The Islamic University of Gaza Deanship of Research and Graduate Studies Master of Crisis and Disaster Management الجامعة اإلسالمي ة بغزة عمادة البحث

The Islamic University of Gaza Deanship of Research and Graduate Studies Master of Crisis and Disaster Management الجامعة اإلسالمي ة بغزة عمادة البحث العلمي والدراسات العليا ماجستير إدارة األزمات والكوارث Assessment of Health System Crisis and Disaster Preparedness among Governmental Hospitals in Gaza Strip, Palestine تقييم مدى جهوزية النظام الصحي لحاالت األزمات والكوارث في المستشفيات الحكومية في قطاع غزة - فلسطين by Tamer Salameh El Qadoud Supervised by Prof. Dr. Yousef Al jeesh Prof. of Public Health A thesis Submitted in partial fulfillment of the requirements for the degree of Master of crisis and disaster management in the Islamic university of Gaza September /2018

إقرار أنا الموقع أدناه مقدم الرسالة التي تحمل العنوان: Assessment of Health System Crisis and Disaster Preparedness among Governmental Hospitals in Gaza Strip, Palestine تقييم مدى جهوزية النظام الصحي لحاالت األزمات والكوارث في المستشفيات الحكومية في قطاع غزة - فلسطين أقر بأن ما اشتملت عليه هذه الرسالة إنما هو نتاج جهدي الخاص باستثناء ما تمت اإلشارة إليه حيثما ورد وأن هذه الرسالة ككل أو أي جزء منها لم يقدم من قبل بحثية أخرى. اآلخرين لنيل درجة أو لقب علمي أو بحثي لدى أي مؤسسة تعليمية أو Declaration I understand the nature of plagiarism, and I am aware of the University s policy on this. The work provided in this thesis, unless otherwise referenced, is the researcher's own work, and has not been submitted by others elsewhere for any other degree or qualification. Student's name: Signature: Date: اسم الطالب: التوقيع: التاريخ: تامر سالمة القادود تامر 9/9/2018 I

نتيجة الحكم II

Abstract Gaza Strip is frequently exposed to aggressive acts by Israeli forces, and this situation raised the need to have emergency plans to enable hospitals to handle the increased number of casualties and offer effective medical treatment for them. Aim and objectives: This study aimed to assess preparedness of health system for crisis and disaster and to identify factors that affects readiness for disasters. Methods: The researcher used descriptive, cross-sectional design. The study sample is purposive sample, consisted of 87 key persons from 9 governmental hospitals in Gaza Strip. For data collection, the researcher used modified Hospital Disaster Preparedness Self-Assessment Tool which was developed by The American College of Emergency Physicians 2017. The questionnaire was validated by a group of experts and pilot study on 20 participants and Cronbache alpha coefficient was 0.721. Results: The results showed that 56.95% of respondents stated that safety and security measures are available in their hospital, 70% mentioned that logistics were available, 74.5% reported availability of emergency management planning, and 52.2% of medical staff and 58.9% of nurses have completed training about disaster response and preparedness, and 60% mentioned that their hospitals were ready and prepared for disasters. Furthermore, 47.25% reported that Incident Command System is available in their hospitals, and 67.2% mentioned that an emergency / disaster committee is present in their hospitals. Also, 64% said that cache of emergency drugs and antidotes is maintained in emergency department, 61.1% mentioned that triage system was available and implemented, and 63.3% reported availability of patient tracking. Critical incident stress management was not adequately integrated in the emergency plan. In addition, 72% stated that the pharmacy maintain adequate supply of medication, fluids and other consumables, and 78.5% reported that laboratory services are integrated in the emergency plan. Furthermore, 58.8% mentioned that fatality management is integrated in the emergency plan. Moreover, 87.3% stated that their hospitals can send and receive communications, warning, and notification during crisis and disasters, and 91.4% reported that information management was integrated in their emergency planning. Conclusion and recommendations: The results revealed moderate level of preparedness for crisis and disasters among governmental hospitals with average score 64.47%. The study recommended that some necessary modifications in the health system are essential to improve the level of preparedness for crisis and disastrous events. III

ملخص الدراسة يتعرض قطاع غزة العتداءات عنيفة من قبل قوات االحتالل اإلس ارئيلي والتي تؤدي إلى مزيد من الضغوط على المستشفيات في قطاع غزة. أهداف الد ارسة: جهوزية النظام الصحي للتعامل مع حاالت األزمات والكوارث في غزة. الطريقة واإلج ارءات: موزعين على تسع مستشفيات تكونت عينة الد ارسة من حكومية في قطاع غزة 87 وسا هدفت هذه الد ارسة إلى التعرف على مدى موظفا المستشفيات الحكومية في قطاع من متخذي الق ارر في المستشفيات تخدم الباحث استبانة معدلة لقياس مدى جهوزية المستشفيات للعمل في حالة الكوارث وهي من إعداد الكلية األمريكية ألطباء الطوارئ وتم )2017( عرض االستبانة على مجموعة من الخب ارء ألخذ أ ارءهم في محتوى االستبانة كما تم إج ارء د ارسة استطالعية على عينة مكونة من االرتباط ألفا بلغ 20.0.721 نتائج الد ارسة: فردأ بينت نتائج الد ارسة أن أفادوا بتوفر معايير األمن والسالمة في المستشفيات المستشفيات وبإج ارء اختبار ألفا كرونباخ تبين أن معامل وأشار %56.95 من المشاركين في %70 إلى توفر %74.5 أشاروا إلى وجود خطة للطوارئ في مستشفياتهم المهمات اللوجستية الد ارسة في %52.2 من األطباء و %58.9 من الممرضين أكملوا دو ارت تدريبية حول الجهوزية واالستجابة في حاالت الطوارئ والكوارث كما أن أظهرت النتائج أن في حالة الطوارئ كما أن %60 من المشاركين في الد ارسة أفادوا بجهوزية المستشفيات لحاالت الكوارث. %47.25 من المشاركين كما في الد ارسة أفادوا بتوفر نظام خاص باألوامر والتعليمات %67.2 أشاروا إلى وجود لجنة للطوارئ في المستشفيات. كما أن من المشاركين في الد ارسة أفادوا بتوفر كمية كافية من األدوية والمضادات في أقسام الطوارئ. %61.1 بوجود نظام فرز المرضى في أقسام الطوارئ كما أن %64 وأفاد %63.3 أفادوا بوجود لوحات إرشادية لتسهل عملية تحرك المرضى داخل المستشفى. وبينت النتائج عدم دمج الجانب النفسي ضمن خطة وذكر الطوارئ. %72 من المشاركين في الد ارسة بأن صيدلية المستشفى توفر كميات كافية من األدوية والمحاليل والمستهلكات الطبية وأفاد %78.5 أن خدمات المختبر متضمنة في خطة الطوارئ. وأشار %58.8 إلى توفر جزء خاص بالعناية بجثث الموتى حسب األصول ضمن خطة الطوارئ. وبينت النتائج أن وارسال المعلومات والتحذي ارت %87.3 من المشاركين في الد ارسة أفادوا بتوفر إمكانية االتصال والتواصل مع المؤسسات األخرى خالل األزمات والكوارث كما أفاد المشاركين في الد ارسة بوجود نظم إدارة المعلومات في خطة الطوارئ. النتائج وجود مستوى متوسط من الجهوزية واالستعداد لألزمات والكوارث تلقي %91.4 من %64.47. وأوصت الد ارسة اإلجمال والتوصيات: بينت بمتوسط درجات بلغ بالحاجة إلدخال بعض التعديالت الضرورية في الجهاز الصحي بهدف تحسين مستوى جهوزية المستشفيات للتعامل واالستجابة لألزمات والكوارث. IV

اقتباس " قل هل يستوي الذين يعلمون والذين ال يعلمون إمنا يتذك ر أولو األلباب " ]الزمر 9 ] V

Dedication All the kind feelings to my parents who were praying for me all the way. I would like to convey my sincere gratitude to the great woman to my wife and my daughters who encouraged me all the way through this study without their support and encouragement, this work wouldn't reach the end Special thanks to my sisters and my brother for their support which provided me with extra energy to complete my study. I would like to express my appreciations to all those who contributed to the completion of this thesis. VI

Acknowledgement First of all, praise to Allah, the lord of the world, and peace and blessings of Allah be upon our prophet Muhammad, all thanks for Allah who granted me the capability to accomplish this thesis. I would like to express my deepest thanks to the academic and administrative staff at the Islamic University for the knowledge and skills I gained through my study. I had the great fortune to complete this study under the supervision, and guidance of Proff. Dr. Yousef Aljeesh. I would like to convey my warm thanks to all the staff in governmental hospitals for their cooperation during data collection. To my friends, and all those who contributed to the completion of this study, thank you very much. Tamer El Qadoud September, 2018 VII

Table of contents Declaration... I Abstract... III Sammary... IV... V اقتباس Dedication... VI Acknowledgement... VII Table of contents... VIII List of Tables... XI List of Figures... XII List of Appendices... XIII List of Abbreviations... XIV Chapter 1 Introuduction... 2 1.1 Background... 2 1.2 Research Problem... 4 1.3 Significance of the Study... 4 1.4 General Objective... 5 1.5 Specific Objectives... 5 1.6 Definition of Terms... 7 1.7 Limitation of the Study... 9 1.8 Overview of Thesis... 9 Chapter 2 Literature Review... 12 2.1 Introduction... 12 2.2 The Need for Disaster Preparedness... 13 2.3 Hospital Disaster Plan (HDP)... 14 2.3.1 Pre-disaster Phase... 14 2.3.2 Disaster Phase... 14 2.3.3 Post disaster Phase... 15 2.4 The Scope of Hospital Disaster Preparedness... 15 2.5 Indicators of Hospital Disaster Preparedness... 22 2.5.1 Communication and Coordination:... 22 2.5.2 Surge Capacity (SC)... 22 VIII

2.5.3 Triage... 23 2.5.3.1 Triage in Hospitals... 23 2.5.3.2 Classification of Victims in Triage... 23 2.5.4 Safety and Maintenance of Life Line Facilities... 24 2.6 Impact of Disasters on Hospitals and Healthcare System... 25 2.7 Barriers to Readiness of Health Facilities to Crisis and Disasters... 26 2.8 Impact of the Palestinian Israeli Conflict on Hospitals in Gaza Strip... 27 2.9 Impact of Great Return March on Healthcare System... 29 2.10 Characteristics and Capacity of Hospitals... 32 2.11 Summary... 34 Chapter 3 Material and Methods... 36 3.1 Study design... 36 3.2 Population of the Study... 36 3.3 Sample of the Study... 36 3.4 Setting of the Study... 37 3.5 Period of the Study... 37 3.6 Eligibility Criteria... 37 3.6.1 Inclusion Criteria... 37 3.6.2 Exclusion Criteria... 38 3.7 Instrument of the Study... 38 3.8 Pilot Study... 38 3.8.1 Validity... 39 3.8.2 Reliability... 39 3.9 Data Collection and Management... 39 3.10 Ethical Considerations... 40 Chapter 4 Results and Discussion... 42 4.2 Hospital Profile... 43 4.2.1 Hospital Staffing... 43 4.2.2 Safety and Security... 44 4.2.3 Availability of Logistics... 45 4.3 Emergency Management Planning (EMP)... 48 4.3.1 Availability of Emergency Management Plan... 48 4.3.2 Facility Readiness and Training... 50 IX

4.3.3 Incident Command System (ICS)... 52 4.3.4 Hospital Emergency Management/Disaster Preparedness Committee... 53 4.3.5 Capacity of Emergency Department... 54 4.3.6 Patient Triage... 55 4.3.7 Patient Tracking... 56 4.3.8 Critical Incident Stress Management (CISM)... 57 4.3.9 Pharmacy Services... 58 4.3.10 Laboratory Services... 59 4.3.11 Management of Fatalities... 60 4.3.12 Communications, Warning, and Notification... 61 4.3.13 Management of Information... 63 4.4 Health System Preparedness... 64 4.5 Discussion..74 Chapter 5 Conclusion and Recommendations... 83 5.1 Conclusion... 83 5.2 Recommendations... 84 5.3 Suggestions for Further Studies... 85 The Reference List... 87 X

List of Tables Table (2.1): Number of casualties in GRM from 30/3 30/7/2018... 31 Table (2.2): Site of injury of casualties in GRM from 30/3 25/7/2018... 32 Table (2.3): Characteristics of the hospitals participated in the study... 32 Table (2.4): Description of hospitals capacity... 33 Table (3.1): Distribution of study sample... 37 Table (3.2): Cronbache alpha coefficient... 39 Table (4.1): Description of safety and security... 44 Table (4.2a): Availability of logistics in hospitals... 45 Table (4.2b): Availability of logistics in hospitals... 47 Table (4.3): Availability of emergency management planning in hospitals... 48 Table (4.4): Percentage of staff who have completed disaster preparedness training... 50 Table (4.5): Facility readiness and training... 51 Table (4.6): Availability of incident command system... 52 Table (4.7): Hospital emergency management/disaster preparedness committee... 53 Table (4.8): Emergency Department Capacity (EDC)... 54 Table (4.9): Availability of patient triage system... 55 Table (4.10): Availability of patient tracking... 56 Table (4.11): Presence of critical incident stress management (CISM)... 57 Table (4.12): Availability of pharmacy services (PHARS)... 58 Table (4.13): Availability of laboratory services (LABS)... 59 Table (4.14): Availability of fatalities management (FM)... 60 Table (4.15): Availability of communications, warning, and notification (CWN)... 61 Table (4.16): Availability of information management (IM)... 63 Table (4.17): Average scores of preparedness in all the hospitals... 64 XI

List of Figures Figure (4.1): Distribution of respondents according to hospitals... 42 Figure (4.2): Distribution of respondents by department... 43 XII

List of Appendices 1. Hospital Disaster Preparedness Self-Assessment Tool (Arabic version) 97 2. Hospital Disaster Preparedness Self-Assessment Tool (English version)... 104 3. List of experts.. 114 4. Approval letter from the Islamic University Gaza 115 5. Approval letter from Helsinki Committee.. 116 6. Approval letter from Ministry of Health.. 117 XIII

List of Abbreviations ADPC Asian Disaster Preparedness Center BLS Basic Life Support ED Emergency Department EGH European Gaza Hospital EP Emergency Plan EU European Union FTSP Field Trauma Stabilization Point GS Gaza Strip GRM Great Return March HDP Hospital Disaster Plan HVAC Heating, Ventilation and Air Conditioning ICRC International Committee of Red Cross ICS Incident Command System ICU Intensive Care Unit IFRC International Federation of Red Cross and Red Crescent Societies IT Information Technology KAP Knowledge, Attitudes, and Practice KSA Kingdom of Saudi Arabia MoH Ministry of Health NGOs Nongovernmental Organizations NMC Nasser Medical Complex PAHO/WHO Pan American Health Organization / World Health Organization UNDP/GOI United Nations Development Program and government of India UNISDR The United Nations Office for Disaster Risk Reduction WB West Bank WHO World Health Organization XIV

Chapter 1 Introduction

Chapter 1 Introduction 1.1 Background The health system is one of the important components of any society, and the development of any country is measured by the health services provided and the life expectancy of its people. Hospitals as part of the health system offer medical treatment to people in normal daily life and during emergency events. Hospitals are complex and multidisciplinary institutions, relying on support and supply from external resources, and during a crisis event, an interruption of standard communications, external support services, or supply delivery can disrupt essential hospital functions and even a high number of casualties who need admission can make overcrowd in the hospital beyond its capacity (World Health Organization WHO, 2011). A clear, written emergency plan (EP) is necessary for every hospital, and every hospital need to be ready and prepared to handle work overload resulted from disasters because hospitals are the last line of defense against loss of human lives due to disasters (Sakharkar, 2009). In addition, hospital staff need to be aware of disaster management and well prepared to work under pressure during disasters. This is one of the important ways to mitigate the loss of human life due to disasters (Sharma et al., 2016). Disasters and crisis are events that resulted in a heavy burden of morbidity and mortality. According to Global Assessment Report on Disaster Risk Reduction (2015), since 1990, 1.6 million people worldwide died because of disasters, making for an approximate average of 65,000 deaths per year. During disasters, hospitals are expected to function as a safe 2

environment for personnel and provide essential medical care to the casualties (Djalali et al., 2014a). From my experience as a nurse working in governmental hospitals in GS, I noticed that hospitals suffer from an insufficient resources including supplies, essential drugs, and personnel, and that affects their ability to offer safe, quality care to patients and victims. This is consistent with results of previous studies which revealed weakness in hospital disaster management, including confusion over roles and responsibilities, poor communication, lack of planning, and suboptimal training (Djalali et al., 2014b; Juffermans and Bierens, 2010; US Department of Health & Human Services, 2015). These findings raised the need to improve management of disaster and crisis events and treat the high number of victims properly. Gaza Strip suffered from three aggressive wars in the past years by Israeli military forces; in December 2008 for 21 days, in November 2012 for 8 days, and in July 2014 for 51 days, and these wars left thousands of martyrs and wounded people from different ages. In addition, the Great Return March (GRM) started in 30 th of March 2018 added extra pressure on the healthcare system and more specifically on the hospitals in GS. The hospitals are overwhelmed with casualties suffering from different serious complicated injuries, and the hospitals suffered from severe shortage of medical supplies and consumables, and medical staff had to work under pressure and scarcity of supplies. These circumstances led the researcher to carry this study to investigate the degree of hospitals' preparedness to face such critical events, and in the light of obtained results to suggest plan of actions to be able to manage such critical events. 3

1.2 Research Problem Natural and man-made hazardous events often induce catastrophic emergencies. GS is considered a safe area free of natural disasters such as earthquakes, or volcanoes, but is exposed to aggressive violent acts of bombing and air raids by Israeli military forces during the long years of Palestinian struggle for freedom. In addition, the long-term siege inflicted hard circumstances in all aspects of life including health services with severe shortage of medical supplies and long hours cut-off electricity and uncertainty about adequacy of fuel for generators. In the past few months since 30 th of March, the Palestinians in GS started a big protest GRM against the siege imposed on GS, which resulted in high number of casualties and serious trauma that need urgent and complicated medical and surgical interventions. This situation raised the need to have well organized plans and adequate supplies and equipment in all the hospitals to enable these hospitals to handle the increased number of victims and be able to offer proper medical treatment for them. 1.3 Significance of the Study Hospitals are the main facilities that offer a wide range of health care services to people in all circumstances. In emergency situations, the need for hospitals increase to save lives of casualties. The ability of any hospital to meet the demands depends on many factors, including its size, functional capacity, presence of adequate equipment and supplies, and availability of adequate qualified health care staff. Gaza Strip could be described as a war-inflicted zone. The people of GS live in hard and exhausted situation as they were exposed to three wars by Israeli military forces in the past years which resulted in a big number of deaths, injuries and disabilities. 4

Without appropriate EP, hospitals become overwhelmed in attempting to provide care during critical events. To enhance the readiness of hospitals to cope with the challenges created by these wars and disasters, hospitals need to be prepared to offer priority actions that can help facilitate a timely and effective hospital-based response. Due to these unstable circumstances, the hospitals in GS have to be ready and prepared to response effectively to critical events. In this study, the researcher will assess the preparedness of governmental hospitals to meet the emergency events with large number of casualties. 1.4 General Objective The general objective of the study is to assess health system crisis and disaster preparedness among governmental hospitals in Gaza Strip. 1.5 Specific Objectives 1. To describe the degree of crisis and disaster preparedness among governmental hospitals in Gaza Strip in regard to safety and security, and availability of logistics. 2. To describe the level of crisis and disaster preparedness among governmental hospitals in Gaza Strip in regard to availability of emergency management plan. 3. To identify the extent of crisis and disaster preparedness among governmental hospitals in Gaza Strip in regard to readiness and training, incident command system, emergency management disaster preparedness committee. 4. To determine the level of crisis and disaster preparedness among governmental hospitals in Gaza Strip in regard to patient triage, tracking, and stress management. 5. To identify the level of crisis and disaster preparedness among governmental hospitals in Gaza Strip in regard to pharmacy and laboratory services. 5

6. To identify the extent of crisis and disaster preparedness among governmental hospitals in Gaza Strip in regard to communication, warning and notification, and information management. 7. To identify the level of preparedness of the health system to deal with crisis and disaster at governmental hospitals in Gaza Strip. 8. To set recommendations to the key persons at the Ministry of Health (MOH) to improve health system crisis and disasters preparedness at governmental hospitals in Gaza Strip. 1.6 Questions of the study 1. What is the degree of crisis and disaster preparedness among governmental hospitals in Gaza Strip in regard to safety and security, and availability of logistics? 2. What is the level of crisis and disaster preparedness among governmental hospitals in Gaza Strip in regard to availability of emergency management plan? 3. What is the extent of crisis and disaster preparedness among governmental hospitals in Gaza Strip in regard to readiness and training, incident command system, emergency management disaster preparedness committee? 4. What is the level of crisis and disaster preparedness among governmental hospitals in Gaza Strip in regard to patient triage, tracking, and stress management? 5. What is the level of crisis and disaster preparedness among governmental hospitals in Gaza Strip in regard to pharmacy and laboratory services? 6

6. What is the extent of crisis and disaster preparedness among governmental hospitals in Gaza Strip in regard to communication, warning and notification, and information management? 7. What is the level of preparedness of the health system to deal with crisis and disaster at governmental hospitals in Gaza Strip? 8. What are the recommendations to the key persons at the Ministry of Health to improve health system crisis and disasters preparedness at governmental hospitals in Gaza Strip? 1.7 Definition of Terms Disaster Any event or series of events causing a serious disruption of a community infrastructure, often associated with widespread human, material, economic, or environmental loss and impact, the extent of which exceeds the ability of the affected community to mitigate using existing resources (WHO, 2011). Crisis It is an event or series of events representing a critical threat to the health, safety, security or wellbeing of a community, usually over a wide area. Armed conflicts, epidemics, famine, natural disasters, environmental emergencies and other major harmful events may involve or lead to a humanitarian crisis (WHO, 2007). 7

Emergency A sudden occurrence demanding immediate action that may be due to epidemics, to natural, to technological catastrophes, to strife or to other man-made causes (Inter Agency Secretariat of the International Strategy for Disaster Reduction, 2004). Preparedness Preparedness is defined as actions taken to effectively anticipate, respond to, and recover from the impact of likely or current hazard events or conditions (UNISDR, 2009). Disaster preparedness Disaster preparedness refers to measures taken to prepare for and reduce the effects of disasters. That is, to predict and, where possible, prevent disasters, mitigate their impact on vulnerable populations, and respond to and effectively cope with their consequences (International Federation of Red Cross, 2018). Hospital disaster plan Defined as the systematic procedures that clearly detail what needs are to be performed, how, when, and by whom before and after the time an anticipated disaster event occurs (Ae, Samia, & Gehan, 2011). Crisis management The process by which an organization deals with a disruptive and unexpected event that threatens to harm the organization or its stakeholders (Bundy et al., 2017). 8

Crisis management plan (CMP) It is a clearly defined and documented plan of action for use at the time of a crisis. Typically a plan will cover all the key personnel, resources, services and actions required to implement and manage the crisis management process (http://www.bcmpedia.org. 2018). Triage The process of categorizing and prioritizing patients with the aim of providing the best care to as many patients as possible with the available resources (WHO, 2007). Hospitals The researcher defines hospitals as: any governmental general hospital in Gaza Strip that offer emergency medical care as part of its services. 1.7 Limitation of the Study The limitations that faced the researcher included: - Long hours cut-off electricity - Financial constraints - Time allocation - Limited literature and resources. 1.8 Overview of Thesis This study consists mainly from five chapters: introduction, literature review, methodology, results and discussion, conclusion and recommendations. The first chapter presented general introduction to the study, where a brief background regarding the subject of the study was provided. The researcher illustrated the research 9

problem, significance of the study, the general goal and specific objectives, research questions, definition of terms and limitation of the study. The second chapter included the literature review related to the study topic and variables. Indepth detailed theoretical inquiry including previous studies were presented to enrich the study. The third chapter described methodology including study design, population, sample, instruments, pilot study including validity and reliability of study instruments, ethical considerations, and statistical analysis procedures. The fourth chapter presented the study results and discussion. The researcher presented the results in form of figures and tables that make it easy for the reader to understand and make comments. The results were discussed in relation to available previous studies that directly related to the topic of this study and its objectives. Finally, in the fifth chapter, the researcher presented conclusion, recommendations, and suggestions for further research in the light of the study results. 10

Chapter 2 Literature Review 11

Chapter 2 Literature Review 2.1 Introduction During disasters, hospitals are the main facilities within the health-care system that provide medical care to casualties. Disasters and crises can occur at any time, causing pain, human suffering and loss of life, so if health systems are not prepared to deal with a crisis, the vulnerability of both individuals and communities becomes even more pronounced. Thus, preparing a health system for crises is not optional task. Strengthening stewardship, implementing preparedness planning as a continuous process with a multihazard approach and establishing sustainable crisis-management and health-related riskreduction programs are vital to any country (WHO, 2012). During emergencies with high influx of casualties and the need for more beds for the incoming casualties we have to think about available beds and potential places for extra beds. Through our experience in governmental hospitals in GS, the hospitals expand bed capacity for emergencies by early discharge of stable patients and refer them to primary health centers for follow up, coordination with private and charity hospitals like Ahli Arab Hospital in Gaza and Dar Al Salam Hospital in Khanyounis, and Red Crescent Hospitals in Gaza and Khanyounis to admit and follow the patients who are transferred from governmental hospitals, and these interventions gave the governmental hospitals to have more available beds for serious cases and increased healthcare providers ability to take care of urgent cases without delay. In this regard, Kaji and Lewis, (2006) reported that hospitals can do a number of things to increase their capacity and extend their resources, but there are serious limitations on this expansion of their capabilities, and surveys 12

indicated that the number of available beds, ventilators, isolation rooms, and pharmaceuticals may be insufficient to care for victims of a large-scale disaster. 2.2 The Need for Disaster Preparedness Disasters are unexpected events that may occur with mass destruction and high number of casualties. Thus, preparedness is one major step in health system plans and activities. Preparedness for disasters is dynamic and continuous process that is not tied with specific time, but should be always ready. Disasters cause mass destruction that disrupt people's lives and causing human suffering (Chimenya, 2011). Thus, being prepared for disasters increase our the ability to adapt, and reduce the impact of disaster on our lives The United Nations International Strategy for Disaster Risk Reduction - UNISDR (2009) disaster preparedness means the capacity and ability of governmental and community organizations to respond effectively, and recover from the negative impacts of disasters. Hospitals play a major role in response and recovery from disastrous events and their role mainly focusing on saving lives. Thus, hospitals must be able to remain functioning all the time (Mulyasari et al., 2013). According to Keim and Giannone (2006) preparedness for emergencies aims to prevention of morbidity and mortality, provision of care for casualties, management of adverse conditions, ensuring restoration of normal health, reestablishment of health services, protection of staff, and protection of public health and medical assets. In our hospitals in GS, mental health and psychological counseling are neglected part in most of the hospitals. Only two hospitals started this years to integrate mental health as part of comprehensive treatment of patients (Andonesy hospital and Nasser Medical Complex). Hospitals usually focus on medical treatment from physical aspect including 13

medical and surgical interventions. It is obvious that mental well-being is an important aspect of general health of any individual and for proper recovery mental health should be integrated in the treatment besides medical treatment and should be clearly identified in the hospital services. 2.3 Hospital Disaster Plan (HDP) Being prepared to emergencies and disastrous events is an active role of any hospital administration. Each hospital should have written and applicable plan for emergency events, and these plans should categorize emergency events in levels according to the nature of the event. Also, the plan should identify teams and staff availability with defined tasks for each team and staff. According to United Nations Development Program and government of India (UNDP/GOI, 2002) recommends that the hospital emergency preparedness planning process be divided into three phases: pre-disaster phase; disaster phase; post disaster phase. This will ensure that all aspects of the disaster continuum are included in the plan. 2.3.1 Pre-disaster Phase The pre-disaster phase involves the process of preparedness which is very important for effective response to disastrous events. For hospitals, this phase involves planning for emergencies, staff education and training to improve their skills and ability to work under pressure with mass casualty events and high influx of victims with different types of trauma and injuries (Chimenya, 2011). 2.3.2 Disaster Phase This phase can be subdivided into three phases (UNDP/ GOI, 2002:18): a. Activation phase; during this phase the hospital incident commander is appointed. His role is to direct all hospital activities and operations (UNDP/GOI, 2002:26). 14

b. Operational phase; in this phase, all the hospital operations for mass casualties are conducted in accordance with the EP. c. Deactivation phase; occurs when the flow of victims decreased and is not overwhelming the hospital resources and the EP is deactivated. 2.3.3 Post disaster Phase As part of the planning process, post disaster phase should be integrated in the EP. This phase involves evaluation and feedback for all the activities of the pre-disaster and disaster phases, and define actions for improvement in the future (Chimenya, 2011). It is obvious that developing and writing a disaster plan is essential for health facilities, but training and preparing the staff involved in responding to disasters is also essential. So, after planning for emergencies, training and education should be the next step, aiming to empowering and enabling the emergency management personnel to carry out their tasks and take appropriate actions when faced with different types of emergencies (Chimenya, 2011). 2.4 The Scope of Hospital Disaster Preparedness The goal of medical services during emergency is to offer the most effective treatment to a large number of casualties with the available resources; therefore hospitals need to be ready and well prepared for emergency events. Hospitals are central to provide emergency care and hence when a disaster strikes, the society depends on the hospitals to provide immediate emergency medical care (WHO, UNDP, 2008). Even though there are a variety of management systems and guidelines for disaster and emergency situations, there is still differences between hospitals in terms of their preparedness for disasters, which reflects how some hospitals have a different level of management system than others (FEMA, 2006). Differences are in many areas, such as the hospital s 15

capability to perform the identified tasks, characteristics, and management styles; these differences are affected by the size and location of the hospital and its community (Corbaley, 2010). Although there are many definitions of crisis, it is mostly defined as a situation in which several casualties and victims are referred to hospitals to use the health services and facilities. In such a situation, readiness of hospitals is vital and is considered as a specific requirement for them (Jacques et al., 2014). Hospital readiness is a multidimensional term which is related to medical restrictions and other relevant conditions. Managers of health institutions should completely know the hazards of crises and try to improve their readiness for confronting to these conditions (Kearns et al., 2014). Preparedness is defined as "actions taken to effectively anticipate, respond to, and recover from the impact of likely or current hazard events or conditions" (UNISDR, 2009). It is important to hospital disaster preparedness that the plan for massive influx of casualties be known and understood by professionals who will apply it including ED staff (Paganini et al., 2016). One of the main indicators in determining hospitals' readiness is the ability of their personnel. Many hospitals suffer inadequate beds and nursing services during crises. Appropriate readiness is needed for proper reaction to unexpected events. Every event is unique, and each hospital has its own situation, but there must be a clear plan to confront the crises in all hospitals (Barbera and Macintyre, 2014; Mastaneh and Mouseli, 2013). Thus, an appropriate plan against crises needs expertise, education, resources and readiness to be cost and time effective, and can afford other hospital requirements (Mortelmans et al., 2014). 16

A descriptive, cross-sectional study aimed to assess readiness of hospitals for crisis and disastrous events. The study included 45 hospitals in Los Angeles County, and the results indicated that 96% of hospitals were based on the Hospital Emergency Incident Command System (ICS), and the majority had protocols for hospital lockdown (100%), canceling elective surgeries (93%), early discharge (98%), day care for children of staff (88%), designating victim overflow areas (96%), and pre-disaster vendor agreements (96%). All had emergency medical services-compatible radios and more than three days-worth of supplies. Fewer hospitals involved law enforcement (56%) or had mutual aid agreements with other hospitals (20%) or long-term care facilities (7%). Although the vast majority (96%) conducted multiagency drills, only 16% actually involved other agencies in their disaster training. Only 29% hospitals had a surge capacity of greater than 20 beds, 42% had ten or more isolation rooms, and 60% of hospitals were on diversion greater than 20% of the time, 29% hospitals had immediate access to six or more ventilators, 42% had warm-water decontamination, while 51% had a chemical antidote stockpile and 42% had an antibiotic stockpile (Kaji and Lewis, 2006). Another prospective observational study aimed to investigate the knowledge about hospital EP among health care providers in Italy. The study included 85 of Italian EDs, and the results found that only 45% of participants know what an EP for massive influx of casualties, 41% know who has the authority to activate the plan, 38% knew who is in charge of intra-hospital operations, and generally, the results demonstrated a poor knowledge-base of basic hospital disaster planning concepts by Italian ED physicians (Paganini et al., 2016). Furthermore, a cross sectional study aimed to examine hospital preparedness and ability to response to emergency events. The study had been conducted in Japan and included 902 respondents from 6 hospitals. The results reflected low rate of preparedness with a mean scores for 17

preparedness was 2.63, response abilities was 2.02, and evaluation was 2.05 (all scored below normal on a 6 point Likert scale). Overall, nurses felt they were unable to respond in a variety of disaster situations, were aware of their workplace emergency disaster plan, but did not think they could execute them, and were not aware of the level of preparedness of the healthcare systems in their communities (Öztekin et al., 2016). Another study aimed to describe nurses' perception of readiness to manage disaster situations in Texas, USA. The study included 620 nurses, revealed that most nurses are not confident in their abilities to respond to major disaster events. The nurses who were confident were more likely to have had actual prior experience in disasters or shelters. Self-regulation of behavior (motivation) was a significant predictor of perceived nurse competence to manage disasters only in regard to the nurse's willingness to assume the risk of involvement in a disaster situation, while job satisfaction was not a determinant of disaster preparedness (Baack and Alfred, 2013). A cross-sectional analysis study aimed to determine preparedness of health system in European Union (EU) countries to respond to disastrous events. The study included all the 27 EU countries, and the results revealed that the average level of disaster management preparedness in the health systems of EU member states was 68% (Acceptable). The highest level of preparedness was seen in the United Kingdom, Luxemburg, and Lithuania. Considering the elements of disaster management system, the highest level of preparedness score was in health information elements (86%), and the lowest level was for hospitals, and educational elements (54%) (Djalali et al., 2014b). In India, A cross sectional study carried out in a tertiary hospital aimed to examine knowledge, attitudes, and practice (KAP) of health care providers about hospital disaster plan. The study included 186 health care providers (22.6% of participants were doctors, 18

27.6% were nurses, 28.6% were technicians, and 21.4% were administrative staff). The results indicated that 40.5% of the study participants knew the concept of a disaster plan whereas 61.3% were aware of disaster drills, 83.3% had a positive attitude towards the fact that all health-care workers should be aware of the disaster plan, 90.5% felt that training for disaster preparedness is essential for all staff, and 82.7% agreed that management should be prepared for disaster, 70% of the participants were not aware of any drills being conducted at the hospital whereas 93% of the participants were not aware if the hospital was conducting any training for disaster preparedness (Sharma et al., 2016). In South Africa, a study conducted in Johannesburg aimed to identify KAP of health care providers about disaster preparedness plans. The results found that selected health-care workers were aware of disaster preparedness plans, and their attitudes to drills were largely positive. However, the practices were deficient, and work is needed to be done on training, performance of drills, and the frequency of updating of plans (Moabi, 2008). In Iran, a study conducted in Tehran aimed to investigate hospital preparedness and response to crisis situations. The study included 21 hospitals in Tehran, and the results showed that 33% of hospitals had specific programs to increasing the capacity of the hospital for admitting the injured and victims, 36.8% of the hospitals provided the hospital staff duties at crisis, but 52.4% of them have been treatment teams for delivering health services during crises, admission and registration system is somewhat good. Also, the results showed that function of the hospital during crisis, function of the crisis committee, personnel education and situation of facilities and equipment were satisfactory. Unfortunately, organizing the personnel at crisis, admission capacity of the 19

emergency wards, information and communication systems at crisis, management of crisis and crisis commanding system and morbidity and mortality recording system were unsatisfactory (Zaboli and Sajadi, 2014). In Arab countries, very few studies had been conducted to examine hospital preparedness to disaster and ability to response to these disastrous events. It was noticed that most of the studies have been carried out in the Kingdom of Saudi Arabia (KSA) and that was explained because of the huge collection of Muslims from different parts of the world during Al Haj in Mecca and Al Madina in KSA. A study carried out in Mecca aimed to examine hospital preparedness to disasters and capacity to response to such events. The study included 14 hospitals in Mecca, and the results found that 64% of hospitals reviewed their disaster plan within the preceding two years, 64% were drilling for disasters at least twice per year, 79% of hospitals had their own ICS present in their plans. All hospitals described availability of some supplies required for the first 24 hours of a disaster response, such as: N95 masks, antidotes for nerve agents, and antiviral medications, and only 36% of hospitals had a designated decontamination area, 64% of hospitals reported ability to re-designate inpatient wards into an intensive care unit (ICU) format, 50% respondents had a protocol for increasing availability of isolation rooms to prevent the spread of airborne infection, and 71% of hospitals had a designated disaster-training program for health care workers (Al-Shareef et al., 2017). Also, a quantitative, non-experimental, descriptive study conducted in KSA aimed to examine knowledge and practices about disaster preparedness. The results indicated that nurses in KSA have moderate level of knowledge about disaster preparedness. However, nurses in military hospitals exhibited more knowledge than 20

those who work in governmental hospitals, and the majority of nurses gained their knowledge and skills from disaster drills (Al-Thobaity, et al., 2015). Furthermore, a cross sectional study aimed to explore knowledge and awareness of nurses about their role during disasters and to identify key elements of strategies to manage disastrous events. The study included 106 registered nurses in hospital EDs, and the results reflected that although emergency nurses' clinical role awareness in disaster response was reported to be high, nurses reported limited knowledge and awareness of the emergency and disaster preparedness plans. More than 50% of the emergency nurses in had not thoroughly read the plan, and almost 10% were not even aware of its existence. Also, emergency nurses reported seeing their main role as providing timely general clinical assessment and care (Alzahrani and Kyratsis, 2017). Moreover, a study carried out in Jeddah, KSA aimed to identify indicators of hospital preparedness for emergencies. The study included 6 hospitals, and the results showed availability of tools and indicators of hospital preparedness, but they lack training and management during disaster (Bajow and Alkhalil, 2014). In Jordan, a cross-sectional survey conducted to assess hospital preparedness and training on disasters. The study included 474 respondents from different hospitals, and the results indicated that 65% of respondents described their current disaster preparedness as weak, 18% medium, 12% good, and 5% felt their preparation was very good. Also, 31% received disaster education in undergraduate programs, 8% in graduate nursing programs, 31% in facility drills, and 22% in continuing education courses, while 11% had participated in a real disaster (Al Khalaileh et al., 2012). 21

Review of previous studies revealed low attention of researchers in Arab countries on examining health systems and preparedness of hospitals to response to crisis and disastrous events. It is of great importance to concentrate on more studies about preparedness for disaster situations to gain insight about ability of health care systems in Arab countries to response to crisis and disasters to be able to identify strengths and weaknesses and taking actions to overcome weaknesses to improve health systems response to unexpected disastrous events. 2.5 Indicators of Hospital Disaster Preparedness Running a hospital is a complex task under the normal circumstances, and preparing a hospital for a disaster is infinitely more complicated. Planning for disaster preparedness involves many questions and activities. The following are suggestions for hospital disaster preparedness indicators. 2.5.1 Communication and Coordination: Internal and external communication systems are necessary for proper hospitals functioning, cooperation and coordination with other health facilities. Communication is essential to call the staff, sending messages, and coordination of patients transfer between hospitals (Bagaria et al., 2009). 2.5.2 Surge Capacity (SC) Every health system faces a challenging demand on its resources. In addition to a longterm increase in patient volume, there may be short-term increases in demand for emergency healthcare services, or surge (McManus et al., 2006). The ability to manage daily operations, adequate amounts of space, and staffing directly affects how hospitals will handle patient surges during an emergency. While both daily and disaster surge necessitate coordination of multiple issues, the disaster requires coping with these 22

issues on a larger scale. ED overcrowding is a critical daily surge issue that impacts, yet differs from a mass influx of trauma cases combined with possible hospital system failure like power outages or flooding (National Association of Public Hospitals and Health Systems - NAPH, 2007). Surge capacity is the capability of a hospital to expand its resources to respond to a large number of casualties, and to do so, a number of actions can be taken including discharging stable patients, cancelling elective surgeries, opening alternate care areas, and calling off-duty staff. 2.5.3 Triage Triage is the process of determining the priority of patients' treatments based on the severity of their condition into three categories: a) those who are likely to live, regardless of what care they receive; b) those who are unlikely to live, regardless of what care they receive; c) those for whom immediate care might make a positive difference in outcome (Iserson and Moskop, 2007). 2.5.3.1 Triage in Hospitals Most of the hospitals nowadays use triage system to determine priority of treatment for different patients and casualties brought to ED. In this system, a qualified nurse or physician is assigned in the triage area to assess all the patients and classify them according to severity of the disease or injury and the need for treatment. 2.5.3.2 Classification of Victims in Triage Area In cooperation with the International Committee of Red Cross (ICRC), a triage system was established and implemented in governmental hospitals in GS. Selected qualified nurses and physicians have been trained on triaging and periodic monitoring is 23

performed to evaluate the effectiveness of the system. The triage system in Gaza hospitals use colored tags to categorize patients according to their need for treatment as follows: Red color: This kind of patients have the highest priority and need immediate lifesaving intervention. This type of patients are suffering from life-threatening conditions including catastrophic bleeding, respiratory distress or respiratory failure, severe head injury. Yellow color: These patients suffer from moderate illness or injury but their condition is stable and can wait for 1 2 hours. These patients need observation and periodic assessment to detect any changes in their condition. Examples of these patients include stable fractures, wounds without active bleeding, abdominal pain. Green color: These patients complain of minor injury or illness and usually coming to ED walking. They do not need immediate treatment and can wait for several hours or days. These patients can take proper medication and go home or follow up in outpatient clinic. Examples of these patients include low grade fever, headache, renal colic Black color: These patients or casualties are so severely injured and unlikely to survive with medical or surgical intervention. In mass casualty events, these patients are usually placed in special area and let them die peacefully, but in normal situations, usually the physicians or surgeons take some interventions to save their lives. These patients include large-area burns, severe multiple trauma including brain tissue injury, severe chest wounds (ICRC, 2016). 24

2.5.4 Safety and Maintenance of Life Line Facilities Each hospital must have safety management protocols of lifeline facilities to ensure continuity of hospital operations under all circumstances. Important lifeline facilities include electrical supply, power generators, clean water supply, medical gas supply and storage, emergency exit system, and waste management and disposal system (WHO, 2006; Hick et al., 2004). 2.6 Impact of Disasters on Hospitals and Healthcare System The impact of disaster can disrupt or destroy the ability of hospitals to function and serve a large scale of victims. As a result, hospitals may lose ability to withstand disaster, and this situation could create negative impacts on the health system and collapse of emergency health services, which lead to delay in treatment of trauma injuries and death (United Nations - UN, 2009). In addition, the cost of treating victims, and other effects on the provision of health care after a disaster can collectively raise social issues and inflict socioeconomic impacts on the health sector (PAHO/WHO 2005). Moreover, Communication and coordination between different organizations that offer emergency services is essential for the delivery of effective health services during disaster situation and failure of communication and coordination often leads to duplication, waste of resources, and inappropriate response to disastrous events (Asian Disaster Preparedness Center ADPC, 2009). The unique position of hospitals in terms of complexity and occupancy make them vulnerable to hazards. Hospitals are in need of adequate medical supplies and drugs in addition to demands for continuous supply of power, water, and medical gases. Also, 25

hospitals are occupied with medical and support staff and patients, and many patients need an uninterrupted power supply for life-supporting equipment (PAHO 2005). In addition, some hospitals may experience problems like personal inadequacy, interference of duties, and interference of activities during the crises resulted from unexpected events (Kearns et al., 2014). During disasters there will be overwhelming number of injured people who need to receive proper care and attention. Some people may lose their homes and come to hospitals for shelter. The important roles that hospitals can play during disasters to save people's lives gives hospitals a challenging responsibility that requires them to be prepared for such hard times (Alshehri, 2012). From our experience during the last 51-days war against GS on summer 2014 many families escaped from fight areas, other families had their homes demolished and became homeless. Hundreds of families came to the hospitals in Gaza for shelter and safety. This situation put extra pressure on the hospitals because these families were in need for clean water, food, and they occupied hospital's parks, gardens, and some families occupied the out-patient clinics. 2.7 Barriers to Readiness of Health Facilities to Crisis and Disasters Hospitals are complex and dependent on external support and supply lines, thus without appropriate EP, hospitals can become overwhelmed in their ability to provide care during a disastrous event. Limited resources, high demand for medical services, and the disruption of communication and supply lines create a significant barrier to the provision of health care (WHO, 2011). 26

A review study aimed to investigate obstacles that hinders effective management of crisis in the Bam earthquake showed that there were many problems in various aspects of planning including: lack of coherent programs, lack of attention to the needs of health care, poor coordination between agencies and organizations and lack of appropriate training of volunteers and people (Nekoei-Moghadam et al., 2016). In GS with long-term siege, all aspects of life became hard and the health system suffered from a lot of obstacles that rendered its development. The hospitals became overcrowded with patients, severe shortage of essential drugs and supplies, inadequate fuel, shortage of staff, poor salaries and migration of qualified surgeons and nurses. All these circumstances put the health services in hospitals on the edge and make it difficult to cope with the high number of patients to be treated with scarce resources. Hospital staff need to apply coping mechanisms to ensure that service provision continued to meet the most pressing needs. All these obstacles increased the pressure on the already exhausted health system and made it difficult to put applicable emergency plans for hospitals in GS. 2.8 Impact of the Palestinian Israeli Conflict on Hospitals in Gaza Strip The long-term prolonged Israeli military occupation and ongoing conflict has affected all aspects of life and constitutes a real challenge for Palestinians health care system. Under these circumstances, the emergency services especially in GS are carried out under a huge pressure, with inadequate human resources, lack of medication and life-saving equipment, and sometimes, as in the case of GS, with frequent electricity cuts. The demand on medical services frequently increases with the flare of Israeli violence against 27

Palestinians, where EDs become overwhelmed with the influx of injuries and traumas (Hamdan and Abu Hamra, 2017). Furthermore, after a decade of an Israeli-imposed blockade and the aftermath of three deadly wars, the last of which was in 2014, hospitals in GS have been suffering a severe shortage of medical supplies and consumables. The WHO reported in February 2018 that 42% of drugs were totally depleted while 23% of needed disposables are at zero stock. Since the GRM began, Gaza's MOH has been calling on medical and international organizations to intervene in the critical situation and provide hospitals with needed medical supplies. Political divisions have also played a role in the deterioration of Gaza's health system, and according to the WHO, more than 6,000 doctors and medical personnel have not received salaries since July 2014. Moreover, the Palestinian Authority continues to impose a 30% wage cut on 60,000 civil servants, which has been implemented since April 2017 (Al-Safadi, 2018). A study carried out in GS aimed to discuss the performance of the health system in response to the Israeli military attack during Nov 14-21, 2012. The study included review of documents, participants' observations, in-depth interviews with nine health providers, and a focus group of key informants. The findings of the study revealed that the violent events of past decades have affected the capacities and vulnerabilities of the health system in the GS for dealing with emergency situations, different health stakeholders have improved their preparedness because of their experiences, and the health facilities "namely hospitals" are barely adequate for dealing with the regular situations. Although hospitals increased their capacity during emergency situations by discharging patients and suspending regular operations, the burden of casualties was not equitably distributed 28

between hospitals. The capacity and the performance of human resources in response to most of the emergencies were adequate, making it possible to overcome various logistical deficiencies, inadequate training, and suboptimal organization of work (Ashour et al., 2013). During the war against GS in summer 2014, the hospitals in GS were overwhelmed with casualties who sustained different types of injuries due to Israeli bombing and air raids besides huge destruction of homes and infrastructures. All the hospitals were filled with thousands of victims and hundreds of people who lost their homes settled in the hospitals seeking for safe shelter which added extra pressure on the already crowded hospitals. 2.9 Impact of Great Return March on Healthcare System Since the 30 th of March 2018 the starting day of GRM, with thousands of Palestinian refugees in GS protest on the border fence east of GS, the hospitals received large number of casualties with severe injuries from gun fire and gas suffocation. On Monday 14 th May 2018, the big protest left more than 70 martyrs and around 2700 injured people. This big number of casualties influx in the hospitals in few hours. Al Shifa hospital received about 600 injured people and Shohada Al Aqsa received about 400 injured people, and European Gaza Hospital received about 200 injured people in the afternoon. The MOH declared emergency situation in all the health facilities in GS and raised appeal for assistance from other organizations like WHO and International Committee of Red Cross because of severe shortage of medical supplies and consumables. The hospitals worked in full capacity the whole day and night and all the operation rooms worked till morning of the second day. To meet the demand for extra beds, many patients have been 29

discharged, elective and scheduled operations have been cancelled, extra beds in surgical departments and ICUs to increase surge capacity. Health facilities in GS are struggling to deal with the number of casualties. Following his visit to Shifa hospital, the Humanitarian Coordinator, Mr. Jamie McGoldrick, stated: "I am deeply concerned by the tragedy unfolding in Gaza. The medical teams at Shifa are overwhelmed, dealing with hundreds of cases of injured, including women and children. They are stretched to the limit and are running out of essential medical supplies. Particularly worrying is that public hospitals in GS have less than a week of fuel reserves to continue their operations" (United Nations Office for the Coordination of Humanitarian Affairs - OCHA, 2018). Another report by United Nations Population Fund - UNFPA (2018) mentioned that "The health system in GS is on the verge of collapse as its struggles to manage the massive injuries; a challenge that adds to a protracted humanitarian crisis caused by a blockade, shrinking humanitarian space and chronic shortages of essential drugs and medical supplies". Ministry of Health report released on 21 June 2018, spokesman of MOH said "challenges facing the health sector exceeded medical capabilities of any health system in the world, where the hospitals in GS received on Fridays 280 case per hour which overpassed what happened in 2014 Israeli offensive, where hospitals received only 9 cases per hour. Furthermore, Director General of hospitals stated that MOH- Gaza, has installed field trauma stabilization points (FTSP) in five areas near the buffer zones along GS eastern borders to make triage for the casualties of the GRM. He said, without our FTSP we would have lost large numbers of injured, and large numbers would have arrived to the emergency rooms of our hospitals. In that regard the MOH staff have dealt with more 30

than 13672 injuries 7451 of them have arrived to our hospitals. We used to receive 700-800 injured on Fridays within 4-6 hours, which means a huge numbers flocked in short time, putting a strain on our limited hospital resources (capacity and staff). As a result, MOH expanded temporarily the physical capacity of ICUs and emergency rooms (MOH, 2018). This crisis situation emphasize the need to evaluate the hospitals readiness for such events and take actions to improve surge capacity and proper use of available resources for the maximum number of casualties. Table (2.1): Number of casualties in GRM from 30/3 25/7/2018 Item Number Martyrs 152 Total number of injuries 16750 Live ammunition (high velocity bullets) 4250 Rubber bullets (steal-coated) 534 Gas suffocation 7536 Fragments and other injuries 4430 Source: MOH media report, 25.7.2018 31

Table (2.2): Site of injury of casualties in GRM from 30/3 25/7/2018 Site Number Head and neck 620 Chest and back 370 Abdomen and pelvis 400 Upper extremity 1255 Lower extremity 5410 Multiple injury 1120 Source: MOH media report, 25.7.2018 2.10 Characteristics and Capacity of Hospitals The study included nine governmental hospitals (6 general hospitals and 3 pediatric hospitals). Description of characteristics of these hospitals reflect that Al Shifa hospital in Gaza was the largest hospital with total capacity of 750 beds, 600 physicians, and 900 nurses, followed by NMC in Khanyounis with 406 beds, 250 physicians, and 389 nurses, followed by EGH in Khanyounis with 253 beds, 193 physicians, and 320 nurses, followed by Shohada Al Aqsa in mid zone with 228 beds, 150 physicians, and 230 nurses. Table (2.3): Characteristics of the hospitals participated in the study Variable Al Shifa Andonesy Shohada Al Aqsa EGH NMC Al Najar Al Nassr Al Dora Al Rantesy Address Gaza North Mid Khan- Khan- Rafah Gaza Gaza Gaza Gaza zone Younis Younis Total beds 750 110 228 253 406 65 134 89 131 Number of physicians 600 97 150 193 250 65 53 42 40 Number of nurses 900 148 230 320 389 110 140 70 117 Number of Lab. Staff 50 26 33 41 38 16 24 12 18 Number of radiology 60 27 31 42 29 20 13 8 11 staff Number of 360 86 120 201 189 73 55 54 66 administration staff Number of security personnel 100 10 16 38 27 11 8 6 0 32

Hospitals capacity of essential machinery and equipment revealed that all the hospitals have ambulances to serve for transporting patients from one hospital to another. It is noticed that Al Najar hospital is a small hospital but it has 8 ambulances used to transfer patients to neighborhood hospitals EGH and NCM in Khanyounis. Also, all the hospitals have portable X-ray machines and ultrasound. All the hospitals have portable cardiac monitors for hemodynamic monitoring during transferring patients within the hospital and between hospitals. In addition, all the hospitals have mechanical ventilators, the largest number was in Al Shifa hospital with total of 34 ventilators, EGH with 20 ventilators, Al Nassr Pediatric hospital with 16 ventilators. Also, all the hospitals have ICU beds except Al Najar hospital. Available ICU beds in Al Shifa are 19 beds, EGH 17 beds, Andonesy hospital 10 beds, and less number was noticed in Shohada Al Aqsa hospital with 5 beds and NCM with 6 ICU beds. Al Shifa hospital has the largest number of operating rooms (ORs) with 22 available ORs, EGH has 8 ORs, Andonesy hospital has 4 ORs, Shohada Al Aqsa and NCM has 3 rooms each. Table (2.4): Description of hospitals capacity Variable Al Shifa Andonesy Shohada Al Aqsa EGH NMC Al Najar Al Nassr Al Dora Al Rantesy Number of ambulances 4 3 6 4 9 8 0 1 3 Portable X-ray machine Yes Yes Yes Yes Yes Yes Yes Yes Yes Number of portable cardiac monitors 14 9 4 6 10 6 2 2 2 Portable ultrasound Yes Yes Yes Yes Yes No Yes Yes Yes Total number of ventilators 34 13 7 20 6 1 16 5 4 Available ICU beds 19 10 5 17 6 0 10 5 4 Available operating rooms 22 4 3 8 3 2 0 0 0 33

2.11 Summary Hospitals are essential components in the health system because of their role in treating patients and casualties with different types of disease and injuries, saving lives and reducing disabilities. GS is living under continuous pressure and conflicts with Israeli forces and that leads to higher number of casualties who demand health services. Hospitals in GS are barely adequate for dealing with the regular situations. Although hospitals increased their capacity during emergency situations by discharging patients and postponed regular operations, the burden of casualties was not equitably distributed between hospitals. The health system should identify EP and each hospital must have its own EP that enable the hospital to respond properly to crisis and disasters with high number of casualties with different injuries. A good EP should be multidisciplinary, identifying hospital capacity, specialties, logistics and supplies, staff availability, communication systems, incident command system, and information management. Also, ensuring availability of strategic stockpile of supplies and medication is vital for ability to offer health services, and the EP should include pharmacy and laboratory departments in the plan. 34

Chapter 3 Material and Methods 35

Chapter 3 Material and Methods 3.1 Study design The researcher used descriptive, cross-sectional design in this study. Descriptive study describes the investigated phenomena as it naturally occurs. Cross sectional design can provide a snapshot of the characteristics of the subjects under investigation at a particular point in time. It is relatively inexpensive and takes little time to conduct (Levin, 2006). 3.2 Population of the Study The study population included all the governmental hospitals in GS. The total number is 13 hospitals distributed in GS. 3.3 Sample of the Study The study sample included 9 governmental hospitals which offer emergency health services (6 general hospitals and 3 pediatric hospitals). Four hospitals excluded from the study (The psychiatric hospital, the ophthalmic hospital, Bet Hanoon Hospital, and Al Emaraty maternity hospital). Bet Hanoon hospital have been excluded because it acts as a transfer hospital, and all casualties are transferred to the neighborhood Al Andonesy Hospital. Key persons were included from each hospital (general director, medical department, administrative department, nursing office, Radiology department, laboratory, pharmacy, maintenance and engineering). These individuals were selected in this study because they are the main individuals who play a major role and carry responsibility in hospital management, preparedness and functioning. The researcher distributed 126 questionnaires for key persons and 87 persons agreed to participate in the study and filled the questionnaires with response rate 69%. Those who did not 36

participate in the study said that they don't have time to fill the questionnaire and others said that they do not want to participate in the study. Table (3.1): Distribution of study sample Hospital Number of key persons Number of respondents Al Andonesy 15 9 Al Shifa Medical Complex 20 11 Shohada Al Aqsa 15 6 Nasser Medical Complex 19 16 European Gaza Hospital 15 9 Al Najjar 12 9 Al-Nassr Pediatric 10 9 Al-Rantesy Pediatric 10 9 Al Dora Pediatric 10 9 Total 126 87 3.4 Setting of the Study The following hospitals were included in the study (Al Andonesy Hospital in the north, Al Shifa Hospital in Gaza, Shohada Al Aqsa Hospital in the middle zone, Nasser Hospital in Khanyounis, European Gaza Hospital in Khanyounis, and Al Najjar Hospital in Rafah, Al- Nassr Pediatric hospital in Gaza, Al-Rantesy Pediatric hospital in Gaza, and Al Dora Pediatric hospital in Gaza). 3.5 Period of the Study The study have been carried out during the period from November 2017 to July 2018. 3.6 Eligibility Criteria 3.6.1 Inclusion Criteria - Governmental hospitals that offer general health care services. - Governmental hospitals that offer pediatric health care services. 37

3.6.2 Exclusion Criteria - Maternity hospitals, psychiatric hospitals, and ophthalmic hospital. - Nongovernmental hospitals 3.7 Instrument of the Study The researcher used constructed, self-administered questionnaire to assess hospital disaster preparedness. The questionnaire was adapted with modification, based on Hospital Disaster Preparedness Self-Assessment Tool which was developed by The American College of Emergency Physicians (ACEP) and the Hospital Emergency Analysis Tool (American College of Emergency Physicians, 2017). The questionnaire consisted of the following parts (annex 1 & 2): Part one: Hospital profile including: Hospital staffing, other hospital capacities, safety and security, and logistics. Part two: Emergency management planning including: Availability of Emergency management plan, facility readiness and training, incident command system, hospital emergency management/ disaster preparedness committee, emergency department capacity, patient triage, patient tracking, critical incident stress management, pharmacy services, laboratory services, fatalities management, communication, warning, and notification, information management 3.8 Pilot Study A pilot study was conducted (pre-test of instrument) on 20 participants to test reliability of the questionnaire as shown in table (3.2). The piloted questionnaires were included in the actual sample. 38

3.8.1 Validity To examine validity of the questionnaire, the researcher distributed the questionnaire to a panel of expertise in health field to ensure clarity and validate the contents of the questionnaire (annex 3). Their comments and advices were considered in finalization of the questionnaire. 3.8.2 Reliability The researcher used Cronbache alpha coefficient to examine the reliability for each dimension of the questionnaire. The results are shown in the table (3.2). Table (3.2): Cronbache alpha coefficient Dimension Number Alpha Safety and security 6 0.771 Logistics 20 0.682 Emergency management planning 15 0.933 Facility readiness and training 10 0.717 Incident command system 6 0.905 Hospital Emergency Management / Disaster Preparedness 8 0.547 Patient triage 7 0.627 Patient tracking 3 0.584 Critical incident stress management 6 0.905 Pharmacy services 5 0.744 Laboratory services 6 0.694 Fatalities management 5 0.775 Communications, warning, and notification 8 0.607 Information management 3 0.616 Total score 108 0.721 3.9 Data Collection and Management Data had been collected by the researcher by distribution of questionnaires for the selected persons. Relevant instructions and explanation was provided to study participants for proper filling of the questionnaire. 39

After data collection, the researcher used SPSS (version 20) for data analysis. The researcher performed design coding and entering model of data to the computer. The researcher used frequencies, percentage, cross tabulation, and parametric tests to analyze data. 3.10 Ethical Considerations Before conducting the study, the researcher obtained approval from the IUG (annex 4). Then approval letter was obtained from Helsinki Committee (annex 5) and from MOH (annex 6) to conduct the study in the governmental hospitals. Participants in the study have been asked for voluntary participation in the study, and data that will be collected will be used for research purposes. 40

Chapter 4 Results and Discussion 41

Chapter 4 Results and Discussion This study was carried out in 9 governmental hospitals in GS (6 general hospitals and 3 pediatric hospitals), and included 87 respondents. The respondents were directors and supervisors with administrative and technical responsibilities. Characteristics of respondents and hospitals are illustrated below. 4.1 Characteristics of Respondents and Hospitals 20 18 16 14 12 10 8 6 4 2 0 12.6 10.3 6.9 Al Shifa Andonesy Shohada Al Aqsa 10.3 14.8 EGH NMC Al Najjar Al Nassr Ped. 10.3 10.3 10.3 10.3 Al Dora Ped. Al Rantesy Ped. Figure (4.1): Distribution of respondents according to hospitals (N= 87) Figure (4.1) shows that the highest number of participants were from NMC 16 (18.4%), followed by Al Shifa hospital 11 (12.6%), while the lowest number of participants were from Shohada Al Aqsa hospital 6 (6.9%). 42

4.2 Hospital Profile 4.2.1 Hospital Staffing 30 25 20 23 26.4 19.5 15 10 9.2 10.3 9.2 5 2.3 0 Figure (4.2): Distribution of respondents by department Figure (4.2) shows that the highest number of participants were from nursing office 23 (26.4%), followed by administrative department 20 (23%), while the lowest number of participants were from maintenance and engineering department 2 (2.3%) and Radiology department and pharmacy department with 8 (9.2%) for each of them. 43

4.2.2 Safety and Security Table (4.1): Description of safety and security Al Shifa Andonesy Shohada Al Aqsa EGH NMC Al Najar Al Nassr Al Dora Al Rantesy Average % χ2 P value Security personnel on duty 24 hours/ 7 days per week in ED No 9.1 22.2 0 0 25.0 11.1 33.3 25.0 88.9 23.8 Yes 90.9 77.8 100.0 100.0 75.0 88.9 66.7 75.0 11.1 76.2 27.79 0.001 Facility can post additional security personnel in ED No 0 11.1 50.0 0 56.2 44.4 55.6 50.0 88.9 39.5 Yes 100.0 88.9 50.0 100.0 43.8 55.6 44.4 50.0 11.1 60.5 28.85 0.000 Available armed police force No 9.1 22.2 33.3 0 43.8 0 11.1 88.9 100.0 34.3 Yes 90.9 77.8 66.7 100.0 56.2 100.0 88.9 11.1 0 65.7 44.891 0.000 Facility has a memorandum of understanding with local law enforcement to provide additional security No 36.4 66.7 16.7 44.4 18.8 22.2 77.8 66.7 88.9 48.7 Yes 63.6 33.3 83.3 55.6 81.2 77.8 22.2 33.3 11.1 51.3 22.633 0.004 A plan is in place to provide information to large numbers of concerned family and friends and to control crowds No 72.7 77.8 33.3 55.6 31.3 22.2 88.9 77.8 88.9 61.0 Yes 27.3 22.2 66.7 44.4 68.8 77.8 11.1 22.2 11.1 39.0 22.043 0.005 All entrances and exits are controlled, monitored with cameras., and can be locked No 27.3 100.0 0 11.1 43.8 22.2 77.8 88.9 88.9 51.0 Yes 72.7 0 100.0 88.9 56.3 77.8 22.2 11.1 11.1 49.0 39.355 0.000 Grand average No 43.05 Yes 56.95 Table (4.1) shows that 76.2% of respondents stated that security personnel are available 24 hours a day in ED with statistically significant differences between hospitals in favor of Shohada Al Aqsa and EGH (P= 0.001), followed by 65.7% of respondents mentioned that armed police force is available in the hospital with statistically significant differences 44

between hospitals in favor of EGH and Al Najjar hospital (P= 0.000). While 39% of respondents reported that a plan is available to provide information to families who are concerned about their injured sons with statistically significant differences between hospitals in favor of Al Najjar hospital (P= 0.005), and 49% of respondents mentioned that all hospital gates are controlled and monitored with cameras with statistically significant differences between hospitals in favor of Shohada Al Aqsa and EGH. In general, 56.95 of respondents stated that safety and security measures are available in their hospital. 4.2.3 Availability of Logistics Table (4.2a): Availability of logistics in hospitals Al Shifa Andonesy Shohada Al Aqsa EGH NMC Al Najar Al Nassr Al Dora Al Rantesy Average % χ2 P value Presence of emergency power generator Yes 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 NA NA Emergency power is adequate to provide electricity for all essential services for three days No 0 0 16.7 0 12.5 0 0 33.3 11.1 8.2 Yes 100.0 100.0 83.3 100.0 87.5 100.0 100.0 66.7 88.9 91.8 Facility has documented which essential services will receive power No 9.1 11.1 0 11.1 0 22.2 11.1 11.1 11.1 10.8 Yes 90.9 88.9 100.0 88.9 100.0 77.8 88.9 88.9 88.9 89.2 Load testing is performed annually on generator No 9.1 11.1 0 11.1 0 22.2 11.1 22.2 10.3 10.8 Yes 90.9 88.9 100.0 88.9 100.0 77.8 88.9 77.8 89.7 89.2 How does the facility get fuel for generators? MOH 100.0 100.0 100.0 100.0 100.0 100.0 88.9 100.0 100.0 100.0 Own supply 0 0 0 0 0 0 11.1 0 0 0 Facility has an on-campus fuel source which can provide sufficient fuel for 3 days of full-load demand No 0 0 33.3 11.1 12.5 0 0 11.1 0 7.5 Yes 100.0 100.0 66.7 88.9 87.5 100.0 100.0 88.9 100.0 92.5 On-campus fuel source is in secured area No 18.2 11.1 16.7 0 12.5 22.2 44.4 11.1 11.1 16.3 Yes 81.2 88.9 83.3 100.0 87.5 77.8 55.6 88.9 88.9 83.7 Source of water supply Municipal 90.9 0 0 100.0 75.0 22.2 100.0 100.0 0 54.2 Own suppl. 9.1 100.0 100.0 0 25.0 77.8 0 0 100.0 45.8 Secondary source of water if primary source is cutoff No 9.1 11.1 33.3 0 6.3 11.1 11.1 11.1 0 10.3 Yes 90.9 88.9 66.7 100.0 93.7 88.9 88.9 88.9 100.0 89.7 Facility has adequate food on hand for staff and patients for a 3-4 days No 27.3 66.7 66.7 0 18.8 77.8 33.3 66.7 11.1 41.0 Yes 72.7 33.3 33.3 100.0 81.2 22.2 66.7 33.3 88.9 59.0 Security of food products is maintained at all times during: Delivery, storage, and preparation 45 13.037 0.111 4.255 0.833 5.318 0.723 8.767 0.362 11.293 0.186 8.021 0.431 141.525 0.000 6.334 0.610 25.849 0.001

Al Shifa Andonesy Shohada Al Aqsa EGH NMC Al Najar Al Nassr Al Dora Al Rantesy Average % χ2 P value No 18.2 22.2 33.3 11.1 6.3 22.2 33.3 11.1 11.1 18.8 Yes 81.8 77.8 66.7 88.9 93.7 77.8 66.7 88.9 88.9 81.2 5.610 0.691 As Shown in table (4.2a) all the respondents stated that emergency power generators are available in all the hospitals to supply electricity to hospital departments when the general electricity is cut-off, and 92.5% of respondents mentioned that the hospital has its own storage of fuel for 3 days without statistically significant differences between hospitals (P= 0.186), and 91.8% of respondents reported that the generators supply adequate electricity for essential services for about three days without statistically significant differences between hospitals (P= 0.111). Concerning water supply, 54.2% of respondents stated that the hospital gets water supply from the municipality sources, while 45.8% of respondents stated that the hospital has its own source of water with statistically significant differences between hospitals in favor of EGH, Al Nassr pediatric hospital and Al Dora pediatric hospital. Concerning food supply, 59% of respondents reported that the hospital has adequate food available for staff and patients for a 3-4 days with statistically significant differences between hospitals in favor of EGH (P= 0.001). 46

Table (4.2b): Availability of logistics in hospitals Al Shifa Andonesy Shohada Al Aqsa EGH NMC Al Najar Al Nassr Al Dora Al Rantesy Average % χ2 P value Facility has medical gasses to last 3-4 days without re-supply No 0 0 0 0 12.5 11.1 11.1 11.1 0 5.0 Yes 100.0 100.0 100.0 100.0 87.5 88.9 88.9 88.9 100.0 95.0 5.464 0.707 Medical gasses are in a secured area No 27.3 0 16.7 11.1 6.3 11.1 55.6 33.3 11.1 19.0 Yes 72.7 100.0 83.3 88.9 93.2 88.9 44.4 66.7 88.9 81.0 14.764 0.064 Maintenance and engineering staff are available 24 hours a day No 9.1 11.1 50.0 0 6.3 66.7 11.1 33.3 88.9 30.7 Yes 90.9 88.9 50.0 100.0 93.7 33.3 88.9 66.7 11.1 69.3 36.874 0.000 Facility can isolate and shut down Heating, Ventilation, and Air Conditioning (HVAC) system zones in an emergency No 18.2 22.2 0 11.1 12.5 11.1 11.1 11.1 0 10.8 Yes 81.8 77.8 100.0 88.9 87.5 88.9 88.9 88.9 100.0 89.2 3.471 0.901 HVAC shutdown has been exercised in past year No 72.7 77.8 33.3 55.6 37.5 44.4 88.9 55.6 88.9 61.6 Yes 27.3 22.2 66.7 44.4 62.5 55.6 11.1 44.4 11.1 38.4 14.481 0.070 Guidelines are in place for emergency HVAC shutdown No 81.8 88.9 83.3 44.4 31.3 33.3 77.8 88.9 77.8 67.5 Yes 18.2 11.1 16.7 55.6 68.7 66.7 22.2 11.1 22.2 32.5 21.520 0.006 Sections of the facility can be isolated No 45.5 77.8 16.7 44.4 18.8 33.3 44.4 66.7 88.9 48.5 Yes 54.5 22.2 83.3 55.6 81.2 66.7 55.6 33.3 11.1 51.5 19.228 0.014 Facility has procedures for management, transfer, and disposal of contaminated wastes, goods, and fluids No 54.5 44.4 16.7 33.3 12.5 11.1 55.6 55.6 55.6 37.7 Yes 45.5 55.6 83.3 66.7 87.5 88.9 44.4 44.4 44.4 62.3 13.510 0.095 Facility maintains current inventory of equipment, supplies and other essential material required to effectively respond to a mass casualty event No 45.5 33.3 50.0 11.1 43.8 77.8 44.4 33.3 22.2 40.2 Yes 54.5 66.7 50.0 88.9 56.2 22.2 55.6 66.7 77.8 59.8 10.532 0.230 Grand average No 30.0 Yes 70.0 As shown in table (4.2b), 95% of respondents mentioned that their hospitals have medical gasses to last 3-4 days without re-supply without statistically significant differences between hospitals (P= 0.707), 89.2% of respondents stated that their hospitals can isolate and shut down heating, ventilation, and air conditioning (HVAC) system zones in an 47

emergency, but 38.4% of respondents said that exercise have been done to shutdown HVAC in past year without significant differences between hospitals, and 32.5% of respondents reported that guidelines are in place for emergency HVAC shutdown with statistically significant differences between hospitals in favor of NMC and Al Najjar hospital (P= 0.006). 4.3 Emergency Management Planning (EMP) This part presents issues related to presence of written emergency plan within each hospital, besides other aspects including command system, warnings, other services like pharmacy, laboratory, and information management. These aspects presented in details in the following tables. 4.3.1 Availability of Emergency Management Plan Table (4.3): Availability of emergency management planning in hospitals Al Shifa Andonesy Shohada Al Aqsa EGH NMC Al Najar Al Nassr Al Dora Al Rantesy Average % χ2 P value Facility has an EMP that addresses the four phases of emergency management. No 18.2 22.2 16.7 11.1 6.3 0 22.2 11.1 11.1 13.2 Yes 81.8 77.8 83.3 88.9 93.7 100.0 77.8 88.9 88.9 86.8 3.841 0.871 The EMP addresses internal and external emergencies No 0 11.1 16.7 11.1 6.3 11.1 55.6 22.2 22.2 17.4 Yes 100.0 88.9 83.3 88.9 93.7 88.9 44.4 77.8 77.8 82.6 14.637 0.067 The EMP is easily accessible to mentors or to staff No 18.2 66.7 16.7 44.4 37.5 22.2 66.7 33.3 22.2 36.4 Yes 81.8 33.3 83.3 55.6 62.5 77.8 33.3 66.7 77.8 63.6 11.512 0.174 The EMP addresses all hazards events No 9.1 22.2 16.7 55.6 25.0 55.6 66.7 33.3 11.1 32.8 Yes 90.9 77.8 83.3 44.4 75.0 44.4 33.3 66.7 88.9 67.2 15.382 0.052 The EMP includes arrangements for rapid transfer of ED patients to inpatient units No 9.1 11.1 16.7 22.2 6.3 22.2 66.7 44.4 11.1 23.3 Yes 90.9 88.9 83.3 77.8 93.7 77.8 33.3 55.6 88.9 76.7 17.924 0.022 The EMP includes arrangements for early discharge and transfer of inpatients from the facility No 0 22.2 16.7 33.3 12.5 11.1 55.6 22.2 22.2 21.8 Yes 100.0 77.8 83.3 66.7 87.5 88.9 44.4 77.8 77.8 78.2 11.669 0.167 The EMP addresses plans for follow-up outpatient care as needed No 0 22.2 16.7 22.2 12.5 22.2 55.6 55.6 11.1 24.2 Yes 100.0 77.8 83.3 77.8 87.5 77.8 44.4 44.4 88.9 75.8 15.923 0.043 48

Al Shifa Andonesy Shohada Al Aqsa EGH NMC Al Najar Al Nassr Al Dora Al Rantesy Average % χ2 P value The EMP includes written and validated arrangements for surge staffing No 18.2 22.2 16.7 22.2 25.0 0 55.6 11.1 11.1 20.2 Yes 81.8 77.8 83.3 77.8 75.0 100.0 44.4 88.9 88.9 79.8 10.330 0.243 The EMP includes arrangements to cancel non-emergent services No 36.4 11.1 16.7 22.2 6.3 0 55.6 11.1 11.1 19.0 Yes 63.6 88.9 83.3 77.8 93.7 100.0 44.4 88.9 88.9 81.0 15.303 0.054 Spiritual care is integrated into EMP No 36.4 22.2 16.7 22.2 12.5 0 55.6 22.2 11.1 22.0 Yes 63.6 77.8 83.3 77.8 87.5 100.0 44.4 77.8 88.9 88.0 11.389 0.181 The EMP includes provisions for recovery and return to normal operations No 36.4 22.2 16.7 22.2 12.5 11.1 66.7 33.3 11.1 25.8 Yes 63.6 77.8 83.3 77.8 87.5 88.9 33.3 66.7 88.9 74.2 12.804 0.119 The EMP is shared with the appropriate local and state emergency agencies No 54.5 22.2 16.7 44.4 25.0 11.1 66.7 66.7 55.6 40.3 Yes 45.5 77.8 83.3 55.6 75.0 88.9 33.3 33.3 44.4 59.7 14.431 0.071 All staff receives orientation to the EMP No 54.5 55.6 33.3 44.4 31.3 11.1 66.7 33.3 11.1 38.0 Yes 45.5 44.4 66.7 55.6 68.7 88.9 33.3 66.7 88.9 62.0 11.733 0.164 Emergency Department staff receive at least twice-annual training on response to emergency events No 72.7 33.3 50.0 33.3 12.5 22.2 66.7 55.6 44.4 43.4 Yes 27.3 66.7 50.0 66.7 87.5 77.8 33.3 44.4 55.6 56.6 15.136 0.057 All physicians and nurses maintain current Basic Life Support registration No 27.3 11.1 0 11.1 18.8 0 22.2 33.3 11.1 15.0 Yes 72.7 88.9 100.0 88.9 81.2 100.0 77.8 66.7 88.9 85.0 6.707 0.569 Grand average % No 25.5 Yes 74.5 Table (4.3) shows that 88% of respondents reported that spiritual care is integrated into EMP (P= 0.181) which indicated insignificant differences between hospitals, 86.8% stated that their hospitals have an EMP that identify the four phases of emergency management without statistically significant differences between hospitals (P= 0.871), and 82.6% of respondents mentioned that the EMP addresses internal and external emergencies (P= 0.067) which indicated insignificant differences between hospitals. Lower scores obtained reflected that 59.7% of respondents stated that the EMP is shared with the appropriate local and state emergency agencies (P= 0.071) which indicated insignificant differences between hospitals, and 56.6% of respondents mentioned that ED 49

staff receive at least twice-annual training on response to emergency events (P= 0.057) which indicated insignificant differences between hospitals. In general, the results reflected that 74.5% of respondents reported availability of emergency management planning and its related aspects in the hospitals in GS. 4.3.2 Facility Readiness and Training Table (4.4): Percentage of staff who have completed disaster preparedness training Al Shifa Andonesy Shohada Al Aqsa EGH NMC Al Najar Al Nassr Al Dora Al Rantesy Average % Percent of total staff who have completed disaster response/preparedness training % 32.7 60.0 31.6 38.8 55.9 81.6 35.0 47.2 66.1 52.8 Percent of medical staff who have completed disaster response/preparedness training % 32.7 56.6 37.5 40.0 62.1 84.4 39.4 48.8 68.3 52.2 Percent of nursing staff who have completed disaster response/preparedness training % 35.4 78.8 47.5 43.3 64.3 85.5 53.3 50.5 71.6 58.9 From table (4.4) and according to respondents opinion, 52.8% total staff, 52.2% of medical staff, and 58.9% of nursing staff have completed training about disaster response/preparedness. According to the results, highest disaster response and preparedness training was in Al Najar hospital followed by Andonesy hospital and NMC. 50

Table (4.5): Facility readiness and training Al Shifa Andonesy Shohada Al Aqsa EGH NMC Al Najar Al Nassr Al Dora Al Rantesy Average % χ2 P value Facility exercises EMP at least twice per year No 90.9 88.9 66.7 100.0 12.5 44.4 100.0 77.8 33.3 68.3 40.526 0.000 Yes 9.1 11.1 33.3 0 87.5 55.6 0 22.2 66.7 31.7 Facility participates in at least one community-wide exercise /year No 90.9 55.6 33.3 88.9 18.8 33.3 88.9 77.8 77.8 62.8 29.073 0.000 Yes 9.1 44.4 66.7 11.1 81.2 66.7 11.1 22.2 22.2 37.2 All ED personnel participate in at least twice-annual mass casualty exercises No 90.9 77.8 50.0 77.8 6.3 55.6 88.9 77.8 66.7 65.8 31.255 0.000 Yes 9.1 22.2 50.0 22.2 93.7 44.4 11.1 22.2 33.3 34.2 Facility has exercised evacuation of staff and patients in the last 12 months No 100.0 88.9 83.3 66.7 50.0 22.2 100.0 77.8 88.9 75.3 26.725 0.001 Yes 0 11.1 16.7 33.3 50.0 77.8 0 22.2 11.1 24.7 Facility has a procedure for conducting after-action reviews of simulated or actual emergency events No 36.4 33.3 16.7 33.3 12.5 33.3 77.8 66.7 66.7 58.1 17.613 0.024 Yes 63.6 66.7 83.3 66.7 87.5 66.7 22.2 33.3 33.3 41.9 Facility uses after-action reports to identify strengths and weaknesses of the EMP No 45.5 22.2 16.7 33.3 18.8 44.4 77.8 55.6 11.1 36.2 15.310 0.053 Yes 54.5 77.8 83.3 66.7 81.2 55.6 22.2 44.4 88.9 63.8 Facility incorporates information gathered from after-actions reports into their EMP No 45.5 22.2 16.7 22.2 6.3 44.4 77.8 55.6 11.1 33.5 20.574 0.008 Yes 54.5 77.8 83.3 77.8 93.7 55.6 22.2 44.4 88.9 66.5 No 40.0 Grand average % Yes 60.0 Table (4.5) shows that 31.7% of respondents stated that the hospitals exercises EMP at least twice per year (P= 0.000) which is statistically significant in favor of NMC, and 24.7% of respondents said that the hospital has exercised evacuation of staff and patients in the last 12 months (P= 0.001) which is significant in favor of Al Najjar hospital. In addition, 63.8% of respondents stated that the hospital uses after action reports to identify strengths and weaknesses of the EMP (P= 0.053) which is not significant, and 66.5% of respondents said that facility incorporates information gathered from after 51

actions reports into their EMP and 33.5% disagreed (P= 0.008) which is significant in favor of NMC. In general, 60% of respondents mentioned that their hospitals were ready and trained for disasters, and the highest readiness and participation in training was in NMC. 4.3.3 Incident Command System (ICS) Table (4.6): Availability of incident command system Al Shifa Andonesy Shohada Al Aqsa EGH NMC Al Najar Al Nassr Al Dora Al Rantesy Average % χ2 P value Presence of Incident Command System (ICS) in the hospital No 72.7 33.3 16.7 55.6 18.8 22.2 88.9 55.6 11.1 41.6 Yes 27.3 66.7 83.3 44.4 81.2 77.8 11.1 44.4 88.9 58.4 ICS is exercised at least twice annually No 100.0 77.8 50.0 77.8 31.3 55.6 88.9 77.8 88.9 72.0 Yes 0 22.2 50.0 22.2 68.7 44.4 11.1 22.2 11.1 28.0 Incident commander is known by all staff No 72.7 77.8 50.0 88.9 37.5 88.9 88.9 66.7 11.1 64.7 Yes 27.3 22.2 50.0 11.1 62.5 11.1 11.1 33.3 88.9 35.3 There is a procedure to designate an incident commander No 54.5 66.7 16.7 66.7 31.3 22.2 88.9 55.6 77.8 53.4 Yes 45.5 33.3 83.3 33.3 68.7 77.8 11.1 44.4 22.2 46.6 Staff assigned to ICS leadership roles are oriented to their responsibilities No 54.5 44.4 16.7 44.4 18.8 33.3 88.9 55.6 33.3 43.3 Yes 45.5 55.6 83.3 55.6 81.2 66.7 11.1 44.4 66.7 56.7 All staff know where to go when the ICS is activated No 54.5 44.4 16.7 55.6 25.0 22.2 88.9 55.6 11.1 41.5 Yes 45.5 55.6 83.3 44.4 75.0 77.8 11.1 44.4 88.9 58.5 Grand average % No 52.75 Yes 47.25 24.212 0.002 22.076 0.005 24.457 0.002 17.890 0.022 15.182 0.056 18.728 0.016 Table (4.6) presents results concerning presence of incident command system. The results indicated that 58.4% of respondents stated that there is an ICS in their hospitals (P= 0.002) which is significant in favor of Al Rantesy hospital, but only 28% of respondents stated that ICS is exercised at least twice annually (P= 0.005) which is significant in favor 52

of NMC, and 35.3% of respondents mentioned that incident commander is known by all staff (P= 0.002) which is significant in favor of NMC. In general, 47.25% of respondents reported that ICS is available in the hospitals, which reflected that less than half of the hospitals have ICS with its related aspects. 4.3.4 Hospital Emergency Management/Disaster Preparedness Committee Table (4.7): Hospital emergency management/disaster preparedness committee Al Shifa Andonesy Shohada Al Aqsa EGH NMC Al Najar Al Nassr Al Dora Al Rantesy Average % χ2 P value A hospital emergency management/disaster preparedness committee exists and provides leadership to staff No 18.2 22.2 0 33.3 0 0 33.3 44.4 11.1 18.0 Yes 81.8 77.8 100.0 66.7 100.0 100.0 66.7 55.6 88.9 82.0 14.793 0.063 Committee is multidisciplinary No 18.2 22.2 16.7 33.3 6.3 33.3 33.3 66.7 22.2 28.0 Yes 81.8 77.8 83.3 66.7 93.7 66.7 66.7 33.3 77.8 72.0 12.347 0.136 Open meetings are held regularly No 54.5 55.6 33.3 66.7 18.8 22.2 66.7 55.6 66.7 49.0 Yes 45.5 44.4 66.7 33.3 81.2 77.8 33.3 44.4 33.3 51.0 12.762 0.120 If yes, how often? Freq. 0-5 0-5 0-5 0-1 0-12 0-4 0-4 0-6 0-4 5 -- -- Committee meeting minutes/action plan are available for review No 18.2 55.6 16.7 55.6 31.3 33.3 66.7 44.4 77.8 44.4 Yes 81.8 44.4 83.3 44.4 68.7 66.7 33.3 55.6 22.2 55.6 20.804 0.186 Committee is knowledgeable of hospital "system" plans that could override local plans No 45.5 66.7 16.7 55.6 18.8 11.1 66.7 44.4 33.3 39.9 Yes 54.5 33.3 83.3 44.4 81.2 88.9 33.3 55.6 66.7 60.1 14.202 0.077 Committee forwards critiques of all drills to appropriate services in a timely manner No 27.3 33.3 16.7 55.6 25.0 55.6 66.7 44.4 22.2 38.5 Yes 72.7 66.7 83.3 44.4 75.0 44.4 33.3 55.6 77.8 61.5 9.537 0.299 Committee communicates with and/or cooperates with other hospitals in the community No 0 22.2 16.7 33.3 12.5 11.1 0 0 11.1 11.9 Yes 100.0 77.8 83.3 66.7 87.5 88.9 100.0 100.0 88.9 88.1 9.180 0.327 Grand average % No 32.8 Yes 67.2 Table (4.7) shows that 82% of respondents agreed that a hospital emergency management / disaster preparedness committee exists and provides leadership to staff (P= 0.063) which indicated insignificant differences between hospitals, and 72% of 53

respondents mentioned that committee is multidisciplinary without significant differences between hospitals (P= 0.136). In addition, all respondents from NMC said that up to 12 meetings are held annually, and the other hospitals had between 1 6 meetings annually, and 55.6% of respondents stated that committee meeting minutes/action plan are available for review (P= 0.186) which reflected insignificant differences between hospitals. In general, 67.2% of respondents mentioned that an emergency / disaster committee is present in the hospitals. 4.3.5 Capacity of Emergency Department Table (4.8): Emergency Department Capacity (EDC) Al Shifa Andonesy Shohada Al Aqsa EGH NMC Al Najar Al Nassr Al Dora Al Rantesy Average % χ2 P value Emergency Department (ED) Capacity (beds). Beds 44 14 20 12 16 14 19 15 3 17 Average daily ED visits Visits 1000 300 350 150 500 300 220 150 30 333 Cache of emergency drugs and antidotes is maintained in ED No 36.4 33.3 16.7 44.4 37.5 88.9 55.6 0 11.1 36.0 Yes 63.6 66.7 83.3 55.6 62.5 11.1 44.4 100.0 88.9 64.0 20.982 0.007 Table (4.8) shows variations in ED capacity between hospitals according to size, catchment area, and type of the hospital. The highest capacity was in Al Shifa hospital with 44 beds in ED and average daily visits of 1000 patients, followed by Shohada Al Aqsa hospital with capacity of 20 beds in ED and average daily visits of 350 patients, and the lowest was in Al Rantesy Pediatric hospital with capacity of 3 beds in ED and 54

average daily visits of 30 patients. In addition, 64% of respondents said that cache of emergency drugs and antidotes is maintained in ED, and the highest was in Al Dora Pediatric hospital followed by Al Rantesy Pediatric hospital (88.9%), and Shohada Al Aqsa hospital (83.3%). 4.3.6 Patient Triage Table (4.9): Availability of patient triage system Al Shifa Andonesy Shohada Al Aqsa EGH NMC Al Najar Al Nassr Al Dora Al Rantesy Average % χ2 P value Facility uses a triage system No 0 11.1 0 0 0 0 77.8 44.4 66.7 34.4 55.852 0.000 Yes 100.0 88.9 100.0 100.0 100.0 100.0 22.2 55.6 33.3 66.6 Triage tags are maintained in ED No 36.4 0 0 11.1 6.3 88.9 77.8 77.8 100.0 44.3 52.748 0.000 Yes 63.6 100.0 100.0 88.9 93.7 11.1 22.2 22.2 0 55.7 Protocol includes 'deceased' category for victims beyond help (Black) No 27.3 55.6 33.3 22.2 12.5 55.6 88.9 88.9 100.0 53.8 41.349 0.000 Yes 63.7 44.4 66.7 77.8 87.5 44.4 11.1 11.1 0 46.2 Protocol includes 'immediate' category for life-threatening condition (Red) No 0 0 0 0 0 55.6 77.8 88.9 100.0 35.8 66.000 0.000 Yes 100.0 100.0 100.0 100.0 100.0 44.4 22.2 11.1 0 64.2 Protocol includes 'delayed' category for serious non-life threatening condition (Yellow) No 9.1 0 0 0 0 55.6 77.8 88.9 100.0 36.8 62.320 0.000 Yes 90.9 100.0 100.0 100.0 100.0 44.4 22.2 11.1 0 63.2 Protocol includes 'minor' category for minimal care requirement (Green) No 0 0 0 0 0 55.6 66.7 88.9 88.9 33.3 58.967 0.000 Yes 100.0 100.0 100.0 100.0 100.0 44.4 33.3 11.1 11.1 66.7 Facility has an alternate treatment area to accommodate casualty surge / overload No 9.1 22.2 0 11.1 6.3 44.4 88.9 55.6 66.7 33.8 33.740 0.000 Yes 90.9 77.8 100.0 88.9 93.7 55.6 11.1 44.4 33.3 66.2 No 38.9 Grand average % Yes 61.1 Table (4.9) shows that 66.6% of respondents agreed that their hospitals use a triage system (P= 0.000) which is significant in favor of general hospitals, and 55.7% of 55

respondents said that triage tags are maintained in ED with significant differences between respondents in favor of Andonesy and Shohada Al Aqsa hospital (P= 0.000). In general, 61.1% of respondents mentioned that triage system was available and implemented in their EDs, and that general hospitals adopted the triage system more than the pediatric hospitals. 4.3.7 Patient Tracking Table (4.10): Availability of patient tracking Al Shifa Andonesy Shohada Al Aqsa EGH NMC Al Najar Al Nassr Al Dora Al Rantesy Average % χ2 P value Facility has a method for casualty tracking (labeled tracks) No 81.8 88.9 66.7 88.9 62.5 88.9 55.6 100.0 88.9 80.2 Yes 18.2 11.1 33.3 11.1 37.5 11.1 44.4 0 11.1 19.8 Facility can track patients that are transferred to another local facility No 18.2 22.2 0 22.2 6.3 11.1 11.1 22.2 11.1 13.8 Yes 81.8 77.8 100.0 77.8 93.7 88.9 88.9 77.8 88.9 86.2 Facility can track patients that are evacuated out of the community No 18.2 22.2 16.7 11.1 0 11.1 33.3 33.3 0 16.2 Yes 81.8 77.8 83.3 88.9 100.0 88.9 66.7 66.7 100.0 83.8 Grand average % No 36.7 Yes 63.3 10.838 0.211 3.680 0.885 9.870 0.274 Table (4.10) shows that 19.8% of respondents said that their hospital has a method for casualty tracking (labeled tracks) without significant differences between hospitals (P= 0.211), and 86.2% of respondents said that facility can track patients that are transferred to another local facility without significant differences between hospitals (P= 0.885), and 83.8% of respondents said that their hospital can track patients that are evacuated out of the community without significant differences between hospitals (P= 0.274). 56

4.3.8 Critical Incident Stress Management (CISM) Table (4.11): Presence of critical incident stress management (CISM) Al Shifa Andonesy Shohada Al Aqsa EGH NMC Al Najar Al Nassr Al Dora Al Rantesy Average % χ2 P value Facility has Critical Incident Stress Management team or equivalent mental health services No 54.5 88.9 83.3 100.0 93.7 100.0 100.0 88.9 11.1 80.0 Yes 45.5 11.1 16.7 0 6.3 0 0 11.1 88.9 20.0 41.428 0.000 Mental health services are available during and after a mass casualty event No 54.5 88.9 83.3 100.0 93.7 55.6 100.0 88.9 77.8 82.5 Yes 45.5 11.1 16.7 0 6.3 44.4 0 11.1 22.2 17.5 16.541 0.035 Mental health team members are trained in crisis care and emergency response No 63.6 88.9 66.7 100.0 93.7 55.6 100.0 88.9 77.8 81.7 Yes 36.4 11.1 33.3 0 6.3 44.4 0 11.1 22.2 18.3 14.311 0.074 Mental health services are represented on the Emergency Management Planning Committee No 81.8 100.0 83.3 100.0 93.7 55.6 100.0 88.9 77.8 86.8 Yes 18.2 0 16.7 0 6.3 44.4 0 11.1 22.2 13.2 13.901 0.084 A plan is in place to assess the physical and psychological well-being of disaster response workers No 81.8 88.9 100.0 100.0 93.7 88.9 100.0 100.0 77.8 92.3 Yes 18.2 11.1 0 0 6.3 11.1 0 0 22.2 7.7 5.608 0.691 If yes, Plan identifies physiological, emotional, cognitive and behavioral signs of stress including anxiety, irritability, memory loss, difficulty making decisions etc. No 81.8 88.9 100.0 100.0 93.7 88.9 88.9 100.0 77.8 91.0 Yes 18.2 11.1 0 0 6.3 11.1 11.1 0 22.2 9.0 5.608 0.691 Grand average % No 85.7 Yes 14.3 Table (4.11) shows that 80% of respondents said that the hospital does not have CISM, (P= 0.000) which is statistically significant in favor of Al Rantesy hospital, 82.5% of respondents said that mental health services are not available (P= 0.035) which is statistically significant in favor of Al Shifa hospital, and 86.8% said that mental health services are not represented (P= 0.084), which revealed statistically insignificant differences between hospitals. In general, 85.7% of respondents indicated that stress management and mental health services are not integrated in the EMP. 57

4.3.9 Pharmacy Services Table (4.12): Availability of pharmacy services (PHARS) Al Shifa Andonesy Shohada Al Aqsa EGH NMC Al Najar Al Nassr Al Dora Al Rantesy Average % χ2 P value Pharmacy maintains a stockpile of antidotes No 18.2 11.1 50.0 0 37.5 66.7 11.1 44.4 22.2 29.0 Yes 81.8 88.9 50.0 100.0 62.5 33.3 88.9 55.6 77.8 71.0 16.477 0.036 Pharmacy monitors daily medication usage No 0 11.1 0 11.1 12.5 0 0 11.1 0 5.0 Yes 100.0 88.9 100.0 88.9 87.5 100.0 100.0 88.9 100.0 95.0 5.464 0.707 Pharmacy maintains a stockpile of medication for one month No 18.2 44.4 50.0 11.1 31.3 55.6 33.3 22.2 11.1 30.8 Yes 81.8 55.6 50.0 88.9 68.7 44.4 66.7 77.8 88.9 69.2 8.964 0.345 Pharmacy maintains a stockpile of IV fluids for one month No 18.2 44.4 16.7 0 37.5 88.9 33.3 11.1 11.1 29.0 Yes 81.8 55.6 83.3 100.0 62.5 11.1 66.7 88.9 88.9 71.0 24.441 0.002 A plan exists to ensure rapid delivery of medications from suppliers during an emergency No 45.5 55.6 50.0 33.3 31.3 100.0 55.6 33.3 11.1 46.2 Yes 54.5 44.4 50.0 66.7 68.7 0 44.4 66.7 88.9 53.8 18.272 0.019 Grand average % No 28.0 Yes 72.0 Table (4.12) shows that 95% of respondents said that the pharmacy team monitors daily medication usage (P= 0.707) which indicated statistically insignificant differences between hospitals, 71% of respondents mentioned that pharmacy maintains a stockpile of antidotes (P= 0.036) which is statistically significant in favor of EGH, and 71% of respondents said that pharmacy maintains a stockpile of IV fluids for one month (P= 0.002) which is statistically significant in favor of EGH. In general, the results indicated that 72% of respondents agreed that the pharmacy maintain adequate supply of medication, fluids and other consumables during emergency events. 58

4.3.10 Laboratory Services Table (4.13): Availability of laboratory services (LABS) Al Shifa Andonesy Shohada Al Aqsa EGH NMC Al Najar Al Nassr Al Dora Al Rantesy Average % χ2 P value Laboratory staff are trained for surge capacity (increased specimen load) No 0 11.1 0 0 12.5 0 33.3 0 0 6.3 Yes 100.0 88.9 100.0 100.0 87.5 100.0 66.7 100.0 100.0 93.7 14.754 0.064 Plan is available to re-supply media, reagents and other critical supplies No 18.2 44.4 50.0 33.3 18.8 66.7 33.3 11.1 11.1 31.9 Yes 81.2 55.6 50.0 66.7 81.2 33.3 66.7 88.9 88.9 68.1 12.676 0.124 An arrangement is in place to transfer workload if laboratory is overwhelmed No 27.3 66.7 50.0 55.6 50.0 22.2 22.2 33.3 0 36.4 Yes 72.7 33.3 50.0 44.4 50.0 77.8 77.8 66.7 100.0 63.6 13.825 0.086 Blood bank services have surge capacity plans in place and are trained for surge activity No 9.1 22.2 0 11.1 6.3 11.1 22.2 33.3 0 12.8 Yes 90.9 77.8 100.0 88.9 93.7 88.9 77.8 66.7 100.0 87.2 7.910 0.442 Memorandum of understanding is in place with regional blood center for emergent delivery of blood products No 9.1 22.2 0 0 0 11.1 22.2 0 0 7.2 Yes 90.9 77.8 100.0 100.0 100.0 88.9 77.8 100.0 100.0 92.8 10.545 0.229 Blood product delivery system has been exercised in last 12 months and is deemed reliable No 54.5 44.4 16.7 44.4 37.5 22.2 66.7 11.1 11.1 34.3 Yes 45.5 55.6 83.3 55.6 62.5 77.8 33.3 88.9 88.9 65.7 12.494 0.130 Grand average % No 21.5 Yes 78.5 Table (4.13) presents laboratory services as part of preparedness for disasters and emergency events. The results shows that 93.7% of respondents stated that laboratory staff are trained for surge capacity (increased specimen load) (P= 0.064) which indicated statistically insignificant differences between hospitals, and 92.8% of respondents stated that memorandum of understanding is in place with regional blood center for emergent 59

delivery of blood products (P= 0.229) which indicated statistically insignificant differences between hospitals. In addition, 87.2% of respondents mentioned that blood bank services have surge capacity plans in place and are trained for surge activity (P= 0.442) which is statistically insignificant. In general, 78.5% of respondents agreed that lab. services are integrated in the EMP for hospital preparedness. 4.3.11 Management of Fatalities Table (4.14): Availability of fatalities management (FM) Al Shifa Andonesy Shohada Al Aqsa EGH NMC Al Najar Al Nassr Al Dora Al Rantesy Average % χ2 P value Adequate plans are in place for management of fatalities No 27.3 33.3 16.7 33.3 12.5 22.2 55.6 11.1 33.3 27.3 Yes 72.7 66.7 83.3 66.7 87.5 77.8 44.4 88.9 66.7 72.7 7.650 0.468 Refrigerated storage facilities for fatalities are available No 18.2 0 0 0 6.3 0 44.4 88.9 88.9 27.4 Yes 81.8 100.0 100.0 100.0 93.7 100.0 55.6 11.1 11.1 72.6 53.197 0.000 Mortuary services staff are trained for surge No 72.7 66.7 16.7 55.6 25.0 22.2 77.8 88.9 77.8 56.0 Yes 27.3 33.3 83.3 44.4 75.0 77.8 22.2 11.1 22.2 44.0 23.145 0.003 Extra storage areas for fatalities have been designated within the facility No 54.5 55.6 33.3 55.6 18.8 66.7 100.0 77.8 88.9 61.2 Yes 45.5 44.4 66.7 44.4 81.2 33.3 0 22.2 11.1 38.8 23.566 0.003 The fatalities management plan addresses the cultural and religious needs of survivors No 18.2 11.1 0 22.2 12.5 22.2 77.8 66.7 77.8 34.3 Yes 81.8 88.9 100.0 77.8 87.5 77.8 22.2 33.3 22.2 65.7 30.761 0.000 Grand average % No 41.2 Yes 58.8 60

Table (4.14) presents management of fatalities as part of EMP. The results indicated that 72.7% of respondents stated that adequate plans are in place for management of fatalities (P= 0.468) which indicated statistically insignificant differences between hospitals, 72.6% of respondents reported that refrigerated storage facilities for fatalities are available (P= 0.000) which is statistically significant in favor of general hospitals (Andonesy, Shohada Al Aqsa, EGH and Al Najjar hospital), and 38.8% of respondents mentioned that extra storage areas for fatalities have been designated within the facility while 61.2% did not agree (P=0.003) which is statistically significant in favor of Andonesy hospital. In general, 58.8% of respondents agreed that fatalities management is integrated in the EMP. 4.3.12 Communications, Warning, and Notification Table (4.15): Availability of communications, warning, and notification (CWN) Al Shifa Andonesy Shohada Al Aqsa EGH NMC Al Najar Al Nassr Al Dora Al Rantesy Average % χ2 P value Facility can send and receive emergency warning and notification information No 9.1 11.1 16.7 0 6.3 0 22.2 11.1 0 8.5 Yes 90.9 88.9 83.3 100.0 93.7 100.0 77.8 88.9 100.0 91.5 Facility can receive warnings of imminent emergency conditions from external agencies No 0 22.2 0 0 6.3 0 22.2 44.4 77.8 19.2 Yes 100.0 77.8 100.0 100.0 93.7 100.0 77.8 55.6 22.2 80.8 Facility can send warnings to external agencies No 9.1 33.3 0 22.2 12.5 22.2 44.4 44.4 55.6 27.0 Yes 90.9 66.7 100.0 77.8 87.5 77.8 55.6 55.6 44.4 73.0 Facility can notify on-duty and off-duty staff of emergency status and recall to duty No 9.1 0 0 0 6.3 0 11.1 0 22.2 5.4 Yes 90.9 100.0 100.0 100.0 93.7 100.0 88.9 100.0 77.8 94.6 Facility has a plan to notify on-duty and off-duty staff of emergency status No 9.1 0 16.7 11.1 0 11.1 22.2 22.2 0 10.3 Yes 90.9 100.0 83.3 88.9 100.0 88.9 77.8 77.8 100.0 89.7 Facility has staff notification with up-to-date, verified phone and other contact information No 9.1 0 16.7 33.3 0 0 11.1 0 0 7.8 Yes 90.9 100.0 83.3 66.7 100.0 100.0 88.9 100.0 100.0 92.2 Staff can receive warnings by text messages on their wireless phones 5.724 0.678 34.854 0.000 12.766 0.120 7.783 0.455 7.582 0.475 14.872 0.062 61

Al Shifa Andonesy Shohada Al Aqsa EGH NMC Al Najar Al Nassr Al Dora Al Rantesy Average % χ2 P value No 18.2 11.1 16.7 0 0 11.1 0 11.1 0 7.6 Yes 81.8 88.9 83.3 100.0 100.0 88.9 100.0 88.9 100.0 92.4 Specific spokespersons have been identified for specific events No 9.1 11.1 16.7 22.2 18.8 11.1 22.2 11.1 22.2 16.0 Yes 90.9 88.9 83.3 77.8 81.2 88.9 77.8 88.9 77.8 84.0 Grand average % No 12.7 Yes 87.3 7.006 0.536 1.732 0.988 Table (4.15) presents issues related to communications, warnings, and notification. The results shows that 92.2% of respondents stated that facility has staff notification with upto-date, verified phone and other contact information (P= 0.062) which is statistically insignificant, 92.4% of respondents agreed that staff can receive warnings by text messages on their wireless phones (P= 0.536) which is statistically insignificant, and 91.5% of respondents stated that the hospital can send and receive emergency warning and notification information (P= 0.678) which indicated statistically insignificant differences between hospitals. In addition. In general, 87.3% of respondents agreed that issues related to communications, warning, and notification were integrated in the EMP. 62

4.3.13 Management of Information Table (4.16): Availability of information management (IM) Al Shifa Andonesy Shohada Al Aqsa EGH NMC Al Najar Al Nassr Al Dora Al Rantesy Average % χ2 P value Essential information system and data storage have offsite storage and recovery capabilities No 9.1 11.1 0 0 0 0 0 11.1 0 3.5 Yes 90.9 88.9 100.0 100.0 100.0 100.0 100.0 88.9 100.0 96.5 System has protection from viruses and intentional attacks (hacking) No 18.2 11.1 33.3 0 12.5 44.4 11.1 33.3 0 18.2 Yes 81.8 88.9 66.7 100.0 87.5 55.6 88.9 66.7 100.0 81.8 Information management staff are present in emergency events No 9.1 11.1 0 0 6.3 0 0 11.1 0 4.2 Yes 90.9 88.9 100.0 100.0 93.7 100.0 100.0 88.9 100.0 95.8 Grand average % No 8.6 Yes 91.4 6.298 0.614 11.873 0.157 4.371 0.822 Table (4.16) presents issues related to information management. The results shows that 96.5% of respondents agreed that essential information system and data storage have offsite storage and recovery capabilities (P= 0.614) which reflected statistically insignificant differences between hospitals, 95.8% of respondents agreed that information management staff are present in emergency events (P= 0.822) which reflected statistically insignificant differences between hospitals, and 81.8% of respondents agreed that the system has protection from viruses and intentional attacks (hacking) (P= 0.157) which indicated statistically insignificant differences between hospitals. Furthermore, In general, 91.4% of respondents agreed that information management was integrated in EMP. 63

4.4 Health System Preparedness To determine health system preparedness, the researcher calculated average scores of preparedness in all the hospitals included in the study. The results are presented in table (4.17). Table (4.17): Average scores of preparedness in all the hospitals Domain Average score Rank Safety and security 56.95 12 Availability of logistics 70.00 6 Availability of emergency management planning (EMP) 74.50 4 Facility readiness and training 60.00 10 Availability of incident command system (ICS) 47.25 13 Emergency management / disaster preparedness committee 67.2 7 Triage system 61.10 9 Patient tracking 63.30 8 Critical incident stress management (CISM) 14.30 14 Pharmacy services 72.00 5 Laboratory services 78.50 3 Fatalities management 58.80 11 Communication, warning, and notification 87.30 2 Information management 91.40 1 Overall average 64.47 Table (4.17) shows that the highest scores obtained in information management domain with average score 91.40, followed by communication, warning, and notification domain with average score 87.30, and laboratory services with average score 78.50, while the lowest scores obtained in critical incident stress management domain with average score 14.30, followed by incident command system domain with average score 47.25, and safety and security domain with average score 56.95. The overall average score was 64.47 which indicated moderate level of preparedness for crisis and disaster events among governmental hospitals in GS. 64

4.5 Discussion Readiness and preparedness of hospital require complex operations and commitment. It is a serious challenge because it is difficult to determine how much time, money, and effort should be spent in preparing for an event that may occur suddenly or may not occur. Health facilities especially hospitals are the core of health system and should be a source of strength during emergencies and disasters, and should be ready to save lives and to continue providing essential care to patients. The hospitals in GS are living in emergency situation on daily basis as a result of the unstable security conditions due to the continuous, ongoing conflict and aggressive acts by Israeli military forces, and lately the GRM with weekly protests by the border fence east of GS, which resulted in thousands of casualties with various serious injuries that require prompt treatment. This study aimed to assess governmental hospitals preparedness for crisis and disastrous events in GS. The study sample consisted of 87 respondents from nine governmental hospitals (6 general and 3 pediatric hospitals). Hospital Characteristics and Capacity Al Shifa hospital in Gaza and NMC and EGH in Khanyounis are the biggest three hospitals by size and bed capacity, while Al Shifa hospital and EGH are offering unique services of neurosurgery, chest surgery, and vascular surgery which are not available in the other hospitals, which added extra responsibilities and pressure on these hospitals during disastrous events. The results indicated that all the hospitals have essential machinery and equipment that contribute to better functioning of the hospitals including ambulances to transfer 65

patients between hospitals, portable X ray machines, monitors to assess hemodynamic status of patients, mechanical ventilators for respiratory support, ICU beds except Al Najjar hospital in Rafah. It is worth to mention that Al Najjar hospital is a small hospital and the only general governmental hospital that serves about 240,000 inhabitants of Rafah, and unavailability of ICU beds puts patients with life-threatening problems in greater risk as these patients have to be transferred to EGH or NMC in Khanyounis. During emergencies, hospitals can do a number of things to extend their resources, but serious limitations may restrict hospital resources expansion. During crisis days especially on 14 th of May which was one of the hardest days of GRM, the hospitals in GS were overwhelmed with huge influx of casualties with serious injuries which was beyond capacity of some hospitals and put the hospitals on the edge to collapse due to insufficient beds and medical equipment. This condition was consistent with Kaji and Lewis, (2006) who indicated that serious limitations may restrict hospital resources expansion including the number of available beds, ventilators, isolation rooms, and pharmaceuticals may be insufficient to care for victims of a large-scale disaster. Safety and Security Concerning safety and security, the results indicated that all the hospitals have security personnel but there were variations in coverage on 24-hours daily basis, and that most of the hospitals can post extra security personnel in ED during emergency situation. In addition, all the general hospitals and some of pediatric hospitals have armed police station to support the security personnel and control crowds during emergency events. Moreover, the general hospitals are closely monitored by cameras placed in different places within the hospital to ensure optimal monitoring and controlling of hospital properties, entrances and exits. 66

In general, 56.95% of respondents agreed about safety and security measures in the hospitals. This is a low score and further actions should be taken by hospitals administrations to increase safety and security measures which are vital for proper and safe treatment of patients. It is worth to say that during disasters, hospitals play an important role in ensuring the safety of their vulnerable clients (PAHO/WHO, 2005). Availability of Logistics Concerning logistics, all the hospitals have emergency power generator and these generators can provide adequate electricity for all essential services for three days in most of the hospitals. Also, all the hospitals receive fuel from MoH and the vast majority of the hospitals have on-campus fuel storage placed in secured areas, and the fuel is sufficient for three days. Our results agreed with Hick et al. (2004) who reported that electricity is essential component for functioning of machinery and equipment and without electricity, the hospital will collapse and become unable to play its role in serving patients, thus electrical supply in the hospital must be clear, well organized and safe. Hence, in case of disaster an alternative power supply must be available and work properly. In addition, some hospitals receive water supply from municipal source and some hospitals have their own water supply. Continuous water supply is essential for any hospital either for drinking or cleaning purposes, and to ensure continuity of water supply each hospital should have secondary source of water supply to be used in emergency situations when the primary source is unable to offer adequate water supply to the hospital. Our results were consistent with report issued by WHO (2006) which emphasized that an alternative water source must be available, and this source of water 67

must be clean and secure and in case of emergency it should be ready to be used quickly. Moreover, more than half of the hospitals have adequate food on hand for staff and patients for a 3-4 days and security of food is maintained in the majority of hospitals. Another important issue is that the vast majority of hospitals have adequate medical gasses to last 3-4 days without re-supply and these gases are in a secured area. Medical gases especially those used in operation rooms for anesthesia and oxygen are essential for surgical procedures and EDs and critical care units and without these gases many operations would not be performed and thus putting lives of many casualties in danger. Our results were consistent with Hick et al. (2004) indicated that, to maintain adequate supply of medical gases, a well-ventilated place should be available for medical gas storage, and medical gases must be kept in a secure and safe location. The results also reflected that more than two thirds of respondents said that maintenance and engineering staff are available 24 hours a day. This result raising the question of how that hospital will function in case of problems with generators, electricity supply and some vital equipment like monitors or ventilators. I believe that maintenance and engineering department is one of the vital departments for safe and proper functioning of hospitals, so their staff should be on duty 24-hours a day. HVAC systems are important for hospitals functioning, but during disastrous events HVAC system are shut down as a safety measure, but the results indicated that more than two thirds of respondents said that HVAC shutdown has not been exercised in past year, and there are no written guidelines for emergency HVAC shutdown, which may put the whole facility in danger. In addition, two thirds of respondents mentioned that 68

their hospital has procedures for management, transfer, and disposal of contaminated wastes, goods, and fluids, while one third of respondents said that procedures for management of wastes are not available. Our results agreed with the Guidelines for Hospital Emergencies Preparedness Planning (2002-2008) which emphasized that availability of proper system of waste disposal is very important to get rid of solid waste especially in disaster events. If this waste stayed it will affect the public health. In addition, California Hospital Association (2009) reported that having an effective waste system is vital of any community since waste water system may be affected by hazards and disasters. It is worth to say that hospital wastes including solid and fluid wastes are harmful to people and could predispose to health problems, so there should be special procedures based on scientific based-evidence protocols to get-red of these wastes in a safe way that is harmless to human being. Equipment and supplies are vital for offering appropriate health care. The results showed that almost two thirds of respondents reported that their hospital maintains current inventory of equipment, supplies and other essential materials. During emergency events the demand for supplies and materials increased to meet the needs of casualties, so, it is essential for the hospital stores to have accurate records of quantity of different supplies and materials and to have strategic storage of supplies adequate to meet the needs in case of mass casualty events. In general, the results indicated that more than two thirds of respondents said that adequate logistics are available in their hospitals. 69

Availability of Emergency Management Plan Concerning EMP, the vast majority of respondents mentioned that their hospitals have an EMP, and that the EMP addresses internal and external emergencies, but more than one third of respondents said that the EMP was not accessible to staff, and more than two thirds of respondents agreed that the EMP addresses all hazards events. In addition, more than two thirds of respondents agreed that the EMP includes written arrangements for surge staffing, and the majority of respondents agreed that the EMP includes arrangements to cancel non-emergent services. Moreover, the majority of respondents reported that spiritual care is integrated into EMP and the EMP includes recovery process and return to normal operations. The EMP should be communicated with hospital staff and staff need training on response to emergencies, but our results reflected that more than one third of respondents did not receive orientation to the EMP and almost half of staff did not receive training on response to emergency events, while the majority of physicians and nurses received training on BLS. In general, the results revealed that three quarters of respondents stated that EMP was available but there was a problem in orientation and training on the EMP. Concerning training, the results indicated that more than half of nurses, physicians have completed training about disaster response and preparedness. These results reflected the need to increase awareness of hospital staff concerning EMP through communication and training. During emergencies and disastrous events, the goal of hospitals is to achieve the most effective way of treating large number victims with the available resources; therefore hospitals need to be well prepared for emergencies. Our results disagreed with a study carried out by Kaji and Lewis (2006) which indicated that almost all the hospitals in Los 70

Angeles conducted multiagency drills. Moreover, our results agreed with the results obtained by Paganini et al. (2016) which found that less than half of participants declared to know what an EP for massive influx of casualties is and this result reflected a poor knowledge-base of basic hospital disaster planning concepts by Italian ED physicians, and Öztekin et al. (2016) results indicated low rate of preparedness, and that nurses felt they were not able to respond in a variety of disaster situations, and they were aware of their workplace emergency disaster plan, but did not think they could execute them. Also, Baack and Alfred (2013) found that most nurses are not confident in their abilities to respond to major disaster events. Moreover, Sharma et al. (2016) found that less than half of respondents knew the concept of a disaster plan, two thirds were aware of disaster drills, and the vast majority felt that training for disaster preparedness is essential for all staff. Moreover, our results agreed with Moabi (2008) who found that EMP practices were deficient, and more efforts are needed to be done on training, performance of drills, and the frequency of updating of EMP. It is crucial to hospital disaster preparedness that the plan for massive influx of casualties be known and understood by those professionals who will apply it. ED employees are usually the first hospital responders in the event of disasters and are the front lines of preparedness (Paganini et al. 2016). Facility Readiness and Training Concerning readiness and training, the results showed that only one third of respondents said that their hospitals exercise EMP at least twice per year and 37.2% of respondents said that their hospitals participate in at least one community-wide exercise per year, and one third said that all ED personnel participate in at least twice- 71

annual mass casualty exercises, and one fourth of participants mentioned that their hospitals has exercised evacuation of staff and patients in the last 12 months. These results reflected low interest and low participation in training on implementation of EMP. Our results disagreed with the results obtained by Al-Shareef et al. (2017) which showed that two thirds of hospitals reviewed their disaster plan within the preceding two years, two thirds were drilling for disasters at least twice per year, and the majority of hospitals did not rely on a hazard vulnerability analysis to develop their EP. It is worth to say that having written, clear EMP is important for each hospital, but it is more important to train hospital staff on proper implementation of the plan and that increase level of readiness for emergency events, and through training, we can be sure that everyone knows his roles and ability to fulfilling his roles. Our results were consistent with the results obtained by Alzahrani and Kyratsis, (2017) which indicated that more than half of the emergency nurses in Mecca's public hospitals had not thoroughly read the plan, and very few were not even aware of its existence. Also, emergency nurses reported seeing their main role as providing timely general clinical assessment and care. In addition, less than half of respondents reported that their hospitals have a procedure for conducting after-action reviews of emergency events, and two thirds of respondents said that their hospitals use after-action reports to identify strengths and weaknesses of the EMP, and that feedback incorporated in modifying the EMP. In general, two thirds of respondents agreed that their hospitals are interested and practiced preparedness and training activities to enable them to manage disastrous events effectively. Our results disagreed with the results obtained by Al Khalaileh et al. 72

(2012) which found that more than two thirds of respondents described their current disaster preparedness as weak, one fifth described it as medium, and very few described it as good or very good. Also, one third received disaster education in undergraduate programs, one third in facility drills, and one fifth in continuing education courses, while very few had participated in a real disaster. It is worth to say that the planning process generates response measures and protocols, which can be documented in a written plan. It is however important to note that the written plan does not guarantee preparedness, but should be viewed as one of the elements of preparedness activities aiming at improving emergency response (Adini et al., 2006). Incident Command System (ICS) Concerning ICS, the results indicated that more than half of respondents (58.4%) agreed that ICS is present in their hospitals, but only one third of respondents said that ICS is exercised twice yearly, and more than one third of respondents said that incident commander is known to hospital staff, less than half of respondents agreed about the presence of procedures to designate an incident commander, and more than half of respondents agreed that all staff know where to go when the ICS is activated. In general, less than half of respondents agreed about the availability and activation of ICS in their hospitals. Our results agreed with Al-Shareef et al. (2017) who found that more than three fourth of hospitals had their own ICS present in their plans, and Kaji and Lewis, (2006) reported that the vast majority of hospitals were based on the hospital emergency ICS, while Bajow and Alkhalil (2014) mentioned that weakness was apparent in the hospital emergency ICS. 73

The ICS commander role is very important because he is the person responsible for all aspects of an emergency response including quickly developing incident objectives, managing all incident operations, application of resources as well as responsibility for all administration team, hospital director or the medical director because he has the experience of hospital operations and have the authority to give instructions or orders to hospital staff. Hospital Emergency Management/Disaster Preparedness Committee Concerning hospital emergency management/disaster preparedness committee, the majority of respondents said that a multidisciplinary committee is present, but half of the respondents agreed that the committee holds regular meetings, and minutes from meetings are available for review. In addition, two thirds of respondents agreed that committee members are oriented and knowledgeable of hospital plans, committee forwards critiques of all drills to appropriate services in the hospital, and 88.1% of respondents agreed that the committee communicates with and/or cooperates with other hospitals in the community. In general, more than two thirds of respondents agreed about the presence of hospital emergency management/disaster preparedness committee. It is obvious that appropriate readiness is needed for proper reaction to crisis events. So each hospital should have a predestined plan to confront any crises event in all the hospitals (Barbera and Macintyre, 2014; Mastaneh and Mouseli, 2013). To be effective, an appropriate plan against crises needs expertise, education, resources and (Mortelmans et al., 2014), and to do so, emergency committee including qualified, expert staff from different specialties should be present and assigned in each hospital, and members of emergency 74

committee should be available during crisis events to lead the hospital staff, take decisions, and manage the situation properly within the available resources. Capacity of Emergency Department The results reflected variations in capacity of EDs between hospitals depending on hospital size, catchment area, and type of the hospital. It is obvious that the highest capacity was in Al Shifa hospital with 44 beds in ED and average daily visits of 1000 patients. Al Shifa hospital is the largest hospital in size and capacity in GS with almost all specialties of surgical and medical subspecialties, followed by Shohada Al Aqsa hospital with capacity of 20 beds in ED and average daily visits of 350 patients. Shohada Al Aqsa hospital serves a large population and covers a wide catchment area including all the Midzone governorate. In addition, 64% of respondents said that cache of emergency drugs and antidotes is maintained in ED. EDs are vital departments for hospitals, and these departments are considered the front line for emergency health services within each hospital. EDs should be well equipped with adequate emergency equipment, supplies, drugs, and above all, qualified staff. Also, a good design of the structure and infrastructure of the hospital should allow for expansion of ED and increase the number of emergency beds in case of mass casualties. From our experience during the GRM protests with high number of casualties, many hospitals increased the number of emergency beds. For example, EGH normally have 12 beds in ED, and during mass casualties especially on 14 th of May, the pediatric ED shifted to the out patients Clinic and used the day care unit for emergencies and that enable the hospital to increase emergency beds up to 45 beds and resuscitation beds increased from two beds to five beds. Also, Al Shifa hospital made some modifications and 75

expanded the ED by using the medical ED as extension to ED to increase ability to handle the high number of casualty influx to the hospital. Patient Triage The results reflected that more than two thirds of respondents mentioned that their hospitals use a triage system in their EDs, and patients are categorized by colored labels according to severity of illness and the urgency need for medical interventions. When faced with mass casualties, medical services can be overwhelmed, so it is necessary to prioritize patients according to medical need. Our results were consistent with Carley and Mackway, (2005) who indicated that the aim of triage is to deliver the right patient to the right place at the right time so that they receive optimum treatment, and can be applied in situations where the casualty load exceeds the skilled help available. In governmental hospitals in GS, a qualified nurse is assigned to work in triage area to assess patients and categorize them according to seriousness of their illness. This is consistent with Visser et al. (2015) who reported that within the hospital system, the first stage on arrival at the ED is assessment by the hospital triage nurse, and the triage nurse will evaluate the patient's condition, as well as any changes, and will determine their priority for admission. Triage concerns with the methods used to assess patients' severity of injury or illness within a short time after their arrival, assign priorities, and transfer each patient to the appropriate place for treatment (Christ et al., 2010). In governmental hospitals in GS, triage system have been implemented only two years ago. The triage system was established and initiated in cooperation and coordination 76

between MOH and ICRC in Gaza. The ICRC sponsored the renovation of EDs in governmental hospitals and made modifications in the structure and infrastructure of EDs to enable the EDs to implement the triage system with classification of patients mainly in three colors; red color tag for serious cases that needs immediate intervention, yellow color tag for patients who need intervention but can wait for one to two hours, and green color tag for minor conditions that may need treatment but do not need admission. Patient Tracking Having colored lines for patient tracking is a major problem especially during emergency events. Our results showed that less than one fifth of respondents said that their hospital has a method for casualty tracking (labeled tracks), but there are no colored lines that guide patients on their movement to definite sections in the hospital. The results also indicated that the majority of hospitals have lines of communication to transfer and accept patients according to availability of specialties and availability of beds. Generally, the results reflected that more than two thirds of respondents agreed about availability of patient tracking. In all the hospitals in GS there are written signs and labels that identify sections and departments within the hospital, but there are no colored lines that clarify the tracks to help patients and audience to move to definite sections, and usually patients and audience will ask hospital staff about the section that they want. I believe that having clear, colored lines in the floor or on the walls will ease the movement of patients or their escorts within the hospital, and they will not ask hospital staff, and that will make movement more smooth and free hospital staff from responding to unnecessary 77

questions especially during emergency events when hospital staff are busy in caring for casualties and offering urgent treatments. Critical Incident Stress Management (CISM) Stress management is an important part in the response process to crisis events, and management of stress and aftermath psychological disturbances is neglected in most of the hospitals in GS. Our results indicated that one fifth of respondents stated that the hospital has CISM team and less than one fifth of respondents said that mental health services are available during and after a mass casualty event, and very few said that mental health services are represented in the EMP committee, and generally, the majority of respondents mentioned that stress management and mental health services are not included in the EMP. Pharmacy and Laboratory Services Pharmacy and laboratory services are essential components of any emergency preparedness and plan to response to emergency events. Our results indicated that almost three quarters of respondents stated that the pharmacy maintain adequate supply of medication, fluids and other consumables during emergency events, and 78.5% of respondents agreed that lab. services are included in the EMP for hospital preparedness. It is obvious to say that an essential component of an effective hospital surge capacity is ensuring that sufficient equipment and pharmaceuticals are on hand. However, widespread financial struggles experienced by the healthcare sector make it difficult for healthcare facilities to meet this need. The situation in GS is difficult due to long years of siege and restrictions in incoming supplies of health-related equipment 78

and pharmaceuticals, and that make the situation more difficult in emergency events with large influx of casualties and the need for more consumables as dressings, sterile gauze, antiseptic solutions, IV fluids, bandages. From our experience during emergency events, we noticed shortage in these items and nurses have to be careful in using these items to be able to treat the largest possible number of casualties with available supplies. I believe that healthcare sector should search for additional sources for medical supplies. An example of these sources could be WHO office in Gaza, ICRC, and NGOs that are interested in healthcare aids. The importance of close, pre-established relationships with these organizations should be considered by stakeholders and appeals for aid in emergency events would bring help from these organizations. Management of Fatalities Management of fatalities is an important aspect in normal daily functioning of hospitals and in crisis events. Management of fatalities is required as an ethical practice, and as a medical practice, and as a religious practice. Our results reflected that about three quarters of hospitals integrated management of fatalities in their plans, most of the hospitals have refrigerated storage for fatalities, but there are no official professional staff assigned and trained to work in mortuary services and most of personnel who offer mortuary services are volunteers. It is worth to say that during disasters high number of fatalities is expected so adequate place for fatalities should be available, but in our results only one third of respondents agreed that extra storage areas for fatalities have been designated within their 79

hospitals. This problem was clear during previous war on 2014 when hospitals have been overwhelmed with martyrs who can't be buried because of shelling and bombing and that made the mortuary rooms condensed with dead bodies. Communications, Warning, and Notification Communication is an important component in any emergency event. Our results indicated that the majority of hospitals have communication systems and can send and receive emergency warning and notifications. Also, the vast majority of respondents agreed that the hospital can notify on-duty and off-duty staff of emergency status and recall to duty and that their hospitals have staff notification with up-to-date, verified phone and other contact information. Our results agreed with deboisblanc, (2005) who emphasized that ensuring that internal and external communication systems are functioning is vital during emergency events to ensure adequate staffing, and coordination with other health and community facilities. Failure of communications can occur from damage or from the overloading of either internal or external healthcare facility communication systems or both. The loss of communication shuts the hospital off from the outside world, including response agencies, and further complicates the hospital's ability to obtain appropriate support. Internally, the loss of communication adversely affects the coordination of the disaster response and patient care as individual departments and incident command members can't readily exchange information. In addition, Rabkin (2005) reported that to prevent communication breakdown during disasters, healthcare facilities must have effective, collaborative interdisciplinary and intergovernmental planning for interoperable communications. 80

Management of Information Our results showed that the vast majority of respondents stated that essential information system and data storage have offsite storage and recovery capabilities and that the system has protection from viruses and intentional attacks, and that information management staff are present in emergency events. Integration of information management in the EMP is of great importance for patients and for the hospital coordination of work, storage of data, management and reporting of essential data. The information technology department (IT) plays an essential role in maintaining and keeping the information system functioning well and keeping accurate records of patients. Our results agreed with Chimenya, (2011) who emphasized the importance of maintaining accurate and proper patients' records before, during, and after disasters, because there can be patients on chronic medications that still need their medicines during disasters. Maintaining records also allows for reimbursement of care provided during disasters. 81

Chapter 5 Conclusion and Recommendations 82

Chapter 5 Conclusion and Recommendations 5.1 Conclusion Effective preparedness for crisis and disasters is a task that requires continuing commitment and should be well supervised and monitored by stake-holders in the health system. Our results reflected moderate level of preparedness for disasters within the governmental hospitals in GS with strong points especially in information management aspect and communication and notification, while weak points existed in command system and critical incident stress management aspects. It is worth to say that disasters can often cause short-term disruptions within the family or they can be longterm and change the lives of family members dramatically especially when there is loss of family members. Disastrous events inflict psychological and social impacts that can undermine the long-term mental health and psychosocial well-being of the affected population. Thus, it is important to integrate psychological and mental health teams within each hospital to support the casualties and their families and decrease the negative psychological impacts of trauma and injuries, and even death of victims. Also, the study reflected very weak coordination and cooperation with other community agencies and institutions such as civil defense, municipality, private sectors and local community clubs. The researcher believes that cooperation and coordination between 83

these institutions in an organized network will support the hospitals in performing essential functions more efficiently and obtain better outcomes for the casualties. Our results reflected generally moderate level of preparedness for disasters, and these findings must be considered as a preliminary to further studies to improve the level of hospitals preparedness for crisis and disastrous events. 5.2 Recommendations Based on the results of the study, the researcher suggests the following recommendations: For decision-makers in MoH - To integrate mental health and psychosocial well-being in the emergency plan and to establish mental health teams in all the governmental hospitals all the time and not only during disastrous events. - To increase hospitals capacity to manage fatalities and finding extra appropriate place to keep high number of deceased bodies. - To conduct exercise and drills of the emergency plan in cooperation with other hospitals, civil defense, and other health agencies, aiming to empower knowledge and skills of staff in managing emergency events more effectively. For hospital administration - Emphasize the need to disseminate the emergency plan to be well known to all the employees within the hospital. 84

- To keep strategic storage of essential medical equipment and consumables in each hospital adequate for at least three months, taking in consideration the possibility of inability to get supplies from the main stores of the Ministry of Health. - The need to establish incident command system in every hospital, and to identify a well-qualified personnel as commanders during disasters. For Primary health centers - To train and prepare primary health care staff and integrate them in the emergency plan, so they can treat mild cases and reduce the overload on hospitals. 5.3 Suggestions for Further Studies - To carry out a study aiming to examine level of cooperation and coordination between governmental hospitals and private sector and civil defense during crisis and disasters. - To conduct a study to evaluate the effectiveness of emergency training programs in empowering knowledge and skills of healthcare providers during emergency events. - To carry out a study to determine levels of posttraumatic stress disorders and its impact on quality of life among casualties of crisis events. 85

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Appendix 96

Appendix 1: Hospital Disaster Preparedness Self-Assessment Tool (Arabic version) بسم هللا الرحمن الرحيم السيد الفاضل... السيدة الفاضلة/ السالم عليكم ورحمة هللا وبركاته مرفق استبانة لرسالة ماجستير وهي بعنوان: "تقييم مدى جهوزية النظام الصحي لحاالت األزمات والكوارث في المستشفيات الحكومية في قطاع غزة فلسطين" Assessment of Health System Crisis and Disaster Preparedness among Governmental Hospitals in Gaza Strip, Palestine وقد تم تصميم االستبانة بعد االطالع على مقاييس مماثلة تم تصميمها من خالل الكلية األمريكية لطب الطوارئ. يرجى االستجابة على فق ارت االستبانة بكل أمانة وذلك بهدف الوقوف على الوضع الحقيقي لجهوزية المستشفيات لحاالت الطوارئ واالستفادة من نتائج الد ارسة لتطوير الخدمات الصحية في حالة الطوارئ. وتقبلوا فائق التحية والتقدير الباحث/ تامر القادود جوال / 0595696272 97

يرجى تعبئة االستبانة كاملة حسب التعليمات لكل سؤال......... نسمة......... طبيب... ممرض... موظف... موظف... موظف... سرير نعم ال... سيارة نعم ال نعم ال... جهاز نعم ال نعم ال............ نعم ال نعم ال نعم ال الجزء األول: بيانات خاصة بالمستشفى اسم المستشفى: 1 العنوان / المدينة: 2 عدد السكان الذين ينتفعون من خدمات المستشفى: 3 المسمى الوظيفي لك: 4 القسم الذي تعمل به: 5 تعداد الموظفين: عدد األطباء: 1 عدد الممرضين: 2 عدد العاملين في المختبر: 3 عدد العاملين في قسم األشعة: 4 عدد العاملين في األقسام اإلدارية: 5 العدد الكلي ألسرة المستشفى: 6 قدرات / إمكانيات أخرى هل توجد سيارات إسعاف خاصة بالمستشفى 1 عدد سيارات اإلسعاف المتوفرة بالمستشفى: 2 هل يتوفر جهاز تصوير أشعة متنقل 3 هل تتوفر أجهزة مونيتور مراقبة للقلب 4 عدد أجهزة المونيتور المتوفرة 5 هل يتوفر جهاز ألترا ساوند متنقل 6 هل تتوفر أجهزة تنفس صناعي متنقلة 7 العدد الكلي ألجهزة التنفس الصناعي المتوفرة: 8 العدد المتوفر من أسرة العناية المركزة. 9 العدد المتوفر من غرف العمليات. 10 األمن والسالمة عدد أفراد موظفي األمن في المستشفى: 1 توفر موظفي األمن على مدار الساعة كل يوم 2 إمكانية زيادة عدد موظفي األمن في قسم الطوارئ عند الحاجة. 3 4 توفر قوة شرطية مسلحة. 98

ال نعم ال نعم ال نعم ال نعم ال نعم ال نعم ال نعم الوزارة مصادر ذاتية ال نعم يوجد تفاهم مع أجهزة إنفاذ القانون لتوفير عدد إضافي من رجال الشرطة عند الحاجة 5 توجد خطة لتزويد الجمهور بالمعلومات في حال الطوارئ للتقليل من االزدحام 6 كل مداخل ومخارج المستشفى يتم مراقبتها والسيطرة عليها بواسطة األمن كاميرات... 7 األغراض اللوجستية يوجد مولد كهرباء للطوارئ )في حال انقطاع الكهرباء(. 1 مولد الكهرباء قادر على تغطية الخدمات الضرورية للمستشفى لمدة 3 أيام. 2 تحدد المستشفى أي الخدمات الضرورية التي يجب مدها بالكهرباء من المولد. 3 يتم فحص األحمال على المولد بشكل دوري. 4 مصادر الوقود الالزم لتشغيل المولد. 5 يتوفر في المستشفى كمية من الوقود تكفي لتشغيل المولد لمدة 3 أيام متتالية. 6 مخزن الوقود في المستشفى موجود في مكان آمن. 7 مصادر المياه في المستشفى. 8 توفر مصدر احتياطي للمياه في حال انقطاع المياه. 9 توفر الطعام للمرضى والموظفين لمدة 3 4 أيام. 10 توفر معايير السالمة للمواد الغذائية والطعام خالل مراحل التوريد والتخزين واإلعداد. 11 توفر الغازات الطبية لمدة 3 4 أيام متتالية. 12 الغازات الطبية موجودة في مكان آمن. 13 توفر موظفي الهندسة والصيانة على مدار الساعة. 14 يمكن إغالق أنظمة التدفئة والتهوية والتكييف في حالة الطوارئ. 15 تم التدريب على إغالق أنظمة التدفئة والتهوية والتكييف في حالة الطوارئ خالل العام الماضي. 16 توجد لوائح مكتوبة بخصوص إغالق أنظمة التدفئة والتهوية والتكييف في حالة الطوارئ. 17 يمكن عزل مناطق في المستشفى. 18 يوجد نظام / آلية إلدارة النفايات الصلبة والسائلة. 19 يوجد مخزون / رصيد كافي من األدوات والمهمات الطبية للتعامل مع الطوارئ بشكل فعال. 20 ال نعم البلدية مصدر خاص ال نعم ال نعم ال نعم ال نعم ال نعم ال نعم ال نعم ال نعم ال نعم ال نعم ال نعم ال نعم 99

نعم نعم نعم نعم نعم نعم نعم نعم نعم نعم نعم نعم نعم نعم نعم %... %... %... نعم نعم نعم نعم نعم ال ال ال ال ال ال ال ال ال ال ال ال ال ال ال ال ال ال ال ال الجزء الثاني: خطة إدارة الطوارئ يوجد خطة للعمل في حالة الطوارئ تتضمن المراحل األربعة للطوارئ )الجهوزية االستجابة تقليل الضرر التعافي(. 1 الخطة تشمل الطوارئ الداخلية والخارجية. 2 الخطة مكتوبة وفي متناول جميع الموظفين المعنيين. 3 الخطة تشمل كل أنواع الطوارئ. 4 الخطة تشمل آلية للنقل السريع للمرضى من قسم الطوارئ لألقسام الداخلية. 5 الخطة تشمل آلية للخروج المبكر للمرضى وإمكانية التحويل لمستشفيات أخرى. 6 الخطة تشمل آلية لمتابعة المرضى في العيادة الخارجية حسب الحاجة. 7 الخطة تتضمن بيانات مكتوبة ومحدثة عن الموظفين. 8 الخطة تتضمن إلغاء / تأجيل الخدمات الغير مستعجلة. 9 الخطة تتضمن المحافظة علة الممارسات / المعايير الدينية. 10 الخطة تتضمن إجراءات التعافي والعودة للحالة الطبيعية التي كانت قبل الطوارئ. 11 تم إشراك الخطة / التعريف بالخطة مع مؤسسات المجتمع التي تنشط في حاالت الطوارئ )اإلسعاف الدفاع المدني...(. 12 يتم تعريف العاملين في المستشفى بخطة الطوارئ 13 يتلقى العاملين في قسم الطوارئ تدريب خاص بحاالت الطوارئ على األقل مرتين في السنة. 14 كل األطباء والممرضين العاملين في قسم الطوارئ مدربين على التعامل مع حاالت السكتة القلبية.BLS 15 الجهوزية والتدريب نسبة الموظفين الذين تلقوا تدريب على الجهوزية واالستجابة لحاالت الطوارئ. 1 نسبة األطباء الذين تلقوا تدريب على الجهوزية واالستجابة لحاالت الطوارئ. 2 نسبة الممرضين الذين تلقوا تدريب على الجهوزية واالستجابة لحاالت الطوارئ. 3 تقوم المستشفى بتنفيذ تدريب يحاكي حالة الطوارئ مرتين في السنة. 4 تشارك المستشفى في تدريب مشترك يحاكي حالة الطوارئ مع مؤسسات المجتمع مرة في السنة. 5 كل العاملين في قسم الطوارئ يشاركون في تدريب ميداني للطوارئ مرتين في السنة على األقل. 6 نفذت المستشفى تدريب إخالء للمرضى والموظفين مرة واحدة على األقل خالل العام الماضي. 7 توجد في المستشفى ألية للمراجعة وتقييم األداء بعد أحداث الطوارئ الحقيقية أو 8 100

ال نعم ال نعم ال نعم ال نعم ال نعم ال نعم ال نعم ال نعم ال نعم ال نعم ال نعم... عدد المرات ال نعم ال نعم ال نعم ال نعم... سرير... مريض ال نعم ال نعم ال نعم ال نعم ال نعم المصطنعة. تستخدم المستشفى نتائج المراجعة وتقييم األداء لتحديد نقاط القوة والضعف في خطة الطوارئ. 9 يتم دمج نتائج المراجعة وتقييم األداء في تعديل خطة الطوارئ. 10 نظام تفعيل الطوارئ (ICS) Incident Command System يوجد في المستشفى نظام تفعيل الطوارئ. 1 يتم التدريب على نظام تفعيل الطوارئ مرتين في السنة على األقل. 2 نظام تفعيل الطوارئ معروف لدى جميع الموظفين. 3 توجد آلية لتحديد المكلف بتفعيل نظام الطوارئ. 4 األفراد المكلفين بإدارة نظام الطوارئ يعرفون المهام الملقاة على عاتقهم. 5 يعرف الموظفين األماكن التي سيتواجدون فيها في حالة تفعيل نظام الطوارئ. 6 لجنة إدارة الطوارئ والكوارث في المستشفى توجد لجنة في المستشفى إلدارة الكوارث والطوارئ. 1 اللجنة تضم أعضاء من تخصصات مختلفة. 2 تعقد اللجنة اجتماعات دورية. 3 إذا كانت اإلجابة نعم كم مرة تجتمع اللجنة في السنة 4 محاضر اجتماع اللجنة موجودة ويتم مراجعتها. 5 اللجنة لديها معرفة بنظام الطوارئ في المستشفى والذي قد يتعارض مع أنظمة الطوارئ في مؤسسات أخرى. 6 تقوم اللجنة بتوجيه انتقادات بناءة / تغذية راجعة لذوي االختصاص حول األداء في حالة الطوارئ. 7 في حالة الطوارئ يتم التنسيق والتعاون مع المستشفيات األخرى. 8 القدرة االستيعابية لقسم الطوارئ عدد األسرة الفعلية المتوفرة في قسم الطوارئ 1 عدد الحاالت المرضية التي تتردد على قسم الطوارئ بشكل يومي 2 توفر كمية كافية من األدوية واألدوية المضادة في قسم الطوارئ 3 فرز المرضى Triage تستخدم المستشفى نظام فرز المرضى triage في قسم الطوارئ. 1 البطاقات الملونة متوفرة باستمرار في قسم الطوارئ. 2 يتضمن نظام الفرز اللون األسود لحاالت الوفاة أو المتوقع وفاتها. 3 يتضمن نظام الفرز اللون األحمر للحاالت التي تتطلب تدخل مباشر. 4 101

يتضمن نظام الفرز اللون األصفر للحاالت التي تتطلب تدخل ولكن يمكنها النتظار لفترة محددة. 5 يتضمن نظام الفرز اللون األخضر للحاالت البسيطة التي ال تحتاج تدخل طبي أو تحتاج تدخل بسيط. 6 يوجد مكان احتياطي يمكن استخدامه كقسم طوارئ في حالة وصول عدد كبير من المرضى في القسم األصلي. 7 خطوط السير / مسارات المرضى يوجد نظام مسارات ملون لمساعدة المرضى في التنقل داخل المستشفى. 1 تقوم المستشفى بتوجيه المرضى المنقولين لمستشفيات محلية أخرى. 2 تقوم المستشفى بتوجيه المرضى المنقولين لمستشفيات خارجية. 3 إدارة الضغط النفسي الناتج عن حالة الطوارئ يوجد في المستشفى فريق للصحة النفسية إلدارة الضغط النفسي. 1 خدمات الصحة النفسية متوفرة في المستشفى خالل وبعد حاالت الطوارئ. 2 فريق الصحة النفسية مدرب على حاالت الكوارث واالستجابات الطارئة. 3 فريق الصحة النفسية ممثل ضمن لجنة خطة إدارة الطوارئ. 4 توجد خطة لتفحص السالمة الجسدية والنفسية للعاملين في حالة الطوارئ. 5 إذا كانت اإلجابة نعم عن السؤال السابق الخطة تحدد العالمات الفسيولوجية العاطفية العقلية والسلوكية المتعلقة بالضغط النفسي مثل القلق الشعور بعدم 6 االرتياح فقدان الذاكرة وعدم القدرة على اتخاذ القرارات. خدمات الصيدلية توفر الصيدلية رصيد كافي من األدوية المضادة. 1 ترصد الصيدلية االستخدام اليومي لألدوية. 2 تحتفظ الصيدلية برصيد من األدوية يكفي لمدة شهر. 3 تحتفظ الصيدلية برصيد من المحاليل الطبية يكفي لمدة شهر. 4 توجد خطة للتوريد السريع لألدوية من الموردين في حالة الطوارئ. 5 خدمات المختبر العاملين في المختبر مدربين على إدارة الكم المتزايد من التحاليل المخبرية في حالة الطوارئ. 1 توجد خطة إلمداد المختبر بكمية إضافية من لوازم المختبر والمستهلكات الطبية في حالة الطوارئ. 2 توجد ترتيبات إلجراء التحاليل المخبرية في مختبرات أخرى لتخفيف الضغط عن مختبر المستشفى في حالة الطوارئ. 3 نعم نعم نعم نعم نعم نعم نعم نعم نعم نعم نعم نعم نعم نعم نعم نعم نعم نعم نعم نعم ال ال ال ال ال ال ال ال ال ال ال ال ال ال ال ال ال ال ال ال 102

نعم نعم نعم نعم نعم نعم نعم نعم نعم نعم نعم نعم نعم نعم نعم نعم نعم نعم نعم ال ال ال ال ال ال ال ال ال ال ال ال ال ال ال ال ال ال ال العاملين في بنك الدم مدربين للعمل في حالة الطوارئ والحاجة المتزايدة لعمليات نقل الدم. 4 توجد اتفاقية وتفاهم مع بنك الدم لمد المختبر بوحدات الدم عند الحاجة. 5 تم التدريب على نظام توريد الدم من أماكن أخرى إلى مختبر المستشفى. 6 التعامل مع حاالت الوفاة والجثث توجد خطة لكيفية التعامل مع حاالت الوفاة وجثث الموتى. 1 يوجد مكان به تبريد لوضع جثث الموتى. 2 فريق خدمات الوفيات مدرب على التعامل مع عدد كبير من حاالت الوفاة. 3 يوجد مكان إضافي مناسب لالستخدام في حالة وجود عدد كبير من الوفيات. 4 خطة التعامل مع حاالت الوفاة تراعي االعتبارات الثقافية والدينية للناجين. 5 أنظمة االتصال والتواصل اإلنذار اإلبالغ المستشفى قادرة على إرسال واستالم إنذارات ومعلومات بخصوص حالة الطوارئ. 1 المستشفى يمكنها استالم تحذيرات لحاالت الطوارئ من مؤسسات خارج المستشفى. 2 المستشفى يمكنها إرسال تحذيرات بالطوارئ لمؤسسات أخرى خارج المستشفى. 3 المستشفى قادرة على إبالغ العاملين في المستشفى بحالة الطوارئ واستدعاء العاملين من بيوتهم. 4 توجد خطة إلبالغ الموظفين )المداومين وغير المداومين( عن حالة الطوارئ. 5 توجد لدى المستشفى بيانات محدثة حول عناوين وأرقام تليفونات الموظفين. 6 يمكن للموظفين استالم رسائل على الجوال بخصوص حالة الطوارئ. 7 تم تحديد متحدث رسمي باسم المستشفى في حالة الطوارئ. 8 إدارة المعلومات يوجد نظام تخزين واسترجاع للمعلومات الضرورية. 1 نظام تخزين المعلومات محمي من الفيروسات واختراقات الهاكرز. 2 موظفي تكنولوجيا المعلومات متوفرين في حالة الطوارئ. 3 103

Appendix 2: Hospital Disaster Preparedness Self-Assessment Tool (English version) Hospital Disaster Preparedness Assessment Questionnaire PART ONE: HOSPITAL PROFILE 1 Hospital name:.. 2 Address / City:. 3 Number of population served by the hospital... 4 Person completed survey (Title):.. 5 Department:.. Hospital staffing (number of employees) 1 Physicians / surgeons: 2 Nurses: 3 Lab. technicians: 4 X-Ray & Radiology: 5 Administration: 6 Total beds capacity: Other Hospital Capacities 1 Does the hospital has its own ambulances? Yes No 2 Number of ambulances: 3 Does the hospital has portable X-ray machine? Yes No 4 Does the hospital has portable cardiac monitors? Yes No 104

5 Total number of cardiac monitors: 6 Does the hospital has portable ultrasound? Yes No 7 Does the hospital has portable ventilators? Yes No 8 Total number of ventilators:. 9 Number of available ICU beds:. 10 Number of available operating rooms: Safety and Security 1 Number of security personnel. 2 Security personnel on duty 24 hours/ 7 days per week in Emergency Department. Yes No 3 Facility can post additional security personnel in ED. Yes No 4 Available armed police force. Yes No 5 Facility has an Memorandum of understanding with local law enforcement to provide additional security. Yes No 6 A plan is in place to provide information to large numbers of concerned family and friends and to control crowds. Yes No 7 All entrances and exits are controlled, monitored with cameras., and can be locked. Yes No Logistics 1 Presence of emergency power generator. Yes No 2 Emergency power is adequate to provide electricity for all essential services for three days. Yes No 3 Facility has documented which essential services will receive power. Yes No 105

4 Load testing is performed annually on generator. Yes No 5 How does the facility get fuel for generators? MOH supply Own 6 Facility has an on-campus fuel source which can provide sufficient fuel for 3 days of continuous, full-load demand. Yes No 7 On-campus fuel source is in secured area. Yes No 8 Source of water supply. Municipality Own supply 9 Secondary source of water if primary source is cutoff. Yes No 10 Facility has adequate food on hand for staff and patients for a 3-4 days. Yes No 11 Security of food products is maintained at all times during: Delivery, storage, and preparation. Yes No 12 Facility has medical gasses to last 3-4 days without re-supply: Yes No 13 Medical gasses are in a secured area: Yes No 14 Maintenance and engineering staff are available 24 hours a day. Yes No 15 Facility can isolate and shut down Heating, Ventilation, and Air Conditioning (HVAC) system zones in an emergency. Yes No 16 HVAC shutdown has been exercised in past year. Yes No 17 Guidelines are in place for emergency HVAC shutdown. Yes No 18 Sections of the facility can be isolated. Yes No 19 Facility has procedures for management, transfer, and disposal of contaminated wastes, goods, and fluids. Yes No 106

Facility maintains current inventory of equipment, supplies and other 20 essential material required to effectively respond to a mass casualty Yes No event. PART TWO: EMERGENCY MANAGEMENT PLANNING (EMP) 1 Facility has an EMP that addresses the four phases of emergency management: preparedness, response, mitigation, and recovery. Yes No 2 The EMP addresses internal and external emergencies. Yes No 3 The EMP is easily accessible to mentors or to staff. Yes No 4 The EMP addresses all hazards events. Yes No 5 The EMP includes arrangements for rapid transfer of ED patients to inpatient units. Yes No 6 The EMP includes arrangements for early discharge and transfer of inpatients from the facility. Yes No 7 The EMP addresses plans for follow-up outpatient care as needed. Yes No 8 The EMP includes written and validated arrangements for surge staffing. Yes No 9 The EMP includes arrangements to cancel non-emergent services. Yes No 10 Spiritual care is integrated into EMP. Yes No 11 The EMP includes provisions for recovery and return to normal operations. Yes No 12 The EMP is shared with the appropriate local and state emergency agencies. Yes No 13 All staff receives orientation to the EMP. Yes No 14 Emergency Department staff receive at least twice-annual training on Yes No 107

response to emergency events. All physicians and nurses maintain current Basic Life Support 15 registration. Yes No Facility Readiness and Training (FRT) 1 Percent of total staff who have completed disaster response/preparedness training.. % 2 Percent of medical staff who have completed disaster response/preparedness training.. % 3 Percent of nursing staff who have completed disaster response/preparedness training.. % 4 Facility exercises EMP at least twice per year. Yes No 5 Facility participates in at least one community-wide exercise /year. Yes No 6 All ED personnel participate in at least twice-annual mass casualty exercises. Yes No 7 Facility has exercised evacuation of staff and patients in the last 12 months. Yes No 8 Facility has a procedure for conducting after-action reviews of simulated or actual emergency events. Yes No 9 Facility uses after action reports to identify strengths and weaknesses of the EMP. Yes No 10 Facility incorporates information gathered from after actions reports into their EMP. Yes No Incident Command System (ICS) 108

1 Presence of Incident Command System (ICS) in the hospital. Yes No 2 ICS is exercised at least twice annually. Yes No 3 Incident Commander is known by all staff. Yes No 4 There is a procedure to designate an Incident Commander. Yes No 5 Staff assigned to ICS leadership roles are oriented to their responsibilities. Yes No 6 All staff know where to go when the ICS is activated. Yes No Hospital Emergency Management/Disaster Preparedness Committee (HEMDPC) 1 A hospital emergency management/disaster preparedness committee exists and provides leadership to staff. Yes No 2 Committee is multidisciplinary. Yes No 3 Open meetings are held regularly. Yes No 4 If yes, how often? \.. months 5 Committee meeting minutes/action plan are available for review. Yes No 6 Committee is knowledgeable of hospital system plans that could override local plans. Yes No 7 Committee forwards critiques of all drills to appropriate services in a timely manner. Yes No 8 Committee communicates with and/or cooperates with other hospitals in the community. Yes No Emergency Department Capacity (EDC) 1 Emergency Department (ED) Capacity (beds). Beds 2 Average daily ED visits. Patients 109

3 Cache of emergency drugs and antidotes is maintained in ED. Yes No Patient Triage 1 Facility uses a triage system. Yes No 2 Triage tags are maintained in ED. Yes No 3 Protocol includes deceased category for victims beyond help (Black). Yes No 4 Protocol includes immediate category for life-threatening condition (Red). Yes No 5 Protocol includes delayed category for serious non-life threatening condition (Yellow). Yes No 6 Protocol includes minor category for minimal care requirement (Green). Yes No 7 Facility has an alternate treatment area to accommodate casualty surge / overload. Yes No Patient Tracking 1 Facility has a method for casualty tracking (labeled tracks). Yes No 2 Facility can track patients that are transferred to another local facility. Yes No 3 Facility can track patients that are evacuated out of the community. Yes No Critical Incident Stress Management (CISM) 1 Facility has Critical Incident Stress Management team or equivalent mental health services. Yes No 2 Mental health services are available during and after a mass casualty event. Yes No 3 Mental health team members are trained in crisis care and emergency Yes No 110

response. 4 Mental health services are represented on the Emergency Management Planning Committee. Yes No 5 A plan is in place to assess the physical and psychological well-being of disaster response workers. Yes No If yes, Plan identifies physiological, emotional, cognitive and behavioral 6 signs of stress including anxiety, irritability, memory loss, difficulty making decisions etc. Yes No Pharmacy Services (PHARS) 1 Pharmacy maintains a stockpile of antidotes. Yes No 2 Pharmacy monitors daily medication usage. Yes No 3 Pharmacy maintains a stockpile of medication for one month. Yes No 4 Pharmacy maintains a stockpile of IV fluids for one month. Yes No 5 A plan exists to ensure rapid delivery of medications from suppliers during an emergency. Yes No Laboratory Services (LABS) 1 Laboratory staff are trained for surge capacity (increased specimen load). Yes No 2 Plan is available to re-supply media, reagents and other critical supplies. Yes No 3 An arrangement is in place to transfer workload if laboratory is overwhelmed. Yes No 4 Blood bank services have surge capacity plans in place and are trained Yes No 111

for surge activity. 5 Memorandum of understanding is in place with regional blood center for emergent delivery of blood products. Yes No 6 Blood product delivery system has been exercised in last 12 months and is deemed reliable. Yes No Fatalities Management (FM) 1 Adequate plans are in place for management of fatalities. Yes No 2 Refrigerated storage facilities for fatalities are available. Yes No 3 Mortuary services staff are trained for surge. Yes No 4 Extra storage areas have been designated within the facility. Yes No 5 The fatalities management plan addresses the cultural and religious needs of survivors. Yes No Communications, Warning, and Notification (CWN) 1 Facility can send and receive emergency warning and notification information. Yes No 2 Facility can receive warnings of imminent emergency conditions from external agencies. Yes No 3 Facility can send warnings to external agencies. Yes No 4 Facility can notify on-duty and off-duty staff of emergency status and recall to duty. Yes No 5 Facility has a plan to notify on-duty and off-duty staff of emergency status. Yes No 6 Facility has staff notification with up-to-date, verified phone and other contact information. Yes No 112

7 Staff can receive warnings by text messages on their wireless phones. Yes No 8 Specific spokespersons have been identified for specific events. Yes No Information Management (IM) 1 Essential information system and data storage have offsite storage and recovery capabilities. Yes No 2 System has protection from viruses and intentional attacks (hacking). Yes No 3 Information management staff are present in emergency events. Yes No 113

Appendix 3: List of experts Name Dr. Hamza Abed Aljawad Dr. Ali Al Khateeb Dr. Ziad Abu Hain Dr. Ashraf Al Jady Dr. Ahmed Al Shaer Dr. Nezam Al Ashqar Dr. Abed Al Shokrey Dr. Hussam Al Najjar Dr. Azam Abu Habib Place of work Al Quds University University College of Applied Sciences The Islamic University Gaza The Islamic University Gaza The Islamic University Gaza The Islamic University Gaza The Islamic University Gaza The Islamic University Gaza UNRWA 114

Appendix 4: Approval letter from the Islamic University Gaza 115

Appendix 5: Approval letter from Helsinki Committee 116