Workshop on CHEMICAL EMERGENCY PLANNING PREPAREDNESS AND RESPONSE-BEST

Workshop on CHEMICAL EMERGENCY PLANNING, PREPAREDNESS AND RESPONSE-BEST PRACTICES AND INTERNATIONAL EXPERIENCES. (21 st Oct. 2010) Dept. of Factories, Go. AP and National Safety Council Chemical Off-Site Emergencies. Ambulance Services’ Dr G V Ramana Rao MD, DPH, PGDGM Executive Partner & Head Emergency Medicine Learning Centre and Research GVK EMRI

Agenda • ‘ 108’ GVK EMRI emergency response services • Chemical emergencies and pre-hospital care

Innovative Pro-Poor PPP (Public Private not for Profit Partnership) Service Delivery Model to provide free Emergency Response Services at one / Citizen / Month Serving 1 Emergency every 8 seconds and Saving 1 Life every 8 minutes

GVK Emergency Management and Research Institute A Non-profit organization

Why this Innovation ? • 75, 000 emergencies occur per day • 80% are at the bottom of the pyramid • 80% deaths occur in hospitals in the first hour • 4 M deaths p. a. (Cardiac, Road Accidents, Maternal, Suicidal attempts, Neonatal / Infant / Pediatric, Diabetic related, etc) due to absence of 4 As : • Access to a universal toll-free number • Availability of Life Saving Ambulance to reach quickly nearest and appropriate health facility • Affectionate Care by trained paramedics (Compassion, Ability, Resourcefulness & Energy) • Affordability by every citizen independent of income, religion and community • Hence, GVK EMRI was born in April 2005

Vision of GVK EMRI • To respond to 30 million emergencies and save 1 million lives annually by 2011 • To deliver services at global standards through Leadership, Innovation, Technology and Research & Training Leadership Innovation Technology R&T • To become One Of Eight Wonders of the World

What is Unique in this Innovation ? • Integrated Emergency Response Services for Medical, Police and Fire emergencies with single universal tollfree number ‘ 108’ • Free services (no cost to citizen) • PPP framework • Government provides funds for OPEX & CAPEX • Private Partner brings leadership, innovation, execution and technological capabilities • Conducting Research and building capability in Emergency Medicine and Management

Launched on 15 th Aug, ‘ 05 in Hyderabad and expanded to 10 other States Jammu & Kashmir Himachal Pradesh Punjab Arunachal Pradesh Uttarakhand Haryana Delhi Sikkim Rajasthan Uttar Pradesh Assam Bihar Jharkhand Gujarat Madhya Pradesh Meghalaya West Bengal h ga r tis Ch at Andhra Pradesh Goa Karnataka Tamil Nadu Kerala Orissa Manipur Mizoram Tripura Maharashtra Nagaland

Successfully Implemented by GVK EMRI in PPP Framework • Political will, Public Servants’ commitment and Public Support • 100% of Capital expenditure and Operational expenses by Government (Public) • GVK funds Leadership, Innovation (Infrastructure, Process), Collaborations, Research and Training, Knowledge transfer and Quality assurance • Mahindra Satyam provides free IT solutions as technology partner • GVK EMRI manages and leverages government resources for better outcomes to serve poor • Partnership involving Pain and Pleasure

Building Blocks of GVK EMRI’s Innovation Three digit toll-free No. Accessible from Land lines and Mobile phones Modern, spacious and open ERC Cost effective ambulances to provide quality care for Indian emergencies with facilities for rescuing and balancing patient care with public safety and patients relatives comfort GIS / GPS to locate victim / ambulance and hospital Trained personnel for providing PHC

Innovative Process Sense Reach Care Follow up after 48 hrs • Developed detailed process understanding and well defined responsibilities through out the organization • Maintained all information related to emergency in Patient Care Records (PCRs) • Patient information is shared with the hospital on arrival • 48 hour follow up with the patients admitted to hospital

COMPUTER SERVER ROOM Innovative use of Technology Public Switching Telephone Network (PSTN) Caller in distress Dial 108 Nortel Switch SCCS, CCT & Voice Telephone DB Logger ERS DB GIS DB Dispatch Officers (DO) Communication Officers (CO) ERC Transfer CO Supervisor DO Supervisor ERCP Conference EMT in Ambulance FIELD Ambulance Base Location Victim Location (Scene) Victim Shifted to Hospital CCT: Communication Control Toolkit; SCCS: Symposium Call Centre Server; ERCP: Emergency Response Center Physician; EMT: Emergency Medical Technician

Innovative Pre-Hospital Care • Emergency Medical Technician (EMT) in the ambulance is trained not only to provide pre-hospital care but also to handle emergency situations • EMT gets support over phone from qualified medical practitioner called ERCP (Emergency Response Centre Physician) located at the ERC • ERCPs are in the ERC round the clock to provide support to EMT and to people at emergency scene until ambulance arrives

Collaboration for transfer of Knowledge and Technology know-how, Best practices, Research & Training Stanford University, USA Singapore Health Services Carnegie Mellon University, USA American Academy for Emergency Medicine in India Public Health Foundation of India Geomed Research American Assoc of Physicians Of Indian Origin (AAPI) Shock Trauma Center, USA

Impact. . Size • One Center for 40 M population against one for every 0. 05 M population in USA • 372 M population covered in 9 States (increased reach of health care in rural , hilly and tribal areas) • Trained 35, 650 people (11, 500 - EMTs, 10, 000 – Pilots, 3, 100 - Doctors, 2, 100 - Nurses, 6, 800 - First Responders and AHA/ ITLS Certification for - 2, 150) • 12, 170 + emergencies handled per day (9. 3 Million cumulative) • 2, 600 Ambulances - 4. 5 trips a day • 15, 900 + GVK EMRI Associates Speed • Went live in less than 4 months from signing Mo. U • 91% calls taken in first ring • < 15 minutes (urban) and < 25 minutes (rural) Ambulances reached Govt. of A. P. Govt. of Gujarat Govt. of MP Govt. of Uttarakhand Govt. of Tamilnadu Govt. of Goa Govt. of Assam Govt. of Karnataka Govt. of Meghalaya Govt. of Chhattisgarh Govt. of HP

Impact Type of Emergencies and Lives saved • Pregnancy related - 29%, Vehicular Trauma – 18%, Acute Abdomen – 13% Cardiac – 4%, Respiratory – 4%, Suicidal – 2%, Animal Bites 1% Costs • Cost per ambulance trip Rs. 600 to Rs. 700 against $ 600 to $700 in USA Qualitative Outcomes • Angel of Mercy – 108 Ambulance • 300+ lives were saved per day (247, 021 + till now) and 11, 870 victims per day received timely, highquality pre-hospital care • Successful PPP • Well documented systems, impressive EMT training, high order management competence • A historic landmark in health care delivery system • Built more trust in the health system as a whole • Increased institutional deliveries and reduced maternal mortalities by 20 – 25% • A model for replication across the Country in any state

Impact - Doing More with Less for More Bomb Blasts Ahmedabad

A Gandhian Innovation July-Aug 2010

PRE-HOSPITAL CARE – AMBULANCE SERVICES

An injured patient needs (i) Treatment for life threatening injuries to maximize the likelihood of survival, (ii) Treatment for potentially disabling injuries to minimize disabilities and promote return to optimal functioning, and (iii) Reduction in pain and suffering (Mock et al. 2004).

Chemical Industrial Emergencies • • • Evacuation of Casualties Decontamination Triage Resuscitation Treatment Transport

Ambulance

Advanced Life Saving Ambulance

AMBULANCE EQUIPMENT SPIINE BOARD WHEEL CHAIR AUTOLOADER SCOOP AIR LIFTING STRETCHERS EXTRICATION TOOLS

MEDICAL EQUIPMENT SUCTION APPARATUS VENTILATOR AUTOMATED EXTERNAL DEFIBRILLATOR VACUUM SPLINTS

Rescue and evacuation

Four common triage categories (IDME) T 1 Immediate Delayed T 3 Minimal T 4 Expectant T 2

WALKING YES INJURED NOT NO T 3 INJURED SURVIVOR RECEPTION CENTRE DEAD NO OPEN BREATHING YES RESPIRATORY RATE 10 - 29 PULSE RATE NO AIRWAY BREATHING YES less than 10 30 or more t en s ab lse in pu l /m 0 ia 12 rad > or radial pulse <120/min T 1 T 2

Key Message 1 • Do Triage based on Airway, Breathing and Circulation when more than 3 patients are involved.

Triage and onsite treatment techniques

Andhra Pradesh: Mock Drill at GVK EMRI, Secunderabad on 5 th September ‘ 07 32

Andhra Pradesh: Mock Drill at Secunderabad Rly Station on 17 th October ‘ 08 33

Uttarakhand: Mock Drill at Parade Grounds, Dehradun on 20 th November’ 09 34

MCI- Important Roles – On site and Transportation • • • Ambulance Incidence Officer (AIO) Triage Officer(TO) Treatment Area Supervisor (TAS) Treatment Area Officer (TAO) Logistic Officer (LO) Equipment Officer (EO) Ambulance Parking Officer (APO) Ambulance Loading Officer (ALO) Safety Officer (SO) Public Information Officer (PIO)

Evacuation of Casualties – NDMA- MP-MPE- Major Recommendations – Ambulances Reference NDMA EMRI Response time -Maintain minimum ( Golden hour) Urban 14 mts; Rural – 21 mts <10 mts – 2/3 of RTA & cardiac. Medical Equipment For resuscitation, Essential drugs, Spine board/ CPR skills; 106 drugs under medical directions; Collapsible / Scoop /Pediatric / Chair stretchers; Cell phones. Stretchers 2 -way communication Support Staff SOPs Well versed with equipment usage Quality checks Yes (training) Maintenance of vehicles Yes including preventive maintenance, repair/accident processes etc. (Fleet managers) Yes (OE wkly visits; Qrtly. Checks by quality teams)

Evacuation of Casualties – NDMA- CIDM- Medical Emergency Plans Reference CIDM EMRI District Off-site Plan Mock drills Yes Dedicated To be identified / established institutes for CDM Can be seriously considered for training and research. Community awareness Develop mechanism –kits. Voi. CE program SOPs To be laid out – can cascade and provide Decontamination; risk and resource inventory, proper casualty chemical treatment kits,

Integrated Eo. C Services EMRI and NDMA • • • Computer – Cellphone Integration (CTI) Ambulance network Community Awareness (Voi. CE) Preparedness &Mock Drills (Medical/Police/Fire/ Railways) First Responders (> 3000 trained and handbook) Emergency Medical Technicians and Paramedics (PGPEC) Standard Operating Protocols (SO, MD, CCPs, MCI) Hospital Network (>6000 Mo. Us) Documentation (Pre-hospital Care Record PCR)

Essential elements for IAN • • • Strategy partnerships Strategic support – technology, training and research Size and scale SOP Skills set Surface ambulances Site experiences Simulation SLA

Our legacy • Like so many other things that are Indian, Mahatma worked as volunteer in South African war in 1899 and served injured people.

Thank you www. emri. in Ramanarao_gv@emri. in