760123

review-article2018
HKJ0010.1177/1024907918760123Hong Kong Journal of Emergency MedicineRezaei et al.

Review Article

Hong Kong Journal of Emergency Medicine

Hospitals preparedness using WHO 2018, Vol. 25(4) 211–222

© The Author(s) 2018

guideline: A systematic review and

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https://doi.org/10.1177/1024907918760123
DOI: 10.1177/1024907918760123
meta-analysis journals.sagepub.com/home/hkj

Fatemeh Rezaei1, Mohammad Reza Maracy2,

Mohammad H Yarmohammadian3 and Hojat Sheikhbardsiri4

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 hospi-
tal activities not only endanger patients’ lives and the con-
1Department of Health in Disaster and Emergencies, Health
Management and Economics Research Center, Isfahan University of
Medical Sciences, Isfahan, Iran
2Department of Biostatistics and Epidemiology, School of Health, Isfahan
University of Medical Sciences, Isfahan, Iran
3Health Management and Economics Research Center, Isfahan
University of Medical Sciences, Isfahan, Iran
4Isfahan University of Medical Sciences, Isfahan, Iran

tinuity of care for the surrounding community, but can

also affect hospital staff and associated suppliers. Corresponding author:
Mohammad Reza Maracy, Department of Biostatistics and Epidemiology,
Therefore, it is necessary for a hospital to maintain critical School of Health, Isfahan University of Medical Sciences, 8174673461
activities, even in an unexpected crisis. Hospitals across Isfahan, Iran.
countries increasingly understand their role in emergency Email: mrmaracy@yahoo.co.uk

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use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and
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212 Hong Kong Journal of Emergency Medicine 25(4)
Figure 1.  PRISMA 2009 Flow Diagram.
From Moher et al.34 Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement.
preparedness to improve the capability and capacity
before a major incident.1–3
Disaster impact on health sectors causes secondary dis-
aster 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 treat-
ment 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 sustainabil-
ity 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 arti-
cle 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 man-
agement principles and best practices and integrates prior-
ity action developed by WHO Regional Office for Europe
to assist hospital administrators and emergency managers
in responding effectively to the most likely disaster sce-
narios. This tool is structured according to nine key compo-
nents 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;
Table 1.  An overview of characteristics of articles included.

Authors Year Study type Location Sample Hospital type Disaster type Key components/percentage of included RAs STROBE
sizea score
CC C SS T SC CES HR LSM PDR
Rezaei et al.

Aladhrai et al.8 2015 Cross- Sana, Yemen 11 7 Public Revolution 2011 100 100 100 100 100 100 100 100 100 73%
sectional hospitals, 4 (AI)
private hospitals
Apisarnthanarak 2013 Cross- 15 Central 104 Secondary and Flooding (N) 42.8 – – – – – 13.3 10 – 73%
et al.9 sectional provinces, tertiary care
Thailand hospital
De Jong et al.10 2014 Cross- 38 European, 236 Primary, Ebola virus 42.8 11 18 10 – – 6.6 20 – 73%
sectional Turkey, Israel secondary, or pandemic (N)
tertiary care
Leonhardt 2015 Cross- Wisconsin, 225 Not mention Ebola virus 100 55.5 36.3 30 7.6 25 60 60 – 68%
et al.11 sectional USA pandemic (N)
Martin et al.12 2015 Cross- England 112 Acute National Ebola disease (N) 28/5 11 18 – – – 13 10 – 77%
sectional Health Service
(NHS) hospital
Mortelmans 2014 Cross- Belgium 100 Hospitals with Chemical, 28.5 – 45.4 – 7.6 – 33.3 10 – 77%
et al.13 sectional an emergency biological,
department (ED) radiation, and
nuclear incidents
(AN)
Mulyasari et al.5 2013 Cross- Tohoku and 14 Hub Hospitals Earthquake (N) – 22 9 10 30.7 25 6.6 10 11 68%
sectional Nankai, Japan and General
Hospitals
Murakawa6 2013 Case study Fukushima, 1 Medical Fukushima 14.2 22 45.4 20 38.4 50 13.3 20 22.2 50%
Japan University earthquake (N)/
Hospital nuclear power
disaster (AN)
Niska and 2011 Cross- United States 395 Non- Epidemics and 14.2 22.2 – 10 30 12/5 13/3 20 – 77%
Shimizu14 sectional institutional, pandemics (N)
nonfederal, acute
care, and short-
stay hospitals
Reidy et al.15 2015 Cross- Republic of 46 Acute public and Influenza 42.8 – 9 – 7.6 60 10 – 86%
sectional Ireland private hospitals pandemic (N)
Shokouh et al.16 2014 Cross- Tehran, Iran 15 Affiliated Earthquake (N) 14.2 – 9 – 7.6 12.5 6.6 10 – 68%
sectional hospitals with
Shahid Beheshti
University of
Medical Sciences
(Continued)
213
 214

Table 1. (Continued)
Authors Year Study type Location Sample Hospital type Disaster type Key components/percentage of included RAs STROBE
sizea score
CC C SS T SC CES HR LSM PDR
Scarfone et al.17 2011 Case study Delaware 1 The urban, Pandemic 28.5 33.3 54 40 38 12.5 20 30 – 68%
Valley, tertiary care influenza A
Philadelphia, children’s (H1N1) virus (N)
USA hospital
Verni18 2012 Case study Great Neck, 3 North Shore Hurricane Irene 71.4 22.2 27.2 10 46 25 20 40 44.4 64%
New York, Long Island (N)
USA Jewish Health
System—flood-
prone zones
hospitals—
nonprofit,
secular
Valesky et al.19 2013 Cross- Cape Town, 9 RICU, NICU, FIFA World – – – – 15.3 – – – – 86%
sectional South Africa MICU, general Cup tournament
medical/surgical gathering (AN)
beds in each
hospital
Cheng et al.20 2016 Case study New Taipei, 1 A tertiary care Dust explosion 57 – – 20 7.6 – 6.6 10 – 68%
and Chen et al.21 Taiwan teaching hospital (AN)
Bolster et al.22 2016 Case study Seattle, USA 1 Trauma center, Highway accident 57 – – – – – – – – 50%
radiology (AN)
department
Haverkort 2016 Case study Utrecht, 1 A governmental Flooding (N) 71 22 9 – 15 12.5 20 10 11 77%
et al.23 Netherlands major incident
hospital (MIH)
Carles et al.24 2016 Cross- Nice, France 2 Children Terrorist attack 42 – – 30 – – 6.6 – – 45%
sectional Hospital, Pasteur (AI)
adult Hospital
King et al.25 2016 Cross- New York, 7 Intensive care Hurricane Sandy 28 – – 10 – 62 13 – – 91%
sectional USA unit (ICU) (N)
Hang et al.26 2016 Case study China 1 General hospital, Terrorist attack 14 22 – 10 7.6 – 6.6 20 – 73%
burn department (AI)
Harper and 2016 Case study Philadelphia, 1 Not mentioned Amtrak 28 22 9 60 – 12.5 6.6 – – 86%
Rehman27 USA derailment (AN)
Gregan et al.28 2016 Case study Christchurch, 1 Public tertiary Earthquake (N) – 11 – – – 25 20 26 11 68%
New Zealand hospital
Hong Kong Journal of Emergency Medicine 25(4)
 Rezaei et al.

Table 1. (Continued)

Authors Year Study type Location Sample Hospital type Disaster type Key components/percentage of included RAs STROBE
sizea score
CC C SS T SC CES HR LSM PDR
Moughrabieh 2016 Cross- Aleppo, Syria 5 Trauma centers, War (AI) – 22 – – – – 20 – – 54%
and Weinert29 sectional relief donation
hospital
Valerio et al.30 2016 Case study Verona, Italy 1 Not mentioned Mass CO 14.2 11 – 20 12.5 – 13 10 – 77%
poisoning (AN)
Eyre et al.31 2016 Quantitative– Boston, USA 6 Academic- Explosions (AI) – – – – 12.5 – – – – 68%
qualitative affiliate
community
hospital,
pediatric and
adult trauma
centers

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.
aHospital(s) and Trusts/Trusts: NHS hospitals in England are managed by hospital trusts, which represent one or more hospitals in a geographical area.12
215
 216

Table 2.  Examples of the key components and recommended actions from the included studies.

Authors Key Recommended actions

components
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
Hong Kong Journal of Emergency Medicine 25(4)
Table 2. (Continued)

Authors Key Recommended actions

components
Rezaei et al.

Leonhardt CC Establishing an organizational response team included leaders, experts, and frontline health care providers from the organization potentially
et al.11 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

(Continued)
217
Table 2. (Continued)
218

Authors Key Recommended actions

components
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 CC Three levels of command were defined: (1) the Crisis Management Team (CMT): responsible for external communication and the continuity of
et al.23 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 departments
there 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 CC Incident command leadership role was defined for ICU evacuation, the ICU evacuation leaders were preferred rather than the chief medical
et al.25 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.
Hong Kong Journal of Emergency Medicine 25(4)
Rezaei et al. 219
(7) human resources (HR) with 15 RAs; (8) logistics and
supply management (LSM) with 10 RAs; and (9) post-dis-
aster recovery (PDR) with 9 RAs.7 The information of arti-
cles 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 com-
mand and control (CC), the percentage of included RAs
would be 42.8%.
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 hospi-
tals (like pediatric). As WHO hospital emergency response
checklist developed in 2011 and hospital-based emergency
preparedness principles have changed or updated alterna-
tively, 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 report-
ing 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 rec-
ommended 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 crite-
ria. 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.
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 hospi-
tals 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 com-
ponents based on disaster types (naturals (N), AN, and
AI).
The homogeneities appeared mostly in AN disaster type.
The overall effect sizes of five key components in the stud-
ies 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 disas-
ter preparedness concepts were dedicated to CC in the stud-
ies 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 pre-
paredness 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
 220

Figure2.  Results of meta-analysis on key components and recommended actions by disaster type.
Hong Kong Journal of Emergency Medicine 25(4)
Rezaei et al. 221
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 com-
ponents 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 disas-
ters. 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, hos-
pitals do not affect by disasters. But, lack of enough per-
sonnel 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 sug-
gests planning sections as follows: assignment of responsi-
bilities, command and control, information management,
communication, introductory material, purpose of the plan,
planning assumptions, the concept of operations, adminis-
tration and finance, plan development and maintenance,
and authorities.36,37
Conclusion
We recommend using the proposed disaster categories sug-
gested 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 reli-
able 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 vulnera-
ble 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 sys-
tems. Future research could be implementing based on vul-
nerable components that have paid less attention in the
literature.
Acknowledgements
The authors solely did the research with no assistance of any other
individuals or research center. The STROBE and PRISMA check-
list 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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