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Abstract

Background:

Hospitals play a critical role in providing communities with essential medical care during disasters.

Objectives:

In this article, the key components and recommended actions of WHO (World Health Organization) Hospital emergency response checklist have been considered to identify current practices in disaster/emergency hospital preparedness in actual or potential incidents.

Methods:

Articles were obtained through bibliographic databases, including ISI Web of Science, PubMed, Science Direct, Scopus, Google Scholar, and SID: Scientific information database. Keywords were “Disaster,” “Preparedness,” “Emergency Preparedness,” “Disaster Planning,” “Mass Casualty Incidents,” “Hospital Emergency Preparedness,” “Health Emergency Preparedness,” “Preparedness Response,” and “Emergency Readiness.” Independent reviewers (F.R. and M.H.Y.) screened abstracts and titles for eligibility. STROBE (STrengthening the Reporting of OBservational studies in Epidemiology) checklist was used to qualifying the studies for this review.

Results:

Of 1545 identified studies, 26 articles were implied inclusion criteria. They accounted for nine key components and 92 recommended actions. The majority of principles that had been rigorously recommended at any level of the hospital emergency preparedness were command and control and post-disaster recovery. Surge capacity was considered less frequently.

Conclusion:

We recommend considering the proposed disaster categories by FEMA (Federal Emergency Management Agency). In this framework, different weights for nine components can be considered based on disaster categories. Thus, a more valid and reliable preparedness checklist could be developed.

Keywords

Hospitals disasters mass casualty incidents preparedness

Introduction

During a disaster, health care facilities in an affected area can fall into a functional decline. If hospitals are damaged by a major disaster, hospital functions and activities may see a marked decrease, and immediate external support may not always be available. The sudden halt of all hospital activities not only endanger patients’ lives and the continuity of care for the surrounding community, but can also affect hospital staff and associated suppliers. Therefore, it is necessary for a hospital to maintain critical activities, even in an unexpected crisis. Hospitals across countries increasingly understand their role in emergency preparedness to improve the capability and capacity before a major incident.^1–3

Disaster impact on health sectors causes secondary disaster as a result of damages to the health facilities. Hospital failure to withstand also creates huge impacts on the health system due to collapse of health services, delay in the treatment of trauma injuries, collapse of emergency functions, and obstruction of ongoing public health and sanitation campaigns.⁴ Post-disaster impacts on hospitals differ due to several factors, such as type of disaster, vulnerability and capacity of the health system, and risk-related conditions.⁵ For example, hospitals’s response to the Great East Japan earthquake and subsequent disasters could hold sustainability in the society as previous preparedness in aspects of human recourse, safety and security, continuity of essential services, logistic and supply management, surge capacity, and triage.⁶ In this article, key component of World Health Organization (WHO) guideline of hospital preparedness in mass causality incidents and disasters has been reviewed that could be used in emergency preparedness planning.

Method

Search strategy

Published articles were searched in English languages. The search entered studies from April 2011 up to December 2016. Studies obtained through bibliographic databases, including ISI Web of Science, PubMed, Science Direct, Scopus, Wiley Online Library, Google Scholar, ISD (SID: Scientific information database), and other Governmental, databases and websites. Keywords were used in the search were “Disaster”, “Preparedness” and related terms included “Emergency”, “Disaster Planning”, “Mass Casualty Incidents”, “Hospital”, “Health”, “Response,” and “Readiness.” The selection of these terms was made with the help of MeSH service in PubMed website databases.

Data extraction

Independent reviewers (F.R. and M.H.Y.) screened abstracts and titles for eligibility. When the reviewers felt that the abstract or title was potentially useful, full copies of the article were retrieved and considered for eligibility by both reviewers. If discrepancies occurred between reviewers, the reasons were identified and a final decision was made based on third reviewer (M.M.) agreement in a blinded way.

Eligibility criteria

Studies that used qualitative and quantitative methods focusing on measuring or evaluating the concept of hospital preparedness were included. The first inclusion criterion was articles that comprised hospital-based emergency management principles and best practices and integrates priority action developed by WHO Regional Office for Europe to assist hospital administrators and emergency managers in responding effectively to the most likely disaster scenarios. This tool is structured according to nine key components each with a list of recommended actions (RAs): (1) command and control (CC) with 6 RAs; (2) communication (C) with 9 RAs; (3) safety and security (SS) with 11 RAs; (4) triage (T) with 10 RAs; (5) surge capacity (SC) with 13 RAs; (6) continuity of essential services (CES) with 8 RAs; (7) human resources (HR) with 15 RAs; (8) logistics and supply management (LSM) with 10 RAs; and (9) post-disaster recovery (PDR) with 9 RAs.⁷ The information of articles was extracted and then categorized regarding to the key components and RAs of the WHO checklist (Tables 1 and 2). The percentage of the included RAs for each key component indicated in Table1. For example, if an article discussed about three recommended actions (RAs) of command and control (CC), the percentage of included RAs would be 42.8%.

Table 1.

An overview of characteristics of articles included.

Authors	Year	Study type	Location	Sample size^a	Hospital type	Disaster type	Key components/percentage of included RAs									STROBE score
Authors	Year	Study type	Location	Sample size^a	Hospital type	Disaster type	CC	C	SS	T	SC	CES	HR	LSM	PDR	STROBE score
Aladhrai et al.⁸	2015	Cross-sectional	Sana, Yemen	11	7 Public hospitals, 4 private hospitals	Revolution 2011 (AI)	100	100	100	100	100	100	100	100	100	73%
Apisarnthanarak et al.⁹	2013	Cross-sectional	15 Central provinces, Thailand	104	Secondary and tertiary care hospital	Flooding (N)	42.8	–	–	–	–	–	13.3	10	–	73%
De Jong et al.¹⁰	2014	Cross-sectional	38 European, Turkey, Israel	236	Primary, secondary, or tertiary care	Ebola virus pandemic (N)	42.8	11	18	10	–	–	6.6	20	–	73%
Leonhardt et al.¹¹	2015	Cross-sectional	Wisconsin, USA	225	Not mention	Ebola virus pandemic (N)	100	55.5	36.3	30	7.6	25	60	60	–	68%
Martin et al.¹²	2015	Cross-sectional	England	112	Acute National Health Service (NHS) hospital	Ebola disease (N)	28/5	11	18	–	–	–	13	10	–	77%
Mortelmans et al.¹³	2014	Cross-sectional	Belgium	100	Hospitals with an emergency department (ED)	Chemical, biological, radiation, and nuclear incidents (AN)	28.5	–	45.4	–	7.6	–	33.3	10	–	77%
Mulyasari et al.⁵	2013	Cross-sectional	Tohoku and Nankai, Japan	14	Hub Hospitals and General Hospitals	Earthquake (N)	–	22	9	10	30.7	25	6.6	10	11	68%
Murakawa⁶	2013	Case study	Fukushima, Japan	1	Medical University Hospital	Fukushima earthquake (N)/nuclear power disaster (AN)	14.2	22	45.4	20	38.4	50	13.3	20	22.2	50%
Niska and Shimizu¹⁴	2011	Cross-sectional	United States	395	Non-institutional, nonfederal, acute care, and short-stay hospitals	Epidemics and pandemics (N)	14.2	22.2	–	10	30	12/5	13/3	20	–	77%
Reidy et al.¹⁵	2015	Cross-sectional	Republic of Ireland	46	Acute public and private hospitals	Influenza pandemic (N)	42.8	–	9	–	7.6		60	10	–	86%
Shokouh et al.¹⁶	2014	Cross-sectional	Tehran, Iran	15	Affiliated hospitals with Shahid Beheshti University of Medical Sciences	Earthquake (N)	14.2	–	9	–	7.6	12.5	6.6	10	–	68%
Scarfone et al.¹⁷	2011	Case study	Delaware Valley, Philadelphia, USA	1	The urban, tertiary care children’s hospital	Pandemic influenza A (H1N1) virus (N)	28.5	33.3	54	40	38	12.5	20	30	–	68%
Verni¹⁸	2012	Case study	Great Neck, New York, USA	3	North Shore Long Island Jewish Health System—flood-prone zones hospitals—nonprofit, secular	Hurricane Irene (N)	71.4	22.2	27.2	10	46	25	20	40	44.4	64%
Valesky et al.¹⁹	2013	Cross-sectional	Cape Town, South Africa	9	RICU, NICU, MICU, general medical/surgical beds in each hospital	FIFA World Cup tournament gathering (AN)	–	–	–	–	15.3	–	–	–	–	86%
Cheng et al.²⁰ and Chen et al.²¹	2016	Case study	New Taipei, Taiwan	1	A tertiary care teaching hospital	Dust explosion (AN)	57	–	–	20	7.6	–	6.6	10	–	68%
Bolster et al.²²	2016	Case study	Seattle, USA	1	Trauma center, radiology department	Highway accident (AN)	57	–	–	–	–	–	–	–	–	50%
Haverkort et al.²³	2016	Case study	Utrecht, Netherlands	1	A governmental major incident hospital (MIH)	Flooding (N)	71	22	9	–	15	12.5	20	10	11	77%
Carles et al.²⁴	2016	Cross-sectional	Nice, France	2	Children Hospital, Pasteur adult Hospital	Terrorist attack (AI)	42	–	–	30	–	–	6.6	–	–	45%
King et al.²⁵	2016	Cross-sectional	New York, USA	7	Intensive care unit (ICU)	Hurricane Sandy (N)	28	–	–	10	–	62	13	–	–	91%
Hang et al.²⁶	2016	Case study	China	1	General hospital, burn department	Terrorist attack (AI)	14	22	–	10	7.6	–	6.6	20	–	73%
Harper and Rehman²⁷	2016	Case study	Philadelphia, USA	1	Not mentioned	Amtrak derailment (AN)	28	22	9	60	–	12.5	6.6	–	–	86%
Gregan et al.²⁸	2016	Case study	Christchurch, New Zealand	1	Public tertiary hospital	Earthquake (N)	–	11	–	–	–	25	20	26	11	68%
Moughrabieh and Weinert²⁹	2016	Cross-sectional	Aleppo, Syria	5	Trauma centers, relief donation hospital	War (AI)	–	22	–	–	–	–	20	–	–	54%
Valerio et al.³⁰	2016	Case study	Verona, Italy	1	Not mentioned	Mass CO poisoning (AN)	14.2	11	–	20	12.5	–	13	10	–	77%
Eyre et al.³¹	2016	Quantitative–qualitative	Boston, USA	6	Academic-affiliate community hospital, pediatric and adult trauma centers	Explosions (AI)	–	–	–	–	12.5	–	–	–	–	68%

STROBE (STrengthening the Reporting of Observational studies in Epidemiology) N: naturals; AN: anthropogenic non-intentional; AI: anthropogenic intentional; CC: command and control; SC: surge capacity; HR: human recourses; LSM: logistics and supply management; CES: continuity of essential services; T: triage; C: communication; SS: safety and security; PDR: post-disaster recovery; RICU: respiratory intensive care unit; NICU: neonatal intensive care unit; MICU: medical intensive care unit; CO: Carbon monoxide.

Hospital(s) and Trusts/Trusts: NHS hospitals in England are managed by hospital trusts, which represent one or more hospitals in a geographical area.¹²

Table 2.

Examples of the key components and recommended actions from the included studies.

Authors	Key components	Recommended actions
Verni¹⁸	CC	Identifying and training of additional backup personnel for emergency operations center, improving the rotation schedule and stagger shift changes (enough rest of decision makers), deferring decision-making in any given instance to leaders in the individual hospitals and other facilities that had the data and on-the-ground access, activating health system emergency plans and emergency operation plan a transport officer manually checked identification wristbands against charts and confirmed that the patient was about to be transported to the assigned facility and in the appropriate vehicle type, having job action Tool (a checklist of tasks and responsibilities for people assigned to a regional command center), staffing emergency operation center with high level health system leaders.
	C	Communication issues between city agencies slowed the evacuation (road closures enforced by the New York Police delayed ambulances and buses) until health system officials reached police radio dispatchers, updated master lists were periodically sent to the Emergency Operations Center for patient tracking purposes and backup information established between city agencies
	SS	functional evacuation plan, automated patient tracking (bar-coded wristbands), and many plans follow a 1:1 matching system and consider this system to be only a last resort
	T	overhauling the matching patients to beds on a 1:1 basis plan with triage, developing protocols for streamlined screening of people who do not seek emergency medical care
	SC	Group transport of patients with similar needs to facilities that could accommodate them instead of matching of patients, each hospital would know in advance the types of patients it should prepare to receive and have beds, supplies, and staff ready with this SC model, emergency management of leaders have been consulted by numerous outside institutions and reviewed others’ evacuation plans, rapid discharge and surge planning, elective admissions and surgeries were cancelled
	CES	evacuating, transporting, and placing of patients without any deaths/injuries, risks of evacuating patients—especially the elderly, infants, and those requiring critical care, housing many homebound people whose needs could not be met in a shelter, including mechanically ventilated people who feared the loss of power at their homes.
	HR	Surveying all employees—collecting detailed information on all licensures and certifications—to better use people’s skills during emergencies, mandating full-scale interfacility evacuation drills, upgrading employee advisories to alerts, low absenteeism among health care workers, detailing personnel readiness actions
	LSM	Emergency leasing and purchasing of equipment and supplies, transporting patients by advanced and basic life-support ambulances, ambulettes, and public and private buses, trucking in extra beds borrowed from an unaffiliated, shuttered hospital
	PDR	improving Design of Flood-Prone Facilities (information technology, power generators, and critical patient service areas, such as radiology, above ground level, with electrical systems built from the top down and heating. Heating, ventilation, and air-conditioning systems with connections to backup power supplies, blizzards, and other weather emergencies). conducting “hot washes”—retrospective reviews of what happened with each part of the system’s command structure and each facility. Filing reports, evaluating and prioritizing procedural and training needs arisen from the experience, filing post disaster RECOVERY CHECKLIST (including access, buildings, communications, equipment and supplies, facilities and engineering, infection control, ancillary services, security, patient care areas, and surgery and treatment areas), estimating overall cost by finance officers
Leonhardt et al.¹¹	CC	Establishing an organizational response team included leaders, experts, and frontline health care providers from the organization potentially affected by EVD, strategic priorities of health systems’ plans were on the basis of the framework recommended by the CDC: identify possible EVD cases, isolate the patient, and inform the authorities, control. Ebola plan and all associated forms were vetted through a team of experts including senior clinical leaders, compliance, risk management, and the legal department, implementing Ebola plan through site-specific operations, developing procedures for donning and doffing PPE, developing clinical policies, procedures, and protocols for the treatment of patients with EVD, referring unresolved issues to professional advisory councils comprising public and private health care providers, emergency medical services, laboratory services, and waste management, To accommodate the rapid change, the plan included separate appendices, coalition was established to ensure dissemination, coordinating and implementing guidelines, each team member was responsible for monitoring of external references (i.e. CDC) and submitting revisions to their respective section of the plan, continuous plan review, vetting, and approval before dissemination of the plan, training and drills, receiving feedback from frontline HCWs and patients during implementation of the plan and made adjustments, detailed making written instructions and videos available to HCWs, evolving PEE requirements and guidelines. Aurora and UW coordinated their plans on the basis of best practices from experienced health systems, reviewing of the literature, and available equipment
	C	Developing a system-wide communication approach, making relations with community and media, conveying Ebola plan and preparedness activities to HCWs, verifying compliance and preparedness at clinical sites, coordinating and disseminating internal communications, developing patient education materials (posters), providing site-based infection prevention guidance, media management, and alerts, the plan was posted electronically, making accessible to all HCWs through their respective system’s intranet, local health departments participated regularly in web-based meetings organized by the Wisconsin Department of Health Services, regional symposium of health leaders from public and private sectors took place, general education through online curricula, grand rounds, and a website, onsite education in the clinics, urgent care, and emergency departments using training materials developed by infection prevention experts, the simulation center at UW Health and Aurora’s assessment facility were used for the core members of the team who would be called upon to treat a patient with EVD, conducting conference calls and meetings
	SS	Establishing preparedness nad prevention teams implementing rigorous infection prevention practices, creating processes for testing of potential and confirmed EVD patients, defining security and visitor policies, patient transportation, visitor control, and education was provided on new human resource policies that were developed to ensure patients and HCWs were protected from unintentional risk
	T	preparing site for patient with potential EVD, harnessing the electronic health record (EHR) to screen and triage patients with the relevant travel history and symptoms of possible EVD, monitoring implementation of plan, enacting procedures to enhance early identification of potential EVD patients (screening), standardizing universal screening process, developing screening criteria, and tools in EHR
	SC	Preparing sites with laboratory testing
	CES	coordinating efforts through public health collaborations, waste management, and safe disposal of all hazardous wastes, The alliance between Aurora and UW Health was facilitated by existing professional relationships.
	HR	Addressing human resources and policies, establishing advisory councils that included infectious disease physicians and infection prevention experts, preparing the sites with education, supplying of (PPE), defining visitor policy, training HCWs, providing HCWs with basic education regarding the epidemiology and transmission of EVD, preparing clinical teams to treat potential or confirmed EVD cases, identifying precautions to protect HCWs exposed to potential and confirmed EVD patients, providing consultation to all subcommittees, training, creating online education, conducting train-the-trainer sessions across both systems: PPE donning/doffing, developing drills curriculum, return to work policy for exposed employees, refusal to work policy, conducting and monitoring drills to ensure compliance throughout both organizations in emergency departments and treatment center facilities, contracting with ambulance services and environmental care teams, training the clinical care teams, selecting and purchasing of appropriate PPE, limited guidelines on PPE, which were modified frequently and did not account for the varying levels of exposure risk for HCWs, requiring education for HCWs and patients, reiterating infectious prevention practices to ensure that HCW compliance would meet the criteria for reducing the risk of transmission
	LSM	ensuring PPE availability at clinical sites, prioritizing resources for highest risk clinical settings, developing ambulance contracts for patient transport, specimen collection, and transportation processes, defining appropriate PPE for various clinical situation, ordering and distributing PPE across system, identifying facility and physical plant requirements, coordinating local health department with acute care health facilities in their municipal jurisdictions to ensure that these facilities were prepared to care for EVD patients and prevent transmission to HCWs, PPE was in short supply, limited availability of equipment, especially for hoods and powered air-purifying respirators, sourcing and obtaining the PPE supplies was a major endeavor conducted by the logistics department at each organization
Haverkort et al.²³	CC	Three levels of command were defined: (1) the Crisis Management Team (CMT): responsible for external communication and the continuity of the processes in the adjoining hospitals. (2) The Crisis Coordination Team (CCT): assessing continuity of care in the hospitals and the availability of resources and personnel. (3) The Command Team, led by an on call the trauma surgeon, having an emergency response protocol enables admittance of up to 100 patients after a start-up time of only 15 min. Doctors and nurses were trained for commanding in the wards
	C	Meetings took place regularly with coordinating staffs the Command Team and department supervisors provided situation reports, made crucial decisions, shared the information, and discussed bottlenecks of departmentsthere was one mobile phone with the pager for every person, wireless phone system, private GSM network, and walkie-talkies for communication between the ambulance hall and trauma bays were provided
	SS	The patient barcode registration system integrated with the hospital information system
	SC	The Command Team should actively report the hospital capacity to the medical center of the university and dispatch center. The referral hospital was operational for of 3–5 days. Patients were discharged or referred to another institution with an adequate level of care to expand the capacity
	CES	Electric power, elevators were out of order, systems for heating, distilled water, hot and cold water for consumption and steam production, were destroyed
	LSM	The hospital in this case was alerted 5 h before receiving the first patient. Announced patient counts varied between 40 and 100. Patients’ arrival within every 15–30 min by five ambulances undertook under police guidance
	HR	Permissions for external staff to work in the referral hospital faced with legal problems. Therefore, they were not allowed to prescribe medicine and request examinations. Therefore, dual treatment responsibility appeared. After making an agreement, the chair of the external surgical department played a role of external advisor for effective communicating with the evacuated hospital and personnel management. Volunteers from the Dutch Red Cross were available in patient care and transport. An aftercare team for personnel addressed the emotional impact of major incident victim relief
	PDR	It took 2 weeks to build temporary utility systems, repair elevators, and execute security and stability checks in the evacuated hospitals.
King et al.²⁵	CC	Incident command leadership role was defined for ICU evacuation, the ICU evacuation leaders were preferred rather than the chief medical officer, the Incident Commander, emergency medical services, federal authorities, in regional hospital evacuation planning before the hurricane was assessed
	T	Patient triage was performed using predetermined ICU evacuation criteria
	CES	ICUs of hospitals had been evacuated because of the hurricane, manual documentation of ICU resource requirements was conducted for each patient during evacuation (flashlights, Med Sleds/transport devices, oxygen tanks/RT supplies, portable ventilators, walkie-talkies/phones, batteries, etc.), medications were sent with the patient for transport time or 24 h, limited appropriate means of disposing dead bodies while evacuation were noticed. Common transfer forms used instead of disaster forms; continued care in transport or receiving facility was evaluated
	HR	Lack of water, food, and toilets cause to personal issues (concern regarding family members) during ICU evacuation

CDC: Centers for Disease Control and Prevention; CC: command and control; SC: surge capacity; HR: human recourses; LSM: logistics and supply management; CES: continuity of essential services; T: triage; C: communication; SS: safety and security; PDR: post-disaster recovery; HCW: health care worker; PPE: personnel protective equipment; CBRN: chemical, biological, radiological, and nuclear disasters; EVD: ebola virus disease; ICU: Intensive care unit.

Second inclusion criterion was assessment of hospitals preparedness based on any real disaster or real potential hazard and vulnerability. Study population was hospitals, departments of hospitals, or specialized services for hospitals (like pediatric). As WHO hospital emergency response checklist developed in 2011 and hospital-based emergency preparedness principles have changed or updated alternatively, articles before this year were excluded.

Quality assessment and risk of bias

The quality of the included cross-sectional studies was examined using the statement of strengthening the reporting of observational studies in epidemiology (STROBE).³² It assigns 22 items to each observational study: two for introduction and background, nine for method, five for results, and four for discussion. The quality of case study was assessed by Case Study/Case Series Checklist approved by the Institutional Review Board Guidance Document University of Texas at El Paso.³³ It contains eight-points to each case study. The guideline of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was used to prepare scientific writing.³⁴

Statistical analysis

The main outcome variables were measures of percentage and 95% CI for the estimate of hospital preparedness according to nine key components each with a list of recommended actions (RAs). All nine components were equally important according to WHO checklist.⁷ Using random-effects model was applied to estimate variation between-study, the overall effect size was calculated. Between-study heterogeneity was assessed using Cochran’s Q-test and I² statistic. In case of significant between-study heterogeneity, we used subgroup analysis to find out the possible sources of heterogeneity. Publication bias was examined by visual inspection on Begg’s funnel plots. All statistical analyses were conducted using STATA12 (STATA Crop., College Station, TX, USA). P-values <0.05 were considered statistically significant.

Results

A total of 1545 articles were extracted (Figure 1). Of these, 74 papers were selected as potential studies based on their titles and abstracts. However, after reviewing full text paper, only 26 of those actually fulfilled the inclusion criteria. The main reasons for exclusion were (1) not assessing any real disaster, Mass casualty incident (MCI), or real potential hazard, and (2) assessing preparedness outside the hospitals, departments of hospitals, or specialized services of hospitals. All studies focused on hospital preparedness in different types of real or potential disasters.

Figure 1.

PRISMA 2009 Flow Diagram.

The included studies accounted for 9 key components and 92 RAs. Details of each study and their special features are provided in Table 2.

Eleven papers were case studies and 14 of them were designed as cross-sectional. In selected studies, 1047 hospitals in 50 countries surveyed. Types of included disasters were natural hazards such as atmospheric, geological, hydrological, extraterrestrial and biological, anthropogenic non-intentional (AN) such as technological, hazardous materials, and anthropogenic intentional (AI) hazards such as mass shootings.³⁵

Table 2 demonstrates exact description of RAs in the studies. For example, if you want to understand what were the results of Apisarnthanarak et al.’s study in the field of CC, you can see that they focus more on incident command group, prospective replacements of directors, focal points, and consultation core internal and external documents. Figure 2 shows forest plot of nine key components based on disaster types (naturals (N), AN, and AI).

Figure2.

Results of meta-analysis on key components and recommended actions by disaster type.

The homogeneities appeared mostly in AN disaster type. The overall effect sizes of five key components in the studies that worked on AN disaster type were as follow: CC(33.2%), CES(31.25%), T(28%), C(18.33%), and LSM(10%). The highest score related to command and control (CC). For example, this means that 33.2% of disaster preparedness concepts were dedicated to CC in the studies that worked on AN. In natural disasters, just the effect size of PDR (16.27) was considerable. These values and units can be clearly seen in Fig 2 and the supplementary material.

Discussion

This systematic review evaluated the hospital preparedness according to WHO guideline. The finding indicated that order of key components applied in all disasters was PDR (46.17%), CC (41.76%), SS (27.34%), C (26.6%), LSM (24.73%), HR (24.07%), SC (20.26%), CES (18.96%), and T (16.28%) (Figure 2).

The finding surprised us based on homogeneity analysis was that CC and CES identified as the first priorities for hospitals to deal with. They covered most of disaster preparedness concepts. However, LSM received the least attention (Figure 2). This might be due to the routine duty of LSM for the hospitals. LSM is critical for hospitals even in circumstances where no hazardous condition is going to threaten them. However, during disaster, CC received higher importance as these concepts play a critical role in hospital disaster management. In addition, as the most of disasters happened out of hospitals and they must be responsive after disaster, CES could get the high priority for hospitals to deal with. The other factor might be due to retrospective report of incident in 26 articles. Thus, studies dealt with CSR challenges and function more.

Aladhrai et al.⁸ applied 100% of key components and recommended actions (RAs) in their study as they use checklist of WHO to review the impact of revolution on hospital preparedness (Table 1). Pay attention to other 25 studies (Table 1), it is clear that some hospitals in territory of United State got the highest score in applying key components of CC,C,SS, SC, CES, LSM, and PDR. However, HR got the highest score in Ireland. In addition, CC, C, SS, HR, and LSM components got the highest score in hospitals that have to deal with epidemic and pandemic disasters. Therefore, this means that during epidemic prone disasters, hospitals pay more attention to these components. However, SC, CES, and PDR got the highest score in hospitals that have to deal with hurricane disasters. These results are reasonable as in disasters such as hurricane, infrastructures at hospitals, structural safety, and medical equipment would be destroying by disasters. Therefore, hospitals got in trouble in providing essential services. However, during epidemics and pandemic, hospitals do not affect by disasters. But, lack of enough personnel and communication with people and media, and safety and security provision for the personnel is more important.

Weak studies based on STROBE checklist were Murakawa,⁶ Bolster et al.,²² Carles et al.,²⁴ and Moughrabieh and Weinert.²⁹ In these studies, risk of bias may cause to lower score of the checklist. The strategies in the literature, which applied recommended actions (RAs) in real disaster fields, are shown in Table 2. Command and control is the benchmark for hospital emergency management. Coordinated health-sector response to an emergency requires having permanent Hospital Emergency Committee (HEC). HEC is responsible for developing the Hospital Emergency Risk Management Program (HERMP) and establishing an incident command group. The Federal Emergency Management Agency (FEMA) framework suggests planning sections as follows: assignment of responsibilities, command and control, information management, communication, introductory material, purpose of the plan, planning assumptions, the concept of operations, administration and finance, plan development and maintenance, and authorities.^36,37

Conclusion

We recommend using the proposed disaster categories suggested by FEMA. In this framework, different significant weights for each nine-component can considered base on disaster categories and then evaluate a more valid and reliable preparedness scores.

Another important point is that countries have different vulnerabilities to each nine key components. For examples, low and middle-income countries might be more vulnerable to disasters that threat their infrastructures and CES component appear to be more important. As a result, it is better to focus on interpretation and justification of why some components are more important in each of health systems. Future research could be implementing based on vulnerable components that have paid less attention in the literature.

Supplemental Material

HKJ760123_online_supplement – Supplemental material for Hospitals preparedness using WHO guideline: A systematic review and meta-analysis

Supplemental material, HKJ760123_online_supplement for Hospitals preparedness using WHO guideline: A systematic review and meta-analysis by Fatemeh Rezaei, Mohammad Reza Maracy, Mohammad H Yarmohammadian and Hojat Sheikhbardsiri in Hong Kong Journal of Emergency Medicine

Footnotes

The authors solely did the research with no assistance of any other individuals or research center. The STROBE and PRISMA checklist was used in this article.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research,authorship,and/or publication of this article.

Funding

The author(s) received no financial support for the research,authorship,and/or publication of this article.

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