guide in the appropriate route to the alternate care site

32. TECHNICIANS AND HELPERS in ICU Technicians: Prepares to shift out the patient Disconnects and moves monitor to the bed M oves arterial line transducer to the bed and He lps nurses in moving pumps to the bed Ensures ambu bags are available at all bedside and will assist in shifting patients to surge areas Shifts ventilator to the Alternate care site Attender : Gets 2 trolleys and keeps them ready in case transfer to trolley required (for eg-bed on fire) Oxygen cylinder on the bed

33. Role of staff from alternate care site Make sure alternate site is kept ready to receive patients Few staff to move to the location Help shifting of patients from ICU to alternate care site Receive patients in the alternate care site and take care .

34. ADMINISTRATION DIRECTOR , ASSOCIATE DIRECTOR, MS, GS, NS, PRO, QUALITY MANAGER, SAFETY OFFICER has to rush to the Central Command Centre Role of MS & NS: Open the bed occupancy status in the Central Command Center computer and be ready If required mobilize extra doctors and nurses to assist in evacuation Speak to alternate care site and arrange for bed If the alternate care site is full arrange bed in another area / ward Make appropriate announcements on bed availability and alert alternate care site MS to deploy more medical manpower if required (from emergency department) Role of GS: Mobilize extra support service staff to assist in evacuation Arrange for extra resources based on the request by CFO/CSO Liaise with Chief Fire Officer / Security Officer and get the updates Once the information on the situation under control is received from Chief Fire Officer, order for event call off in consultation with the Admin Officers.

35. Role of Director: Guide PRO in managing the Press & Media Liaise with PRO and get updates Role of Quality Manager / Safety Officer: Assist the Admin Officers in familiarizing the protocols when required Help in announcing the information through PA system Role of Communication Technical Engineer: Coordinate the whole technical communication process Assist the Admin Officers in getting the bed occupancy status and the required information in the computer Admin officers have to analyse the situation based on the information given by the Chief Fire Officer (CFO) and Chief Security Officer (CSO) If required inform TN fire service and local police station through Chief Fire Officer (CFO) and Chief Security Officer (CSO) If the situation is brought under control evaluate the safety and order for continuation of work

36. ALTERNATE CARE SITE & ROUTE FOR ICUs – CRITICAL PATIENTS S. No ICU Alternate care site 1 Route Alternate care site 2 Route 1 STICU ENT OR / Recovery STICU – Move towards C ward – turn right towards E ward – take Q block bridge and reach Q block lift lobby – take lift 47C to 1 st floor – ENT OR / Recovery P2 or Q2 STICU – Move towards C ward – turn right towards E ward – take Q block bridge and reach Q block. Enter into P2 or Q2 2 MICU / MHDU ENT OR/ Recovery MICU/MHDU – Move towards E ward – turn right towards E ward – take Q block bridge and reach Q block lift lobby – take lift 47C to 1 st floor – ENT OR / Recovery P2 or Q2 MICU/MHDU – Move towards E ward – turn right towards E ward – take Q block bridge and reach Q block. Enter into P2 or Q2 3 KICU ENT OR/ Recovery Move towards Q block to reach ENT OR / Recovery P1or Q1 Move towards Q block. Enter into P1 or Q1 4 PHDU Q6S Level 2 PHDU - Move towards Q6W and reach Q6S AICU / Paul Brand Level 3 PHDU - Move out in the rear entrance of PHDU – Take lift no.10 to ground floor – Move through MCTT counters to reach ISSCC ramp – Get down through the ramp – Go to AICU/ Paul Brand Building 5 ED (Critical) CCU ED - Move towards cardiology corridor – Turn left through GS gate (Security check point) – move towards GS Office corridor – turn right and then left to CCU Injection room ED to Injection room Note: If alternate care site is full or if not accessible, can move to any of the COVID ICUs mentioned in the table.

37. ALTERNATE CARE SITE & ROUTE FOR ICUS – CRITICAL PATIENTS S. No ICU Alternate care site Route Alternate care site 2 Route 6 PES (Critical) ED PES - Move through MCTT counters to reach ISSCC ramp – Get down through the ramp and cross the road to reach ED CCU PES - Move through MCTT counters to reach ISSCC ramp – Get down through the ramp and cross the road to ED - Move towards cardiology corridor – Turn left through GS gate (Security check point) – move towards GS Office corridor – turn right and then left to CCU 7 CCU ED CCU - Take GS Office corridor and move towards chapel side – turn left towards CBMO to reach GS gate (security check point) – turn right in cardiology corridor to reach ED KICU Take ENT lift – get down in first floor - Move in the connecting bridge towards Q block – Turn left towards KICU 8 AICU ENT OR / Recovery AICU - Take lift 35 to 1 st floor – Move in the connecting bridge to reach Main Building – Turn right towards B ward – Turn left through Nuclear Medicine corridor to reach ENT OR NTICU AICU - Take lift 35 to 1 st floor – Move in the connecting bridge to reach Main Building – Turn right towards B ward – Turn left through Nuclear Medicine- Turn right towards N-ward, turn left into N2 ward and reach NTICU 9 NTICU KICU NTICU - Move in the connecting bridge towards Q block – Turn left towards KICU ENT OR / Recovery Move to ENT OR / Recovery

38. 4. Test the Plans 38 Will the plan work? How do you know? Two methods to test the plan Lecture and response sessions. Tabletops. Lectures and response sessions allow stakeholders to ask questions, find solutions to bridge the gaps in the plans. Tabletops allows participants to simulate the response and not to actually physically perform the actions needed.  The most important element is identifying weak links or action items. Note: Drills should be performed after validating the results of the lecture and tabletop sessions. 

39. 5. Update all Staff 39 First responder - All staff. Communication - All staff. Codes - All staff (Code Red, Pink, Violet, Blue, Black). Specific and focus training to different groups: Handling hydrants - Fire and security teams. Evacuating sick patients - Nurses, doctors and technologists.

40. Mock Drills and Types

41. Culture of Drills can Save Lives One of the most gripping stories of disaster drill planning is the story of Rick Rescorla. Rescorla safely led 2,687 Morgan Stanley employees out of the World Trade Center’s South Tower on Sept. 11, 2001. As Morgan Stanley’s security chief, he was one of the few who saw the vulnerability of the towers. After surviving the 1993 terrorist attack on the Twin Towers, Rescorla was certain they would eventually be attacked again. He made Morgan Stanley employees practice orderly and swift evacuation drills once in every three months. Rescorla’s foresight and leadership saved lives. 41

42. What is a mock drill? 42 Mock drill  is a  practice   to save life/ lives in real time situation of any kind of danger or calamity that occurs suddenly with no time or very little time to react.

43. Why mock drills? To review the emergency preparedness plan of the organisation . To evaluate standard operating procedure. To check the understanding of the staff on their roles and responsibilities.  To enhance coordination among the emergency support functions and various departments. To check the workability of the systems and installations for mitigating the risk. For example: Fire alarms and detectors. To understand gaps in the system to remove deficiencies and to execute further improvement plan to avoid life and property loss. To enhance the ability to respond faster. 43

44. Importance of Mock Drills in Hospitals 44 Patients are weak and require external help to evacuate.  Presence of many relatives and visitors. Less staffing and different categories of staff. Presence of equipment that adds to vulnerability.

45. Classification of Mock Drills 45 ‘In-house’ mock drill: It is conducted within the organisation without involving outside agencies for any sort of response, apart from being observers. ‘Out-house’ mock drill: It involves external stakeholders like local, district or State jurisdiction, in order to assess the response mechanism and to update the SOPs of the organisation. Depending on Stakeholders Involved

46. Classification of Mock Drills 46 Pre-announced drills It is conducted after informing staff about the drill. It involves: Establishing new protocols. Performing a drill for the first time in the area/ department. Performing a drill in sensitive/ vulnerable areas. Unannounced drills It is conducted after the staff are clear about the mock drills and have attained a certain level of proficiency. Based on the Level of Preparedness

47. Categories of Drills and Exercises 47 Tabletop exercise Functional drill Full scale drill

48. Three Basic Types of Drills 48 Tabletop Exercise (TTE) Facilitated analysis of an emergency situation in an informal and stress-free environment. Simplest Functional Drill Simulates an emergency in the most realistic manner possible, short of moving real people and equipment to an actual site. Medium complexity Full Scale Drill As close as possible to the real event, it takes place on location using equipment and personnel that would be called upon in a real event. Complex

49. Table Top Exercise (TTEx) It is a very useful training tool. It is a precursor to mock exercise. It is largely a discussion guided by a facilitator (or sometimes two facilitators who share responsibilities). Is like a problem-solving or brainstorming session. Unlike a functional exercise, problems are tackled one at a time and talked through without stress. It is an excellent tool for understanding the awareness of staff. 49

50. Table Top Exercise ( TTEx ) - Virtual Instead of physical TTEx Very easy to conduct Can have many participants Excellent tool for simulating the situation Can be a great tool to evaluate understanding and response Can be hybrid- mix of both physical drill and interview 50

51. How to Conduct Mock Drills?

52. Pre-requisites for an Effective Program Regardless of the size, complexity and risk involved in the drill, an effective drill/exercise should include the following essential elements: Adequately trained team personnel/equipment required/logistics supported. Well-defined process for drill design/conduct. Definite criteria for evaluation. Qualified evaluators. 52

53. Purpose of Coordinating Conference 53 To delineate: Objectives of mock exercise. Scope of exercise. Selecting the type of emergency/ crisis for mock exercise. Selecting the coordinator/lead. Deciding the date and venue for tabletop/ mock exercise. To identify involvement of p articipants: Players in a drill/exercise. Departments. Number of participants. To invite media for coverage (If required).

54. Steps to Conduct Mock Drill 54 Pre-drill briefing - Scenario narrative. Positioning of independent observers. Drill initiation. Drill activity. Drill termination. Drill critiquing. Drill evaluation: Observations and recommendations. Feedback from the participants. Evaluation. Drill evaluation report.

55. Pre-drill Briefing 55 Announced drill Pre-drill briefing with the participants to explain the scene and the ground rules for executing the drill. Review of operational procedures and safety precautions with the participants. Briefing of the drill procedure. It involves briefing by the coordinator to the drill team and the observers.

56. Positioning of Independent Observers 56 Independent observers should be trained and conversant with the protocol. Independent observers should be deployed at key locations of the mock drill. Observers should be provided with checklist/ evaluation format of the response expected which is drawn from the protocol. Response mechanism during the drill should be closely observed. C onformances and gaps identified should be documented.

57. Mock Drill Checklist - Sample

58. Drill Initiation The drill should be initiated by the lead/ coordinator The scenario narrative should describe the events leading up to the time the exercise begins. It should set the scene for later events and capture the attention of the participants. 60

59. Drill Activity Every activity and response should be carried out according to the SOPs . Independent observers should document all activities based on the criteria of the drill scenario. 61

60. Observations during the Mock drill 62

61. Observations during the Mock drill 63

62. Deviation Checklist 64

63. Drill Termination 65 The drill scenario should be allowed to continue till completion of the stated objectives. The drill should be terminated by the lead/ coordinator in accordance with the plan.

64. Critiquing Drills The lead/ coordinator should hold a session to critique the drill along with the observers and drill team. It should be two-way communication between the drill team and the participants. The process should first involve self-evaluation by the participants, then a discussion of the evaluation notes, checklists, actions taken and the overall drill performance. The critical analysis should highlight the successes, shortcomings of the drill scenario, personnel’s actions and equipment accessibility. 66

65. Drill Evaluation Report 67 Evaluation should broadly have the: Details of the drill and gaps in conducting the drill with limitations. Observations and recommendations: Report the gaps identified with suggestive actions to improve the preparedness. Feedback from the participants.

66. Example   Expected Actual Did the staff shout for help Y Y Did the staff 1 try to put the fire with nearest fire extinguisher Y Y Did the staff 2 inform the fire office Y Y Did the fire team arrive on time Y Y Did the Electrical team arrive on time Y N Did the AC team arrive on time Y N Did the Medical Gas team arrive on time Y N Did the STSG arrive on time Y Y Did the Fire officer announce level 2 Y Y Did the Charge nurse assign staff for the patients Y Y Did the security clear the way for the fire team to arrive Y Y Total opportunities 11 Deviation 3 Variation in mock drill (In %) 27%

67. Template for Evaluation of Mock drills 69 Introduction Scope and objectives Drill/exercise scope Participants/participating agencies Mock drill objectives Scenario summary Initial conditions Sequence of events Critique Scope of evaluation Notification and communications Operations and field responses Equipment and facilities Standard operating procedures Drill-related problems Other observations Outcomes Significant findings/successes Loopholes/deficiencies/omissions Opportunities for improvement Plan of action for corrective actions

68. Follow-up Activity 70 Reviewing the performance. Assigning responsibility to close the gaps. Documenting closures and presenting to committee. Ensuring timelines for closures.

69. Mock Drills Calendar 71 Emergency drills and exercises should be conducted regularly in a hospital to test the plan and to develop the capacity of staff to respond to an emergency/ disaster/crisis. Drills offer the opportunity to identify training needs, establish new reflexes and to teach through action, repetition and to update/change the plan.

70. Mock Drill Calendar - Example 72

71. Mock Drill Calendar - Example 73

72. Mock Drill as a Safety Indicator 74 Month Number of steps to be followed* Number of violations in protocol % of violation Jan 2017 54 24 44% May 2017 60 22 37% October 2017 59 15 25% Mar 2018 57 9 16% Aug 2018 57 8 14% *Number of steps to be followed need not be constant as it will vary according to the inclusion/deletion of protocols from the previous drill.

73. References Vivian C. McAlister, MB. Drills and exercises: the way to disaster preparedness, Can J Surg. 2011 Feb; 54(1): 7–8. Hospital and Health Facility Emergency Exercises Guidance Materials. World Health Organization (WHO) Regional Office for the Western Pacific with support from the European Commission Humanitarian Aid department (ECHO), 2010 https://blog.pocketstop.com/steps-to-conduct-a-fire-drill-at-work SOP on “Conduct of Mock Exercises”. National Disaster Response Force. Government of India. Ali, M., & Williams, M. D. (2019). No-Notice Mystery Patient Drills to Assess Emergency Preparedness for Infectious Diseases at Community Health Centers in New York City, 2015-2016. Journal of community health, 44(2), 387–394. Chou, W. K., Lin, C. H., Cheng, M. T., Chen, Y. C., & Shih, F. Y. (2019). The Value of Functional Exercise in Pediatric Mass- Casualty Incident Training.  Journal of acute medicine ,  9 (3), 118–127. Guidelines for Hospital Emergencies Preparedness Planning. Guidelines for Hospital Emergencies Preparedness Planning. 2002 5 steps to emergency preparedness for any disaster, Robert Lang, https://www.facilitiesnet.com/emergencypreparedness/article/5-Steps-To-Emergency-Preparedness-For-Any-Disaster-- 17186 75

74. Thank You!