Hospital Casualty Management System

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					                                                                     WHO Conference at Phuket on 5th May, 2005



                     Hospital Care and Trauma Management
                                                                                      Nakhon Tipsunthonsak
                                                                                    Witaya Chadbunchachai
                                                                           Trauma Center Khonkaen, Thailand




H e a l t h       p r o t e c t i o n          a n d      d i s e a s e            p r e v e n t i o n
Needs Assessment

       Disasters usually have an unforeseen, serious, and immediate affect on health. They do not
only cause victims but also attracts considerable attention. Either family member, friends of the
victims, people who voluntary assist, health organization and also the media, are instead of
providing help, interfere with the work of the medical and paramedical personnel. This disorder
happened in every sites of the disaster.

        Health protection and disease prevention during the disaster within hospital is fully
integrated into the emergency medical service (EMS) system and strives to meet the needs of all
injured patients requiring an acute care facility, regardless of severity of injury. The system
recognizes the necessity of other health care facilities. The goal is to match a facility’s resources
with a patient’s needs so that optimal and cost-effective care is achieved.

        The appropriateness of the infectious control during the disaster in Khonkaen Trauma
Center was being done parallel with the medical resuscitation life-support and rehabilitation. A
definitive specialized care facility is a key component of the system.

        The adequacy of health protection and disease prevention coordinates care among all levels
of injuries. One of the most common failures in system development is to designate too many
trauma centers. It means the dilution of the experience necessary to maintain trauma expertise and
adequate levels of training and for educational opportunity and research. The public support begun
by establishing the need for trauma care improvement, injured patient database, resources
assessment and management should have been reconsidered for the future planning, including the
hospital providers and facilities for acute care, specialty and rehabilitative.

         The effectiveness of health protection was involved at the beginning in trauma care system.
The indicator for essential service was prepared to carry out the receiving casualties, either direct or
from first aid posts, providing initial, casualty care, and marking non-critical cases to be transferred
to their home or base hospital.

        The efficiency for disease prevention in hospital was controlled by the triage system on
arrival at the emergency department. Triage is often based on incomplete information because the
detailed information and status of patient may not be immediately obtainable. However, decisions
have to be made on the best information available. Frequently, it is not possible to obtain such
parameters as vital signs on the victims in multiple casualties. In deed, it is necessary in many
instances to make decision by surveying an entire situation at a distance and determining on that
basis which of the patients are most severely injured. Part of the triage process also involves a
determination of the most appropriate mode of transfer to definitive care including the efficiency
tetanus prophylaxis and adequate preparation for contingencies during the transfer process.

       The connectedness of the aspects both national and international intervention in technical
and organizational is the needs of initial assessment in order of prioritized in multiple victims. In
some instances it may be necessary to prioritize patients based on salvage ability. The guideline

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                                                                    WHO Conference at Phuket on 5th May, 2005



should be done standardized nation wide in providing resources for optimal care of the injured
patient, consultation for trauma system, and guideline for trauma care system. It is fundamental to
the development of a system that the number of designated trauma centers be limited to those
necessary for the patient population at risk for major injury. A complete dataset, including data
from acute care facilities, will allow accurate determination of where injured patients received their
care and therefore can establish the true rate of over- and under-triage.

Coordination

        The Khonkaen Trauma Center coordinates with Khonkaen University hospital, Srinagarind.
The resources management for mass casualty is integrated for optimal care in both institutions. It is
appropriate for considering the correlation with constant liaison to the police and local
administration to be maintained so that early information about the expected number and nature of
casualties being sent to the hospital is readily available.

        The past disaster in the South of Thailand indicated that we still need an adequacy of proper
equipment and effective personnel in communication in aspect of the medical report. The
continuing of casualty care as needed in hospital required an effectiveness coordination from the
site of incident. The health protection for injured patients needed as important as disease control
and prevention due to the referral system with the core efficiency personnel.

       The intervention for coordinating in health protection should need support from United
Nations both the technical and organizational to maintain the standard of expectation in caring the
mass casualty.

Gap filling

        During the situation in December, 2004, survivals and other outcomes measured after the
complex surgical procedures correlate directly with the volume of experience for both institution
and the surgeons, supporting concentrating and limiting resources to care for injured patients with a
defined geographic area. Qualified general surgeons were expected to participate in major
therapeutic decisions and were presented in the emergency department for major resuscitations and
at operative procedures in all seriously injured patients. 24-hour-in-house availability of the
attending surgeons was the most direct method for providing this involvement. A postgraduate year
4 or 5 resident was approved to begin resuscitation while awaiting the arrival of the attending
surgeons. Additionally, the attending general surgeon would be responsible for the timely
evaluation every trauma admission.

        It could say that there were never enough surgeons who can perform correctly advanced
trauma life support. But what did happen show that we have done the best for the arrival of the
casualties. This institution is expected to manage large numbers of injured patients with a certain
severity of injury. This trauma hospital is not only serves as the lead trauma facility but also
expected to have an outreach program which incorporates smaller institutions in their service area.
This should accomplish all the effectiveness in the population-dense area of Khonkaen and as well
supplements the clinical activity and expertise of a level 1 institution. It is more efficiency working
together to optimize resources, cooperative environment.

Capacity Building

       The country capacities being strengthened so as to be better prepared for the future disasters
by having a standardized national planning. All principles player must be involved at the
beginning. In the inclusive system, consideration must be given to the role of all the acute care



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facilities in the area which care for injured patients. Representatives from these non-trauma center
facilities must be included in the planning process appropriately.

        The financial consideration is the most important key for adequate in classification system
and the assessment true needs for trauma care. Especially the effectiveness of trauma center is up to
the limitations on the number of verified trauma centers within the given area. The efficiency of a
good trauma system is the availability of dedicated, efficient health care professionals.

        The aspects of national and international intervention for better preparation in future
disasters in both technical and organizational is to improve and integrate the number of
knowledgeable facility and health care personnel in trauma care, especially in mass casualty.



Health Services delivery
Needs Assessment

        On arrival, principal management is to derive from concept developed to detect specific
injuries – defined prospectively by protocol triage. The appropriateness is to know the mechanism
of forces which could lead to severe injury and to provide on-scene initial assessment and
management due to the advanced trauma life support guidelines. For medical direction on arrival
the hospital is by preexisting protocol/indirect medical direction. Protocols which guide patient
care is established by trauma health care providers such as surgeons, emergency physician, medical
director for ambulance service, and trained basic and advanced emergency medical personnel.

        For the effectiveness in assessing the needs is to initiate of resuscitation by establishing
survey from ABCs. The disaster plan should establish in advance of the mechanisms necessary for
identification and registration of the patients who are admitted.

        The forms for recording data, identification cards, and card for triage should be available
and accessible efficiency. Registration forms, which subsequently will serve to document the
clinical history, should be designed to collect the most essential information. The use of triage
cards, whatever the model, should be standardized whenever possible and accepted by the
community in such a way that the emergency medical services and the hospital are familiar with
their use.

       Technically when there happened to be a mass casualty, the hospital takes measures to
expand its care capacity, many cases may require specialized care for which the Khonkaen Trauma
Center is not equipped such as the cardio vascular surgery, or simply the demand exceeds the
hospital’s capacity, for these cases, the plan should envision the alternative of referring patients to
other hospital of which allied and coordinates. This highlights the need for an organized network
within the community for example, the referral system from Khonkaen Trauma Center to
University Hospital nearby or to private hospitals surrounding in sub-rural area.

Coordination

        Khonkaen Trauma Center can be notified of a disaster from various sources, the police, the
fire department, the emergency ward, or individuals. The operator on duty or the person notified
should identify the person sequentially starting from staff at the ER then to the call center (1669-
Nation Wide) and spread throughout the personnel involved named in disaster written plan
appropriately.



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         The communication inadequacy is always number one of the main problem in every mass
casualty occurrences. The lack and shortness of medical chief commander both in ER and at the
disaster sites, made the loss of golden period for life-saving in many cases. The problem was that
we have too many commanders. The confusion occurred during the initiate working zones. Finally
every volunteer and medical personnel all work individually without correlation or cooperation due
to the conflict between the commanders themselves. The effectiveness communication should be
established in the same standard and be announced to be used throughout the country. Job
description for the commander in each field should be made as a protocol which guide to rapid
transportation to the appropriate facility. The indicator to maintain the efficiency of the
coordination is including of the resources management and sharing within the allied health care
institutional and provider.

       An internal system of communication between the hospital various wards and, departments
must be improved such as the portable loud speakers, internal telephone lines, and two-way radios
are a few possible alternatives. The planning for improvement should include arrangements for
communicating with off-duty hospital staff. Usually, each hospital employee contacts two or three
previous designated colleagues. The sophisticated communication system in hospital should be
standardized as in the worldwide.

Gap filling

        The needs of the patient in mass casualty are the timely and efficient emergency medical
care, as well as ensure the rational use of ground and air transport, communication coordination
between the hospital and the various agencies involved of vitalities. Each activity of hospital care
requires a response time and the likelihood of the victims survival is reduced if the total response
time, between notification of the disaster and care at a hospital, is prolonged.

        The inadequacy in coordination between the hospital staffs and each other rescuer members
is quite a main problem in the transferals system. A periodic inventory of ambulances, mobile unit,
and other in-service vehicles contributes ineffectively – to the operating capacity of a hospital. The
plan should be improved in clearly indicate priorities regarding the use of hospital vehicles. The
problem occurred while there was no provision for fuel and designates staff to be in charge.

        The efficiency for equipment used to move patients, such as stretchers and wheelchairs,
should be inventoried and areas designate for storage and circulation inside the hospital. The staff
assigned to the incoming patient and the staff on duty at key services, should use some form of
visible identification for organization as services as well as security reasons. Key personnel should
identify themselves with a colored armlet or badge.

Capacity Building

        Thailand are being strengthened for better prepared for future disasters by establishing the
specific manual for each department or ward, as well as instructions how to establish personnel
working, groups, lines of command, alternate leadership, and relationships with other institutions.

        The major cause of inadequacy documents is the various practice guidelines of which being
used in vary trauma center. The clearly set of documents should be identified and easy to get to.
Furthermore, instruction cards should be conspicuously placed in each hospital room indicating
actions to be taken incase of emergency.

         The effectiveness for successful disaster preparation is the up to date staff training. Ongoing
training must be provided covering all aspects of the plan. Drills should be carried out once a year
to test and improved the efficiency of the plan. Khonkaen Trauma Center carry out the rehearsal for

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disaster simulation once a year, using the difference scenarios in varies situations involvement with
the mass casualties.



Health policy and coordination
Needs Assessment

        The appropriateness of health policy of Khonkaen Trauma Center is to provide
comprehensive trauma care in two distinct environments. The first is in the population-dense area
where level II supplements the clinical activity and expertise of a level I institution. The second for
the level II serve in less population-dense areas as the lead trauma facility. Khonkaen Trauma
Center has beds available at 800 and can be admitted up to 120%. Furthermore, from the
correlation between the university hospital and the privates, the mass casualties can be transferred
up to approximately at 1,200.

        The administrative support is adequacy in providing the human resource management,
educational activities, community outreach activities, and community cooperation. The medical
staffs at Khonkaen Trauma Center have a commitment to support the trauma program by their
professional activities to provide enough specialty care to support the optimal care of the injured
patient. Each discipline provides the appropriate skills as team members working in correct
implement treatment based upon a prioritized plan of care.

       The effectiveness performance improvement evaluation of this care must extend to all over
the involved departments. A board certified surgeon (usually general surgeon) with special interest
in trauma care acts as a trauma director at Khonkaen Trauma Center. The director leads the
multidisciplinary activities efficiency of the trauma program such as developing trauma protocol,
cooperating with the nursing administration to support the nursing needs of the trauma patients.

        Khonkaen Trauma Center has a trauma team with a high level response to a severely injured
patient. The services include adequate personnel and other resources necessary to ensure
appropriate and efficient care delivery.

Coordination

        Khonkaen Trauma Center guarantees immediate availability of specialized surgeons,
anesthesiologist, other physician specialists, nurses and resuscitation life-support equipments 24
hours a day. The system coordinates care among all levels of trauma centers and facilities so that
efficient and prompt interfacility communication and transfer can take place according to patient
need. Access to rehabilitation service, initially in the acute care hospital and subsequently in more
specialized facilities is one of the coordination policies.

Gap filling

        The need for resources is primarily based on the concept of being able to provide immediate
medical care for unlimited numbers of injured patient at any time. Optimal resources at such a
trauma center would include in-house board-certified emergency medicine physicians, general
surgeons, anesthesiologist, and specialty board surgeons. This center would require a certain
volume of injured patient to be admitted each year, and these patients would include the most
severely injured patient within the system. Quality and cost effectiveness will improve with
experience and patient volume. Certain injuries that are infrequently seen would be concentrates in
this special center to ensure that these patients could be properly treated and studied, providing the
opportunity to improve the care of these patients.
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Capacity Building

        The Khonkaen Trauma Center would have an integrated concurrent performance
improvement (PI) program to ensure optimal care and continuous improvement in care. This center
would also be responsible for assessing care delivered not only within its trauma program, but also
within the entire trauma system. One resource of a trauma center that can not be limited is the
surgical commitment and surgical leadership. This commitment is a valuable resource which is
integral to a successful trauma program.




REFERENCES

Health Sector Contingency Plan for Management of Crisis Situation in India. Part III Guidelines for
Mass Casualty Management Hospital Contingency Plan. Citation on Web Searched. April 2005

Schwartz, Richard B. Hospital Preparedness for Mass Casualty Disasters. Paper Presented at the
Annals of Emergency Medicine Conference. 2004

American College of Surgeons Ad Hoc Committee on Disaster and Mass Casualty Management of
the Committee on Trauma. Statement on disaster and mass casualty management. 2003

Chadbunchachai, Witaya. Field Commander. Paper Presented at the Commander in Mass Casualty
Situation Conference. Khonkaen, Thailand. 2003

Chadbunchachai, Witaya. Disaster Plan for Trauma and Critical Care Center Khonkaen Regional
Hospital.. January 2002

Green, Walter G. Integrated Medical Disaster Response: A Case Study of the Virginia Emergency
Medical Services System. Paper presented at the American Academy of Medical Administrators
Conference. 2001

Committee on Trauma. American College of Surgeons. 1999 Mass Casualties. Resources for
Optimal Care of the Injured Patients: 1998




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