June 23, 2004

DOH ADMINISTRATIVE ORDER NO. 2004-0155

I. Background and Rationale

Many lives have been lost in mass casualty situations because resources were not mobilized efficiently. During emergencies and disasters resulting in large number of injuries the community is the first to provide emergency assistance. Thus, attention was given to the training for emergency personnel in first aid and/or "first responses". The basic approach is the "scoop and run" method that does not require specific technical ability from the rescuers. While this method can be justified for the management of small numbers of victims in certain circumstances such as accidents occurring in the immediate proximity of available emergency care services, this will not be ideal in mass casualty incidents.

For the past 20 years, first responders were trained to provide victims with basic triage and field care before evacuation to the nearest available receiving health care facility. However, the field organization (often involving non-health sector responders) and the receiving health care organization are often totally divorced from the pre-hospital problem. In a mass casualty situation, this approach will quickly result to chaos as what we experienced during the Ozone Disco Disaster, the Lung Center Fire and the Manor Hotel Incident.

Mass Casualty Management, the most sophisticated approach, includes pre-established procedures for resource mobilization, field management and hospital reception. It is based on specific training of various levels of responders and incorporates links between field and health care facilities through a command post. It acknowledges the need for a multi-sectoral response for triage, field stabilization and evacuation to appropriate health care facilities. The challenge we face is this: the scarcer the resources are, the more efficient the organization must be. This guideline wishes to adopt MCI Management practiced in other countries with some changes appropriate to our country that will ensure the highest possible survival rate for victims of MCI. Although, it should touch on the involvement of other sectors like the police, the firefighters, non government organizations like the Red Cross volunteers, etc. as they are considered First Responders, the discussion will focus more on the health sector, the Department of Health (DOH) being the leader of this sector. Furthermore, as terrorism is a global concern, this guideline will likewise cover MCI related to weapons of mass destruction (WMD). STCDaI

This Order prescribed guidelines as a basis for establishing systems, procedures and implementing mechanisms including the development of an integrated and comprehensive action plan for field management and hospital reception that shall reduce possible loss of life and prevent disability in cases of Mass Casualty Incidents.

II. Objectives

A. General

To implement a mass casualty management system and procedures for resource mobilization, field management and hospital reception to ensure a comprehensive and well coordinated response in mass casualty incidents.

B. Specific

1. To improve the effectiveness of DOH systems, structures and mechanisms for managing mass casualty events.

2. To strengthen links between field and health care facilities.

3. To guide hospitals in their preparedness and response to Mass Casualty Incidents (MCI).

4. To understand and apply Unified Command by observing the Incident command System used in all Mass Casualty Incidents.

5. To develop a Philippine approach to MCI based on the available human and material resources. AHCcET

III. Scope and Coverage

This Order shall apply to all Department of Health Center of Health Development and DOH Hospitals. All stakeholders and partners in the health sector responding to Mass Casualty Incidents are encouraged to adopt this order.

IV. Definition of Terms

A. Casualty are victims both dead and injured, physically and/or psychologically.

B. Mass Casualty Incident Any event resulting in a number of victims large enough to disrupt the normal course of health care services usually a result of natural and man made disasters including terrorism or the use of WMD.

C. Mass Casualty Management (MCM) Management of victims of a mass casualty event, aimed at minimizing loss of life and disabilities.

D. Mass Casualty Management System The group of units, organization and sectors that work jointly through institutionalized procedures, to minimize disabilities and loss of life in a mass casualty event through the efficient use to of all existing resources.

E. Field Management encompasses the procedures used to organize the disaster area in order to facilitate the management of victims.

F. Triage is the process of identifying victims needing immediate transport to health facilities and those whose care can be delayed. Triage is based essentially on urgency (victim status) and, secondly, on likelihood of survival.

G. Coordination the bringing together of organizations and elements in order to ensure effective counter-disaster response. It is primarily concerned with the systematic acquisition and application on resources (organization, manpower and equipment) in accordance with the requirements imposed by the threat or impact of a disaster.

H. Medical Controller a designated senior Department of Health Officer appointed to assume the overall direction of the medical response to mass casualty incidents and disasters. Control is established from a designated Operation Center either in the Central Operation Center or the Regional Operation Center and whose main responsibility is to coordinate all the services of the Sector.

I. Incident Medical Commander The highest representative of the Department of Health or Local Health Office as designated by the city/town/Local Executive (depending on the extent of the disaster) who shall serve as the liaison officer of the Health Sector to the Command Post headed by the Incident Commander. For Regional disasters it should be the highest representative from the DOH CHD.

J. Weapons of Mass Destruction (WMD) are radiological, nuclear, biological or chemical elements in nature used for large-scale damage to life and property, usually by those perpetrating terrorist activities.

K. Terrorism The premeditated use or threatened use of violence or means of destruction perpetrated against innocent civilians or non-combatants, or against civilian and government properties, usually intended to influence an audience (Memorandum No. 121).

V. General Guidelines

A. These guidelines shall be a component of the National Disaster Plan. These shall ensure an effective and efficient management of mass casualty incidents. This shall be implemented in accordance with the procedures provided for by the National Disaster Coordinating Council and shall observe Local Government Code provisions pertaining to Mass Casualty Incidents.

B. DOH shall strengthen the Operation Center under the Health Emergency Management Staff (HEMS). The HEMS shall monitor all health and health related events that may have MCI implications. It shall provide overall coordination in mass casualty incidents.

C. Adequate MCI program coordination and management systems shall be put in place in all DOH CHD offices and facilities. DOH shall strengthen key areas of coordination and integration between and among other agencies of the government, the local government units, non-governmental organizations, the general public including international agencies in mitigating the effects of MCI. TCaSAH

D. Training sessions and drills relative to MCI shall be institutionalized and organized annually in all DOH Hospitals and Center for Health Development to continually upgrade levels of knowledge and maintain a state of readiness. All physicians, nurses and other emergency responders shall be required to undergo MCM training.

E. All personnel trained in emergency can be tapped to augment manpower needs of DOH health facilities or offices during MCI.

F. All DOH personnel mobilized in response to emergencies and disasters like MCI shall be entitled to overtime pay and other allowable benefits based on actual time rendered due them even during Saturdays, Sundays and holidays. This shall be supported through the issuance of a pertinent hospital/office order which shall state funding of such overtime from savings of the hospital, HEMS STOP DEATH funds or any other funds subject to the usual accounting and auditing rules and regulations.

G. To institutionalize the MCI response strategy, a Manual of Operating Procedures shall be developed by the Department of Health, in coordination with other partners in the health sector.

VI. Implementing Guidelines

A. Components of Mass Casualty Management System

1. Policy and Planning

a. All hospitals shall develop and organize a response team that can be dispatched in the event of a Mass Casualty Incident.

b. All CHD's and hospitals shall include in their regional/hospital preparedness plans a section in MCI Management.

c. All CHD's and hospitals shall adapt the Incident Command System in handling MCI.

d. All hospitals should strictly implement the Code Alert System (AO no. 182 s. 2001)

e. For internal disaster in hospitals it shall observe and activate the Hospital Emergency Incident Command System.

2. Capability Building

a. Basic Life Support (BLS) training shall be mandatory for all health personnel.

b. Advance Cardiac Life Support (ACLS) and Pediatric Cardiac Life Support (PCLS) shall be a requirement for all medical personnel assigned in the Emergency Rooms.

c. All Response Teams shall have additional training in Emergency Medical Technician's Course Basic and Mass Casualty Management.

d. A regular simulation exercises shall be done at least once a year.

3. Operation Center/Surveillance System

a. All Operation and Dispatch Centers (central, regional and hospitals) shall be strengthen to include monitoring of MCI.

b. Diseases with a potential for outbreaks, especially those associated with WMD, shall be included in the existing list of reportable diseases.

c. Networking and reporting system shall be institutionalized among the key partners/members in the Health Sector. cHAaCE

4. Facilities Development

a. Hospital facilities and capacities shall be enhanced and upgraded to meet the needs of Mass Casualty Incidents. The HEMS shall coordinate with the National Center for Health Facilities Development in order to identify the infrastructure, facilities, equipment and human resource requirements of MCI relative to various health facilities.

5. Documentation/Research

a. Reporting and documentation of MCIs shall be institutionalized. Particularly, postmortem evaluation to analyze response, and lessons learned shall be developed as inputs for policymaking and program improvement.

b. Researches in MCI shall be encouraged and promoted.

B. Operations and Dispatch Center

1. Functions of the Operation and Dispatch Center

a. Receives all warning messages via connections with all major offices/services that are monitoring and responding to emergencies through telephone, fax machines, radio, etc. ASaTCE

b. Serves as Dispatch Center in times of emergencies.

c. Anticipates scenarios and alerts additional teams needed by receiving hospitals.

d. Reviews required logistics.

2. Conditions for dispatching teams

a. All hospitals and Regional Operation Centers shall dispatch teams within their catchment area upon monitoring or receiving a call confirming a Mass Casualty Incident.

b. Any hospital and/or CHD teams can also be dispatched even outside their catchment area upon a request of help from neighboring facilities or upon instruction of HEMS Central Operation Center.

c. The HEMS Central Operation Center, upon the instruction of HEMS Director, can dispatch teams from any hospital and CHD offices upon monitoring events that necessitate response from the Department of Health or upon request of agencies of government with authority over certain events (NDCC, NSC, etc.).

While the initial teams is dispatched, the Operation Center anticipates the scenario and alerts additional teams that might be needed, nearby hospitals especially the receiving hospitals, and starts reviewing its logistics.

C. Organization of Field Management

In the event of an MCI, health operation and dispatch centers shall coordinate closely with their counterparts at the local government and other agencies. DOH and other MCI health operation and dispatch centers shall enforce and respect the rules of engagement in inter-agency response to MCI.

1. Initial Assessment

a. Identify immediate extent and potential risk of the problem.

b. Mobilize adequate resources to correctly organize field management.

c. Conduct immediate assessment of initial incident.

2. Data Requirements for initial assessment and reporting

a. Precise location of the event

b. Time of the event

c. Type of incident

d. Estimated number of casualties

e. Added potential risk

f. Exposed population

g. Right resources needed

3. Reporting to Operation Center

a Submission of initial assessment

i. Submit immediately initial assessment

ii. Refrain from starting any haphazard or unplanned work to avoid delay in the mobilization of resources

b. Processing of initial assessment by Operation Center

i. Dispatch the necessary teams required and immediate resources needed

ii. Alert and put on stand-by additional responders that might be required

iii. Coordinate with the receiving hospitals to prepare for the deluge of patients cDICaS

iv. Prepare other hospitals in the event that the volume of patients is beyond the capacity of the receiving hospital

v. Review logistical requirements

vi. Report to Superiors

vii. Report to HEMS Central Operation Center

viii. Report to Disaster Coordinating Council depending on level

D. Pre-Identification of Field Areas

Identification of field areas for various purposes prior to dispatch and operations will allow various incoming resources to reach their places rapidly and efficiently. This is the first part of the deployment. This should consider the topographical area, the wind direction, and access roads. Maps could be used initially and will help in the management of restricted areas and, potential risks to victims and the population are graphically determined including boundaries. The following should be mapped out and identified.

1. Impact Zone

2. Command Post Area

3. Advance Medical Post Area

4. Evacuation Area

5. Staging Area

6. VIP and Press Area

7. Access Roads

E. Safety Measures

Safety measures are implemented to protect victims, responders and exposed population from immediate and/or potential risk (extension of the accident, responding to traffic accidents, hazardous materials, etc.)

1. Direct actions include risk reduction by fire fighting, confinement of hazardous materials, use of protective clothing, and evacuation of exposed population.

2. Preventive actions (for WMD) include the establishment of the following restricted areas.

2.a Impact Zone/Hot Zone strictly restricted to professional rescuers who are adequately equipped such as HAZMAT teams, WMD teams, etc.

2.b Secondary area/Warm Zone restricted to authorized staff working in rescue operation, care delivery, command and control, communications, ambulance services, security/safety. The Command Post, the Advance Medical Post, the evacuation center and parking for the various emergency and technical vehicles will be set up in this area. This is approximately 100 meters from the Impact Zone and depend on wind direction.

2.c The Tertiary area/Cold Zone is to be accessed by press officials and serve as a "buffer" zone to keep onlookers out of danger. This is approximately 50-100 meters from the warm zone, also depending on wind direction.

3. Minimum Personal Protective Equipment (PPE) of any medical responder who is in contact with a patient are the following. EHSAaD

a. gloves

b. goggles

c. mask

4. For suspicious of Weapons of Mass Destruction incidents medical responders are allowed only at the cold zone with proper protective clothing. Only those with the appropriate protective clothing and with proper training will be allowed entry into the hot and warm zone.

F. Command Post

1. Functions of the Command Post (CP)

a. The CP shall serve as the multi-sectoral control unit established to coordinate the various sectors involved in field management. The CP shall serve as the communication/coordination hub of pre-hospital care. This ensures the provision of adequate supply of equipment and manpower. It is likewise responsible for providing informations to official and the media.

The Command Post is where the Incident Commander shall stay together with all the different representatives of the Government. The Incident Commander is usually the highest local official depending on the level (location and coverage) of the disaster.

b. The CP, under the leadership of the Incident Commander, shall provide the management structure handling the event. The highest-ranking health-official (depending on the MCI or disaster) in the Disaster Coordinating Council (DCC) should be represented in this post. The health official assigned to this management structure for a particular MCI shall be known as the Incident Medical Commander (IMC). The IMC should take note that MCM would entail a lot of management decisions and not technical decisions.

2. Responsibilities of the IMC

a. The DOH or local health representatives should be knowledgeable of the structure of the department, and how resources are mobilized through adequate networking.

b. The IMC should keep abreast with reports on the MCI, inter-agency plans in response to the MCI, and make necessary recommendations for the management of victims. DSEaHT

c. The IMC shall be responsible for evaluating and reporting all medical information to the Incident Commander and gives feedback to the Operation Center and the Secretary of Health.

d. The Incident Medical Commander shall be responsible for knowing all incoming medical teams arriving at the scene. Likewise, he should assist in the planning activities in the IC and anticipate requirements such as scheduling of teams in the event of a prolonged activity.

e. The IMC and or his/her staff in the Advance Medical Post should not make press conference on their own in order to avoid differences in the reporting. The IMC is liable for the behavior of his/her staff. At no instance will the IMC leave the post without a representative until the event is terminated. DAcaIE

G. Management of Victims

1. Search and Rescue

This activity shall be handled only by skilled teams such as those coming from the Bureau of Fire, Coast Guard, 501 Engineering Brigade, CSSR, 505 Fighter Wind, etc. In situations where there might be a need for on-site assistance of medical personnel in order to commence stabilization of the patient/s during evacuation or extrication of victims, only DOH personnel with training in Search and Rescue should involve themselves (especially in high-risk situations like collapsed buildings or in mountainous areas) except an exceptional situations and with the company of trained rescuers. These teams will:

a. Locate victims

b. Remove victims from an unsafe location to a collecting point, if necessary

c. Assess victim status (on-site triage)

d. Provide first aid, if necessary

e. Transfer victims to the advance medical post, if necessary

2. Advance Medical Post

This shall be established to provide effective field stabilization for victims of a MCI. This is established right away and managed by the Field Medical Commander who is the first knowledgeable medical personnel to arrive at the scene. Upon the arrival of a more experienced person or team he should transfer the command. This is the place where all incoming medical teams will be referred and given specific responsibilities. Right away, the following area and people should be designated:

a. Triage Area with a Triage Officer

b. Treatment Area with a Treatment Officer

c. Transport Area with a Transport Officer

d. Staging Area with a Staging Officer

e. Mortuary Area with a Mortuary Officer

The duties and responsibilities in each particular area shall be incorporated in the Manual of Operations for Mass Casualty and will be discussed in detail together with the protocols and procedures, reporting and documentation.

H. Hospital Management

1. Requirements. The following should be done during MCI.

a. Activation of the Hospital Emergency Plan

b. Implementation of the Code Alert System (AO 182 s. 2001)

c. Adoption of the Hospital Emergency Incident Command System (HEICS)

d. Activation of the Hospital Mass Casualty Plan

2. Reception of Victims. There should be specific areas for easily locating the following:

a. Hospital Triage with Triage Officer

b. Red Treatment Area with Red Treatment Officer

c. Yellow Treatment Area with Yellow Treatment Officer

d. Green Treatment Area

e. Deceased (Black Category) Victims Area

f. Decontamination area for WMD

3. Others:

a. Mobilization of Response Team to the site depending on the hospital plan

b. Activation of the Hospital's Operation Center serving as the area for coordination, reporting and liaising with other agencies

c. Identifying an area for relatives, VIP's and the media HTDAac

d. Preparation of the Emergency Rooms and additional areas for admission of patients

e. Key staff report immediately to the hospital

f. Recall employees depending on the alert code

g. Mobilization staff according to plan and redeployment to the emergency room and other key areas/departments of the hospital

h. Coordination with DOH Operation Center Central/Regional and other Sectors (Police, Fire, Local disaster etc.)

i. Cancel elective operations, activate procedures in clearing in-patients for transfer

VII. Roles and Responsibilities of various DOH Offices/Bureau/Units

A. DOH-HEMS Central Operation Center shall be responsible for the following:

1. Serves as the central body coordinating all Mass Casualty Incidents

2. Repository of all reports from the DOH-Center of Health Development Offices and Hospitals

3. Mobilizes resources needed to the MCI sites

4. Provides advice and report directly to the Secretary of Health and the National Disaster Coordinating Council

5. Monitors, evaluates and formulates new policies and guidelines pertaining to Mass Casualty Management

B. It shall be the responsibility of all DOH Hospitals to ensure that the following requirements are complied with and reported to HEMS

1. Upgrading of hospital capability that shall include the ability to handle trauma victims, burn patients, etc.

2. Ensuring the readiness of the Emergency Rooms in terms of equipment manpower and systems to answer to MCI especially for general hospitals.

3. Availability of sufficient emergency medical kits containing equipment and supplies for treating a minimum of 10 serious casualties. The number should increase depending on the capability of the hospitals. A responding team should have the capability for treating a minimum of 3-5 serious patients. HIACEa

4. Ready availability at all times of at least one ambulance for emergencies/disasters and equipped with all the necessary emergency supplies and equipment including communication equipment to establish coordination.

5. Activating Hospital Emergency Plan, observation of the Code Alert Systems and Hospital Emergency Incident Command System (HEICS) in such situations.

C. All Center for Health Development Offices shall ensure institutionalization of a functional Regional Operation Centers. CHDs shall be responsible for monitoring all health and health related incidents and coordinate all activities within it's region, and regularly update and submit reports to HEMS Central Operation Center. A final report should be submitted to HEMS 2 weeks from time of incident of all coordinated events within the Region.

In particular, the following functions and responsibilities shall be observed by the DOH Hospital and CHDs Point Persons:

1. The HEMS-STOP DEATH Coordinators of the hospital/regions shall directly oversee, the implementation of these guidelines in their respective hospitals/regions. He/she shall report to the Chief of Hospital/Medical Center Chief, CHD Directors and the Director of the Health Emergency Management Staff.

2. The Medical Center Chiefs/Chief of Hospitals shall administer these regulations and support all the policies and guidelines mentioned in this Order. He/she shall lead in the dissemination of these guidelines and integration in the hospital/regional policies. He/She shall ensure availability of personnel and funds to support all the needed training, drills and responses. IaAScD

3. The Center for Health Development Directors shall be responsible for the implementation and adoption of the guidelines and provide feedback, suggestions, and policy recommendations to the Secretary of Health.

D. The roles and responsibilities of the following Offices/Bureau/Units at the Central Office shall include:

1. The Bureau of Health Facilities and Services shall ensure that whenever necessary, applicable or appropriate, policies/guidelines pertaining to this Administrative Order are incorporated among the requirements for the licensing of hospitals.

2. The National Center for Health Facilities Development shall ensure that policies/guidelines provided in this Order be incorporated in hospital policies.

3. The National Epidemiology Center shall include in their surveillance system diseases/events with the potential to Mass Casualty situations. Moreover, it shall endeavor to undergo researches to determine the epidemiology of mass casualty events.

4. The Health Emergency Management Staff shall be responsible for monitoring and evaluating the enforcement and compliance of this order and the subsequent recommendations for policy formulations and amendments.

VIII. Effectivity Clause

This Administrative Order shall take effect immediately. HcTEaA

(SGD.) MANUEL M. DAYRIT, MD, MSc
Secretary of Health