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

Hospital Disaster Response Plan
Momeni A., Yousefi E.
June 2011
APW for developing SOP for hospital emergency service delivery First Deliverable - English
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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: amirmomenibr@yahoo.com
Amir Momeni MD, Project Manager June 2011
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Contents
Chapter 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.
review of benchmark countries is provided, from which we have chosen Turkey as the best benchmark country because while it has 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 the project shall proceed.
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
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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.
evidence that contributed to the conclusions drawn were listed as the references.
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 as well. 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 previous section 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
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 with hospital 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 a series 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, drought and 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 Drought Earthquake (seismic activity) Epidemic Drought ave. per event Earthquake (ground shaking) ave. per event Unspecified ave. per event Bacterial Infectious Diseases ave. per event Heat wave ave. per event Unspecified ave. per event Flash flood ave. per event General flood ave. per event Avalanche ave. per event Landslide ave. per event Unspecified ave. per event Local storm ave. per event Tropical cyclone ave. per event Scrub/grassland fire ave. per event
Killed 2 98 1
Total Damage (000 Affected US$) 37625000 3300000 18812500 1650000 2605604 26587.8 2500 1250 1285520 47611.9 1291066 92219 1075948 34708 44 14.7 100 100 19785 2473.1 13540 1692.5 15000 5000 408300 15122.2 253700 18121.4 6990528 225500.9 10518628 107332.9
147117 1501.2 76 76 296 148 158 158 3816 141.3 2689 192.1 1262 40.7 73 24.3 43 43 248 31 88 29.3 12 12 -
Extreme temperature Flood
1 27 14 31
Mass movement wet
3 1 8 3 1 1 -
Storm
Wildfire
160009 160009 -
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 an estimated 28 people died and 216,000,000 US dollars of damages were left behind.
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.
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.
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. Page 11
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
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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 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 some dynamic 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 define the 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.
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
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 Page 12
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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.
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 be placed nearby.
Figure 2. Progression of Vulnerability
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.
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
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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 actually capacity building does not directly decrease the disaster risk, but it improves and facilitates response to disasters and through this reduces the effects of disaster.
Figure 3 Approaches to Averting Disasters
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.
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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 and health 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
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 one of the priorities of the health system.
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
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 the influx 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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Figure 4. Internal and External Disasters in Hospitals
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.
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 and transporting 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.
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 starts with 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
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 Page 16
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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.
of the hospital. The three levels of protection are as follows: Life protection Investment protection Functionality protection
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 but it 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 financial cost 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).
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 the hospital. 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.
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
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 Page 17
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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.
damages and equipment are kept functional if feasible. Planning: Through 3. Organizational 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.
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 and consist 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
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Chapter 3: A review of benchmark countries

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.
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.
Studies have shown that Turkey enjoys a high level of hospital preparedness. Mehmet Top et al completed a study in 2010 in 251 hospitals and 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.
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:
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
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, Page 19
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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 better use 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.
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.
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.
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.
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.
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Chapter 4: A review of current situation in 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
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 operation centers at local, provincial and national levels.
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 incident command system. However these guidelines also have neglected hospital response plans and the issue of service delivery during emergencies.
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 a comprehensive 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
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 Page 22
June 2011 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 to external 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.
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 using structured 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 had disaster 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
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 Page 23
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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 of disaster 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.
has been either no documentation 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 the country. 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).
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.
Figure 5. Progression of Preparedness
Another weakness is lack of documentation; where there have been initiatives for augmenting preparedness or averting risk, there
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Chapter 5: Hospital Disaster Response Plan

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. There are 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 hospital functions 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 a disaster). 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 Page 25
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useful and adoptable at hospitals around the country. In the following sections of this chapter we have outlined this response plan.
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.
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 unprepared hospital, this issue is addressed in the reception plan of hospital disaster plan. 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 usually two 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.
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
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; Page 26
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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 surge capacity, 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.
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 developed when the reception plan is activated.
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.
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.
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
Figure 6. External Disasters in Hospitaals
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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 an internal 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 is unsuccessful, 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 threat evaluation, 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 topbottom routine, i.e. it is preferable that in vertical evacuation the evacuees are evacuated to a floor nearer to the ground floor. Finally if Page 28
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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.
be abandoned as priority is always given to lives.
For capital protection, there are two aspects that 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 of the 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
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 is resumption 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). This however 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.
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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.
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 a higher 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 third level is facility wide planning.
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.
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
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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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19. http://www.euro.who.int/en/where -we-work/memberstates/turkey/sections/news/2011/0 5/turkeys-health-system-has-a-highlevel-of-preparedness-for-crises,says-report-experience-gained-canhelp-other-countries/note-for-thepress 20. Regional Consultation on keeping hospitals safe from disasters, WHO/SEAR, 2008
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Hospital Disaster Response Plan

Momeni A., Yousefi E.

Hospital Disaster Response Plan

Momeni A., Yousefi E.

APW for developing SOP for hospital emergency service delivery

Amir Momeni MD. EHMTP Director Principal Investigator

Elham Yousefi MD. Technical Officer

Hospital Disaster Response Plan

Momeni A., Yousefi E.

Hospital Disaster Response Plan

Momeni A., Yousefi E.

Hospital Disaster Response Plan

Momeni A., Yousefi E.

Amir Momeni MD, Project Manager June 2011

Hospital Disaster Response Plan

Momeni A., Yousefi E.

Hospital Disaster Response Plan

Momeni A., Yousefi E.

Hospital Disaster Response Plan

Momeni A., Yousefi E.

Hospital Disaster Response Plan

Momeni A., Yousefi E.

Chapter 1: Disaster and its components

Hospital Disaster Response Plan

Momeni A., Yousefi E.

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

Extreme temperature Flood

Mass movement wet

Hospital Disaster Response Plan

Momeni A., Yousefi E.

1.2 Disasters in Iran:

1.3 Vulnerability versus Capability:

Hospital Disaster Response Plan

Momeni A., Yousefi E.

Hospital Disaster Response Plan

Momeni A., Yousefi E.

Figure 2. Progression of Vulnerability

Hospital Disaster Response Plan

Momeni A., Yousefi E.

Figure 3 Approaches to Averting Disasters

Hospital Disaster Response Plan

Momeni A., Yousefi E.

Chapter 2: Hospitals in Disaster

Hospital Disaster Response Plan

Momeni A., Yousefi E.

Figure 4. Internal and External Disasters in Hospitals

2.1 External Disasters and Hospitals:

2.2 Internal Disasters:

Hospital Disaster Response Plan

Momeni A., Yousefi E.

Hospital Disaster Response Plan

Momeni A., Yousefi E.

Hospital Disaster Response Plan

Momeni A., Yousefi E.

Chapter 3: A review of benchmark countries

Hospital Disaster Response Plan

Momeni A., Yousefi E.

Hospital Disaster Response Plan

Momeni A., Yousefi E.

Chapter 4: A review of current situation in Iran

Hospital Disaster Response Plan

Momeni A., Yousefi E.

4.3 Situation Analysis of current level of hospital preparedness in Iran: