Emergency Hospital Service Delivery - JPRM 2011 - First Deliverable - English

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Hospital Disaster Response Plan Momeni A., Yousefi E. June 2011

APW for developing SOP for hospital emergency service delivery First Deliverable - English Page 1


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APW for developing SOP for hospital emergency service delivery

First Report

June 2011

Amir Momeni MD.

EHMTP Director

Principal Investigator

Elham Yousefi MD.

Technical Officer

World Health Organization

&

Ministry of Health and Medical Education of Islamic Republic of Iran

JPRM 2010-2011


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Acknowledgements:

We thank the staff of the Secretariat for Health Risk Management in Disasters of MOHME, especially

Dr. Gholamreza Masoumi without whose support and cooperation this project could not have been

completed. We must also stress our gratitude for members of EHMTP for their excellent field work.

Last but not least we must thank the staff of WHOs Iranian office, especially Dr. Manuel Torres and

Ms. Laleh Najafizadeh, whose technical insight and guidance have greatly improved the quality of this

project.


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Abbreviations:

WHO World Health Organization

MOHME Ministry of Health and Medical Education of Islamic Republic of Iran

EHMTP Emergency Health Management Training Program

Copyright Notice:

All of the figures provided in this document are a property of EHMTP and have been used in this document with the consent

of the governing board of EHMTP.


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Introduction:

This is the first deliverable of the JPRM 2010/2011 project entitled APW for developing SOP for hospital

emergency service delivery which is being completed with collaboration of world health organization and

ministry of health and medical education of Islamic Republic of Iran. In this first deliverable we provide the

results of Systematic Review of Evidence & Situation Analysis (Current procedures, existing

operational plans, gaps and recommendations) as well as a review of selected benchmark countries.

Finally we have outlined a system called comprehensive hospital risk management system from

which we are going to develop the hospital disaster response plan in this project with regard to

internal and external disasters. For any inquiries regarding this project or the findings presented

please contact me by email: [email protected]

` Amir Momeni MD,

Project Manager

June 2011


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ContentsChapter 1: Disaster and its components .......... 9

1.1 Disaster versus Hazard: .......................... 9

1.2 Disasters in Iran: .................................. 11

1.3 Vulnerability versus Capability: ............ 11

Chapter 2: Hospitals in Disaster ..................... 15

2.1 External Disasters and Hospitals: ......... 16

2.2 Internal Disasters: ................................ 16

Chapter 3: A review of benchmark countries . 19

3.1 Turkey: ................................................ 19

3.2 Iraq: ................................................... 19

3.3 Pakistan: .............................................. 20

Chapter 4: A review of current situation in Iran

...................................................................... 21

4.1 Assessment of current disaster

management policies and strategies: ......... 21

4.2 Assessment of policies, regulations and

strategies for hospital disaster management:

.................................................................. 22

4.3 Situation Analysis of current level of

hospital preparedness in Iran: ................... 22

4.4 Conclusion, weaknesses and strength of

the current situation: ................................. 23

Chapter 5: Hospital Disaster Response Plan ... 25

5.1 External Disasters: ............................... 26

5.2 Internal Disasters: ................................ 28

5.3 Common framework for hospital disaster

plan: .......................................................... 30

References: ................................................... 32


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Executive Summary:

This is the first report in a series of three

developed for the JPRM 2011 project APW

for developing SOP for hospital emergency

service delivery. In this first report the

results of the evidence review as well as the

situation analysis have been presented.

In this report a common framework for

hospital disaster planning is explained. This

framework enables planners to develop

hospital disaster plans in three stages; the

three stages are disaster risk reduction,

disaster preparedness and finally disaster

response. In this project the focus is on the

response phase of the hospital disaster

plan. In this framework response to internal

and external events is differentiated which

greatly increases the effectiveness of

response. Irrespective of type and extent of

the disaster that the hospital faces a

common approach to response can be

adopted, this common approach is

introduced in this report and is further

elaborated in the following reports.

This report consists of five chapters; in the

first chapter an introduction of concept of

disaster is provided. In the second chapter,

the effects of disasters on hospitals as well

as the roles hospitals must play in disasters

is explained. In the third chapter a brief

review of benchmark countries is provided,

from which we have chosen Turkey as the

best benchmark country because while ithas demographics, economic status and

hazard profile similar to Iran, its hospitals

are far better prepared than hospitals in

Iran. In the fourth chapter we have

provided a summary of hospital

preparedness level in Iran and finally in the

fifth chapter we have presented the

framework for hospital disaster planning

based upon which the remainder of theproject shall proceed.


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Methodology:

This is the first report in a series of three

developed for the JPRM 2011 project APW for

developing SOP for hospital emergency service

delivery. In this first report the results of the

evidence review as well as the situation analysis

have been presented.

The first task was evidence review. For this a

comprehensive search of all available evidence

online was performed. In this search free

databases including Google Scholar, Medline,

WHO libraries, Indexmedicus and others were

searched for practices and guidelines on

hospital disaster response planning. A separate

search was conducted on google for all

documented hospital disaster plans from

around the world. The neighboring countries

were chosen as the benchmarks for Iran and a

country specific search for hospital

preparedness and response was conducted aswell. The results were skimmed and all useful

documents and resources were selected. The

documents were categorized as policy

documents, technical documents and case

studies. In each category further thematic and

subject based categorization was made. After

documents were assigned to their categories,

they were rated based on content, reliability

and relevancy. Project members then

thoroughly reviewed and summarized the

evidence that was highly rated in the previoussection and a series of meetings were held

during which the topics of the project were

discussed and each member contributed to the

topic based on the evidence she/he had

reviewed. The end result was developed in two

different categories, the first was background

and rationale which is presented in this report

and the second category was best practices

which will be used in developing the generic

plans in the second and third report. The

evidence that contributed to the conclusions

drawn were listed as the references.

The second task was situation analysis. This was

a field work for which a task force was chosen

from the project members and were trained in

conducting objective based interviews. A

questionnaire was developed as well which

assessed the basic level of preparedness in

hospitals. The task force conducted interviews

based on the designed questionnaire withhospital representatives and the results that

were obtained were summarized and in some

cases quantified. As a part of this task, the

MOHME was asked to provide a report on all

policies and regulations related to hospital

disaster management and emergency health

management as well as any experience or

related project. The report was provided and

evaluated, in evaluation all items which did not

have enough supporting documentation were

omitted. The end results were discussed in aseries of sessions and weaknesses as well as

strength of the current situation and conclusion

as to what needs to be done, were determined.

The third task was developing a framework and

outline upon which to proceed, it was agreed

that the outline needs to address both internal

and external disasters and be generic so that it

can be adopted and used in hospitals around

the country. Through a series of sessions the

outline was developed and is presented in this

report.

The final task was summarizing the results and

drafting the report. The report is prepared in

both Farsi and English.


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Chapter 1: Disaster

and its components

1.1 Disaster versus Hazard:

Hazard refers to a situation where there is a

threat towards the health, safety or living

conditions of a population. Most of the hazards

are usually dormant yet they have the potential

for causing harm when activated. If a hitherto

dormant hazard becomes activated or in other

words a hazard develops into a disaster, then a

swift response is needed in order to limit the

harm towards the affected population.

Disasters are either slow or rapid; slow disasters

occur in a relatively long period and require a

chronic and lengthened response; war, droughtand famine are typical examples of such

disasters. While it may seem that responding to

slow disasters is easier, but the chronic nature

of response and implications of these disasters

(which usually lead to population displacement

and an ongoing deterioration of infrastructure)

makes the response a complex and

troublesome issue. However slow disasters

possess another quality which provides the

disaster managers with a chance for prior

planning and preparedness, this quality is

known as early warning. For examples before a

full blown war, and during the initial hostilities,

the hospitals in the conflict zone have a chance

for stacking up on medical resources as well

evacuating the patients. Early warning allows us

to foresee the disaster and prepare ourselves

for responding to it.

On the other hand we have the rapid disasters;

these include natural disasters such as

earthquake and flooding or manmade disasters

such as bombings. Rapid disasters cause

considerable destruction and harm within a

matter of minutes or hours. While usually rapid

disasters are unpredictable, the damage, effects

and the intensity of harm caused by them are

predictable and as such there can be proper

planning and preparedness in order to lessen

their effects. Experience has shown that it is

much easier to plan and prepare for a rapid

disaster than a slow disaster; slow disasters due

to their chronic nature will erode the societys

capacity for response and deprive the chances

of the society for normal living conditions for a

lengthened period of time. Although it must be

mentioned that if there is no effective response

to a rapid disaster, then there is a chance that

the initial rapid disaster lead to a slow disaster

(e.g. population displacement caused by

destruction of property and livelihood), in these

cases, due to increased vulnerability of the

affected population following the initial

disaster, the effects of the slow disaster will be

far more destructive and disruptive and may

incapacitate the society for many years. For

example Haiti after the 2010 earthquake is still

struggling on the road to recovery and it may

still be some years before things are truly back

to normal in Haiti.


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Table 1. Summary of Natural Disasters in Iran (1901 - 2011)

# of Events Killed

Total

Affected

Damage (000

US$)Drought Drought 2 - 37625000 3300000

ave. per event - 18812500 1650000

Earthquake

(seismic activity)

Earthquake (ground

shaking) 98 147117 2605604 10518628

ave. per event 1501.2 26587.8 107332.9

Epidemic Unspecified 1 76 - -

ave. per event 76 - -

Bacterial Infectious

Diseases 2 296 2500 -

ave. per event 148 1250 -

Extreme

temperature Heat wave 1 158 - -

ave. per event 158 - -

Flood Unspecified 27 3816 1285520 408300

ave. per event 141.3 47611.9 15122.2

Flash flood 14 2689 1291066 253700

ave. per event 192.1 92219 18121.4

General flood 31 1262 1075948 6990528

ave. per event 40.7 34708 225500.9

Mass movement

wet Avalanche 3 73 44 -

ave. per event 24.3 14.7 -

Landslide 1 43 100 -


Storm Unspecified 8 248 19785 13540

ave. per event 31 2473.1 1692.5

Local storm 3 88 - 15000

ave. per event 29.3 - 5000

Tropical cyclone 1 12 160009 -


Wildfire Scrub/grassland fire 1 - - -

ave. per event - - -

Created on: Jun-8-2011. - Data version: v12.07

Source: "EM-DAT: The OFDA/CRED International Disaster Database

www.em-dat.net - Universit Catholique de Louvain - Brussels - Belgium"


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1.2 Disasters in Iran:

Iran is a disaster prone country where many

natural, seismic, meteorological and industrial

disasters have occurred during the years. So far

the most devastating disasters that have

occurred have been earthquakes; from 1909

until 2011, 89 major earthquakes have been

recorded which have led to loss of at least

147000 lives and damages estimated at around

10,979,628,000 US dollars (each earthquake on

average has caused 123,637,000 US dollars of

damages). Floods have also been major

disasters in Iran, where 64 major floods in the

past 100 years have caused 7627 deaths and

over 3.5 billion US dollars in damages. However

in recent years due to a lengthened drought

period as well as improvement in infrastructure

by building dams and floodways, the number of

floods have decreased with only major floods

reported occurring in the provinces neighboring

Caspian sea, where high rain fall coupled with

extensive deforestation has made the area

prone to floods. Droughts have also been a

source of major damage; they have caused over

3 billion US dollars of damages in the past years.

Storms and cyclones especially in the

southeastern provinces have also been major

disasters with a death toll of 320 individuals and

more than three hundred million US dollars in

damages. In 2007 Gonu cyclone in Sistan and

Baluchistan province in south eastern Iran anestimated 28 people died and 216,000,000 US

dollars of damages were left behind.

In the past twenty years the country has faced

two major outbreaks of cholera, three

devastating rail accidents, more than 20

airplane crashes, many mass casualty road

accidents (the cumulative effect of which has

surpassed any other disaster), a major and long

war among many other smaller disasters of

different sorts (from industrial explosions to

avalanches).

In the first table, a summary of important

disasters that have affected Iran in the past

hundred years are listed.

1.3 Vulnerability versus Capability:

If we want to provide a comprehensive

definition of a disaster we can say that a

disaster occurs when the functionality of a

society is severely disrupted in a manner that it

causes serious damage to the lives, health,

finances, environment or livelihood of the

affected population. In reality a hazard only

develops into a disaster when it surpasses the

capacity of the society for absorbing the effects

of the disaster and responding to the disaster.

i.e. when the society cannot cope with the

effects of the disaster relying only on its

resources and capacities, necessitating external

aid and help.

Figure 1. Bam Earthquake: Bam Earthquake was one

of the most devastating natural disasters in recent

history of Iran. The two hospitals of the city were

completely destroyed in this earthquake.


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Hazards are either natural or manmade. Events

such as earthquakes, floods and storms are only

a natural phenomenon and only became

hazardous when they occur in an environment

inhabited by humans. Even if these events

happen in a city they do not necessarily cause a

disaster; they only become a disaster when they

surpass the capacity of the affected society and

cause extensive damage to the lives and

livelihoods of the population.

The weakness of the society in opposing the

disasters has many different aspects, for

example the society may be incapable of

organizing search and rescue, evacuating the

injured, providing care, temporary settlement

or recovering from disasters. Disasters are

actually a result of the lifestyle of the society;

the economic and social activities of the

population as well as their relation with nature

and environment determine the vulnerability of

the society towards disasters. For example, the

rapid urbanization process has led to urban

areas with high population with many having to

live on the margins of the city or in places which

are not usually used for housing such as on

hillsides and river banks; this in turn increases

the risk of the society and makes the population

more susceptible to different hazards. In other

words we can state that disaster almost always

happen when hazards occur in a vulnerable

society, so while we cannot prevent many

hazards such as earthquake from occurring but

by eliminating the vulnerabilities or by

developing capabilities that can offset those

vulnerabilities.

Hazards then cannot cause a disaster by

themselves, it is when they occur in an

unprepared and risk prone society that they

cause extensive damage. It can be said that

hazards only act as a trigger and conditions such

as poverty which set the stage for this trigger to

act are called vulnerabilities.

Vulnerability is the result of a dynamic process,

in fact vulnerability can be traced to three levels

of different factors. In the lowest level, there

are the underlying causes which deeply

embedded in the fabric of the society. The most

important underlying causes are the economic

system and the general socioeconomic status of

the population. At the next level there are somedynamic pressures that act upon the underlying

causes and usually worsen their effects, these

include elements such as lack of services,

defective educational system, lack of

knowledge and skills, lack of local investment

and destruction of the environment. The

combination of underlying causes and the

dynamic pressures give rise to the third level

factors which are known as the unsafe

conditions; these conditions ultimately definethe vulnerability of the society towards disaster.

Unsafe conditions can include physical

conditions such as nonstandard and unsafe

buildings or it can include economic factors

such as low income or it can include

organizational factors such as lack of a disaster

preparedness plan. The unsafe society can be

likened to a barrel of gunpowder waiting for a

trigger (in this case the hazards) to explode.

It must also be mentioned that some aspects of

the society have more vulnerability towards

disasters (such as children, elderly or the

patients who are hospitalized at a health

facility). The rest of the society has the

responsibility of caring and protecting these

more vulnerable parts and thus the society


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should develop the capacity for protecting

these people. Hospital is a vital part of the

society and plays a very important role in

disaster management cycle. While the

vulnerability of hospitals is considered an

unsafe condition for the hospital itself, it is

considered a dynamic pressure for the society

that will further drive the society into a

vulnerable state. So reducing the risk of

hospitals should have a high priority in disaster

management initiatives. Risk reduction in

hospitals is achieved through structural,

nonstructural and organizational planning.

Vulnerabilities and capabilities exist as three

sets of parameters: physical/structural,

social/organizational, attitudinal/behavioral. A

successful disaster management initiative

should decrease the vulnerabilities at all three

parameter sets and increase capabilities at all

three parameter sets. In fact it is believed that

such action will lead to an augmented capacity

for the hospital to absorb the shock and the

effects of the disasters and continue

functioning.

For effective disaster risk reduction in hospitals

several approaches can be followed. One way is

avoid disasters and hazards altogether, this

would mean building hospitals in places where

there are no hazards threatening them or

neutralizing the hazards faced by the hospital.

Such hazard prevention, however, is not usually

feasible or even possible because of the costs

involved and also because of the role that

hospitals play in human lives, they need to be

placed where populations are concentrated and

if their target population is placed in a high risk

area then the hospital inevitably should beplaced nearby.

While successful hazard prevention may not be

achieved, but still disaster risk can be

successfully averted by vulnerability reduction.

Vulnerability reduction begins with correction

of unsafe conditions. However this is usually a

temporary solution, a more permanent solution

is to tackle the vulnerabilities at their core level,

which are the underlying causes and dynamic

pressures, but such efforts need the

participation of all of the society and probably

external help as well, in fact such long term

efforts are considered more as a part of

development programs than disaster

management programs. Thus, in hospitals risk

reduction is achieved by reducing or eliminating

the unsafe conditions of the hospital. For

example if the hospitals building is weak and

cannot withstand a strong earthquake, then

through retrofitting and increasing structural

resilience this unsafe condition can be

corrected.

However there is a third approach to disaster

risk reduction as well. This approach is called

Figure 2. Progression of Vulnerability


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capacity building. This approach is highly useful

when we are facing situation where either the

hazard cannot be averted or the vulnerabilities

cannot be reduced. Such capacities enable

those at risk to respond and react swiftly and

correctly to disaster events. Capacity building

has two important advantages; firstly, capacity

building initiatives are relatively low cost

compared to other risk reduction efforts and

secondly, capacity building can be achieved in a

relatively short amount of time. This is why

some consider capacity building initiatives equal

to preparing for disaster. Because actuallycapacity building does not directly decrease the

disaster risk, but it improves and facilitates

response to disasters and through this reduces

the effects of disaster.

Some believe that preparedness is a separate

phase from risk reduction, however, the reality

is that risk reduction is a continuum, at one end

of which the risk of future disasters is reduced

and at the other end we are preparing to

respond to a disaster that may arise any

moment. In other words while we may attempt

to reduce the risks of a hospital, but a disaster

may occur before such effort bear fruit and thus

we need to be ready and prepared for it, so

preparedness and risk reduction should

attempted simultaneously.

In this project, we are focusing on hospital

disaster response and hospital disaster

response plan, this is actually a form of capacity

building in hospitals which will be the

cornerstone of hospital emergency service

delivery.

Figure 3 Approaches to Averting Disasters


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Chapter 2: Hospitals

in Disaster

Health care is provided in three levels; the first

level is primary health care and outpatient care,

the second level is inpatient and specialized

health care and finally the third level is

dedicated to subspecialty health care.

Regardless of the level, a considerable amount

of health care is provided in hospitals andhealth care facilities. Hospitals are the central

points in health care systems and provide a

concentrated package of health services to

patients and this makes them very vital not only

for the health system but also for the society as

a whole. Some of the roles of the hospitals in

the society include:

Providing medical care to patients

Providing preventive health services Presence of reference laboratories in

hospitals

Acting as an educational center

Acting as the response center in public

health emergencies

Acting as a research center

Hospital and health facilities have a very

strategic position in the society, the importance

of this position increases when a disaster

occurs. In disasters, especially mass casualty

disasters or public health disasters, hospitals act

as the cornerstone of the disaster management

response with the society increasingly relying

on their functioning and on the services they

provide. In disasters, hospitals not only have to

deal with effects of hospital within the hospital

but as a medical care center, they need to

provide care to the masses of injured who rush

to the hospital in order to receive medical care.

Due to important position of hospitals in

disaster response, it is sometimes

recommended that the command center for

emergency medical services be established in

hospitals and overall oversight and

management provided from the hospital.

Considering the important role of the hospital

and health care facilities there is a need for

careful disaster planning in hospitals and

preparing hospitals for disasters should be oneof the priorities of the health system.

In reality hospital faces two kinds of disasters.

The first are the external disasters; in external

disasters, the community and the society that

the hospital serves is affected by a disaster and

the hospital is spared from the devastating

effects of the disaster. In this setting the main

effect of the hospital on the hospital is theinflux of casualties and patients. This in turn can

complicate service delivery or worse even in

unprepared hospitals it may lead to paralyzing

of the service delivery system of the hospital.

The second kind of disasters, are those that

involve the hospital itself, in this situation the

hospital itself faces a danger and needs to

respond accordingly in order to ensure no harm

comes to patients, staff or even the equipment.

There are however circumstances when

hospital is facing an internal and external

disaster at the same time and should be able to

cope with both disasters.


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2.1 External Disasters and

Hospitals:

Hospitals play a pivotal role in the society and if

the society faces a disaster then inevitably and

regardless of direct involvement of the hospital

in the disaster, the hospital should deal with the

aftermath of the disaster. The hospital should

be prepared to provide the necessary response

to the disaster; it should identify the needs and

expectations of the disaster affected population

and respond to them.

In disasters and especially in the acute phase of

the relief and response activities the most

important function of the health system is to

provide medical care to the casualties.

Delivering medical care is a chain which startswith search and rescue and basic care provision

at the field; this part of the chain is not usually

considered as a direct responsibility of the

health system. The second link in the chain

consists of field triage and field medical services

by mobile and field medical care units and

finally the third link consists of medical care

delivery at hospitals and health care facilities. If

the local hospital is still capable of service

delivery, it will be the first choice for provision

of medical care to the patients and injured,

otherwise the health system should consider

other options such as establishing a temporary

field hospital or transporting the injured to

another hospital nearby. At the hospital,

secondary triage is performed and

comprehensive medical care is provided. Other

hospitals in the region or in the country form

the fourth link of the chain; in mass casualty

events where local services are overwhelmed

early on following the onset of disaster, the

government may consider transferring andtransporting patients to hospitals in other parts

of the country. There are some who argue that

the model of medical care delivery during

disasters is more like a set of concentric circles

rather than a chain with hospitals forming the

central circle.

As mentioned hospitals play a very important

role in disasters; they not only need to continue

to provide care to patients already hospitalized

they will also need to deal with the casualty

influx in the acute phase of disaster response

and then continue service delivery when the

acute phase is over.

2.2 Internal Disasters:

Hospitals are regarded as very important part of

the infrastructure in the society, in some

instances for example in case of large medical

centers, they are deemed more important that

some other vital parts of infrastructure such as

airports, power plants or fire stations. Hospitals

and schools have very important and symbolic

sociopolitical positions; the emotional burden

Figure 4. Internal and External Disasters in Hospitals


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of a destroyed hospital can lead to despair,

feeling of insecurity and disturbance of social

balance in the affected society. The loss of the

lives of helpless patients also imposes a great

emotional burden.

Regardless of the setting, before or after the

disaster, the society is highly dependent on

hospitals, yet the hospitals themselves are very

vulnerable toward internal disaster. This makes

hospital risk reduction doubly important,

because not only must the hospital survive butit must also provide services to the population it

serves. Another justification for risk reduction in

hospitals is the considerable financial

investment which has gone into hospitals

making their loss a considerable financial

burden for the affected society. It must be

mentioned that following the Bam earthquake

in 2004, the cost of repairing the destroyed

buildings of the hospitals of the city was

estimated at 10.5 million dollars. The financialcost is not limited to the structural damage; a

huge cost is also incurred by damage to

nonstructural elements and loss of valuable

equipment. Then there is the cost of providing

medical care at alternative or temporary sites

while the affected hospital recovers. For

example in Bam earthquake the cost of

establishing and operating the field hospitals

was estimated at 10 million dollar (almost the

same as the cost for rebuilding the affected

hospitals).

Hospitals invariably need protection against

disasters. Such protection is provided in three

levels; as internal disasters cause three main

categories of threats to hospitals which are

threat towards the life, investment and services

of the hospital. The three levels of protection

are as follows:

Life protection

Investment protection

Functionality protection

Protection of lives is the minimum level of

protection mandatory for a hospital, in this level

it must be ensured that the hospital is

structurally intact and there are no threats

towards the lives of the inhabitants of thehospital. The second level (investment

protection), refers to protecting the structural

and nonstructural components of the hospital

from damage or if they are damaged, it refers

to rapid repair and return to service of these

elements. Finally the third level which is the

protection of functionality is the ultimate and

ideal level of protection in a hospital. This level

of protection means that the hospital can

continue functioning when a disaster strikes.

Choosing the objectives of protection in each

hospital, however, depends on the conditions

and settings of that hospital as well as the type

of disaster. Prioritizing between different levels

of protection is a very important decision in

hospital disaster management. Regardless of

the context, life protection should always take

precedence. But there must be a decision on

whether investment protection should have a

higher priority or priority should be given to

continuity of services even at the cost of

causing harm to equipment and resources. To

solve this we must look at the problem from

another perspective; after saving lives the

priority should be given to continuity of care.

i.e. in choosing between protection of


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investment or of functionality we must consider

that which is more effective in continuity of

care. For example, when a nearby unaffected

hospital can provide some of the services such

as imaging services, a hospital can refer its

patients to that hospital for imaging services

and perform essential repairs on its imaging

equipment, in other words, because the nearby

hospital ensures the continuity of care then

investment protection can be given precedence

over functionality protection.

Thus the decision over the priorities of different

levels of protection is a vital one and yet a hard

one to make prior to the onset of a disaster. It is

difficult to know how continuity of care can be

achieved before the onset of a disaster, and

thus the decision is usually postponed until the

disaster has happened. There must, however,

be a predefined set of criteria as well as a

guideline that can facilitate the decision when

the disaster strikes.

The three levels of protection are achieved

through three sets of activities, these are

mentioned below.

1. Structural Strengthening: These efforts

need specialized engineering skills andconsist of retrofitting, structural triage

and temporary measures for

strengthening of the structure or

evacuation in necessary cases.

2. Nonstructural Safety: These efforts

require ensuring nonstructural

elements pose no threat to patients or

stuff, they are protected from possible

damages and equipment are kept

functional if feasible.

3. Organizational Planning: Through

planning, training and drills the

preparedness towards disaster is

increased. As part of a hospital disaster

plan, such efforts can greatly improve

the outcome of an internal disaster.


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Chapter 3: A review

of benchmarkcountries

3.1 Turkey:

Turkey is country that is very similar to Iran in

many aspects; Turkey has a population near to

that of Iran, it has a GDP near to that of Iran and

it is also a disaster prone country especially in

case of earthquakes. As such Turkey can be a

good benchmark of disaster preparedness for

Iran.

Studies have shown that Turkey enjoys a high

level of hospital preparedness. Mehmet Top et

al completed a study in 2010 in 251 hospitalsand measured their level of preparedness.

According to that study, it was found that 233

hospitals (92.8%) had written disaster plans.

When analyzed according to the type of

hospital, 204 public hospitals (93.2%), 19

university hospitals (86.4%) and 10 private

hospitals (100%) were found to have written

disaster plans. According to the study, 63.5% of

the public hospitals, 80% of the private

hospitals and 31.8% of the university hospitals

performed an exercise on an annual basis, as

stated in the disaster plan.

In a report jointly published by the Ministry of

Health of Turkey and the WHO Regional Office

for Europe, Turkeys commitment to crisis

preparedness as well as capacity for responding

to disasters was praised. It was reported that

hospital capacity is extensive in terms of

number of beds, availability of trained staff, and

accessibility to equipment, contingency supplies

and modern medical technology. The

Emergency Medical Services system is well

resourced with staff, ambulances, contingency,

dispatch centers, etc. Every hospital is required

to have a dedicated focal point for emergency

preparedness, as well as an emergency

response plan. A strategy for risk

communication and public information during

emergency situations exists.

Turkey thus can be a very good benchmark for

measuring the progress of Iran. Over the next

years, we should expect that the current gap

between Iran and Turkey is decreased and we

reach the same level of preparedness in our

hospitals as Turkey.

3.2 Iraq:

Despite being one of Irans neighbors, the

health system as well as the disaster context of

Iraq is different from Iran. Hospitals in Iraq have

been coping with conflict related emergencies

and a high influx of casualties from such

emergencies; however the health system and

the hospitals are not still fully prepared for such

events. In a project statement for World Bank

related to improving the health system

response in Iraqi Kurdistan region states that

Recent emergency events have highlighted the

very limited local capacity to respond to

emergencies, e.g., assessment, communication,


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provision of pre-hospital care, referral system.

Lack of adequately equipped ambulances, staff

(including physicians) unprepared to respond to

emergency needs, vulnerability of the

communication system, and the disorganized

response at the level of hospital emergency

departments are a few of the most critical

weaknesses. Even with the very limited

resources of the existing system, there is

considerable scope for improving the quality

and effectiveness of emergency response by

providing targeted support to mitigate critical

bottlenecks in the system and to make betteruse of the existing scarce staff resources. In

particular, the capacity to provide pre-hospital

care can be significantly enhanced by the

provision of communication and transportation

equipment, the training of staff, and the

establishment of a functioning command center

in each of the three provinces covered by the

project.

Overall it seems that the main concerns for

hospitals in Iraq are external disasters in form of

mass casualty events. As Iraq like Iran is only

recently started to plan for mass casualty

management in hospitals, it can be a good

benchmark for measuring the progress in that

area.

3.3 Pakistan:

Pakistan faces many types of disasters, the

variety of which is close to Iran (from flooding

to earthquakes). Pakistan has an overburdened

health care with limited available funds.

Pakistani hospitals have been hard hit by

disasters from the earthquake in 2005 to the

floods in 2010.

Prior to the 2005 earthquake there were 796

health facilities operating in the affected area.

Of that number, 388 (almost 50 per cent) were

completely destroyed. Thirteen of the

destroyed facilities were hospitals, and four of

these were regional or district referral hospitals.

An additional 106 primary health clinics and50

dispensaries were completely lost and often

these were the only sources of health care

within a five-hour walking distance in the

affected rural areas. The remaining facilities

that were able to continue functioning were

overwhelmed. And, in addition to physical

damage to health facilities, the health sector

itself was adversely affected, as many health

professionals suffered direct losses, or worse,

lost their lives.

Pakistan needs a comprehensive and long term

push towards hospitals resilience. In case of

preparedness and disaster risk reduction,especially for internal disasters, Pakistan can act

as a benchmark in this regard.


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Chapter 4: A review

of current situationin Iran

4.1 Assessment of current disaster

management policies and

strategies:

In the recent years there has been an

overgrowing interest and commitment towards

the issue of disaster management. Because Iran

is a disaster prone country on the course of

development, the importance of disaster

planning and policy making is double fold. Of

the important development in the field of

disaster management in recent years we can

point out the following initiatives:

Establishing the national disaster

management organization; this

organization act as the steward for all

disaster related activities in Iran. This

organization facilitates and coordinates

the different sectors involved in disaster

management. Specialized task groups

have been formed in this organization

which has led to specialized, scientific

and evidence based policy making and

strategy setting in the area of disaster

management.

In the recent years, there has been a

growing interest and investment in the

academic arena on the subject of

disaster management. Several higher

education programs have been

developed and further programs are

currently being developed. Several

academic institutes are currently

assigned specifically to advancement of

science of disaster management.

In the fifth five years development plan

there has been a special attention to

the disaster management issue. Article

174 of the plan is dedicated to the

issue.

In the past years, some drills and

exercises have been implemented at

local and provincial levels in order to

increase preparedness.

In the ministry of health and medical education

(MOHME) there have been a set of

comprehensive efforts for reducing the effects

of disasters and increasing the preparedness of

the health system. Some of the efforts are

mentioned below.

Establishing a task force for health in

disasters in MOHME. Planning for establishing the health

volunteers organization.

Developing guidelines for vulnerability

capacity analysis.

Training and establishing disaster

medical assistance teams.

Collaborating with international

partners such as WHO in disaster

related issues.

Establishing the committee for hospital

incident command system and

developing the related guidelines.

Identification and determination of

emergency health functions.

Establishing a public health rapid

response system.


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Intra and extra sectoral coordination

and cooperation on disaster related

issues.

Developing safe community guideline

and establishing safe community

committees.

Designing and implementing

educational programs in health disaster

management in different levels

Investing, reinforcing and improving the

communication systems and

infrastructure of the health system

Establishing emergency operationcenters at local, provincial and national

levels.

4.2 Assessment of policies,

regulations and strategies for

hospital disaster management:

In hospital disaster management field, there

have been some initiatives by MOHME as well

as WHO in Iran. We will point out some of the

more important developments in this field.

As part of the emergency health functions

project, a national guideline entitled national

guideline for hospital preparedness was

developed by Momeni et al. In this guideline acomprehensive hospital risk management

system is introduced and within this system,

hospital disaster management at the

preparedness phase is explained. Further more

general policies and strategies for augmenting

hospitals preparedness across the country are

outlined. This guideline has also provided

general guidance for hospital disaster response

however the main focus has been on

preparedness and issues of risk reduction and

response are neglected to an extent. This

guideline was developed at the national level

and it has not yet been translated to

operational protocols at provincial and local

level.

Aside from the aforementioned guideline, a

series of other guidelines related to hospital

disaster management have been prepared and

distributed. From them we can point out the

guideline for hospital emergency incidentcommand system. However these guidelines

also have neglected hospital response plans and

the issue of service delivery during

emergencies.

There have been some initiatives on risk

reduction especially concerning earthquake and

hospital fires. Hospitals in earthquake prone

areas are being identified and efforts for

structural strengthening and retrofitting have

been planned or are being planned. However

there have been limited efforts on

nonstructural and organizational risk reduction.

In a JPRM 2008/2009 project entitled

developing risk reduction strategies, a general

guideline on hospital risk reduction was

developed as part of the project coupled with a

risk analysis tool.

4.3 Situation Analysis of current

level of hospital preparedness in

Iran:

For this project, a situation analysis was

performed in 11 chosen hospitals; these


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hospitals are all located in the Isfahan province

and operate under Isfahan University of medical

sciences. They provide medical and health

services at secondary and tertiary levels and

were located in urban population centers of

Isfahan, Shahreza and Najafabad. The objectives

of this situation analysis were to determine the

level of preparedness, presence of hospital

disaster plans, finding out about history of

previous disasters and establishing the level of

awareness towards hospital disaster

management as well as technical knowledge in

this field. The analysis was performed usingstructured and targeted interviews; in these

interviews a series of predetermined questions

were asked from hospital representatives. The

findings of the analysis are presented below.

In none of the hospitals risk analysis

was performed. Most of the

representative had general notion of

their hospital being at risk from

disasters, however, they were unaware

of the nature of the hazards that might

pose as a threat for their hospital. They

all identified fire as a possible source of

risk and a representative mentioned

earthquake as well as viral epidemics as

a possible source of threat. Another

representative mentioned nuclear

events as a possible hazard.

None of the hospitals had planning for

internal disasters, and none haddisaster risk reduction plans,

preparedness plans or response plans.

Only one hospital had a plan for a fire

emergency.

Only two hospitals had an established

and functioning triage system. 5 other

hospitals had planned for establishing a

triage system. In one of the hospital

there was a crude plan for surge

capacity. Overall none of the hospitals

had a comprehensive plan for external

disasters.

All hospitals had received the HEICS

protocols and regulations and in 10 of

them, responsible individuals had been

assigned. However, none of the

hospitals had any specific plan for

implementing the command system

protocols and strategies.

None of the hospitals had faced a

major internal disaster. Four of the

hospitals had a history of responding toexternal disasters including mass

casualty events and the H1N1 influenza

epidemic.

5 hospital representatives believed that

currently their emergency department

was already operating at the maximum

capacity. All of the representatives

believed that a major mass casualty

event with a large casualty influx would

cripple their service delivery system. All representatives emphasized on the

importance of hospital disaster

management but except one

representative the others did not had

the technical knowledge for disaster

planning and management. They were

also unaware of the guidelines that

were developed in MOHME.

4.4 Conclusion, weaknesses and

strength of the current situation:

Overall it seems that there is high level of

commitment to disaster management in the

government. In the health system currently,

most efforts are undertaken at the national


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level and mostly they are limited to generalized

approaches to the disasters issue. In reality the

MOHME is preparing the overall framework for

disaster management in the health system.

Within this framework, there has been some

policy making and strategic planning; these

policies will determine the overall direction of

the health system with regard to disaster

management and will facilitate further

initiatives in this field. In hospital disaster

management, also, there have been similar

efforts at policy making, yet these policies are

still not comprehensive and the continuum ofdisaster management from risk reduction to

response to recovery is not completely

addressed in the current policies. There is no

practical protocol on how the hospitals should

react with regard to internal and external

disasters.

However another important weakness is that

the policies and strategies devised at the

national level in the ministry are being

translated into practical operational plans and

protocols at the local level; preparedness is a

progression which happens within a legal

framework, in this progression, preparedness

occurs when the policies and strategies

translate to awareness and preparedness at

local or even personal level. Yet as our situation

analysis showed despite the policies and

guidelines developed, none of the studied

hospitals enjoyed a hospital disaster plan let

alone a response plan.

Another weakness is lack of documentation;

where there have been initiatives for

augmenting preparedness or averting risk, there

has been either no documentation or

questionable documentation.

Overall, by taking the results of evidence review

as well as situation analysis into account, in this

project we aim to further improve the

comprehensive hospital risk management

system already purposed and expand to include

a hospital response plan for internal and

external disasters; this will be a part of the

hospital disaster plan that can be adoptable

with minimum changes at hospitals around thecountry. We are specifically adamant that the

end result is practical, technical and applicable

at the end user level (managers and decision

makers of the hospitals).

Figure 5. Progression of Preparedness


25/34



Chapter 5: Hospital

Disaster ResponsePlan

A considerable amount of health care services

are concentrated in hospitals; people approach

modern hospitals seeking primary, secondary

and tertiary levels of health care. The central

role of hospitals in health systems, gives them a

critical importance in the society, with hospitals

gaining a more important position in disaster

stricken societies. In fact during disasters,

hospitals assume a pivotal role around which

the health system response to disasters shapes.

In disasters, hospitals face a dual problem, on

one hand they must deal with the aftermath of

the disaster within the hospital and on the

other hand they must provide health care to the

injured that are rushed to the hospital. Thereare also incidents when either the disaster is

limited to the hospital or the disaster spares the

hospital and only affects the population which

the hospital serves. In fact the disasters that

hospitals face can be categorized as internal

and external disasters. External disasters cause

a surge of patients and may lead to

overwhelming of the hospital services; during

external disasters the increased patient volume

commonly disrupts the normal hospitalfunctions and may even lead to complete

paralysis of the hospital functionality. However,

in internal disasters hospitals themselves are

mainly threatened, such incidents either threat

the lives of inhabitants of the hospital, or threat

the hospital assets or threat the hospitals

functionality. There are complex instances as

well, when hospitals are faced with both

internal and external disasters at the same

time, e.g. an earthquake can lead to a mass

casualty disaster with many injured rushed to

hospitals in the area which are affected by the

same event. Irrespective of the disaster

category, the success of hospitals in facing

disasters depends on preparedness and

planning. In this chapter we will outline a

comprehensive framework for hospital

response to external and internal disasters.

Hospital disaster management is a three tier

system (to which recovery is added following adisaster). The first tier is the hospital risk

reduction plan and associated activities. An

important element of this tier is risk analysis

which itself is comprised of hazard analysis and

vulnerability/capacity assessment. The results

of the risk analysis are also useful in the other

tiers. In this project we will use the risk analysis

tool previously developed as part of JPRM

2008/2009.

The second tier consists of hospital

preparedness plan and the associated activities.

In this tier education, training and holding drills

are very important. The success of this tier

determines the success of activities in the third

tier; while service delivery in emergencies

occurs at the response tier, yet without

preparedness such a feat cannot be achieved.

The third tier is the hospital response plan. It is

in this tier that response to internal or external

disasters occurs and it is in this tier that

continuity of services which is the main

objective of this project is sought. In this project

we will provide a complete and comprehensive

hospital disaster response plan that can be


26/34



useful and adoptable at hospitals around the

country. In the following sections of this chapter

we have outlined this response plan.

5.1 External Disasters:

Hospitals play a crucial role in the society, and

inevitably if the society faces a disaster, the

hospital will have to burden the effects of the

disaster; the many injured will be rushed to the

hospital and will overwhelm the unpreparedhospital, this issue is addressed in the reception

plan of hospital disaster plan.

It must be mentioned that in mass casualty

disasters, health systems response is organized

as concentric circles; the outermost layer is

search and rescue, the recovered victims then

receive field care and finally those with critical

condition are transported to the hospitals

which is the innermost layer, this process is

otherwise known as Triage, Transfer and

Treatment. Thus the role assigned to hospitals

in external disasters is provision of care.

Providing care has two aspects; firstly the

hospital needs to increase its capacity and then

receive the patients and provide care, or

develop surge capacity and then receive, triage

and treat. The success of the hospital in this

process depends on whether or not the hospital

has had previous planning and preparedness,

this plan is called the hospital reception plan.

Hospitals need to activate their reception plan

in two instances; when the society is faced with

a mass casualty disaster and when a nearby

hospital has faced an internal disaster and

needs to be evacuated. The survival of

casualties in these cases is determined by two

factors; the transfer time and the ratio of

incoming patient load to the hospitals

reception capacity.

The hospitals surge capacity should be planned

in three levels. The first level is increased

capacity; at this capacity the hospital uses its

usual care capacity in addition to using unused

hospital spaces and some additional human and

physical resources. Increased capacity is usuallytwo to three times more than the hospitals

usual full capacity. The second level is the

augmented capacity which involves using

spaces outside the hospital as well as extensive

mobilization of human and physical resources,

and can increase the hospitals capacity up to

ten times. The final level is called the capacity

cap and involves increasing the hospitals

capacity to more than ten times using external

help and field hospitals among other things.

For developing increased capacity the hospital

needs to discharge all patients with favorable

health condition as well as all patients who are

admitted for elective procedures, thus a rapid

discharge protocol should be developed as part

of every hospitals reception plan. The hospitals

bed count should also increase; to achieve this,

extra beds can be put in corridors and common

spaces of the hospital, this is known as indoor

augmentation. The hospital must also have a

call in system that can alert all off duty

personnel in order for them to provide the

necessary extra man power. As for augmented

capacity, In addition to the increased capacity

measures, the hospital needs to use the

physical spaces available in its surrounding;


27/34



these include empty warehouses, schools and

etc, depending on whether the space used is

located within hospital perimeter or outside of

it, this increase of capacity is called outdoor and

off site augmentation, respectively. These sites

must be identified beforehand and the

necessary equipment should be stored nearby

so when capacity augmentation plan is

activated they can be rapidly transformed into

clinical spaces. Man power for this level is highly

dependent on volunteer forces as well as the

capacity provided by medical and nursing

students. However for the third level of surgecapacity, the capacity cap, hospitals will need

extensive external help, field hospitals must be

established and disaster medical assistance

teams should be deployed, this external help,

will involve local, national and even

international aid.

Surge capacity development, however, is not

limited to increasing the scale of hospitals

operations; it may as well involve increasing the

scope of operations as well. In case of external

disasters, the hospital may be forced to provide

services that it does not usually provide in

normal setting. This increment in scope needs

as much planning as increasing the scale of

operations and involves procuring equipment

and trained man power that are not

immediately available.

The process of devising a hospital reception

plan starts with determining the expected surge

need. To determine the expected surge need,

firstly the hospitals service area must be

defined, i.e. the geographical area which the

hospital serves and the population of that area

must be defined. The process is continued with

risk analysis and finally by scenario building. The

scenarios will give estimates of the potential

victim load of the disasters that are likely to

occur in the hospitals service area. This

potential victim load essentially determines the

expected surge need. The next step is to

determine the current hospital capacity by

performing a bed census and determining

factors such as average bed occupancy rate,

nurse to patient ratio and doctor to patient

ratio. The gap between the expected surge

need and the current hospital capacity is the

surge capacity which should be developedwhen the reception plan is activated.

To prevent a total collapse of hospital services

during a casualty influx caused by an external

disaster, in addition to surge capacity plan, the

hospital needs plans for triage and treatment of

the patients. The triage plan should indicate a

triage area within hospital as well as the triage

procedure that should be used in a mass

casualty event. The reception plan should also

include a specific plan for patient flow as well as

outlining the general treatment guidelines.

Figure 6. External Disasters in Hospitaals


28/34



5.2 Internal Disasters:

External and internal disasters demand

different aspects of protection. While in

external disasters the focus is on absorbing the

increased patient flow and continuity of service

delivery, in internal disasters, the priorities

change and protection of lives, capital and

functions become important.

The most important level of protection in aninternal disaster is protection of lives, which

includes the lives of both the patients and the

staff, as such in disaster planning, events should

be given priority that have the most potential to

harm lives. The second level of protection

involves lessening the financial impact of the

disaster, this is managed through capital

protection and finally the hospital must ensure

continuity of services which is otherwise known

as operations protection. It must be mentioned,however, that there are instances when

operations protection takes precedence over

capital protection; if there are no alternative

facilities that can provide care to the patients,

the hospital has a moral obligation to continue

providing services even if it leads to

considerable damage to the capital and

investment.

Protection of lives is achieved using a step wise

approach. This approach starts with threat

identification, i.e. the presence and the nature

of the threat towards the lives of patients or

staff must be identified. The next step is to

evaluate the threat (threat evaluation). In this

step the likely effects of the threat are

determined. These two steps combined will

outline the response and as such, they need to

be performed rapidly after an alert is received.

The third step, which is actually the first step in

responding to a threat, is threat neutralization.

If possible and in order to limit the effects of

the threat, the hospital staff using help from

external sources including firefighters, may

attempt at neutralizing the threat, however the

risks involved must be weighed and if the

attempt at neutralizing the threat might

possibly endanger even more lives, the staff

should refrain from this step. If no attempt at

threat neutralization is made or the attempt isunsuccessful, then the next step is threat

containment, which is intended to restrict the

threat from spreading further and thus limiting

the effects of the threat. Threat containment is

especially important in events such as fires or

chemical spills as well as epidemics or

bioterrorism attacks when quarantines help to

contain the threat. If containment is not

feasible, then the final step is evacuation. It

must be mentioned that if in the threatevaluation, the likely effect of the threat on

lives is deemed to be very large then evacuation

should be attempted early on in order to save

as many lives as possible, however, crisis

evacuation itself is a threat against the lives of

patients especially those with critical conditions

or when the outside conditions including the

weather are unfavorable. Thus evacuation

should be avoided if possible but if it is deemed

necessary it must attempted early on.Evacuation follows a stepwise pattern as well;

first step is horizontal evacuation, i.e. relocation

of patients and staff within the same floor and

away from the threat, however if the threat will

affect the whole floor, then vertical evacuation

is attempted, which should always follow a top-

bottom routine, i.e. it is preferable that in

vertical evacuation the evacuees are evacuated

to a floor nearer to the ground floor. Finally if


29/34



the threat is likely to affect the whole building,

then all of the hospital should be evacuated.

The stepwise approach to protection of lives

should be planned and rehearsed on regular

basis. The staff must be well trained and

frequent exercises will ensure their

preparedness. Protection of lives is the most

important element of hospital disaster plan and

requires the most effort from the staff and

managers alike.

For capital protection, there are two aspectsthat should be addressed. The first is structural

protection, which refers to efforts made at

stabilizing and saving the hospitals building and

structural elements from damage or collapse.

For examples these efforts include reinforcing

weight bearing columns and walls after an

earthquake until definitive repair can be

performed. Structural protection needs a team

of professional workers supervised by civil

engineers. The team must be chosen as part ofthe hospital disaster planning, and the hospital

must enter a contract with them, the team

should regularly inspect the hospital and all

structural plans of the hospital should be made

available to them. In case of an internal

disaster, the team supervisor must immediately

inspect the hospital, evaluate the structural

integrity of the hospital and determine the need

for repairs as well as precautionary or

emergency evacuation of the building. The

second aspect of capital protection is non

structural protection which involves removing,

relocating or protecting non structural elements

of hospitals. If possible all portable and valuable

assets (e.g. ultrasound machine) can be

evacuated from the hospital along with

patients. Although if non structural protection is

in conflict with protection of lives then it must

be abandoned as priority is always given to

lives.

The third level of protection is about ensuring

continuity of services (especially clinical

services) during and after a disaster. This is the

ultimate level of protection and ensures

continued functionality of hospital. On the

other hand, this is the hardest level of

protection to attain as well and needs extensive

planning and highest level of preparedness. The

first step in continuation of services isresumption of normal hospital functions and

delivery of services within the hospital. This is

the preferable site of service delivery if service

delivery is feasible and there are no immediate

threats to the lives of the patients or staff.

However if service delivery is temporarily

impossible inside the hospital, then the next

step is to provide care outside the hospital

building (preferably under a covered space with

protection from environmental elements). Thishowever will be a temporary medical site and

acts as a bridge until either service delivery

within hospital is possible or the patients are

relocated to another care facility. As such the

last step in service delivery is relocation. In

relocation the patients are distributed among

nearby hospitals and health care facilities.

Successful relocation depends on preplanning

and coordination before the disaster event.

Each hospital needs to identify nearby hospitals,

know their extra capacity and enter into

agreement with them for possible relocation

events.


30/34



Figure 7. Internal Disasters in Hospitals

5.3 Common framework for

hospital disaster plan:

Irrespective of the type of disaster the hospital

is facing, a common framework can be applied

in order to manage the disaster. This framework

is based on a set of generic procedures which

can be applied to most disasters, as well as a

series of procedures which are more specific to

external or internal types of disasters.

Each hospital needs to organize a hospital

resilience committee which is tasked with

protecting the hospital from disastrous events.

This committee will include two

subcommittees; the first is the planning

subcommittee which will perform risk analysis

and develop the hospital preparedness plan and

the second is the risk management

subcommittee which is tasked with designing

and implementing risk reduction and

preparedness projects.

Risk analysis starts with hazard identification

and analysis. In this process, all the hazards that

may threat the hospital or its inhabitants are

defined and the probabilities of those hazards

are determined. In the next step, for each

identified hazard, the vulnerabilities and the

capabilities of the hospital is determined, this

step will determine the likely impact of the

hazard on the hospital and its occupants. Finally

the hazards are prioritized based on the

likelihood that they will occur as well as the

possible damage and impact they will have, i.e.

high impact high probability hazards are given ahigher priority. The results of risk analysis are

used for both designing and implementing risk

reduction strategies and projects as well as

hospital disaster plans. Hospital disaster plans

should at least include the following plans: Fire

Plan, Evacuation Plan, Isolation Plan and

Reception and Surge Capacity Plan. Planning

should be performed at three levels, the first

level is the level of individual wards, the second

is planning at floor level and finally the thirdlevel is facility wide planning.

This common framework also includes

preparedness and risk reduction. The most

important element of preparedness is man

power preparedness which is attained by

training and frequent exercises. Through a gap

analysis, the necessary skills and knowledge

that staff members should learn are identified

and then through curriculum planning and

module development, a training program is

prepared for the staff. Drills include both field

drills and paper drills; with field drills exercising

and evaluating the skills of staff and paper drills

assessing the plans and the staff knowledge of

the plans. These drills not only help to increase


31/34



preparedness but they are themselves also a

measure of preparedness as well.

In this common framework, response is

organized not by the hospital resilience

committee but by the hospital incident

command system (HICS). The HICS system is the

corner stone of all hospital disaster plans and is

activated when a threat alert is received. The

HICS system is tasked with transforming HDPs

into action plans and implementing the

response.

Figure 8. Comprehensive Hospital Risk Management System


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References:

1. Milsten A: Hospital responses to acute-

onset disasters: A review. Prehosp

Disast Med2000;15(1): 3245.

2. Joint Commission on Accreditation of

Healthcare Organizations:

Comprehensive Accreditation Manual

for Hospitals: The Official Handbook.

Oakbrook Terrace, IL: Joint Commission

Resources; 2003. p EC-9.3. Joint Commission on Accreditation of

Healthcare Organizations:

Comprehensive Accreditation Manual

for Hospitals: The Official Handbook.

Oakbrook Terrace, IL: Joint Commission

Resources; 2003. p EC-21.

4. Mitigation Planning, How To Guide,

FEMA 2002

5. Department of Health Services of the

State of California. Quality improvement

system. 1992.

6. OSHA. Emergency Plans 29 CFR 1910.38

(a) and 1910.120 (1) (2). 1997.

7. Momeni A., Yusefi A., Khalighinejad

N., Comprehensive Risk

Management, WHO report, JPRM

project 2008

8. Disaster Medicine, Health and

Medical Aspects of Disasters,

Australian Emergency ManualSeries, 1999

9. Landesman, L.Y. Emergency

Preparedness in Health Care

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Documents

Emergency Hospital Service Delivery - JPRM 2011 - First Deliverable - English