HOSPITAL PREPAREDNESS IN CBRN DISASTER

1

To be a Presidential Hospital with International Standard,

Top Referral Hospital and Main Teaching Hospital that The Military Personnel and Communities to be proud of

10/4/16

1. The function of the central level and the highest reference for Indonesia National Army Hospital

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

3. Organizing health services for the President, Vice President, State officials, State Guests and other VVIP.

4. Improve the ability of health workers through continuing education 5. Scientific research and develop continuously

VISION

HOSPITAL MAP

12 DEPARTMENT 9 INSTALLATION/ CENTER 10 UNITS

SCOPE OF SERVICES

1) Surgery

2) Internal Medicine 3) Pediatrics

4) Cardiology 5) Pulmonology 6) Opthalmology 7) Dermatology

8) Obstetry Gynaecology 9) Neurology Department

10) Ear – 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

HOSPITAL STAFF

304

1124

248 1555

MEDICAL STAFF NURSE AND MIDWIFE

OTHER PROFESSIONAL HEALTH SUPPORTING STAFF (9,41%)

(34,79%)

(48,13%)

NUMBER OF VISIT EMERGENCY

2,786

12,843

Emergency

Vs.

Disaster

A SUDDEN & MASSIVE

HAPPENING WHICH

REQUIRES

PROMPT AND HUGE

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

COMPONENTS OF HOSPITAL

PREPAREDNESS

» Incident Command System

» Communication

» Continuity of essential health services and

patient care

» Surge Capacity

» Human Resources

» Essential Support Services

» Infection Prevention and Control

» Case Management

» Surveillance Early Warning and Monitoring

Hazards

Human-made

 Fires

 Explosive devices  Firearms

 Structural collapse  Transportation event

Air, Rail, Roadway, Water

 HAZCHEM / HAZMAT  WMD

 CBRN events

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

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.

CBRN Hazards Effects

» Chemical, Heat & Radiation Burns

» Injuries

» Infections

» Poisoning

» Psychological vulnerability

Chemical Agents Classification

1. Nerve Agents (Organophosphate based, insecticides)

2. Blister Agents

3. Pulmonary/Choking agents (Phosgene, Chlorine) 4. Blood Agents (Cyanide)

Reponse to Chemical Agents

» Decontamination

» Antidotal Therapy

– 2PAM/Pralidoxime

– Atropine

Chemical Incident Types

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

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

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)

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

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)

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

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)

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

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

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

Personal Protective Equipment (PPE)

» Mandated for all personnel who have substantial risk of exposure to hazardous materials (According to the Regulations by OSHA, NIOSH, EPA, JCAHO)

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

open wounds as an “infectious source”, HEPA filter mask upgrade for pneumonic

plague/smallpox/hemorhagic fevers, Precaution Upgrades in areas of the hospital where aerosols coulld be generated (lab, autopsy facilities, etc)

» 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)

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

Readiness Phase

» Inventorial of current capabilities & rectify any

deficiencies

» Personnel training for realistic scenarios

» Plan for :

– Triage “Do the greatest good for the

greatest number of disaster victim in the

light of limited resources”

– Decontamination

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)

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

CBRN Disaster Management Overview

» Preparedness

» Training

» Command, Control, Equipment » PPE

» Decontamination » Detection

» Triage

» Staff Preparedness » Logistics/Supplies

» Hospital Space Utilization » Evidence Preservation

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

GOAL

Presidential Hospital Preparedness

CBRN Disaster Management CBRN Threats

Presidential Hospital

KEYNOTE LECTURE IN

PRESIDENTIAL HOSPITAL FRANCE 2016

COOPERATION WITH THE PRESIDENTIAL HOSPITAL THAILAND

VISIT OF DIRECTOR OF THE CEDARS SINAI HOSPITAL LOS ANGELES

RSPAD GATOT SOEBROTO IN INTERNATIONAL RELATIONSHIP

KEYNOTE LECTURE DI ST. PETERSBURG RUSIA IN MILITARY MEDICINE ASIA PASIFIC

A SHORT BRIEF –ROYAL THAI ARMED FORCES MEDICAL FACULTY CADET IN BANGKOK

PARTNERSHIP AND INTEROPERABILITY IN FRAMING A NATIONAL PLAN FOR RISK MANAGEMENT PANDEMIC INFLUENZA

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