Abstract
Introduction
The public healthcare system has its origins in the early days of mankind. Since then, it has seen regular evolution in normal environments or crisis caused by nature in the shape of disaster or diseases of an unknown nature. Such situations continue to cause significant impacts on community health, loss of life and the economy.
In the context of Community Health, the word disaster has many definitions and so are cures. The vast open natural hazards caused global crises situation where at times even health experts find it difficult to combat or even reduce its impact. The most recent disaster is COVID-19; the most advanced nations of the twenty-first century have failed to contain its spread from a particular locality to adjacent geographic areas, and due to the fast global connectivity mode, the disease has encompassed the entire planet.
Today, the entire world is in the grip of an explosive, disastrous situation caused by the pandemic coronavirus disease—COVID-19. Al Khalaileh et al. referred a definition given by Asian Disaster Center; disaster as a serious disruption of the functioning of a community or a society, causing widespread human, material, economic or environmental losses which exceed the ability of the affected community or society to cope using its own resources (Al Khalaileh et al., 2012). It originates from the Latin word ‘Astrum’, implying calamity due to misalignment of the star (Joshwa Bincy n.d.). The world finds its public health emergency preparedness inadequate to cope with the new untraceable virus causing and ferociously spreading infectious diseases.
Every country has its own set of potential disasters based on the hazards present, as well as the unique vulnerabilities of the community and the community’s preparedness to respond to particular disasters. It seems that with the world turning into a global village, country-wise compartmental confinement of hazardous diseases is no more a preferred option. A study by the United Nations Environment Programme (UNEP) indicates that the deaths and damages increased globally due to natural or manmade disasters have also increased the cost to the global economy, up to USD 50,000 million per year. The death toll may vary from year to year, with a global mean of 250,000 deaths, of which major disasters kill an average of 140,000 people per year. In the year 2020, the death figure due to the COVID-19 virus can be horrifying, because of the vulnerability of the population. India is one of the most disaster-prone countries.
The public health emergency devastation from COVID-19 has highlighted the importance of hospital disaster preparedness and response. There is always a prior need to decide the roles and responsibilities of healthcare workers for improved communication and appropriate planning. Timely training, retraining and community integration are also important aspects to deal with during any public health emergency.
Poverty, rapid urbanisation, population growth and lack of knowledge on the impact of hazards are key factors that increase human vulnerability to disasters. To reduce vulnerability, knowledge about the likelihood and consequences of hazards is required. Empowering individuals, communities and public agencies with knowledge on lowering risk and responding effectively in the event of a hazard is also required. Health emergencies can often be generally predicted, and plans can be implemented for disaster prevention, mitigation preparedness, response and recovery. Key issues include the extent to which the community and its environment are vulnerable to disaster, and how well they will be able to withstand the effects of its impact. This research is primarily focused on developing plans and response actions to deal with issues in hospital preparedness and resilience against public health emergencies in DHs and CHCs.
Methodology
We carried out a descriptive, cross-sectional study. The participants were health officials (doctors only) working at DHs and CHCs in Rajasthan. A semi-structured online questionnaire with 24 questions was e-mailed to 80 health officials. They were free to skip any question or quit the survey if they so desired. No human subject was directly involved or at risk during the survey, so no ethical approval was required for the study. Additionally, we explored the available published and unpublished data for situation analysis. The online survey was conducted using Microsoft Form 2016 and exported as an Excel sheet. After data cleaning, data analysis was conducted using IBM SPSS version 22.
Results
In all, 80 health officials working at various DHs and CHCs all over Rajasthan were sent the questionnaire, of which 58 responded, with a response rate of 72.5 per cent. It was our endeavour to distribute the questionnaire in an even manner, across urban, semi-urban and rural areas all over the state of Rajasthan. The response is a mixed one, comprising 56 male and 2 female health officials. All 56 male health officials (respondents) are in the age group of 30–60 years. The break-up of DHs and CHCs is 52 and 6, respectively. The district-wise break-up of the responses is: 10 from Jaipur, 8 from Pali and the remaining from other DHs and CHCs. Area-wise, 48 responses are from urban areas and 10 from semi-urban areas. The purpose of giving the break-up is to help understand the function and facility level of these DHs and CHCs under normal and emergency situations.
Public Health Emergency Preparedness
Most of the respondents, 62.1 per cent, understand that a disaster or public health emergency ‘exceeds the coping capacity of the community’, ‘interrupts the normal functioning of the community’ and ‘requires external assistance from the community to return to normal functioning’. They also opined that the main goal of “Safe Hospital Policy” is protecting the lives of patients and health workers by ensuring the structural resilience of health facilities. Regular health facilities will not function in the aftermath of emergencies and disasters. “Refer: Risk reduction capacity of health workers including emergency management” (Table 1).
Public Health Emergency Preparedness
Training
Regarding the preparedness of their facilities, it was found that in 58.6 per cent of the facilities, triage areas are marked and triages performed by almost all health officials and staff members (doctors, nurses or paramedics), as per necessity, in 55.2 per cent of the facilities. Isolation room and counselling facility on emergencies are available in 89.7 per cent of the DHs and CHCs for patients and family members. Data analysis indicates that in 37.9 percent facilities do not have fully equipped Isolation room to stabilize a critical patient. In 65.5 per cent of the facilities, an emergency stock of drugs and vaccines to deal with a public health emergency is always available in the pharmacy. As far as test facilities are considered, even general pathology tests’ availability is limited in 17 per cent of the DHs and CHCs only. Such facilities are freely available and easily accessible to everyone (Table 1).
Training
More than 93 per cent of the health officials emphasised the importance of the public health emergency training programme, while only 41 per cent of the doctors and managers are trained to deal with such incidences. On the other hand, 86.2 per cent thought that ‘healthcare workers have unconditional obligations to work with potential life risk’, and 75.9 percent opined that they need more training (Table 2).
Capacity to Deal with an Emergency
Of the responders, 68.3 per cent shared that their facility needs to coordinate with local authorities and 24.4 per cent felt that their facility needs to coordinate with non-government organisation/community representatives; the rest felt that their facilities have the potential to manage such incidences at their own level. These facilities are looking for support in the form of personal protective equipment (PPE) (30.8%), facility development (36.5%) and more training (32.7%) (Table 3).
Capacity to Deal with an Emergency
Prior Experience in Managing an Emergency
Prior Experience in Managing an Emergency
Although public health emergencies are not a common phenomenon, 33 per cent of the respondents each had faced their last disaster in the form of the H1N1 swine flu infection and the recent COVID-19 outbreak, 22.1 per cent had faced an accident (train/bus), 3 per cent had faced an earthquake or a flood, and the rest had had no prior experience with a disaster (Table 4).
Discussion
Public health emergencies are unforeseen events because it is not known when, where and how they are going to happen. They create turmoil, risk of injury or illness and loss of life. There is often a mismatch between resources and needs, amplifying the chaos, threats and losses when disasters or emergencies occur. Also, the figures and division of victims over time or location may differ. Research may help planners avoid frequent management loopholes, thus improving the response of disaster planning. Hospitals often have a major but also vulnerable function in public health emergency management.
Different parameters related to the preparedness and resilience of healthcare facilities were considered. According to the analysis, 58 responses were received out of the 80 questionnaires sent to health officials of DHs and CHCs, at a response rate of 72.5 per cent. The study explores the different risks associated with hospital preparedness and resilience at times of health emergencies. The review reveals significant gaps related to the preparedness of healthcare facilities at times of public health emergencies.
Health emergency planning starts with a broad analysis of risk and vulnerability assessment to classify the most likely threats to a particular hospital and community. Pre-established relationships between hospitals and other community response entities such as fire safety, law enforcement, public health and local government administration add to the probability of an integrated and effective response during a mass emergency.
As discussed by Daily et al. (2010), there is a need for a well-prepared healthcare system and for providers who can meet the needs of a population affected by a disaster or public health emergency. For disaster preparedness, continuous education and proper training are major foundation stones. Thus, training or educational programmes are to be developed to improve the knowledge and skills of healthcare providers regarding treating victims of disasters. These programmes are to be developed at the national and international levels.
While responding on preparedness and triage area, only 58.6 percent of the survey respondents agree that triage areas are marked, and 55.2 that triage is performed by a trained doctor, nurse or paramedical. Isolation room to stabilize a critical patient is not fully equipped in 37.9 percent of health facilities (Table 1). Merely a disaster plan in black and white does not equal preparedness. A written disaster plan without drills may create a sense of false protection among hospital personnel and community leaders. However, unannounced drills and exercises through proper training may be more effective, because emergency departments do not have the comfort of propositioning extra personnel, which often arises in the setting of an announced drill.
Alexander et al. (2005) elucidated that ‘rapid evolution of the scientific, managerial, and administrative skills necessary to deal with the threat of bioterrorism and other disasters resulted in a real need for additional training in basic bioterrorism response and disaster preparedness’ for public health providers. In the study also, it was concluded that more than 93 per cent emphasised the importance of the public health emergency training programme. Also, as suggested by Kizakevich et al. (2003), ‘Educational interference is more effective with a combination of discussion, interaction and simulation with patients’; trained public health professionals and medical emergency response teams work better and are well-coordinated at times of mass casualties.
A key concept in disaster management and planning is ‘emergency preparedness’ in hospitals. According to Hale and Moberg (2005), emergency preparedness can be established before a time of emergency, and this also must be equated with the capacity of a healthcare organisation. Education and workforce training objectives and approaches for emergency preparedness differ widely. There are no standards defined, and guidelines for the training of emergency preparedness do not exist. Gebbie and Qureshi suggest that ‘the first step toward emergency preparedness is the identification of “who” needs to know “how” to do “what”’.
While dilating upon impact of public health emergency on health facilities, 62 percent of the respondents opined that ‘exceeding the cooping capacity interrupts the normal functioning’ and ‘requires external assistance to return to normal functioning’.
As stated by Gebbie and Qureshi (2002), ‘No two emergencies or disasters are alike’. But in each situation, regardless of cause, the competencies nurses need to possess to respond effectively are essentially the same. According to Gebbie and Qureshi (2002), emergency and disaster preparedness ‘No two emergencies or disasters are alike’, but in each situation regardless of cause, the core competencies nurses need to possess for effective respond are essentially the same. We use the term, ‘emergency preparedness competencies’ to cover emergency-disaster preparedness and response skills. As said by Hsu et al, in his research paper mentions that no formal accredited standards for training of health care workers on disaster management are available but several training programs with diverse titles and plans do exist to combat disasters. Hospital resilience is an emerging concept that has been added to the hospital disaster management context. An emergency-resilient hospital is one that can resist, absorb and respond to the alarm of disasters and at the same time still hold on to its most essential functionality (i.e., pre-hospital care, emergency medical treatment, critical care, decontamination and isolation). As a result, the hospital can recuperate to its original status.
Alexander et al. (2005) also explain that an effective disaster response needs a well-synchronised and planned effort with well-qualified and trained professionals who can apply their expertise and skills in difficult situations. Such professionals having managed more than one disaster situations effectively developed skills to deal with emergencies or even disasters as a matter of routine on their workplaces.
Safe and resilient hospitals are those that offer services effectively, are structurally strong, are organised with contingency plans and continue to function at utmost capacity during emergencies. A health facility, whether a hospital or a clinic, should be a source of strength during emergencies and disasters. Its framework should be prepared so as to save lives and to continue providing important health services such as laboratory results, medicines, treatment and rehabilitation. During the analysis, it was found that an emergency stock of medicine, drugs, vaccines, etc. was always available to deal with a public health emergency in 65.5 per cent of the facilities. Health facilities though very important but are quite vulnerable to emergencies thus get debilitated risking the patients and healthcare workers. It is because of its complication in terms of structural, non-structural and functional components, high level of occupancy and exclusive equipment.
Rockenschaub and Harbou (2013) also revealed that the WHO has been promoting national and local ‘Safer Hospitals’ programmes for many years, resulting in global, regional and national policy commitments, offering technical guidance and also assisting managers in the assessment of the structural and functional safety of facilities and emergency preparedness to respond during disasters.
Mulyasari et al, reported “healthcare organizations play vital role in the psychological and socioeconomic revival of the disaster affected people”. They all are considered important because of their role in saving lives. They not only provide medical care at times of disaster but also save patients. Healthcare organisations must remain functional at times of hazards.
Zhong et al. (2014) expressed that disaster resilience in a hospital has four criteria, namely, redundancy, robustness, rapidity and resourcefulness. Hospital resilience aims to improve pre-event strength and promote recovery and rapidity of response, through resourceful strategies and redundant resources.
To improve hospital resiliency and readiness, the government’s role is crucial. In this regard, it is recommended that governments need to: (a) identify disaster-prone areas so that their hospital resiliency and readiness can be assessed; (b) prioritise hospital resiliency and readiness; (c) implement intervention measures; (d) prioritise/reassess the readiness and resilience of hospitals after implementing intervention measures; and (e) develop a framework to ensure that hospitals can maintain resiliency and readiness at all times, as observed by Zhong et al. (2014).
The entire world is in the grip of an explosive, disastrous situation caused by the pandemic COVID-19. According to Watkins (2020), ‘all countries should increase their level of preparedness, alert and response to identify, manage, and care for new cases of COVID-19. Countries should prepare to respond to different public health scenarios, recognising that there is no one-size-fits-all approach to managing cases and outbreaks of COVID-19’. Each country should assess its risk and rapidly implement the necessary measures at the appropriate scale to reduce both COVID-19 transmission and the economic, public and social impacts. According to Dharmshaktu (2020), most of the large religious places in India have been closed as a precaution but a great number of such worshipping places are still open, where special precautions are required. However, a big crowd can be infected by a sick person joining the crowd.
During the analysis, the responders also shared their view that public health emergencies are not a common phenomenon; 33 per cent each had faced their last disaster in the form of the H1N1 swine flu infection and the recent COVID-19 outbreak, 22.1 per cent had faced an accident (train/bus), 3 per cent faced an earthquake or a flood, and the rest had had no prior experience with a disaster. Developing the concept of ‘hospital resilience’ will provide a starting point for what it comprises and how to measure it. The new concept links these key components with an achievable goal to improve hospital pre-event robustness as well as rapidity to recover and adapt for disaster.
Further, consensus on key measures of hospital resilience would improve the consistency of hospitals’ emergency practices and empower them with an improved ability to cope with disasters of all kinds, including a pandemic like COVID-19.
Limitation
The present study is confined to the government DHs and CHCs of Rajasthan only, as the researchers cannot include other states due to limitations of time, resources, etc. The study is confined to public hospitals of Rajasthan only, and the tools and techniques applied in the research depend on the researchers’ resources. The findings of this study are limited by the sample size and quality of the information provided by the healthcare providers surveyed.
Conclusion
Research on disasters or health emergencies is in its primitive stage. Not much has been written about this phenomenon. Advanced studies are needed to better understand not only detailed skills such as basic clinical care and triage but also, more importantly, the transitions that are experienced by providers during emergencies. To achieve efficacy in disaster planning, one must have in-depth knowledge and skills as to ‘what emergency preparedness and professional competencies are required and also that ‘what knowledge, skills, and abilities are needed’. Therefore, each country has to raise its level of awareness to recognise and deal with health emergencies’.
The main objective of this study was to determine and analyse how prepared healthcare providers and hospitals are to deal with unforeseen disasters like COVID-19, in terms of their knowledge, skill competencies and infrastructure. The outburst of COVID-19 has created a global health crisis, which is having a profound impact on the way we perceive our world and on our everyday life. This research establishes that the level of emergency preparedness in terms of knowledge and skill competencies ranges from little to moderate in healthcare providers.
In the light of the established data, more than 93 per cent of the respondents stressed on the significance of the public health emergency training programme, whereas only 41 per cent of the doctors and managers were actually trained to deal with such incidences. Therefore, it is highly important to focus on proper training and education. Clinical care, on the other hand, varies, as a triage area was marked but the isolation room was not fully equipped to stabilise a critical patient. However, there was the availability of an emergency stock of medicines to deal with a health emergency. Nevertheless, testing facilities were limited to 17 per cent only.
It is also an established fact that self-efficacy of healthcare providers is predominantly significant for effective handling of all types of health emergencies, and for that, mental well-being is very important to provide holistic care to the patients.