Consultants Report

WORLD HEALTH ORGANIZATION ORGANISATION MONDIALE DE LA SANTE WHO OFFICE FOR THE MALDIVES SOUTHEAST ASIA REGIONAL OFFICE MISSION REPORT Subject: Place visited Dates of mission Author and designation : : : : Emergency Management in Male, Maldives Male, Maldives 6 November-2 December 2005 Dr. Teodoro J. Herbosa Temporary Consultant, WHO Emergency Preparedness and Response Government of the Republic of Maldives World Health Organization Tsunami Project WHO Maldives Title of project Participating agencies : : Source of funds : Key words Emergency Preparedness / Emergency Medical Services/Emergency Department/Triage Disaster Planning/Disaster Preparedness WORLD HEALTH ORGANIZATION WHO OFFICE FOR THE MALDIVES EXECUTIVE SUMMARY OF A MISSION REPORT Dr. Teodoro J. Herbosa Author Report series number Male, Maldives Place visited Project identifier 6 November to 2 December 2005 Dates of mission Activity code Objectives of the mission: In collaboration with the Ministry of Health (MOH) of Maldives and the Indira Ganhdi Memorial Hospital (IGMH): 1. Assist in upgrading the Emergency Department of IGMH a. assess the protocols and operation of the emergency department b. supervise the triage system c. train medical officers and triage nurses 2. Assist in Implementing a Hospital Emergency Preparedness Plan for mass casualties a. develop a hospital emergency response plan b. train staff in hospital preparedness and mitigation during disasters 3. Submit a proposal to establish an Emergency Medical Service (EMS) in IGMH including training of the paramedical staff. Summary of activities, findings, conclusions and recommendations: 1. The assessment of the Emergency Services at the IGMH was done. The Emergency Department of IGMH in Maldives is very busy. Over 100,000 visit per year. It still has a few written policies. Clear written policies would make the ED more efficient. Eighty percent of the doctors are contracted from foreign nationals mostly from India. This creates a problem in continuity of policies and procedures. It has no triage system at present. It is recommended that it be elevated to a Clinical Departmental status with clear authority and mandate similar to the major clinical departments. For the triage system, it is recommended that senior nurse and doctors do the triage using three tier clietria for prioritization of patients to be seen by the staff. A triage counter needs to be established before the entrance to the ED. 2. There are two written hospital disaster plans. One is for Airport Emergency and the other is for Fire. A workshop was conducted to clarify the issues on Hospital Emergency Preparedness and Response Plan. Improvements were done on the Hospital Plans. Clear Job actions sheets were made by staff and also timelines during an emergency were clarified. These changes need to be practiced in a drill or simulation either partly or in whole. 3. Although there is a national plan for EMS development. It is suggested that IGMH also develop its own hospital based EMS under the supervision of the ED. This involved the acquisition of at least two Advanced Life Support Ambulances and the operation of four old basic transport ambulances. This requires the training of EMS personnel in pre-hospital care. The Clinical Assistant were identified as possible trainees for such a program. This IGMH EMS will be complementary to the EMS being established by the NSS (National Security Service) which will concentrate most likely in Rescue services. The IGMH can be developed for Basic and Advanced Emergency Medical Services 4. The EMS, ED, Triage and Hospital Emergency Preparedness and Response Plan need to be coordinated with the National Emergency Plan and the MOH Health Emergency Plans. Being the only tertiary hospital and biggest resource for health delivery, the IGMH will play a major role in the provision of health services in times of emergencies and disasters. Key words: Emergency Medical Services /Emergency Department/Triage/ Emergency Preparedness / Disaster Planning / Disaster preparedness / Maldives CONTENTS Page 1. PURPOSE OF MISSION …………………………………………………………5 2. BACKGROUND…………………………………………………………………..5 3. ACTIVITIES AND FINDINGS …………………………………………………..7 3.1 Activities……………………………………………………………….………7 3.2 Findings…………………………………………………………………….. 12 4. RECOMMENDATIONS……………………………….......................................14 4.1 A&E Department Recommendations ………………………………………. 14 4.2 EMS Recommendations……………………………….……………………..14 5. ACKNOWLEDGEMENTS………………………………………………………16 ANNEX 1- ACCIDENT AND EMERGENCY EVALUATION…….17 ANNEX 2- EMS SYSTEM PROPOSAL FOR MALDIVES ANNEX 3- HOSPITAL EMERGENCY PREP PLAN PURPOSE OF THE MISSION In collaboration with the Ministry of Health (MOH) of Maldives and the Indira Ganhdi Memorial Hospital (IGMH): 4. Assist in upgrading the Emergency Department of IGMH a. assess the protocols and operation of the emergency department b. supervise the triage system c. train medical officers and triage nurses 5. Assist in Implementing a Hospital Emergency Preparedness Plan for mass casualties a. develop a hospital emergency response plan b. train staff in hospital preparedness and mitigation during disasters 6. Submit a proposal to establish an Emergency Medical Service (EMS) in IGMH including training of the paramedical staff. BACKGROUND The Maldives is an archipelago of nearly 200 small islands to the south of India. A lower middle income country, it has a population of 270,000 and is visited by up to 500,000 tourists per year and has a migrant labor force of 27,000. Atolls are formed by groups of islands that encircle to form geographical regions. There are 20 atolls. Since they are far and widespread, atolls have been further grouped into 6 regions. The Health System of Maldives is a combination of public and private medical care. All medicines sold in pharmacies all over the country are imported and therefore may lead to supply problems. There are several Non-government Organizations (NGO’s) that are focused on specific health problems. These NGO’s are: a) SHE (reproductive health and thalassemia); b) FASHAN (Adolescent issues and HIV/AIDS); c) CARE Society(disabilities and mental health; d) Maldives Eye Society; e)Maldives Association for the handicapped; f) Cancer Society and g) Diabetic Society In 1999, the following professional councils were formed: a) Maldives Medical Council (MMC); b) Maldives Nursing Council (MNC) and c) Maldives Board for Health Sciences (MBHS) There is currently no system of regulation of the private hospital. It was suggested in the health report that licensing and the inclusion of a hospital disaster plan for the private hospitals in line with national health plan especially after the Tsunami There has been a rapid influx of health human resources (56% of staff). In 2003, there were 315 doctors & specialists; 87.9% were government employed. Seventy-nine percent (79.4%) were expatriates. There is a good Patient to Physician Ratio of one physician for every 858 persons. The total Bed capacity of the Maldives is 643 hospital beds. This amounts to about 420 persons per hospital bed in the country. This is a very good ratio. There are 785 nurses; 454 paramedical staff; 119 Community Health Workers (CHW); 333 FHW (family health workers) foolhumaas or TBA’s (Traditional Birth Attendants) 409 TBA’s. For the years 2002 and 2003 there were 31 MBBS Doctors that returned to country. There were 16 new students sent for medical training. And 12 specialist doctors returned from training abroad. The National Government spent in 1996 a total of 11.26 % of national budget on health. This decreased in 2002 to 9.44% of the national budget. Although there was a decrease in percentage points this was actually increase in the total amount by Rf 124.1 million. The Per Capita health expenditure dropped by Rf 34.4 million from 2000—2001. In 2003, 10.6% of national budget was allocated to Health expenditure. This was an increase. There was Rf 31510 million 85 % on recurrent expenses 15% on capital. A large percentage was placed on curative services. This amounted to 57% of the total health care expenditure. There were 21% for support services, and 22% on preventive health. The Organization of Health System of Maldives is unique. A 5-tier referral system in the Department of Public Health exists. The Central Health Services, then the Regional Hospitals 35-50 beds (6 Hospitals) then the Atoll Hospitals followed by the Atoll Health Centers and Island Health posts. This is the decreasing order of the health system. In the Central institutions of the DPH, the IGMH has 236 beds. The National Thalassemia Center (NTC) is a major resource as Thalassemia is prevalent. There are also: the Maldives Water and Sanitation Authority (MWSA); the Male health Center and the Villinggili Health Center. There is an additional tier for those that are sent to other countries for definitive treatment which may or may not be available in Male’. These countries are: India, Sri Lanka, Thailand and Singapore. The National Health Indicators show an Infant Mortality Rate in 2003 of 14/1000 live births. A Child mortality 18/1000; Crude birth rate 18/1000; Crude death rate 4/1000; Maternal Mortality 1/1000; Still birth rate 11/1000; and a life expectancy for both sexes at 73 years. The coordinating units during a disaster includes: the NDMC National Disaster Management Centre (this is Task Force established after the tsunami of December 2004); the Ministry of Defense, National Security, the Ministry of Finance, the Ministry of Planning and Development. The emergency relief and response was augmented by other departments and the different UN agencies, and development partners. The National Disaster Steering Committee created after the Tsunami. This is composed of the Disaster Health Working Group (Technical CU). This was tasked with developing EPR (Emergency Planning and Response) Plans of the health sector. There was also a Health Relief Team that was formed. In the future, the Ministry of Health (MoH) envisions a permanent EPR unit. It also hopes for an efficient coordination across agencies. And some processes of Monitoring and Evaluation (M&E) through drills, rehearsals or simulations. And debriefing after actual emergencies must also be done. The Indira Gandhi Memorial Hospital (IGMH) was an Indian government grant to the government of Maldives about 10 years ago. Previously, the Central Hospital was the highest level of care in the country. This was located beside the National Thalassemia Center. It is now a private hospital called the ADK Hospital. This (ADK) has about 50 beds. It is owned by the Nasir Family and the building is leased from the government. ADK hospital has a Magnetic Resonance Imaging (MRI) and IGMH has the CT scan and Dialysis Unit. The IGMH is about 248 beds. It has all the major clinical departments. However, almost 80% of the physicians are foreign hired. These doctors come mostly from India. There is now a beginning influx of Maldives doctors who graduated abroad who now work for the IGMH. They were under scholarship of the Maldives government. As the seats for medical colleges in India had become very competitive, most of them are now going to Trihbuvan University in Katmandu, Nepal for studies. Since the creation of the IGMH, there has been a steady increase in the number of patients consulting at the IGMH both at the Accident and Emergency (A&E) Department and the Out Patient Department. This has also been found to have increased after the tsunami of December 2004. Largely because of populations of displaced persons who have moved to Male’ as their islands have been devastated by the tsunami. For this reason there is now a daily influx of over 300 patients in the Emergency Department (ED). And thus, there is a daily crisis or disaster type situation in the ED because of the increased number of consults and the relative lack of needed resources. ACTIVITIES I Arrived on November 6, 2005 Sunday in Male Airport after a whole day of travel. No WHO Person was on hand to meet me at the airport. I proceeded to Relax Inn Hotel by Water Taxi. I checked in at Relax Inn at about 11pm Male time. November 7, 2005 Monday At about 830am, I was picked up by Mr. Samad from WHO and walked to WHO Office at the MTCC Building. Dr. Hedvig Pelle was not available as she was at a seminar that morning. I was brought by Mr. Zaheen from the Tsunami Project to IGMH by taxi. There I met Director of Medical Administration(Lady Dr. Fathimah Ali Didi) and Dr. Mohammed Shafiu Surgeon and Hospital Incident Officer of IGMH (a WHO scholar in HEPR Course of Asian Disaster Preparedness Center, ADPC in Bangkok). They welcomed me to the IGMH. I was toured around IGMH with Dr. Shafiu. I met the different key persons in the hospital. I also met with Dr. Ahmed Ziyan from Medical Administration Office. He is a WHO fellow to the WHO program PHEMAP (Public Health Emergency Management for Asia and the Pacific) at the Asian Disaster Preparedness Center. He was in part responsible for my presence in Male, Maldives. I also met with Dr. Vijay Seshan Senior Consultant and current Head of Accident and Emergency Department of IGMH. I was assigned an office at the Medical Administration Office of IGMH with computer and internet access. I met with Dr Hedvig Pelle WHO Tsunami Project Manager in the afternoon at the WHO office. I was introduced to the WHO Maldives staff. I was assigned a key to WHO Office. Got a copy of the Lessons from Tsunami from the health sector (29 Sept 2005). I met with Dr. Jorge Luna WHO Representative to Maldives. He discussed the details of the Health System in Maldives and some possibilities for capacity development. He talked about LSS-SUMA and also telemedicine efforts of WHO. Also there is a consultant from the Red Cross named Dr. Liesolette Schmid on EPR in the Ministry of health. November 8, 2005 Tuesday I checked out at Relax Inn and picked up by vehicle from IGMH. I spoke with the Director General of IGMH Dr. Mohammed Salih. We discussed ED triage, admission, departmentalization. I then started working on the draft HEPR for IGMH. I visited the Casualty Department and talked with Dr. Usama. Spoke with some of the Clinical Assistants about the possibility of First Responders’ training and joining the ambulance team. They were all very interested. I proceeded to make the draft proposal for the Hospital planning workshop on Nov. 19-20, 2005 in IGMH. I was given a security card and cellphone from the WHO office. Then, I moved my belongings to the Maagiri Lodge. November 9, 2005 Wednesday I started looking at Job Action sheets of the disaster plan. Then, I met with the hospital Nursing Director. At 10:00am, I spoke with Dr Schmid and scheduled a meeting with her for the next day. I spoke with Dr. Hedvig on the workshop and Dr. Luna on the IMEESC of Dr. Cherian from WHO Geneva, EHT (Essential Health Technologies) I met with Filipino doctors working in Maldives. Dr. Fauline Fuentespina from the resort in Huvafenfushi; Dr. Rodel Formantez from Four Seasons. Ms. Jo Cabritit, from the resort in Huvafenfushi, and Dr. Joy Quiboy at Private Hospital. They gave me valuable information on Maldives. November 10, 2005 Thursday Met with two Indian doctors, a pediatrician and a cardiologist who work in IGMH. Spoke with Dr. Ali Didi about workshop. At 10:00am, met with Dr. Lieselotte Schmid WHO Consultant on EPR at the Ministry of Health. Did a courtesy call to Deputy Minister of Health Dr. Adbul Azeez Yoosuf. November 13, 2005 Sunday Went to work at 7:30am. I met with Dr. Azeez. He discussed his experience as Hospital Incident Officer in the past. The we met someone from Malaysia promoting Arellano University in the Philippines for Nursing education of Maldivians. Lunch with them. Then I finally met with Dr. Ali Lateef other Incident Officer of IGMH He will be away together with Dr. Azeez during the HEPR Workshop of IGMH. They were attending a meeting in Taiwan. November 14, 2005 Monday I worked the whole day on the computer. I also discussed details of the Hospital Plan with Dr. Shafiu. I talked to Dr. Didi about a EM journal report from Singapore about complaints in ED. The report has similar problems as seen in IGMH. November 15, 2005 Tuesday I met with Dr. Ziyan about his interest in Emergency Medicine training abroad. Then I met with Drs. Latiff and Shafiu regarding the possible participants of the HEPR workshop. I got email from NSET (Nepal Society of Earthquake Technology) regarding HOPE (Hospital Preparednes for Emergencies)Course for Maldives. I had developed this HOPE course with other Asian experts. I scheduled a meeting with NSS, Major Nazim arranged by Dr. Ziyan. Also included a visit of ADK Hospitals and meeting with their officials after that. I discovered that HOPE Course will be sponsored by UNDP. I took some pictures of the Emergency Department of IGMH. I then went to WHO and spoke with Dr. Lis Schmid about the National Health Emergency Plan. I also spoke with the UNDP person Mr. Man Thapa for a meeting. November 16, 2005 Wednesday I met with Ali Didi about the IMEESC meeting on the 23 November 2005. I arranged for meetings/workshop with the A&E staff and department heads I met with Dr. Ali Shafeeq, Senior registrar in Internal Medicine: I then met with Dr. Ahmed Athif Administrator of ADK Hospital, also a member of the People’s Special Majlis (Constituent Assembly) Jailed recently for civil unrest and released because of the Tsunami. I also met shortly Ahmed Nashid Member of People’s Majlis, owner of ADK Hospital. Note that they are at two opposing camps of the political parties. The ADK Hospital had an old written plan and it also was an Airport Plan They are currently in an expansion phase. Dr. Athif recites their experiences during the Tsunami. The Tsunami caused tourists to come to ADK. They treated about 20-30 tourists in ADK in the morning of Tsunami and had about 57 in the afternoon. They went to ADK because they take medical insurance. IGMH takes only cash basis. Most foreigners have medical insurance. Also a lot of ADK patients are actually overflow from IGMH who wait too long to be seen. ADK deals with insurance and credit cards. IGMH does not. They also set up a SARS protocol during the SARS crisis. They monitored temperatures of the tourists from high risk places. They set up the SARS unit in the area where the current ambulances are currently parked. They have two ambulances. A Mercedes and a Toyota. Both have only basic transport capability. Only the Toyota is currently operational. There is a certain competition between the private sector and the government instead of cooperation and collaboration. The example shown was the dialysis unit set up by IGMH. ADK had long had dialysis unit but government claimed to be the “first” to set up in Maldives. This was “childish” and untrue according to Dr. Athif . It just grabs credit from private sector efforts in health care development. A lot of Male’ persons go to ADK for emergency then transfer to IGMH for definitive care because of their higher cost of care. They currently lack space as their OPD now sees more than 100 cases /day. It is circumcision season now so very busy. Collaboration with government also exists. It is in the form of MRI, which ADK acquired. They did not get a CT Scan because, IGMH has that already. He feels that government “controls” too much. Those unhappy with ADK go to IGMH and comments of doctors about “mismanagement or misdiagnosis” issues create a wrong environment. This government has a medical welfare scheme, they send patients to India, Sri Lank, Bangladesh, Thailand and Singapore (where the richest go for health care). This welfare scheme should also look at what the private sector can do and provide before Maldivians are sent abroad for medical care. A very big political issue is present . And he briefed me on his stay in the prison because of alleged leadership in civil unrest. There is also a problem that citizens do not trust the young Maldives doctors. There is a proposed Health Act. I wanted to get a copy. They need health system development. I then had a tour of the hospital. They even have a station for networking with Bummungrad in Thailand. I met with Filipino doctor Dr. Joy Quiboy working there as a GP. In the afternoon, I met with Man Thapa UNDP Disaster Risk Management person. They have new office. The security at UNDP was tight. He graduated in University of the Philippines in Los Banos in social sciences. There is a UNDP Training Needs Report after the tsunami. He promised to email me this. They deal only with Ministry of Defense, NSS and the Nationa Disaster Management Center. The HOPE course was estimated at US$30,000 to conduct to Maldives. I explained what it is about. He then told me he may just send 6 Maldivians to next HOPE course. November 17, 2005 Thursday In the morning, I had a meeting with Maj. Nazir of the NSS and one of his staff. It was a very productive meeting, He is very intelligent and active. Major Mohamed Nazim Office of the Chief of Staff HQ NSS There were 2 courses recently on First Responder. There were 25 participant each course. John Abo from ADPC did the training. They also have a St John’s Ambulance First aid course. This is conducted with the Faculty of health Sciences. The First aid training is about 3 months and incorporated in their Basic Course for all NSS personnel. The Police separated from NSS already since 2003. There is an NSS Medical Service in charge of the welfare of NSS staff and dependents. EMS development is just starting. This is currently in line with NSS MOH IGMH. He states the need for a permanent EMS unit He emphasized the need for water ambulances, development plan 5 regions. First aid training is incorporated in basic training. Basic training is 3 months and done at least twice a year. A Refresher Course is done at the unit level at least once a year after that. Their equipment consists: 1 ambulance; basic transport, high angle rescue equipment and special task force training. They answer distress calls from the boats. The NSS Medical Service in charge of the ambulance. There is no EMS really, 2 converted vans are also available to transport staff. The German Red Cross and Faculty of Health Sciences give first aid courses. In afternoon, had a workshop with the ED staff on the problems of the ED. November 18, 2005 Friday At 10am we took WHO Boat and went to Hurre Island and visited the health post there with Dr. Luna. November 19. 2005 Saturday Day one of HEPR workshop. All went well most of the day. Dr Luna opened. Dr Schmid presented. Dr. Shafiu was busy in the operating theater. November 20, 2005 Sunday Day 2 of HEPR Workshop Al went well also. There were lots of output Dr. Razee, Deputy DG gave out certificates of participation. November 21, 2005 Monday Met with Dr. Mohamed Firdous, Chair of Surgery. Former Director of Central Hospital. Very insightful ideas about Emergency Department. I met with Shafiu, apologized for his absence but he was tied up in surgery. I arranged for meeting of the Faculty of Health Sciences. I talked to Dr. Luna about the IMEESC meeting on Wednesday November 23. I finalized the list of participants for this meeting. I updated the Hospital EPR plan with inputs from the workshop almost done. November 22, 2005 Tuesday I visited Operating Theater with Dr. Shafiu and watched him perform circumcision. There are 3 OT’s with 12-14 OT sisters per shift. There was one anesthetists in each room At that time there was also 1 orthopedics case (tibio fib fx) and 1 urologic case of Phimosis and 1 circumcision There were 12 cases of circumcision There was one more IM nailing scheduled then a Cholecystectomy. November 23, 2005 Wednesday We conducted the IMEESC Workshop in the morning. Worked on the reports the rest of the day. November 24, 2005 Thursday I did a Triage Proposal workshop with the A&E staff in the morning and in the afternoon. November 27-28, 2005 Sunday and Monday I attended the LSS SUMA workshop (Logistics Supply System) at the Villingili Health Center. November 29, 2005, Tuesday Finalized my draft reports. November 30, 2005, Wednesday Conducted a briefing on the Triage System in the morning and then Implemented this at about 1000am. It was well received by the doctors, nurses and majority of the patients. December 1, 2005, Thursday Debriefing meeting with IGMH officials and MOH. FINDINGS The Emergency Department of IGMH in Maldives is very busy. It is the busiest Emergency Department in Maldives. Over 110,000 visit per year. About 300-400 patients are seen in a 24-hour period. It still has a few written policies. Two documents were produced by the A&E Department Head, Dr. Vijay Seshan. Dr. Seshan is an Indian doctor who specializes in Internal Medicine and is now designated Head of the A&E Department. He ha=s been living in Male’ for 9 years now. The two written documents were: 1) Policies and Procedures of the A&E Department for the new doctors of IGMH and 2) Patient Flow at A&E. It is obvious, that more written policies would make the ED more efficient. Several meetings are held when there is an incident but no one has written these policies and only the senior doctors remember the arrangements concluded from these meetings. Eighty percent of the doctors are contract personnel who are foreign nationals mostly from India. This creates a problem in continuity of policies and procedures. Some come from different systems of health care and there is no standardization occurring at the IGMH before employment. There is no accepted triage system at present. Patients often cheat the system by lying down on a stretcher to be seen at an earlier time and not go through the regular queue of patients there. It is strongly recommended that the A&E be elevated to a Clinical Departmental status with a clear authority and mandate similar to the major clinical departments like Medicine and Surgery. This would then allow the presence of Senior Consultants who would take good care of the Department and the patients seeking consult there. The A&E Department suffers from a design problem. It is too public and is too accessible by the public. This leads to overcrowding inside the A&E Department. The Security Guards assigned to the A&E Department are too geriatric to instill some form of crowd control. Also, because this is the system that the Maldivians had been used too, this creates some problem in changing. This may require some public sensitization first. Then, this may require an infrastructure change, with the installation of double doors and security doors like in most modern Emergency Departments. For the triage system, it is recommended that senior nurses and doctors together with their clinical assistants should do the triage using three tier criteria (Emergent, Urgent and Non-urgent) for prioritization of patients to be seen by the A&E staff. A triage counter needs to be established before the entrance to the A&E Department. This will involve the reorganization of the area for waiting which currently occupies the corridors and does not allow for observation of the patients. Also, each patient comes with 3 or more relatives or companions. This adds to the crowd problems in the A&E Department, which creates an impression of chaos and frustration for the patients seeking medical care. The Accident and Emergency Department of IGMH has 15 doctors assigned there. They go on duty in 4 shifts with 6 hours/shift. There are 4 to 6 doctors available during the morning and afternoon shift. During the afternoon some doctors go to the out patient clinics and see patients there. During then night shift (night 12-8am), there are only 2 doctors. The Nurses go on duty also in the same shift. There are 5 in am shift with an additional 1 nurse in charge. There are 5 in the afternoon and 5 in the night There are more than 300 consults in a 24-hour day. It actually functions as a parallel OPD. Unfortunately, there is a mistaken public perception that they all need to be seen in the Emergency Department. This is partly ignorance of the real use of an emergency department and the lack of a proper translation in Divehi for the word emergency. There is a word for immediate which is the one used for translation. The current OPD also has a limit of only 25 patients per shift. This had made some difficulties for some patients in scheduling their OPD visits. The regular OPD opens 9am -1pm and 2pm-6pm. There is a schedule at 7pm to 12mn OPD. The OPD is closed on Fridays and holidays. The Emergency is open 24 hours a day and 7 days a week. It is not closed even during holidays. The EMS findings are incorporated in the attached report on the Proposal of EMS System in Maldives. RECOMMENDATIONS For the EMS development: These were the recommendations: 1. All unanimously claimed that YES, Male and Maldives needs an EMS system to help saves lives and function during disasters. This is badly needed as there are now more motorbikes in male’. More construction and therefore more injuries. There are also more cars and last year stop lights were installed ion Male’. 2. Maldives needs an organized and integrated form of EMS. A static and a mobile team of personnel with ambulances and complete equipment for Male and also for the other big islands. There can be establishment of EMS with land, sea and air capabilities. Sea Planes or helicopters may be necessary aside from fast motor boats. Probably train also the taxi drivers in first response. The public must also be educated 3. The role of IGMH is in assisting in the training of personnel. IGMH can have trained paramedics. The existing ambulance personnel need to be trained and learn how to respond quickly. IGMH can be involved in the planning, training and mobilization of the Pre-hospital EMS in Male’. IGMH can also be involved in the upgrading of the vehicles, the manpower, training of lay persons and set up of communications. It must improve its emergency room facilities as well. IGMH can also lead in conducting mock exercises. Provide the extra manpower for the EMS and the extra beds for emergencies in the EMS system. It can also improve and utilize available resources of materials and manpower nearest to the site of an emergencies. IGMH can assist the national policy development for various injuries and accidents. With the establishment of the EMS, the IGMH needs to also strengthen its services like, emergency. ICCU, trauma and burn care. IGMH can assist in new awareness campaign on safety and injury prevention and control. For the A&E Department of IGMH the recommendations are: 1. Departmentalization of the ED. Creation of a distinct and separate department with its own head and distinct staff. This department must be at par with the other clinical departments like Surgery, Medicine, Pediatrics, Obstetrics and Gynecology etc. This can only be done by the Chief Executive Officer (CEO), Director General (DG) and probably the executive committee of the hospital. This requires an appropriated budget allocated to the newly created department. This will also require the overseas training in Emergency Medicine of certain doctors. Dr. Seshan has expressed interest in a short term study in a modern ED for administration and management. Dr. Ahmed Ziyan and Dr. Usama have signified interest in further training in Emergency Medicine. 2. Implement a Triage System. The following was the proposed protocol for a 3-tier Triage system for IGMH. 3. Develop more detailed written policies than the current existing ones. This can be achieved by the creation of a committee or task force of A&E coordinators representing all the Clinical Departments, administrative departments which are stakeholders in the A&E Department. This process is a continuous process and similar to the hospital emergency plan. This can usually be accomplished in no less than 6 months to one year. 4. Disseminate these written policies. After a consensus is reached, there needs to be a system to disseminate these policies to all doctors, nurses, PRC staff, security and all hospital staff. 5. Community Education about the abuse of the ED as OPD. This also needs to be revised for consumption of the public and better understanding of the use of the A&E department. This can be done through flyers, radio and TV appearances of the IGMH staff. 6. Train Local doctors in Emergency Medicine. This will require the overseas training in Emergency Medicine of certain doctors. Dr. Seshan has expressed interest in a short-term study in a modern ED for administration and management. Dr. Ahmed Ziyan and Dr. Usama have signified interest in further training in Emergency Medicine. The return of specialists in Emergency Medicine will assist in proper supervision of the young doctors who go on duty there. 7. Continuous Emergency Medical Care Education. I recommend implementing IMEESC e learning tool kit of WHO EHT to be implemented here for nurse and doctors. Daily endorsement rounds, weekly audits, monthly mortality reviews need to be conducted to allow some form of continuous quality improvement. 8. Department rotations of all Medical Officers to the different major clinical departments to learn the protocols of each of the clinical departments in times of emergencies. 9. Improve OPD efficiency to unclog ED. Increase the capacity of the OPD by allowing walk in consultations when any of the doctors are not seeing any more patients especially when the scheduled patient is a no show. Allow the medical officers to assist in cases seen at the A&E if the load there is too much. 10. Increase the bed capacity of the IGMH through a buffer bed system. Each ward needs to add 2-4 buffer beds to admit patients awaiting admission at the ED. Perform time and motion studies through monitoring of “through-put” times. By: Teodoro Herbosa, MD Consultant on Emergency Preparedness and Response, IGMH Tsunami Project World Health Organization, Maldives ACKNOWLEDGMENT This document has been prepared through an assistance of the Tsunami Project in Male under the World Health Organization (WHO) Office in Maldives. Several key persons in Indira Gandhi Memorial Hospital (IGMH) were instrumental in making it a success. There is Dr. Mohammed Solih, Acting Director-General, Dr. Fathimath Ali Didi, Deputy Director of Medical Administration, Dr. Ahmed Ziyan staff at the Medical Administration Office, Dr. Mohamed Shafiu, Senior Registrar in Surgery and designated Hospital Incident Officer, Dr. Ali Latheef, Senior Registrar in Internal Medicine and also designated Hospital Incident Officer and Dr. Vijay Seshan, Head of the Accident and Emergency Department. From the Ministry of Health (MOH) there is Dr. Liesolette Schmid, WHO Consultant for Emergency Preparedness and Response at the MOH and Deputy Minister of Health Dr. Abdul Azeez Yoosuf. From the WHO Office in Maldives, there is Dr. Hedvig Pelle, Tsunami Project Manager and Dr. Jorge Mario Luna, WHO Country Representative for Maldives. And all the staff of WHO and IGMH who have helped make this work a success, thank you very much. This work is dedicated to all those who were affected by the Tsunami of December 26, 2004 which ravaged Maldives and led the way to the awareness of the need for the development of these emergency preparedness plans. Teodoro Javier Herbosa MD WHO Consultant Hospital Emergency Preparedness and Response