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