This presentation is about the hospital’s organization in the event of a massive flow of patients during a high casualty accident. It focusses on the phase of the plan describing the return to normal activities at the end of the emergency.

PEIMAF is the acronym that identifies the plan : Piano di Emergenza Intraospedaliera per il Maxi Afflusso di Feriti (Intrahospital Emergency Plan for Maxi Admittance of Patients in the event of Mass Casualties). It is one of the standard products of the Quality System of the Emergency Department of the Hospital, which implies that all the different departments involved in emergencies were involved in the development of the emergency plan.

The plan is split into different phases : before, during and after the event.

Before the event

In order to have a functional emergency plan able to face the massive flow of patients, it is necessary to prepare and limit the effects of possible events. Security forces, together with Civil Defence organizations, analyse environmental risks (rivers, dams, landslides…), prevent critical events (such as terroristic actions, chemical incidents) and create a RISK MAP that can be of interest to the hospital due to its geographical location and its specific mission.

In order to create an emergency plan, a small task force is created, which is dedicated to the development of the different aspects of the emergency plan.

Its mission is to develop the plan according to the hospital’s needs, maintain it, disseminate it to all personnel, and organize specific courses and training.

It then has to identify the roles of the different members of the crisis unit at each moment of the day, most of all during the critical hours, for example a Sunday night when personnel presence is minimum.

The emergency department identifies the areas of the hospital used to admit and treat different groups of patients. At the entrance, there is an allocation area where specialized staff make an initial assessment of the situation and then identify all patients with a colour tag and allocate them to specific treatment areas.

During the event

• Alert classification

Alert classsification is the initial step taken in the emergency. An acronym with letters and numbers is used in order to estimate the event impact and to simplify information.

T is for events with a majority of trauma patients. The subtype is determined by the type of trauma : C is for Crash, U is for Burns and B for blasts / explosions.

M is for events where a majority of patients are suffering from respiratory problems.

The level is determined by estimating the number of patients involved in the incident. Level 1 is for events involving from 5 to 15 patients, level 2 for events with 15 to 50 patients and level 3 for accidents involving more than 50 patients.

Possible sources of contamination are also identified : X stands for chemical contamination and Z for bacteriological or viral contamination. These two conditions determine the need for a decontamination area before allowing patients to enter the emergency department. Hospital staff may also have to use specific protective devices and treatment protocols.

• Alert and activation

Once the alert has been given, the hospital disaster coordinator (HDC) starts the activation of all forces and areas that will be involved during the emergency.

This will be supported by a call center assigned to contact all human resources and deal with other important communications. This is managed by the HDC.

• Preparation and treatment

Preparation and treatment are the main active elements of the emergency.

Preparation involves ensuring that areas, materials and personnel all respect their specific protocols, ready to face the event.

This is followed by the patient treatment phase which involves all stages from diagnosis and patient allocation to actual treatment.

After the event

There are two main phases after the event : the return to normal activities and event review.

• The return to normal

At the end of the emergency, there is a gradual return to normal, in terms of personnel activity and the use of materials and rooms. The emergency ends when all patients involved in the incident have left the emergency department and when emergency wards can return to normal activity. It is important to inform other regional hospitals that the emergency is over, as in the event of mass casualties, one particular hospital may not have sufficient resources available and may therefore have to call on another.

• Review of the event

The review of the event occurs within 15 days of the emergency officially ending. The task force in charge of maintaining the emergency plan prepares audits in cooperation with the crisis unit and all the personnel involved in the event.

The objective is to point out critical situations and to focus on possible solutions.

Indicators are useful for a retrospective assessment of the event and the emergency system’s efficiency. Indicators may include the time taken to achieve readiness following the alarm, the percentage of correctly allocated patients, etc.

Simulation

A simulation technique (Emergo Train System) applies a patent system created by Prof Lennquist of Linkopping University in Sweden. This is widely recognized as an efficient simulation tool for Disaster Medicine and includes management exercises based on disaster scenarios.

Every year the hospital organizes at least one simulation of a mass casualty accident in collaboration with other forces and organizations : fire department, civil protection, army, security forces, etc.