By definition, the hospital is an institution providing medical and surgical treatment and nursing care for sick or injured people. The word hospital comes from the Latin hospes , signifying a stranger or foreigner, and hence a guest. The earliest documented institutions aiming to provide cures were ancient Egyptian temples. Around 100 bc , the Romans constructed buildings called valetudinaria , for the care of sick slaves, gladiators, and soldiers, and, around 300 ad , a hospital and medical training center existed at Gundeshapur, one of the major cities in the Khuzestan province of the Persian empire in what is current-day Iran. By the late nineteenth century, the modern hospital was beginning to take shape, with a variety of public and private hospital systems.
It is unclear when hospital disaster preparedness was first taken under consideration; however, the Second World War is a major milestone. During World War II, some hospitals in England and the United States were systematically prepared to provide efficient medical services to casualties. In 1956 principles of disaster planning for hospitals were developed by the American Hospital Association, and in 1957 the Joint Committee on Accreditation of Hospitals in the United States recognized the importance of hospital disaster planning, making it a point in the scoring for accreditation, ensuring that every hospital had to have a disaster plan.
An important point of progress in hospital organization for managing possible disasters was the adoption of the Incident Command System (ICS), to be used in the hospital-based response to disasters. It was later renamed the Hospital Emergency Incident Command System (HEICS) and then the Hospital Incident Command System (HICS).
The terrorist attacks of September 11, 2001, in the United States, heightened preparedness efforts worldwide, including hospital disaster preparedness. In addition, the development of a worldwide strategy by the United Nations regarding disaster-risk reduction, the Hyogo Framework for Action 2005-2015: Building the Resilience of Nations and Communities to Disasters, was a remarkable improvement in the field of hospital disaster preparedness and safety. As a result of the strategy, 2008 was nominated as the year of the “safe hospital” by the World Health Organization (WHO), and a standardized guideline was introduced by the WHO, regarding hospital safety and functional capacity. In the United States, the American Society for Testing and Materials (ASTM) suggested a consensus-based product such as the “Standard Guide for Hospital Preparedness and Response, E2413-04 (Reapproved 2009).” However, despite the progress in research, planning, and practice, no internationally accepted standards for hospital disaster preparedness and response exist.
Hospitals are usually vulnerable during disasters. Past events have illuminated the destructive effects of disasters on hospital structures and/or functionality, which are not limited to developing countries.
From 1985 to 2001, natural events affected more than 1000 hospitals in various countries of the Americas (e.g., earthquakes affected 276 hospitals in El Salvador, Chile, and Mexico; El Niño affected 437 hospitals in Peru; 302 hospitals in Nicaragua, Dominican Republic, Honduras, Jamaica, and Costa Rica were affected by hurricanes.
According to a WHO report, from 1979 to 2009, 69 hospitals were evacuated because of either natural or human-made disasters, worldwide.
An earthquake struck Northridge, California, on January 17, 1994, and damaged a number of hospitals. Six hospitals either were partially or complete evacuated.
The Chi-Chi Earthquake in Taiwan in 1999 resulted in four hospitals being evacuated because of significant nonstructural damage.
In Iran, the Bam Earthquake in 2003 destroyed three hospitals, and approximately 130 other health facilities.
The flooding in the wake of Hurricane Katrina in 2005 left hospitals in greater New Orleans, Louisiana, and in Mississippi in crisis. Patients and staff were trapped in facilities without essential services, resulting in the largest mass hospital evacuation in U.S. history.
In June 2001, 3 feet of rain from Tropical Storm Allison fell in the Houston area in Texas, causing the flooding and complete disruption of the hospitals. One of the hospitals experienced failure of hospital systems. The water supply failed, and the sewer system stopped functioning. The vertical evacuation of 570 patients was conducted, and the hospital was closed for 38 days.
A sudden and extensive power failure occurred at Huddinge Hospital in Stockholm, Sweden, on Easter Saturday, April 7, 2007. The power failure lasted 1 hour and 22 minutes, but it took longer for activities to return to normal. It put many critically ill patients at great risk, particularly those in intensive care.
In the course of responding to the Great East Japan Tsunami, 2011, a 30-km evacuation radius was decided by the government in response to the Fukushima nuclear accidents. Therefore patients of the hospitals in this radius were transferred to other hospitals.
During the 2001 World Trade Center attack, 194 casualties were triaged and treated within the first 24 hours in Bellevue Hospital, New York City. Despite huge efforts, the hospital lost track of patients, ran out of supplies, and struggled with coordination of health care providers to ensure patient rest and safety. In addition, the University Downtown Hospital received 350 patients within the first 2 hours of the World Trade Center attacks. St. Vincent’s Hospital treated nearly 800 victims. Because St. Vincent’s shared water lines with the World Trade Center and telecommunications lines were routed through it, the functioning of these systems was affected.
The examples herein are only a few of the possible effects that disasters could have on hospitals. Hospitals have collapsed or been damaged during many other events.
Public Expectation of Hospital Function
Hospitals are an integral part of the health care system and a symbol of social progress and political values in society, which contribute to the sense of security and well-being in a community. Moreover, hospitals have a significant economic effect on a society, and are a prerequisite for stability and economic development. ,
Hospitals are expected to be ready to provide medical care in all circumstances. The actual purpose of a hospital, being the initial source of medical care, demands that it remain fully operational in the aftermath of any major disaster. Hospital readiness may be defined as the ability to maintain hospital operations effectively, to sustain a medically safe environment reliably, and to address adequately the increased and potentially unexpected medical needs of the affected population. To be highly prepared and able to respond effectively, hospitals must consider substantial investment in equipment, training, facilities improvements, and supplies to assure that the facility is safe and functional and that adequately trained staffing is available to provide high-quality treatment for disaster victims.
However, ethical challenges with patients and relatives of casualties during disasters can be expected. The community belief is to provide medical care and to put all efforts and resources into caring for the sickest patients, but the key principle of disaster medical care is to do the greatest good for the greatest number of patients.
Elements of comprehensive hospital preparedness for disasters
Preparedness is defined as the knowledge and capacities developed by the community and response and recovery organizations, such as a hospital, to anticipate, respond to, and recover effectively from the effects of disasters. The preparedness process starts with planning based on risk assessment, and it requires a comprehensive approach to reach a reliable level of preparedness. ,
A comprehensive hospital disaster plan follows an all-hazard approach. However, this does not mean that the hospital is prepared for every type of hazard that could occur in a particular community, including the hospital. An all-hazards approach considers things that commonly occur in many kinds of disasters, such as the need for treatment and triage of victims. These things can be addressed in a general plan, to provide the basis for responding to unexpected events. , , The kinds of disasters that might occur must be addressed in a hospital disaster plan; however, the plan and the command and control system need to be adaptable to all events. , ,
Another aspect of a comprehensive disaster plan is considering all phases of the disaster-management cycle: (1) mitigation and prevention, (2) preparedness, (3) response, and (4) recovery and rehabilitation. ,
The third aspect of a comprehensive hospital disaster plan is being part of a community disaster plan. , Hospitals will not work in isolation during disasters, and it is impossible for a hospital to respond effectively to a disaster without assimilating into the overall response system, and contribute to the disaster-management process.
Integration into the community disaster plan will also support a hospital during disasters: for example, with respect to surge capacity. Moreover, the hospitals might receive financial, informational, and business benefits from active participation in the community-focused emergency planning process. This condition might also help hospitals to contain costs by sharing expertise, training resources, and equipment. Among all external organizations, emergency medical service (EMS) is the most important one with which a hospital can have an integrated disaster-management plan; in fact, the EMS performance significantly affects the hospital workload during disasters. As well as being comprehensive, a hospital disaster plan should consider some other principles, such as being predictable, simple, flexible, and concise.
The complexity, occupancy level, specialized services, and specific equipment of hospitals make them vulnerable to the effects of disasters. The potential effect of disasters on hospitals is of major importance for the following reasons :
Hospitals must maintain their normal functions in case of a sudden surge in patients requiring varying levels of treatment following a disaster.
Hospitals accommodate a large number of patients who are unable to evacuate the building easily in the event of a disaster.
Hospitals have a network of electrical, mechanical, and sanitary facilities and expensive equipment that is essential for the routine operation of the hospital.
Generally, disasters may affect health system operations both directly and indirectly. Direct effects include damaged health care facilities and damaged infrastructure across the locality, leading to the breakdown of public services that are indispensable to health facility operations. Indirect effects can include an unexpected number of deaths, injuries, or disease in the affected community, exceeding the capacity of the local health care network to provide treatment. Indirect effects also include spontaneous or organized migrations away from the affected area toward other areas where health system capacity may be overwhelmed by the new arrivals. Increases in the potential risk of a critical outbreak of communicable diseases and an increase in the risk for psychological diseases among the affected population are also indirect effects on health system operations. Additionally, food shortages leading to malnutrition and weakened resistance to various diseases can cause indirect effects on the health system.
There are three elements of vulnerability for a hospital: structural, nonstructural, and administrative and organizational.
The structural elements include foundations, columns, bearing walls, beams, staircases, elevators, and floors. Evaluation of the structural vulnerability and relevant issues are specific to the type of hazard. Generally, the effect of disasters on structural elements differs from slight damage to complete destruction. ,
The nonstructural vulnerability evaluation considers architectural elements (e.g., false ceilings, covering elements, and cornices), equipment and furnishings (e.g., medical equipment, office equipment, and furnishings), and basic installations and services (e.g., drinking water, medical gasses, and air conditioning).
The consequence of damage to nonstructural elements, with regard to injury to the occupants and interfering with the performance of the facility, is categorized as low, moderate, or high. ,
Administrative and Organizational Elements
The administrative and organizational elements include all physical and administrative measures required for organizing the hospital personnel to respond to disasters and to optimize the hospital capacity to function during and after a disaster. , ,
Some important issues in the context of administrative vulnerability are contracting, acquisitions, and routine maintenance, as well as the physical and functional interdependence of the different areas of the facility. Organizational aspects include an optimized organization of personnel, equipment, material, resources, and spatial organization. Regarding administrative and organizational vulnerability, the hospital functionality, during and after disasters, can be classified as good, average, or poor. , ,
It is the duty of health authorities to assess a hospital’s vulnerability to disaster effects and to have an estimation of existing risk levels to ensure the safety and proper response of the hospital to the needs in a disaster response.
Hospital Safety Index
Addressing the priorities of “Hyogo Framework for Actions 2005-2015: Disaster Risk Reduction,” the global campaign “Hospitals Safe from Disasters: Reduce Risk, Protect Health Facilities, Save Lives” was developed by the Secretariat of the United Nations International Strategy for Disaster Reduction (UNISDR) in partnership with the WHO in 2008 to 2009. The aim of the strategy is to ensure that hospitals will not only remain standing in case of a disaster but also function effectively and without interruption.
Making all health facilities safe in the event of disasters poses a major challenge for some countries because of not only the high number of facilities and their high cost but also because there is limited information about current safety levels in hospitals.
A remarkable product of this campaign was the evaluation forms for the safe hospital, the Hospital Safety Index (HSI), which was initially developed by the Pan American Health Organization. The HSI is a rapid and low-cost tool to assess the probability of a hospital or health facility remaining operational in emergency situations. , The tool has been used to evaluate hospitals in various locations, such as Moldova, Iran, Sweden, and Latin America. ,
The HSI consists of two main forms:
Form 1, “General Information about the Health Facility,” includes the name of the facility, number of beds by services or medical specialty, hospital occupancy rate, number of personnel, expansion capacity in case of disaster, etc.
Form 2, “Safe Hospitals Checklist,” is used for preliminary diagnosis of the hospital safety in the event of disasters. It contains 145 variables, and each has three safety levels: low, medium, and high. It is divided into four modules: (1) geographic location of the health facility, (2) structural safety, (3) nonstructural safety, and (4) functional capacity.
The sum of three modules (structural, nonstructural, and functional capacity) gives the HSI. The index is expressed as the probability that a facility will be able to continue its safety and function in a disaster situation, as detailed below.
A (0.66-1): it is likely that the hospital will function in case of a disaster. It is recommended that the hospital improve response capacity and carry out preventive measures in the medium and long term to improve the safety level in case of disaster.
B (0.36-0.65): intervention measures are needed in the short term. The hospital’s ability to function during and after a disaster is potentially at risk.
C (0-0.35): urgent intervention measures are needed. The hospital safety level is inadequate to protect the lives of patients and hospital staff during and after a disaster.
Hazard Vulnerability Analysis
Disaster planning begins with a risk-assessment and hazard-vulnerability analysis to identify the most likely threats to a particular hospital and to prevent or mitigate the effects of hazards on the hospital building and/or function. , The hazard vulnerability analysis (HVA) method, a useful tool to evaluate risk of hazards to a hospital was invented by the Kaiser Permanente Foundation, in the United States. Hospitals were asked to complete an annual HVA as a basis for emergency planning. The method evaluates potential for incident and response among the natural, human-related, technological, and hazardous material events using the hazard-specific scale. The assumption is that each event (e.g., hurricane, earthquake, explosion, electrical failure, hazardous materials [HazMat] accident, etc.) occurs at the worst possible time (e.g., during peak patient loads). The risk of each event is defined as “probability × severity.” The severity also comes from the magnitude (the effects of the event on humans, property, and businesses) and the mitigation (preparedness, internal response, and external response capabilities).
To calculate the risk, issues should be considered for each of the following components :
Probability: known risk, historical data, and manufacturer and vendor statistics
Risk to human life: potential for staff and patient’s death or injury
Impact on property: cost to replace, repair, and recover
Effects on business: employees unable to report to work, interruption of critical supplies, customers unable to reach facility, etc.
Preparedness: plans, training and exercise, alternate systems, insurance, etc.
Internal resources: types and volume of supplies on hand, staff availability, etc.
External resources: agreements with community agencies, coordination with proximal health care facilities, etc.
Hospital Incidence Command System
A hospital disaster plan should address the role of the hospital during disasters in relation to other response organizations in the community. In addition, the overall incident organization of the hospital, based on a strategy of efficient and effective utilization of resources, should be defined, and the chain of command should be addressed as the HICS. , , The HICS (a modification of ICS) was developed by the Orange County, California, EMS. It is currently the most commonly used model for hospital disaster response in the United States. This model is also used in Iran, Taiwan, and Turkey. The HICS is critical to assure the organizational and logistical support to meet incident-generated demands by getting the right personnel and supplies to the right place at the right time, to provide timely and effective patient care. It uses a common organizational terminology and facilitates communication between the hospital, first responders, and other health care facilities. This system is composed of a command group and four sections, including operations, planning, logistics, and finance and administration ( Figure 6-1 ).
The incident command group has the overall responsibility for the incident management activities of the hospital. It consists of the incident commander, the public information officer, the safety officer, the liaison officer, and a group of medical and technical specialists.
The operations section is responsible for managing the tactical objectives outlined by the incident commander. This section consists of one department-level management part and five branches: staging management, medical care operations, infrastructure operations, security operations, business continuity operations, and hazardous material branch.
The planning section is responsible for collecting, evaluating, and disseminating status reports, to display various types of information and to develop the Incident Action Plan (IAP). This section consists of four units: resource, situation, documentation, and demobilization.
The logistics section coordinates all activities to provide necessary resources, from internal and external sources, for hospital functions during disasters. The section has two branches: service and support.
The finance and administrative section is intended to develop financial and administrative procedures to support the program before, during, and after an emergency or a disaster. The section consists of time, procurement, compensation and claims, and cost units.
Each group and section consists of various positions. For each position, a job-action sheet explains the main mission and expected tasks, within immediate (0 to 2 hours), intermediate (2 to 12 hours), and extended (beyond 12 hours) operational periods. It also explains the demobilization and system recovery.
In a disaster situation, no single health care facility standing alone can provide optimal care to all the victims affected. However, a hospital usually receives an influx of casualties within a few hours of an emergency, and it is not possible to receive all requirements from other hospitals. Therefore the medical facility must be able to surge its medical capacity to minimize mortality and morbidity. Hospital surge capacity is defined as the ability of a hospital to expand rapidly and augment services in response to one or multiple incidents, and to manage patients who require unusual or very specialized evaluation or interventions (e.g., contaminated or burn patients). These terms refer not only to the physical space but also the organizational structure, medical and ancillary staff, support, supply, information systems, pharmaceuticals, and other resources required to support patient care efforts, which could be summarized as S4 (“staff, stuff, space, and system”).
To consider the priorities for hospital activities and surge capacity during disasters, the medical services can be rated as (1) dispensable, (2) preferable, (3) necessary, (4) very necessary, and (5) indispensable (e.g., ICU as indispensable; laboratory as very necessary; and dermatology as dispensable) ( Table 6-1 ).
|Emergency care (ED and OR) |
Intensive care unit
Trauma and orthopedic
|Internal medicine |
Gynecology and obstetrics
|Respiratory medicine |
Therapy and rehabilitation
Disasters usually affect directly or indirectly hospitals located in the affected zone. Therefore decline of hospital capacity is expected. Moreover, it is not realistic to assume a full functional capacity for a hospital. To address surge capacity, usually, the first step is to stop all elective operations and visits to free up personnel and space for emergency management activities. The second step is to empty the current space through earlier discharge or disposition of patients to other health and medical facilities. Consequently, more space, staff, and stuff will be available. Another step could be adding extra staff, stuff, and space to the hospital.
It is not possible to calculate an exact number or proportion to estimate hospital surge capacity. However, assuming the intact elements of a hospital, some methods have been suggested by researchers for surge capacity planning. For instance, “the maximal number of victims that any hospital is reasonably capable of absorbing during a mass casualty incident is 20% of the total number of registered beds.” Hospital treatment capacity (HTC), the number of casualties that can be treated in the hospital in an hour, is considered 3% of the total number of beds. Whereas, hospital surgical capacity (HSC), the number of seriously injured patients that can be operated upon within a 12-hour period, is calculated as “number of operation rooms × 7 × 0.25 operations/ 12 hours.” A trauma center that is geographically isolated may enhance its capacity (emergency department, operation rooms, intensive care unit) up to 11%.
Evacuation of hospitals because of imminent or impacting disasters is not a rare event. A review article revealed there were 275 hospital evacuations in the United States within 1971 to 1997. It has also been reported from other areas, such as Italy, Pakistan, China, Indonesia, South American countries, and the United Kingdom, where some hospitals have been evacuated because of earthquake, flood, fire, and other disasters. ,
Evacuation of a hospital is a complex process, with the goal being to safeguard the health and lives of its occupants. In this situation, not only the patient but also relevant equipment and documents must be evacuated, which can results in the functional collapse of a hospital, including critical departments such as the ICU and operating rooms, which are typically in greater demand during a disaster. Hospital evacuations also produce psychological, financial, and social problems for the whole community. ,
Hospital evacuation might be immediate or delayed, vertical or lateral, partial or complete, pre-event (e.g., because of impending tsunami, hurricane, or other disasters) or post-event. The determination to evacuate the hospital must be based on precise criteria and a rapid decision-making process. , Evacuation of an entire hospital is an enormous logistical undertaking, which usually requires outside capabilities. It often requires the cooperation and involvement of other organizations, such as police, fire, and EMS. Supporting organizations may provide transportation, facilities, supplies, equipment, and personnel. All of these services must be precisely orchestrated to accomplish the evacuation efficiently and safely. , ,
Creating a staging location is a crucial phase of the evacuation operation. Patients will be transported to alternate care facilities from the staging area. Hospitals, clinics, hotels, nursing facilities, and others could all be alternate care sites for evacuated patients. ,
Patients can be categorized into three groups: (1) ambulatory and self-sufficient patients, (2) nonambulatory patients who require medical care and support but are not in critical or unstable condition, and (3) patients who need critical and continuous medical services or are fully dependent on technology (e.g., patients in the ICU or isolation rooms).
Maintaining continuous medical services to nonambulatory patients is essential during the evacuation process. However, it may be unrealistic to keep all equipment and procedures with the patients while they are being evacuated, particularly if elevators are not working and patients must be transported by staff on stairs in a high-rise hospital. Moreover, for ethical reasons, triage in evacuation is necessary if it is not possible to evacuate some patients. ,
Areas and floors in highest danger should be evacuated first; however, a top-to-bottom evacuation should be considered if there is no immediate threat to the hospital. Special equipment, stairs, and elevators are used for evacuation, depending on safety issues.
To prepare for a successful evacuation in the event of severe damage to the hospital, the first step is to perform a pre-event assessment of the hospital infrastructure, layout, and demographic situation. The second step is to estimate time needed to evacuate the hospital, both to the staging area and to transport to alternate care sites. The output will vary based on different scenarios. Number of patients, available exit routes, available resources and staff, traffic conditions, and distance to the evacuation sites are factors for determining the required time. The third step is to estimate resources needed to evacuate the hospital, both to the staging area and to transport to alternate care sites. Resources (staff, equipment, and vehicles) are needed for both transportation and continuing the medical services in the appropriate environment, considering temperature, air condition, security, and safety. , It is important to send enough information along with the patients (e.g., name and background information, medical file, time of discharge, equipment sent with the patient, and special considerations and precautions, such as police hold, mental health, and suicide watch). ,
Hospital Readiness for Hazardous Materials Emergencies
HazMat and their accidental or intentional spill are the sources of many human-made disasters. During the past decades, the number of disasters caused by industrial chemical spills, gas leaks, or industrial explosions and fires, has increased across the world. The impact of HazMat incidents on hospitals is significant, and the treatment of contaminated patients is not a rare event. Hospital staffs have been injured while treating these patients, and hospital facilities have been shut down or evacuated because of secondary contamination.
Since the terrorist attacks of September 11, 2001, the need to be prepared to respond to events involving HazMat contaminants in mass casualty scenarios or in situations involving smaller numbers of victims has been increasingly taken under consideration by health facilities, especially in the United States. , However, some studies report that the health system, including hospitals, is not well prepared to handle patients from such emergencies. The necessary level of readiness for HazMat emergencies should be determined by the HVA, which takes into account geographic, demographic, historical, and industrial factors. In addition, different managerial tactics and actions might be considered if the risk comes from either terrorist attacks or industrial events. However, in terms of medical treatment, the approach to dealing with terrorist and industrial CBRN incidents will not differ in most situations. Triage, decontamination, medical treatment, and safety will be the main functions during all HazMat emergencies.
As well as performing the risk assessment, training hospital managers and staff in HazMat emergencies is a priority for the preparedness process. In fact, the lack of awareness and knowledge by hospital managers and staff about the characteristics of HazMat events is a main bottleneck of emergency preparedness and response to such events. A basic training course for hospital managers and staff should cover some core topics (e.g., the threats of a HazMat to the staff, safety issues, and essential equipment and resources, along with medical treatment and decontamination principles).
To list and provide essential equipment and medical resources, such as antidotes, personal protective equipment (PPE), and detection and monitoring instruments, is another important preparedness step to take. PPE is designed to provide protection from serious injuries resulting from contact with HazMat. No single combination of protective equipment and clothing is capable of protecting against all hazards. There are four categories of PPE, and for hospital staff selection of PPE is based on the degree of protection afforded against type and severity of contamination on the casualties.
Level A protection should be worn when the highest level of respiratory, skin, eye, and mucous membrane protection is needed. Usually, it is not used at a hospital if it is placed in a safe zone.
Level B protection should be selected when the highest level of respiratory protection is needed but a lesser level of skin and eye protection is needed. This level of protection is suggested for use by a hospital staff working on the decontamination of victims.
Level C protection should be selected when the type of airborne substance is known, concentration measured, criteria for using air-purifying respirators met, and skin and eye exposure is unlikely. This level of protection is suitable for hospital staff in case of receiving HazMat incident victims. A typical Level C set includes a full-face or half mask, air-purifying respirator; chemical-resistant clothing; chemical-resistant gloves, both inner and outer; and steel toe and shank, chemical-resistant boots.
Level D protection is primarily a work uniform used for nuisance contamination only. It requires only coveralls and safety shoes or boots. Other PPE is designated for use based on the situation, and it should not be worn where respiratory or skin hazards exist.
A safe place to treat contaminated patients is also a key element of hospital preparedness for HazMat emergencies. Two zones are needed: a warm zone and a cold zone. , The warm zone is an isolated place where contaminated victims, equipment, and waste might be present. Triage, medical stabilization, and decontamination are performed in this zone. The cold zone is an area where equipment and personnel are not expected to become contaminated. ,
Development of standardized procedures and guidelines on how to manage the casualties coming from a HazMat incident (both contaminated and not) has a critical role in hospital performance during HazMat events.