Leadership in Disaster Management: Nepal Earthquake

Professor Fary KhanDepartment of Medicine, Royal Melbourne Hospital &

The University of Melbourne

Lead Task force for The Committee on Rehabilitation Disaster Relief (CRDR),ISPRM WHO Liaison Committee Policy Advisory Group international Society of Physical and

Rehabilitation Medicine (ISPRM)

1. The ProblemInter-Agency Standing Committee’s (IASC) Cluster System -global authority for crisis coordination & accountability - WHO - the Health Cluster

Demand for better coordination and control after major international disaster/crisis. • poor clinical competence of providers• unacceptable clinical & management practices • limited scope of guidelines for foreign medical teams (FMTs)

[Global Health Cluster: coordination and registration of FMTs in Humantarian disasters. Strategy position paper. Geneva 2011]

ELRHA: Enhancing Learning & Research for Humanitarian Assistance

I: Registration, coordination & internal quality improvement of FMTs

II: Professionalize training & certification of humanitarian health care providers & accreditation of their academic training centers & trainers

2. Foreign Medical Team Requirements

• Professional & ethical standards

• Accelerate deployments

• Match services with supply & demand

• Create register of FMT provider organizations

• Team composition by specialty, experience & bed capacity

• Standardized data collection & reporting

• Procedures performed by accredited staff

• FMT staff- experience in humanitarian settings

• Process to supervise less experienced

[GHC Concept paper 2011]

Rehabilitation Competencies -HHIHumanitarian response- needs both trauma surgery & Rehab

Early rehabilitation restores function, improves survival & QoL

Rehabilitation for disabling injuries: wounds/ trauma, amps, SCI, TBI, burns

Prevent complications in pw disabilities & disabling injuries, assistive devices

Partnerships with community services & CBR for post-operative care & Rehab

Identify need for psychological services

[Sphere Minimum Standards, IASC Global Health Cluster FMT-WG Health Services Checklist]

Why is this needed?Specialised field HR DM - comprehensive med rehab Ax

Interdisciplinary approach - acute, com & care coordination

Needs’ ax- patient complexity & follow-up

Local & rehabilitation staff training in PM&R

Ensure global & a longer-term approach

3.Nepal Earthquake 2015

4. Rehab FMTs- composition, specific focus, self-funded, independent, partnerships

Team Leader Response• FMT registration with WHO- liaise with rehab sub-cluster• Daily surveillance reports & Exit reports for MoHP• Support desks at the airport- triage critical patients, basic initial symptomatic

management, referral- public hospitals or FMT • Medicine/Equipment Custom Release Help Desk - speedy release of drugs &

medical equipment brought in • Management of dead bodies - National Emergency Operation Center (NEOC),

MoHP– if required• Post Earthquake Hospital Based Disease Surveillance Trauma, ARI, watery

diarrhoea, bloody diarrhoea, fever, total OPD patients, total IPD patients & total surgical cases (minor/major)

• Post-Earthquake Disease Outbreak Surveillance- community• Logistics support- medicines, tents, water, transport, supplies etc.

• Logistic cluster- no rehab physicians, few nurses, AH- be flexible/adapt as needed

• Contact for Medivac, FMT-CC, Exit strategy• National CBR plan- physical, assistive devices, psychosocial, shelter,

transport etc- work with partners, other stakeholders• Gender issues• Safety /security situation• Environmental issues- H2O, sanitation, landslides• Coordination & reporting• Road access• IDP situation

Considerations

Leadership• FMT recruitment, coordination, training etc• Team capacity building - local +FMT• Rehabilitation processes & organisation- liaise local team• Triage & prognosis (based on ASIA scores)• General ward set-up for operational ease• Models of care- CBR + partnerships• Systems of management of referrals, acute & CBR• Medical documentation & record keeping• Need for evidence-based practice

Field Conditions• Logistics & security frame work• Set up of local partnerships to operate in the best legal

conditions possible • Transport & access to trauma care units with a clear mandate

& visibility prepared by the organization • Formulated terms of reference that describe the task

required for the PRM team

Personal skills• Good organizational skills• A resilient mindset & attitude - working environments • Prioritize personal security • Operational & logistical procedures • Flexibility to cope with varying workloads & requirements • Cultural sensitivity• Ideally- speak the local language

Activity Plan- outcomes Discussion with local team re FMT expectations Local unit priority- patient triage tool developed

Gaps identified– Lack of rehabilitation processes, documentation, treatment

approaches & systems of care– Integration with acute hospital (minimal documentation with patient

transfers)– Limited resources/staff/IT

Specific request for teaching on rehab management

Clinical issues (SCI n=101)Traumatic SCI

• Fracture management/bracing/ASIA scoresDisability management

• General medical stabilization, CCs• Spinal shock, resp compromise, AD, paralytic ileus, neurogenic

bladder/bowel, HO etc• Pain & spasticity care• Mobilisation program/precautions• Contractures & complications of immobility• Closed head injury (concurrent if relevant)• Diet, falls, pressure care etc

GapsRehabilitation Medicine capacity, limited imaging & pathologyLack of

• access to timely neurosurgical advice following spinal surgery• electricity , beds (patients in corridors, even prior to 13th May EQ)• procedural training for volunteers• emergency packs in case of evacuation• Glucometers, urine dipsticks, packaged saline for washing wounds• Hand hygiene- disinfectant for staff/patients/visitors

Orthotics - more tools needed; no prefabricated devicesMore supplies: gloves, dressings, tweezers, staple removers, torchesAppropriate wheelchairs & seating, pillows & pressure mattresses

Lessons LearntISPRM -WHO Min Standards & Recommendations for Rehab in Emergencies: Guidance Document for FMTsRequirements for:

• FMT staffing configuration• Standards for rehabilitation in outbreak response• Disability inclusive response & accessibility• Deployment• Patient assessment & data collection• Referral & coordination mechanisms • Rehabilitation equipment & resource requirements • Research & development

Thank Youfary.khan@mh.org.au

AckowledgementsJim GosneyFrederick Burkle IIIDoHP NepalWHO rehab sub-clusterHost - Amatya Family