This is the first narrative report presenting a ‘snapshot’ of the on-ground experience of an FMT assessing and managing SCI patients during and after the major earthquakes in Nepal. Overall, the RMH FMT deployment was productive in providing assistance and management of SCI survivors. The FMT was able to improve clinical disability planning and patient management, educate/train staff and strengthen rehabilitation services. The team developed a one-page structured triage tool and used it for 101 SCI earthquake victims admitted to the facility during their deployment. The triage tool was well received by the clinical staff and assisted in patient flow and management.
Major earthquakes are devastating and associated with high death rates and mass casualties with many traumatic injuries. The earthquakes in Nepal resulted in significant loss of life and long-term disability from severe injuries, including SCI. They created a large socioeconomic burden with major economic loss and long-term negative consequences on human development, infrastructure and the environment. Despite focus on acute care in such settings, the importance of early rehabilitation focusing on prevention of complications in SCI patients cannot be over-emphasized. The importance and role of rehabilitation services during and after a natural disaster are discussed elsewhere [9
]. There is consensus amongst disaster management experts that medical rehabilitation should be initiated in the emergency response phase, and continued in the community over the longer-term to restore function and enhance participation of survivors [15
Reports from previous humanitarian catastrophes suggest that, despite high quality care provided by FMTs in such situations, deployment of FMTs is not based on situational needs, with significant variation in capacities, clinical competencies and professional ethics [21
]. Lack of coordination, systems for monitoring, and common terminologies, definitions and frameworks hindered evidence to guide future deployments and improvement of this system [22
There was a strong consensus in the post-Haiti earthquake PAHO/WHO meeting in Cuba (December 2011), for the need for international standards, greater accountability, more stringent oversight, better coordination, and improved reporting [22
]. A resolution recommending “a flexible mechanism for registration and accreditation of rapid-response FMTs with the goal of improving quality of medical response in coordination with WHO” was passed in 2012 [21
]. Following this, recommendations from a technical expert group from the cuba meeting a FMT working group (FMT-WG) was created to oversee mechanisms for ‘‘complementarity’’ of FMTs, enhance their role and to coordinate their different services before deployment and on arrival [21
]. A classification system for FMTs based on capabilities, professional standards and outline for the various processes for FMTs, such as on-site coordination/registration with national authorities and mechanisms for authorising arriving teams, has since been developed [21
Many of these requirements and standards were applied and implemented in the current Nepalese disaster situation. Rehabilitative care had focal attention. However, as in previous disaster responses, more emphasis was on the acute response, saving lives and treating acute injuries. The role of acute rehabilitation and preventative care, especially in SCI, needs to be highlighted. The MoHP and WHO formed a Rehabilitation Sub-cluster for the FMTs, which included the RMH team and others. A requirement was the submission of daily surveillance reports and an exit report with needs assessments, gaps and recommendations to the MoHP.
The rehabilitation sub-cluster identified SCI care as a critical gap, and flagged funding with WHO and MoHP [24
]. Recently, on 29th
May 2015, the MoHP outlined a 2-year strategic plan for the emergency response and the recovery phase. This feeds directly into the health sector reconstruction, scaling-up of rehabilitation activities following emergencies, and longer-term strengthening of rehabilitation services and links with tertiary, district and grassroots levels. The government has established step-down rehabilitation centres offering nursing and rehabilitation, in and around Kathmandu, with capacity to accommodate over 700 patients [24
]. This initiative ensured 100 free step-down beds in various facilities. Further, plans are nearing completion to establish fixed-point centres or step-down facilities in the worst affected districts and meeting with the main trauma centres to refine referral procedures [6
]. However, this plan is yet to include comprehensive rehabilitation, preventative care (to minimize complications) and CBR programs for societal integration of SCI survivors. The role of early rehabilitation intervention, preventative strategies to prevent complications in SCI, subacute and community-based rehabilitation programs is critical. This may likely duplicate some assessment processes and compromise care provision to patients over time. The MoHP will need to develop minimum standards for rehabilitation facilities, integrate community-based rehabilitation, establish referral systems for care providers, invest in infrastructure, IT support, documentation and record keeping, and basic data collection to inform further action [17
The Rehabilitation FMT team made various suggestions which need to be considered in future planning and responses to SCI management in disaster settings (Box 1).
Lessons learned and the way forward
• More qualified personnel in rehabilitation medicine, nursing and allied health.
• Improved clinical reasoning.
• Improved processes relating to clinical documentation.
• Development of procedures for all process measures from admission to community discharge and longer-term follow-up.
• Development of a referral form and reporting systems for rehabilitation.
• Use of systems and processes for organised delivery of rehabilitation.
• Improved links with acute referrers.
• Expanded community-based rehabilitation through capacity-building.
• Access to capacity building initiatives such as courses, conferences, telemedicine, library, to upskill staff.
• Care-giver training (including PTSD education and support).
• Better communication and improved links with acute hospital referrers and post-discharge follow-up in the community.
• Increased use of information-technology to enhance Continuing Medical Education and promote available services for consumers.
• Increased clinical capacity through organised educational activities e.g. journal club.
• Delivery of evidence-based practice and encourage research.
• Development of Peer Support groups.
• Link with regional organisations, e.g. South Asian Association for Regional Cooperation (SAARC).
• Encouragement of overseas training and mentorship for staff.
• Registration of the Nepalese Rehabilitation Society with the International Society of Physical Rehabilitation Medicine (ISPRM).
• Provision of Key Performance Indicators, Standards of Care & accreditation criteria for Rehabilitation facilities by the MoHP.
Throughout the recent earthquakes, the Nepalese people maintained a positive attitude and a resilient spirit during this difficult time. This report supports the disaster initiatives, coordination and collaborative effort made by the Nepal MoHP and the FMTs. Significant improvements in FMT accreditation during these earthquakes were noted compared with previous Haiti and Pakistan earthquake reports [12
]. However, much more work is needed to strengthen the disaster relief efforts. In our experience there were specific challenges working with some of the international non-governmental organisations. Efforts should be made for better accountability, use of existing resources, reliable data-sets for analyses in trends in morbidity and disability, and for community re-integration of injured persons. The latter however, was beyond the scope of our mission. The ISPRM can assist the WHO rehabilitation sub-cluster with formal policy on disaster management, advocacy and training, standards for rehabilitation in disaster settings, technical standards, rehabilitation leadership roles in FMTs, requirements for deployment, FMT staffing and configuration, referral and information management, assistive devices and equipment, data collection, research and surveillance to inform future action. The psychological impact of earthquakes on survivors needs further study.