Pendekatan sistim menghadapi

Pandemi Covid 19

Arjaty Daud
 Curiculum Vitae
Nama : dr. Arjaty W. Daud, MARS
Alamat : Jl. Moh Kahfi 1, Royal residence Blok A2 Ciganjur Jakarta Selatan
Tmpt / tgl. Lahir : Manado,17 Januari 1969
Email : arjatydaud19@gmail.com
Hp : 0812 1830 7169
PENDIDIKAN
S-1 Fakultas Kedokteran Universitas Sam Ratulangi - Manado , Lulus 1995
S-2 Fakultas Kesehatan Masyarakat, KARS Universitas Indonesia, Lulus 2005

PELATIHAN / SEMINAR
2017 : Update Acreditation Joint Commission International 6th edition Amsterdam
2015 : Practicum Acreditation Joint Commission International 5th edition Singapore
2011 : Practicum Acreditation Joint Commission Internationl 4 th edition Seoul
Patient Safety Course, Singapura
2010 : Safety in Healthcare, Kuala Lumpur
2009 : Hospital Management Asia, Vietnam
Course Risk Management PRMIA Jakarta
2007 : New Perspektif, Conferrence ASHRM, Chicago USA
Certified Profesional Healthcare Risk Management course,
Chicago USA
Risk Management Base Training, Joint Commision Resources (JCR)
Patient Safety Up Date, Joint Commision International (JCI) Singapura
2005 : Lead Audior ISO 9001 – 2000, International Registered Certificated
Auditor (IRCA)
www.manajemenrisiko-imrk.id Manajemen Risiko IMRK
ORGANISASI
• 2020 : Tim Ahli Investigasi KTD Alat Kesehatan Kemkes
• 2018 – saat ini : Ketua Bidang Pelaporan & Analisa Insiden Komite
Nasional Keselamatan Pasien (KNKP)
• 2016 – 2018. : Sekretariat KKPRS
• 2007 – 2012. : Ketua Bidang Pelaporan Insiden KKP RS PERSI ,
Sterring Committe KKP RS
• 2005 - Saat ini :Ketua Institut Manajemen Risiko Klinis (IMRK) /
ICRMI, Member of ASQ (American Quality Society), Member of
Profesional Risk Management International Association
PENGHARGAAN
2019 : Penghargaan Wanita Inspirasi Indonesia (IPEMI)
manajemenrisiko .imrk
PENGALAMAN KERJA

2019 : Technical Assistance WHO

2017 : Konsultan JCI RSK Dharmais, RS Djamil Padang, RS AWS Samarinda, RS Zainal Abidin Banda Aceh

2016 : Konsultan JCI RS Zainal Abidin Banda Aceh

2015 : Konsultan JCI RS Islam Cempaka putih Jakarta, RS Advent Bandung, RS JMC Jakarta, RS Sutomo Surabaya

2014 : Konsultan JCI RS MMC Jakarta, RS Kanujoso Blkppn, RS Sleman Jogja, RS Tarakan Kaltara

2013 : Konsultan JCI RS kanujoso Blkppn, RS Sleman

2012 : Konsultan JCI RSUP Fatmawati, RSUP Wahidin Sudirohusodo Makasar, RS Medistra

2011 : Konsultan JCI RSCM, Konsultan Manajemen Risiko & Keselamatan Pasien RS Tarakan Kaltim

2010 : Konsultan Manajemen risiko RSUP Fatmawati Jakarta, RS Bieuren, RS Lhoksemawe Aceh

2009 : Konsultan Manajemen risiko & Kes Pasien RS Wahidin Makasar, RS Pelni Jakarta, Konsultan RS Aini, RS Sardjito

2007 : Direktur RS Zahirah, Konsultan Manajemen risiko RS Persahabatan, RS Dharmais

2006 : Konsultan Manajemen RS Asri, Konsultan Manajemen RS Medika BSD,

2004 - 2005 : Manajer Operasional Medika Plaza International Clinic

2003 - 2004 : General Manajer Cempaka Medical Centre, Direktur Operasional RS Sentra Medika

2002 - 2003 : Wakil Direktur Medik & Asist Direktur RS Sentra Medika

2000 - 2001 : Kepala Bagian Humas RS MMC

1999 - 2000 : Asisten Konsultan WHO Umbrella Project Depkes Kepala Bagian Rehabilitasi Medik RS MMC
 Pendahuluan
HOLISTIK – Dalam situasi emergensi : KESELAMATAN
01
BUAT SEMUA (SAFETY FOR ALL) : Ekstensi
Keselamatan pasien kepada Keselamatan staf,
Keselamatan masyarakat, Keselamatan lingkungan
dan Keamanan rantai pasokan

MULTIDISIPLIN, MULTI-PROFESIONAL, ACROSS

02 CONTINUUM OF CARE
03

SISTEM YANG DINAMIS DAN AMAN : Proaktif,

03 Fleksibel, dan beradaptasi dalam lingkungan COVID
yang bergerak cepat
Safety in Covid 19 crisis

Arjaty/webinarIMRK/covid19
 FRAME WORK PANDEMI COVID 19
CONTINUUM OF CARE SURGE CAPACITY HIRARKI STRATEGI MITIGASI THE SURGE
RISIKO PANDEMI COVID 19 RESPONSE
FRAMEWORK
Elimination
CONVENTIONAL Substitution
Engineering
control
Administrative
control

Protection
PA N D E M I C

CONTIGENCY
COVID 19

STRATEGIES FOR
SCARCE RESOURCE
CRISIS SITUATIONS
CSC PLAN
• Prepare
• Substitute
SPACES, STAFF, SUPPLIES STANDARD • Conserve
OF CARE • Re-use
(CSC) • Adopt
• Re-allocate
 Pendahuluan
Pandemi merupakan salah satu bencana nonalam
sehingga rencana respon penanggulangan COVID-
19 dapat menggunakan Kerangka kerja Respon
Bencana nasional berdasarkan Prinsip
penanggulangan Manajemen risiko pandemi.
Dokumen Rencana Operasi (renops) perlu direview
dan diperbaharui minimal setiap 2 minggu

Adaptasi Kebiasaan Baru (AKB)

Kondisi dimana Fasyankes harus beradaptasi
dalam memberikan pelayanan untuk
mengantisipasi penularan Covid-19 baik kepada
Petugas, Pasien dan Lingkungan

Hospital must have a medical disaster preparedness and response plan that contains responses related
to a catastrophic incident (referred to as disaster response plan)
Arjaty/webinarIMRK/covid19
 Strategi Penanggulangan Pandemi
Strategi yang komprehensif perlu disusun dalam dokumen Rencana Operasi
(Renops) Penanggulangan COVID-19 yang melibatkan lintas sektor. Renops
mencakup :
1. Koordinasi, perencanaan dan monitoring;
2. Komunikasi risiko dan pemberdayaan Masyarakat
3. Surveilans, Tim Gerak Cepat (TGC), Analisis Risiko, Penyelidikan
Epidemiologi;
4. Pintu Masuk negara/ Wilayah, Perjalanan Internasional dan transportasi
5. Laboratorium;
6. Pengendalian Infeksi;
7. Manajemen Kasus;
8. Dukungan Operasional dan Logistik;
9. Keberlangsungan pelayanan dan sistem esensial dan memperhatikan
kondisi transmisi di komunitas atau kondisi kapasitas terbatas dan kondisi
yang memerlukan bantuan kemanusiaan.

KMK Menkes no 413 2020 Pedoman Pencegahan dan Pengendalian COVID 19

Arjaty/webinarIMRK/covid19
 Implementation of the Surge Response Framework :
Conventional, Contigency and Crisis Response Cycle
•
Setelah terjadi insiden, prioritas pertama adalah
memiliki Kesadaran situasional (Awareness),
kemudian
• Menilai (Assess) situasi sumber daya yang tersedia.
Komandan insiden, bersama dengan para pakar
teknis terkait dan / atau komite medis merespons
proaktif / insiden jangka panjang
• memberikan saran (Advises) tentang strategi dan
mengantisipasi (Anticipates) defisit sumber daya dan
merekomendasikan pasokan / persediaan, staf, dll
yang diperlukan).
• Jika sumber daya langka, strategi adaptif (Adaptive)
(mis. konservasi, substitusi, adaptasi, dan reuse)
harus diterapkan.
• Dalam krisis, keputusan triase untuk mengalokasikan
(Allocate) / realokasi sumber daya perlu dilakukan.
• Dalam semua kasus, respons dan strategi apa pun
harus dianalisis (Analyzed) secara berkala sebagai
bagian dari siklus Rencana respons bencana, dan
elemen2 diulangi hingga insiden berakhir.
Arjaty/webinarIMRK/covid19
Allocation of specific resources along
the care capacity continuum.

Arjaty/webinarIMRK/covid19
 Kerangka kerja / Frame work Continuum of care surge capacity

Kapasitas Konvensional:
• Ruang (spaces), Staf (staff), dan Persediaan (supplies) yang digunakan secara
konsisten dalam pelayanan / praktik sehari-hari di Fasyankes.
Standar
• Ruang2 dan praktik2 ini digunakan selama terjadi insiden dengan korban massal Konvensional
yang memicu / trigger di aktifkan Rencana Emergensi operasional Fasilitas.
Kapasitas Kontinjensi:
• Ruang, Staf, dan Persediaan yang digunakan tidak konsisten dengan pelayanan / RS evaluasi
praktik sehari-hari tetapi menyediakan pelayanan yang secara fungsional setara perubahan
dengan perawatan pasien seperti biasa. pelayanan (4 S) :
1. Space Standar
• Ruang2 atau praktik2 ini dapat digunakan untuk sementara waktu selama insiden 2. Staff Kontigensi
dengan korban massal atau pada saat dan selama bencana terjadi (ketika 3. Supplies
kebutuhan melebihi sumber daya masyarakat). 4. Standard of care
Kapasitas Krisis :
• Adaptasi pada Ruang, Staf, dan Persediaan tidak konsisten dengan standar
pelayanan biasa tetapi memberikan kecukupan pelayanan dalam konteks
bencana (mis., memberikan pelayanan terbaik kepada pasien dengan kondisi dan Standar
Krisis
sumber daya yang tersedia).
• Aktifkan Kapasitas krisis sebagai penyesuaian / adjustment terhadap standar
pelayanan.
Arjaty/webinarIMRK/covid19
 Kerangka kerja / Frame work Continuum of care surge capacity

• Pelayanan konvensional di RS adalah Fase stabil di mana pasien dirawat

dengan standar pelayanan biasa. Selama fase ini, RS memiliki ruang
perawatan yang memadai, staf yang sesuai dan persediaan yang cukup.

• Ketika sumber daya RS meningkat karena pandemi COVID-19, RS dapat

pindah ke tingkat Pelayanan kontingensi, di mana RS mengalami peningkatan
rawat inap, permintaan staf serta persediaan.

• Pada tahap ekstrim pandemi, RS perlu menerapkan standar Pelayanan krisis,

yang diperlukan ketika permintaan ruang, persediaan, dan staf sangat tidak
proporsional dengan sumber daya yang tersedia sehingga RS dipaksa untuk
menjatah pasokan dan memodifikasi standar perawatannya.
Arjaty/webinarIMRK/covid19
Arjaty/webinarIMRK/covid19
Strategi untuk mencegah menipisnya sumber daya saat
kekurangan Ruang, Staf dan Persediaan

• BERSIAP (PREPARE) Tindakan pra-kekurangan seperti menimbun peralatan penting dapat

meminimalkan dampak kelangkaan sumber daya.
• PENGGANTI (SUBSTITUTE) Identifikasi obat-obatan, alat, atau anggota staf yang setara yang dapat
digantikan ketika sumber daya biasa langka.
• BERADAPTASI (ADOPT) Gunakan obat, alat, atau anggota staf yang akan memberikan perawatan yang
memadai ketika sumber daya tipikal tidak tersedia.
• PENGGUNAAN KEMBALI (REUSE). Gunakan kembali barang-barang yang biasanya dianggap sebagai
penggunaan tunggal jika sterilisasi atau desinfeksi yang tepat dimungkinkan.
• MENGHEMAT (CONSERVE) Gunakan lebih sedikit sumber daya dengan menurunkan dosis atau
mengubah praktik pemanfaatan. Konservasi masker wajah, obat-obatan, atau persediaan lain, jika
perlu, dapat memungkinkan rumah sakit untuk mempertahankan tingkat sumber daya yang memadai.
• ALOKASIKAN KEMBALI (RE-ALLOCATE) Batasi penggunaan sumber daya untuk pasien dengan
kebutuhan yang lebih besar.
Arjaty/webinarIMRK/covid19
MECHANICAL VENTILATION/EXTERNAL OXYGENATION
STRATEGIES FOR SCARCE RESOURCE SITUATIONS

Arjaty/webinarIMRK/covid19
OXYGEN - STRATEGIES FOR SCARCE RESOURCE SITUATIONS
03/29/2019 DRAFT REVISION

Arjaty/webinarIMRK/covid19
OXYGEN - STRATEGIES FOR SCARCE RESOURCE SITUATIONS
OXYGEN - 03/29/2019 DRAFT 03/29/2019
REVISION DRAFT REVISION
STRATEGIES FOR SCARCE RESOURCE SITUATIONS
Contingency Capacity – The spaces, staff, and supplies used are Crisis Capacity – Adaptive spaces, staff, and supplies are not consistent
Conventional Capacity – The spaces, staff, and supplies
not consistent with daily practices, but provide care to a standard that with usual standards of care, but provide sufficiency of care in the setting of
used are consistent with daily practices within the institution.
is functionally equivalent to usual patient care practices. These spaces a catastrophic disaster (i.e., provide the best possible care to patients given
These spaces and practices are used during a major mass casualty
or practices may be used temporarily during a major mass casualty the circumstances and resources available). Crisis capacity activation
incident that triggers activation of the facility emergency
incident or on a more sustained basis during a disaster (when the constitutes a significant and adjustment to standards of care (Hick et al,
operations plan.
demands of the incident exceed community resources) 2009).

RECOMMENDATIONS Strategy Conventional Contingency Crisis

Inhaled Medications
• 1. Use compressed or room air for administration of nebulized medications when clinically appropriate.
• 2. Restrict the use of Small Volume Nebulizers when inhaler substitutes are available.
Substitute &
• 3. Restrict continuous nebulization therapy.
Conserve
• 4. Minimize frequency through medication substitution that results in fewer treatments (6h-12h instead of 4h-6h applications).
• 5. Change children from albuterol continuous nebulizers to Albuterol 8 puffs MDI Q2 hrs when they are ready to stop continuous
treatments. Only use albuterol nebulizers in continuous form for truly acute status asthmaticus.
High-Flow Applications
Conserve
• 6. Assure all resuscitation oxygen bags have shut off valves and are shut off when not in use.
• 7. Restrict the use of high-flow adult cannula systems as these can demand 12 to 40 LPM flows.
• 8. Restrict the use of simple and partial rebreathing masks to 10 LPM maximum.
Conserve
• 9. Consider intubation or non-invasive ventilation with a well-sealed mask over the use of high flow oxygen delivery systems for both
adult and pediatric patients during critical shortages.
Air-Oxygen Blenders
• 10. Eliminate the low-flow reference bleed occurring with any low-flow metered oxygen blender use. This can amount to an
additional 12 LPM. Reserve air-oxygen blender use for mechanical ventilators using high-flow non-metered outlets. (These do not Conserve
utilize reference bleeds).
• 11. Disconnect blenders when not in use.
Oxygen Conservation Devices
• 12. Use reservoir cannulas if available at 1/2 the flow setting of standard cannulas. Substitute &
• 13. Replace simple and partial rebreather mask use with reservoir cannulas or venti-masks at flow rates of 6-10 LPM Adapt
• 14. Use High Efficiency nebulizers and use air flow instead of oxygen when clinically possible.
Augment Oxygen Supply
PARTICULATE RESPIRATORS & GENERAL PPE (N95, Elastomeric, PAPR, CAPR)
STRATEGIES FOR SCARCE RESOURCE SITUATIONS

Arjaty/webinarIMRK/covid19
PARTICULATE RESPIRATORS & GENERAL PPE (N95, Elastomeric, PAPR, CAPR)
PARTICULATE RESPIRATORS1 AND GENERAL PPE
(N95, Elastomeric, PAPR, CAPR)
STRATEGIES FOR SCARCE RESOURCE SITUATIONS
STRATEGIES FOR SCARCE RESOURCE SITUATIONS
Contingency Capacity – The spaces, staff, and supplies used Crisis Capacity – Adaptive spaces, staff, and supplies are not
are not consistent with daily practices, but provide care to a
Conventional Capacity – The spaces, staff, and supplies used are consistent with usual standards of care, but provide sufficiency of care in
standard that is functionally equivalent to usual patient care
consistent with daily practices within the institution. These spaces and the setting of a catastrophic disaster (i.e., provide the best possible care
practices. These spaces or practices may be used temporarily during
practices are used during a major mass casualty incident that triggers to patients given the circumstances and resources available). Crisis
a major mass casualty incident or on a more sustained basis during a
activation of the facility emergency operations plan. capacity activation constitutes a significant and adjustment to standards
disaster (when the demands of the incident exceed community
of care (Hick et al, 2009).
resources)

RECOMMENDATIONS Strategy Conventional Contingency Crisis

General Infection Control Procedures
• 1. Screen all patients for symptoms specific to current situation and keep updated to any changing screening recommendations
• 2. At healthcare facilities where patients have scheduled appointments, consider screening prior to arrival to limit exposure and
resources
• 3. Establish procedures for managing visitors and ill healthcare personnel.
• 4. Establish triage procedures and separate areas for ill and well patients.
• 5. Assign dedicated staff to minimize exposure.
• 6. Require, when possible, or strongly encourage vaccination of primary personnel and first responders, according to vaccine
schedule as recommended for existing circumstances by the CDC and the Advisory Committee for Immunization Practices (ACIP).
• 7. Seriously consider creation of a registry to reflect the vaccination status of primary personnel and first responders to aid in
decisions regarding service assignments.
• 8. Educate and routinely train all staff regarding appropriate use and proper donning and doffing procedures of PPE and particulate
respirators.
• 9. Maintain good hand hygiene procedures including gloves, hand washing with soap and water and/or alcohol based hand sanitizers
depending on the current recommendations.
• 10. Maintain plan for N95 Fit Testing

Engineering Controls Prepare

• 11. When applicable to specific institution consider designing and installing engineering controls to reduce or eliminate exposure by
shielding healthcare providers and other patients from infection individuals. Examples of engineering controls include physical
barriers or partitions to guide patients through triage areas, curtains between patients in shared areas, closed suctioning systems for
airway suctioning for intubated patients, as well as appropriate air-handling systems (with appropriate directionality, filtration,
exchange rate, etc.) that are installed and properly maintained.

Cache/ Increase Supply Levels

• 12. Clarify current CDC and OSHA guidelines for respirator and other PPE use; monitor for updates and recommendations.2
• 13. Cache additional supplies of PPE and respirators and their functional components (e.g. fit testing supplies, batteries, cartridges,
filters, hoods etc.).
• 14. Review vendor agreements, contingencies for delivery and production, including alternate vendors.
• 15. Consider other NIOSH approved respirators in times of short supply (e.g. These include N99, N100, P95, P99, P100, R95, R99, and Arjaty/webinarIMRK/covid19
PARTICULATE RESPIRATORS & GENERAL PPE (N95, Elastomeric, PAPR, CAPR)
PARTICULATE RESPIRATORS1 AND GENERAL PPE
STRATEGIES
(N95, Elastomeric, PAPR, CAPR) FOR SCARCE RESOURCE SITUATIONS
STRATEGIES FOR SCARCE RESOURCE SITUATIONS
Contingency Capacity – The spaces, staff, and supplies used Crisis Capacity – Adaptive spaces, staff, and supplies are not
are not consistent with daily practices, but provide care to a
Conventional Capacity – The spaces, staff, and supplies used are consistent with usual standards of care, but provide sufficiency of care in
standard that is functionally equivalent to usual patient care
consistent with daily practices within the institution. These spaces and the setting of a catastrophic disaster (i.e., provide the best possible care
practices. These spaces or practices may be used temporarily during
practices are used during a major mass casualty incident that triggers to patients given the circumstances and resources available). Crisis
a major mass casualty incident or on a more sustained basis during a
activation of the facility emergency operations plan. capacity activation constitutes a significant and adjustment to standards
disaster (when the demands of the incident exceed community
of care (Hick et al, 2009).
resources)

RECOMMENDATIONS Strategy Conventional Contingency Crisis

General Infection Control Procedures
• 1. Screen all patients for symptoms specific to current situation and keep updated to any changing screening recommendations
• 2. At healthcare facilities where patients have scheduled appointments, consider screening prior to arrival to limit exposure and
resources
• 3. Establish procedures for managing visitors and ill healthcare personnel.
• 4. Establish triage procedures and separate areas for ill and well patients.
• 5. Assign dedicated staff to minimize exposure.
• 6. Require, when possible, or strongly encourage vaccination of primary personnel and first responders, according to vaccine
schedule as recommended for existing circumstances by the CDC and the Advisory Committee for Immunization Practices (ACIP).
• 7. Seriously consider creation of a registry to reflect the vaccination status of primary personnel and first responders to aid in
decisions regarding service assignments.
• 8. Educate and routinely train all staff regarding appropriate use and proper donning and doffing procedures of PPE and particulate
respirators.
• 9. Maintain good hand hygiene procedures including gloves, hand washing with soap and water and/or alcohol based hand sanitizers
depending on the current recommendations.
• 10. Maintain plan for N95 Fit Testing

Engineering Controls Prepare

• 11. When applicable to specific institution consider designing and installing engineering controls to reduce or eliminate exposure by
shielding healthcare providers and other patients from infection individuals. Examples of engineering controls include physical
barriers or partitions to guide patients through triage areas, curtains between patients in shared areas, closed suctioning systems for
airway suctioning for intubated patients, as well as appropriate air-handling systems (with appropriate directionality, filtration,
exchange rate, etc.) that are installed and properly maintained.

Cache/ Increase Supply Levels

• 12. Clarify current CDC and OSHA guidelines for respirator and other PPE use; monitor for updates and recommendations.2
• 13. Cache additional supplies of PPE and respirators and their functional components (e.g. fit testing supplies, batteries, cartridges,
filters, hoods etc.).
• 14. Review vendor agreements, contingencies for delivery and production, including alternate vendors.
• 15. Consider other NIOSH approved respirators in times of short supply (e.g. These include N99, N100, P95, P99, P100, R95, R99, and
R100.)5 Arjaty/webinarIMRK/covid19
PARTICULATE RESPIRATORS
PARTICULATE RESPIRATORS1 & GENERAL
AND GENERAL PPE (N95, Elastomeric, PAPR, CAPR)
PPE
(N95, Elastomeric, PAPR, CAPR) FOR
STRATEGIES SCARCE RESOURCE SITUATIONS
STRATEGIES FOR SCARCE RESOURCE SITUATIONS
Contingency Capacity – The spaces, staff, and supplies used Crisis Capacity – Adaptive spaces, staff, and supplies are not
are not consistent with daily practices, but provide care to a
Conventional Capacity – The spaces, staff, and supplies used are consistent with usual standards of care, but provide sufficiency of care in
standard that is functionally equivalent to usual patient care
consistent with daily practices within the institution. These spaces and the setting of a catastrophic disaster (i.e., provide the best possible care
practices. These spaces or practices may be used temporarily during
practices are used during a major mass casualty incident that triggers to patients given the circumstances and resources available). Crisis
a major mass casualty incident or on a more sustained basis during a
activation of the facility emergency operations plan. capacity activation constitutes a significant and adjustment to standards
disaster (when the demands of the incident exceed community
of care (Hick et al, 2009).
resources)

RECOMMENDATIONS Strategy Conventional Contingency Crisis

General Infection Control Procedures
• 1. Screen all patients for symptoms specific to current situation and keep updated to any changing screening recommendations
• 2. At healthcare facilities where patients have scheduled appointments, consider screening prior to arrival to limit exposure and
resources
• 3. Establish procedures for managing visitors and ill healthcare personnel.
• 4. Establish triage procedures and separate areas for ill and well patients.
• 5. Assign dedicated staff to minimize exposure.
• 6. Require, when possible, or strongly encourage vaccination of primary personnel and first responders, according to vaccine
schedule as recommended for existing circumstances by the CDC and the Advisory Committee for Immunization Practices (ACIP).
• 7. Seriously consider creation of a registry to reflect the vaccination status of primary personnel and first responders to aid in
decisions regarding service assignments.
• 8. Educate and routinely train all staff regarding appropriate use and proper donning and doffing procedures of PPE and particulate
respirators.
• 9. Maintain good hand hygiene procedures including gloves, hand washing with soap and water and/or alcohol based hand sanitizers
depending on the current recommendations.
• 10. Maintain plan for N95 Fit Testing

Engineering Controls Prepare

• 11. When applicable to specific institution consider designing and installing engineering controls to reduce or eliminate exposure by
shielding healthcare providers and other patients from infection individuals. Examples of engineering controls include physical
barriers or partitions to guide patients through triage areas, curtains between patients in shared areas, closed suctioning systems for
airway suctioning for intubated patients, as well as appropriate air-handling systems (with appropriate directionality, filtration,
exchange rate, etc.) that are installed and properly maintained.

Cache/ Increase Supply Levels

• 12. Clarify current CDC and OSHA guidelines for respirator and other PPE use; monitor for updates and recommendations.2
• 13. Cache additional supplies of PPE and respirators and their functional components (e.g. fit testing supplies, batteries, cartridges,
filters, hoods etc.).
• 14. Review vendor agreements, contingencies for delivery and production, including alternate vendors.
• 15. Consider other NIOSH approved respirators in times of short supply (e.g. These include N99, N100, P95, P99, P100, R95, R99, and
R100.)5
Arjaty/webinarIMRK/covid19
 STAFFING
STRATEGIES FOR SCARCE RESOURCE SITUATIONS

Arjaty/webinarIMRK/covid19
 STAFFING
STRATEGIES FOR SCARCE RESOURCE SITUATIONS
STAFFING
STRATEGIES FOR SCARCE RESOURCE SITUATIONS
Contingency Capacity – The spaces, staff, and supplies used Crisis Capacity – Adaptive spaces, staff, and supplies are not
are not consistent with daily practices, but provide care to a
Conventional Capacity – The spaces, staff, and supplies used are consistent with usual standards of care, but provide sufficiency of care in
standard that is functionally equivalent to usual patient care
consistent with daily practices within the institution. These spaces and the setting of a catastrophic disaster (i.e., provide the best possible care
practices. These spaces or practices may be used temporarily during
practices are used during a major mass casualty incident that triggers to patients given the circumstances and resources available). Crisis
a major mass casualty incident or on a more sustained basis during a
activation of the facility emergency operations plan. capacity activation constitutes a significant and adjustment to standards
disaster (when the demands of the incident exceed community
of care (Hick et al, 2009).
resources)
RECOMMENDATIONS Strategy Conventional Contingency Crisis
Staff and Supply Planning
• Assure facility has process and supporting policies for disaster credentialing and privileging - including degree of supervision required,
clinical scope of practice, mentoring and orientation, and verification of credentials.
• Encourage employee personal preparedness planning (ready.gov, redcross.org).
• Cache adequate personal protective equipment (PPE) and support supplies.
• Educate staff on facility disaster response and recommend regularly scheduled HICS training.
• Educate staff on community, regional and state disaster plans and resources. Prepare
• Develop facility plans addressing staff’s family / pets or staff shelter needs (such as daycare and unaccompanied minor needs) as well
as transportation plans for staff to get to and from the facility.
• Include a process of staff identification and verification. Recommend photos and hard-copy files.
• Create Job Cards for essential services and functions.
• Pre-identify critical positions and ensure redundant staffing for these.
• Recommend redundant staff communications and notification plans/procedures.
Focus Staff Time on Core Clinical Duties
• Minimize meetings and relieve administrative responsibilities not related to event. Conserve
• Cohort inpatients per OSHA/Public Health or CDC guidelines.
• Reduce documentation requirements. Adapt
Using Supplemental Staff
• Utilize administrative positions (e.g. nurse managers) as patient care extenders.
• Adjust personnel work schedules (longer but less frequent shifts, etc.) if this will not result in skill / PPE compliance deterioration. Substitute
• Voluntary call-back of staff
• Increase use of agency, per diem, travelers, float pools, locums staff
• Retain staff for extended hours (in accordance with labor contract and existing contracts/agreements when applicable)
Adapt
• Use family members/lay volunteers to provide basic patient hygiene and feeding – releasing staff for other duties.
• Postpone and reschedule out-patient non-acute and preventative care appointments to open more acute care out-patient
appointments during surge.
Focus Staff Expertise on Core Clinical Needs
• Personnel with specific critical skills (ventilator, burn management) should concentrate on those skills; specify job duties that can be
safely performed by other medical professionals.
Conserve
• Reduce availability of non-time sensitive laboratory, radiographic, and other studies.
• Postpone and reschedule elective procedures if it will improve staffing and space needs and does not result in undue patient
inconvenience
• Have specialty staff oversee larger numbers of differently specialized staff and patients (for example, medical/surgery nurses working Arjaty/webinarIMRK/covid19
 Crisis Standard of Care (CSC)
Definisi Standard Pelayanan saat Krisis (CSC) :
Perubahan substansial dalam operasional pelayanan dan tingkat pelayanan kesehatan pada saat terjadi
bencana (mis., Pandemi) atau bencana besar (mis. Gempa bumi, angin topan). Perubahan ini dapat
dibenarkan pada keadaan tertentu dan secara resmi ditetapkan oleh pemerintah, dengan mengakui bahwa
operasional pelayanan saat krisis akan berlaku dalam suatu periode waktu yang berkelanjutan. Deklarasi
formal berlakunya Standar pelayanan saat krisis akan memberikan kekuatan hukum / peraturan khusus dan
perlindungan bagi fasilitas pelayanan kesehatan dalam tugasnya untuk mengalokasikan dan menggunakan
sumber daya medis yang terbatas / langka dan menerapkan alternatif operasional di fasilitas pelayanannya

When we need CSC ?

Scarce Medical
Resources

Extreme Crisis PPE

Pandemi Covid Staff
19 Ventilators
Drugs
Vaccines

Arjaty/webinarIMRK/covid19
 Pedoman Implementasi Standard pelayanan saat krisis (CSC)

1. Perawatan krisis harus mencakup strategi yang melampaui atau melampaui rencana kapasitas lonjakan. Kapasitas lonjakan umumnya
digambarkan sebagai kemampuan untuk mengevaluasi dan merawat pasien ketika terjadi peningkatan volume pasien yang nyata —
yang menantang atau melampaui kapasitas operasional secara normal.
2. Perawatan krisis kemungkinan akan diaktifkan selama peristiwa jangka panjang seperti pandemi COVID-19 ketika tidak ada cara
praktis untuk mendapatkan sumber daya kritis.
3. Perawatan krisis tidak memungkinkan RS menunda perawatan pasien; sifat kritis dari perawatan kesehatan yang diperlukan akan
memaksa keputusan segera.
4. Perawatan krisis harus secara bertahap bergerak mundur ke keadaan darurat atau perawatan konvensional ketika sumber daya
tambahan tersedia seperti obat-obatan, peralatan, dan staf.
5. Strategi perawatan krisis harus diperbarui sepanjang krisis sesuai kebutuhan, tergantung pada kekurangan atau peningkatan sumber
daya yang berkelanjutan.

Pastikan Konsistensi implementasi Standar Pelayanan saat Krisis :

”Komite medik, ”Tim triase," SKI Bencana akan mengevaluasi pelayaanan kritis, peer-review dan alat keputusan
lainnya dan merekomendasikan Algoritma yang digunakan ketika sumber daya menjadi langka;

Ketika Fasilitas pelayanan kesehatan mengevaluasi standar pelayanan krisisnya, harus menggunakan
KERANGKA KERJA ETIKA untuk memandu perawatan pasien dan alokasi sumber daya.
Arjaty/webinarIMRK/covid19
 Crisis standard of care (CSC) Plan

4
2
2 2

1
3

Perlindungan Hukum untuk Praktisi dan Fasilitas Pelayanan Kesehatan yang menerapkan Standar Perawatan Krisis Arjaty/webinarIMRK/covid19
 Prinsip2 etika memandu pengambilan keputusan dalam kondisi krisis untuk
memastikan penggunaan sumber daya yang paling tepat.

1. Keadilan (fairness) - standar yang, setinggi mungkin, diakui adil oleh semua pihak yang terkena dampaknya -
termasuk anggota masyarakat yang terkena dampak, praktisi, dan organisasi penyedia, berbasis bukti dan responsif
terhadap kebutuhan spesifik individu dan populasi.
2. Kewajiban merawat (Duty to care) - standar difokuskan pada tugas profesional kesehatan untuk merawat pasien
yang membutuhkan perawatan medis
3. Tugas untuk mengelola sumber daya (Duty to steward resources) - lembaga layanan kesehatan dan pejabat
kesehatan masyarakat memiliki tugas untuk mengelola sumber daya yang langka, yang mencerminkan tujuan
utilitarian untuk menyelamatkan sebanyak mungkin nyawa.
4. Transparansi (Transparency )- dalam desain dan pengambilan keputusan
5. Konsistensi (Consistency) - dalam penerapan lintas populasi dan di antara individu tanpa memandang kondisi
manusianya (mis. Ras, cacat usia, etnis, kemampuan membayar, status sosial ekonomi, kondisi kesehatan yang
sudah ada sebelumnya, nilai sosial, hambatan yang dirasakan dalam pengobatan, penggunaan sumber daya)
6. Proporsionalitas (Proportionality) - persyaratan publik dan individu harus sepadan dengan skala darurat dan tingkat
sumber daya yang langka
7. Akuntabilitas (Accountability) - jika keputusan individu dan standar implementasi, dan pemerintah untuk
memastikan perlindungan yang tepat dan alokasi yang adil atas sumber daya yang tersedia.

Arjaty/webinarIMRK/covid19
 HIRARKI STRATEGI MITIGASI RISIKO PANDEMI
COVID 19
How do you use the Hierarchy of Controls?
The Hierarchy of Controls is a strategy applied to
implement control measures to mitigate risks by
+ COVID-19 tidak dapat sepenuhnya dihilangkan.
reducing hazards to the lowest possible degree.
If a hazard can not be fully eliminated such as
Efektif COVID-19:
Eliminasi risiko : Physical Distancing, Skrining,
Elimination • Use a combination of controls to mitigate risk
• Continuously review hazards and assess risk to
Teleworking, Mengurangi / mengatur jumlah
ensure controls remain effective
• Make hazards and controls visual through
staf yang dapat bekerja dari jarak jauh.
signage and labels so everyone is aware
• Consult with local Occupational Health and
Safety and Infection Prevention and Control
teams to assist in hazard identification and
Walaupun tidak ada kontrol substitusi yang
Substitution
controls, and share new ideas for controls

telah diidentifikasi untuk COVID-19, tapi dapat

menggunakan etanol (hand hanitizier)

Engineering Desain teknik menghilangkan bahaya :

control barrier mis. physical barriers, Fasilitas
Tekanan negatif, HVAC

Administrative Buat kebijakan, Care Pathway, SPO, form2,

control Rambu2 untuk memandu perilaku, Redistribusi
tanggung jawab untuk mengurangi kontak antar
Protection
staf
- Wajib Gunakan APD
Efektif
Arjaty/webinarIMRK/covid19
 Dilemma – Hospital Executives
• Bagaimana menyediakan APD dan alat medis yang dibutuhkan mis masker,
Gown,
• Bagaimana mengatasi kesulitan keuangan khususnya beberapa pelayanan
yang dibatasi sementara.
• Bagaimana cara meningkatkan moral karyawan dalam suasana stagnant
• Bagaimana menjaga dan mempromosikan keselamatan rumah sakit
(Hospital safety)
• Bagaimana mempersiapkan gelombang kedua yang akan datang :
• membuat dan mengelola zona aman di rumah sakit
• merekrut dan melatih lebih banyak specialized staff for emerging
infectious diseases
Arjaty/webinarIMRK/covid19
 Dilemma – Hospital workers
• Meningkatnya kelelahan
• Gabungkan professional work with circular work
(mis. triage)
• Jadwal edukasi yang lebih berat tentang protokol
& pedoman baru tentang Covid 19
• Tidak diizinkan academic meetings
• Kecemasan terinfeksi saat bekerja di RS
• Khawatir terhadap anggota keluarga khususnya
yang bekerja di bangsal Covid-19
• Lebih banyak aturan sosial
• Tidak cukupnya dukungan mental, finansial, dan
fisik mereka

Arjaty/webinarIMRK/covid19
“Knowing is not enough,
we must apply
Willing is not enough,
We must do”…
..Goethe…

Terima Kasih