Journal of Homeland Security and Emergency Management

Journal of Homeland Security and Emergency Management Volume 7, Issue 1

2010

Article 69

An Investigation of Hospital Disaster Preparedness in Turkey Mehmet Top∗

¨ Omer Gider†

Yunus Tas‡

∗

Hacettepe University, Turkey, [email protected] Kocaeli University, Turkey, [email protected] ‡ Kocaeli University, Turkey, [email protected] †

c Copyright 2010 Berkeley Electronic Press. All rights reserved.

An Investigation of Hospital Disaster Preparedness in Turkey ¨ Mehmet Top, Omer Gider, and Yunus Tas

Abstract The objective of this study was to examine the plans that public, university and private hospitals in Turkey have made in preparation for possible disasters, and to further investigate what types of measures have been taken as a way of focusing on plan characteristics and surge capacity. The study involved 430 hospitals throughout Turkey, each of which had 100 or more beds according to statistical data issued by The Ministry of Health of Turkey. Of these 430 hospitals, 358 were public, 40 were university-affiliated, and 32 were private. The questionnaires developed for the study were sent to the hospitals by mail. Only 251 hospitals returned responses. The questionnaire response rate was 58.4%. A total of 32 questions were asked in the survey. Frequency distributions of the data for statistical analysis were made, and tables were created according to the type and capacity of the hospitals. This study found that 233 hospitals (92.8%) have written disaster plans. When analyzed according to the type of hospital, 204 public hospitals (93.2%), 19 university hospitals (86.4%) and 10 private hospitals (100%) were found to have written disaster plans. According to the study, 63.5% of the public hospitals, 80% of the private hospitals and 31.8% of the university hospitals perform an exercise on an annual basis, as stated in the disaster plan. Disasters occur at unexpected times and have the potential to seriously affect the demand for health services. Local hospitals are one of the most significant facilities for providing health services during disasters. In this study, the level of disaster preparation of the hospitals in Turkey was examined. KEYWORDS: hospital disaster plan, disaster management, risk management

Top et al.: Hospital Disaster Plans in Turkey

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INTRODUCTION Natural disasters, such as earthquakes, volcanic eruptions, floods, tsunamis, storms and hurricanes, and man-made disasters, such as terrorist attacks, chemical plant explosions, industrial accidents, building collapses, major transportation accidents, and acts of war, all have the potential to result in significant economic loss and human casualties (Yi et al., 2010). Turkey experienced two powerful earthquakes in 1999. August 17, 1999, was a day of destruction, grief and great personal and material loss for the population of the Marmara (North-Western) region of Turkey. According to official records, an earthquake (measuring 7.4 on the Richter scale) caused the deaths of 18,000 people, injured approximately 50,000 people, and left thousands of people homeless (Gökalp, 2002). Following the Marmara earthquake, various Turkish public and private hospitals have witnessed improvements and have enlarged their hospital disaster plans (HDPs) (Özüçelik et al., 2008; Vatan & Salur, 2010). The nationwide medical economic policy which has compelled the contraction of emergency departments and other hospital services during the past two decades has been increasingly acknowledged by government, politicians, health managers, and disaster authorities. Despite not addressing the underlying problems in medical economic policy, the government has nevertheless established increasingly robust funding for programmes to supplement the hospital industry’s efforts to plan, train, and develop resources for mass casualty incidents (Barbera et al., 2009). Over the past decade, the public health approach to disasters has changed significantly. Today, the management of humanitarian assistance involves many more and varied players, and disaster management is now more keenly recognised as a significant priority of the public health system. Today, prevention, mitigation, and preparedness are all part of the vocabulary of public health officials in national and international organisations and, more importantly, they are used to advance the cause of reducing mortality and morbidity from disasters (Noji, 2005). Undoubtedly, public health approaches are an important part of change, particularly in hospitals. In unusual cases, hospitals and other health institutions have to provide, without external aid, health services which substantially exceed their capacity for services to patients. The preparedness of health facilities is a broad concept involving a large number of fields relating to unusual medical and non-medical cases (Bulut et al., 2005; TTB, 2009; Vatan & Salur, 2010). Hospitals have important tasks in terms of guaranteeing public health and protecting life against the negative consequences of earthquakes and other unusual occurrences. Particularly in developing countries, hospitals and other health organisations are not only places at which patients are provided with health services but are also public health centres where personnel are trained, therefore

Published by The Berkeley Electronic Press, 2010

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JHSEM: Vol. 7 [2010], No. 1, Article 69

containing laboratories for preventing infectious diseases by early warning (TTB, 2009). Without question, healthcare has assumed a more prominent role as an integral component of any community response, which has subsequently resulted in increased funding for hospital preparedness, as well as a plethora of new preparedness guidelines (Barbera et al., 2009). Despite the fact that no natural disasters can be forecast with any degree of certainty, it is particularly important for institutions that provide health services to design their emergency preparedness plans to minimise the number of casualties as much as possible (Kaji et al., 2007). Regardless of their capacity and type, hospitals must have their own plans and programmes for disasters (Hersche & Wenker, 2000). Moreover, hospitals have to be well constructed and designed in mind of unusual cases and natural disasters. According to the World Health Organisation, hospitals first have to provide protection for unusual cases and natural disasters in three areas. These areas are the protection of life, the protection of investment and operational protection. The protection of life is the minimum level of protection with which every structure must comply. It ensures that a building will not collapse and harm its occupants. Many hospitals in developing countries (such as Turkey) do not comply with this basic requirement. However, this situation was also the case in developed countries in the past (PAHO/WHO, 2005). When faced with a disaster, it can be difficult to establish immediate solutions for dealing with problems that unexpectedly emerge. During the approach of a disaster or emergency, the risks must be known and their rate of interaction calculated. Reducing the potential impact of a disaster in advance ultimately depends on good planning and preparedness. For this reason, hospitals that are important health facilities must have detailed, approved and tested written plans describing what should be done during a disaster; this ensures a planned and effective approach can be implemented when disasters occur. In addition, a disaster administration, comprising physicians in hospitals who have trained in this field, must be formed (Tengilimoğlu & Ekici, 2009). The goal of this study was to examine the plans that public, university and private hospitals in Turkey have made in preparedness for possible disasters, and to accordingly investigate what types of measures have been taken with a focus on plan characteristics and surge capacity. This has been achieved using a questionnaire-based survey method and an on-site survey in order to verify and clarify initial responses.

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HOSPITAL DISASTER PLAN (HDP) A hospital disaster plan (HDP) is an emergency management system which utilised positions on an organisational chart, and is a set of procedures, policies, interaction patterns, roles, etc. (Watson et al., 1998). The purpose of a disaster plan is to minimise disruption during a natural disaster or emergency situation, and to thereby allow the resumption of normal daily activities as quickly as possible (Howard & Wiseman, 2001). Another aim of a HDP is to bring about early recovery, and to thereby reduce the death and disability associated with a disaster incident by providing prompt and effective medical care to the largest number of people needing that care (Barbera et al., 2009). Optimal disaster planning is a comprehensive risk assessment and vulnerability analysis which actively identifies the most likely threats to a particular hospital and community (Kaji & Lewis, 2006). Risk and vulnerability assessment is a fundamental element of any disaster preparedness system. In developing countries, such as that of Turkey, however, it is sometimes overlooked or otherwise completely ignored by managers and other personnel involved in public health preparedness for disasters (Sarp et al., 2006). A HDP forms the basis of a hospital’s response to a disaster (Debacker, 1998; Remmen, 2005); however, it is important that the HDP does not remain solely a piece of paper. The mandatory final step of a hospital’s response is a dynamic process comprising education and training in making decisions based on methodical scientific work. The identification of bottlenecks is necessary for evaluating the efficient functioning of a HDP, along with the testing of possible solutions (Remmen, 2005). The HDP must not only be available, but must also be regularly practiced and upgraded. Furthermore, at any point that resources are stretched in a hospital setting, there are lessons to be learned which can also be useful in the case of daily operations (Ford & Schmidt, 2000). Undoubtedly, it is critical that hospitals remain undamaged in the case of a disaster, simply because they are the primary emergency health service providers after disasters. Owing to the importance of this role, hospitals have a HDP for avoiding damage from disasters and providing effective health services afterwards. Hospital managers should therefore consider the costs of a HDP, the health risks associated with disasters, and the benefits to be gained from a hospital’s disaster plan and overall preparedness (Pelteki, 2002). The main goal of a hospital disaster plan is to minimise the number of casualties by providing as many people as possible with medical aid. In order to achieve this primary goal, it is important to form and maintain a functioning partnership amongst institutions and units, all of which are supported by modern technology (Kaji et al., 2007). A standard structure and common terminology, communication plan and functions should be established.


4


Preparing a disaster plan and putting it into practice are essential steps if health institutions are to come through a disaster with a minimum number of casualties and the least damage to buildings, equipment and materials. The hospital administration must take costs and benefits into account in the mediumand long-run, with the costs of exposure to a disaster compared to the risks that a disaster can cause (Pelteki, 2002). In the event of disasters, hospitals are in a position to provide health services different from those of routine health service delivery. In disasters, hospitals have to assign importance to emergency medical services. Furthermore, routine hospital priorities vary during disasters. For any disaster, hospitals must have various procedures in place which have been prepared and standardised in advance (Waeckerle vd., 2001:587). In order to minimise disease and the number of casualties during a disaster, medical resources, personnel, medical equipment and materials must be delivered in such a way that most people can access them easily. Essentially, a hospital disaster plan is the main source of a hospital’s response at the time of a disaster; however, it is important to recognise that a hospital disaster plan does not mean anything on its own. Rather, it is fundamental that these plans are put into practice, with personnel in the field trained and developed. In addition, hospital disaster plans must be dynamic rather than static, and must be continuously tested, reviewed and updated (Kennedy et al., 1996; Debacker, 2000; Ford & Schmidt, 2000; Remmen, 2005). Although it is important for a hospital to have an operational disaster plan, the efficiency of these plans and the adequacy of the preparation for a disaster are important issues for discussion. According to Manley et al. (2006: 81), standards of preparedness for hospitals are not clear and provide no guarantees or assurances that the response will be adequate. In fact, no outcome measures exist to determine whether, during a disaster, the hospital’s written plan is effective or will be followed. For example, the 1999 earthquake in Turkey left more than 44,000 people injured, most of whom were either medically evacuated to distant health facilities because of damage to nearby hospitals or were otherwise treated outdoors on the grounds of the nearest hospital or clinic because the facility was either destroyed or perceived to be unsafe (PAHO/WHO, 2005). Thus, preparing HDPs in Turkish hospitals is critical. Following a disaster, a hospital emergency room (ER) can expect a sudden surge of injured patients (up to three to five times the normal patient volume); this can easily overwhelm hospital resources (Yi et al., 2009). With this taken into account, early emergency medical response capacity at the time of major disasters and mass-gathering disasters consists of the following three capacities: rescue capacity, transport capacity and medical treatment capacity. Rescue capacity and



5

transport capacity depend on fire department capacity, which comparatively has enough of a support system (Takahashi et al., 2007). The capacity of hospitals to deal with emergencies has been lacking (Katz et al., 2006; Avery et al., 2008). Notably, a number of studies of hospitals in Kentucky (Higgins et al., 2004) and the United States in general (Crosse et al., 2003) have established significant gaps in the ability of hospitals to meet the demands of a public health emergency. Capacity shortfalls have been noted in emergency departments, intensive care beds, and general medical/surgical beds (Bazzoll et al., 2003). Likewise, significant infrastructure issues pose barriers to the safe management of patients with highly communicable respiratory infections (Srinivasan et al., 2004). Workforce shortages, pressures from payers and regulatory burdens aggravate the problem of creating hospital capacity to deal with unusual demands (Bentley, 2001; Kaji et al., 2007). Disasters happen at unexpected times, and they seriously affect the demand for and the provision of health services. Hospitals are crucial places for providing health services. This study therefore examines the preparedness of hospitals in Turkey. METHODS The purpose of this study was to examine the disaster plans of hospitals throughout Turkey with a capacity of at least 100 beds, and the measures taken in parallel with such plans. This study has aimed to examine the hospital’s preparedness plans in Turkish hospitals for possible disasters. The study is limited to hospitals with a capacity of 100 or more beds throughout Turkey owing to the fact that such institutions were assumed to be more comprehensive in their technical, administrative and institutional structures. The hospitals were evaluated according to their status as public, private or university institutions, and according to their having a capacity of 100-200 or >200 beds. In Turkey, hospitals with 100-200 beds are usually general hospitals whilst those with >200 beds are usually training and research hospitals. This study has adopted a descriptive approach. According to statistical data issued by The Ministry of Health, there are a total of 430 hospitals with 100 or more beds throughout Turkey, of which 358 are public, 40 are university and 32 are private institutions. This study gathered data from all of the hospitals in question, and did not employ sampling. In an attempt to prepare the data collection questionnaire to be used in the study, the relevant literature (Landesman et al., 1994; PAHO/WHO, 2000; Tsai et al., 2004; Bulut et al., 2005; Kaji et al., 2007; Remmen, 2006; Lök et al., 2009; Yi et al., 2010) were examined, and the contents of the hospital disaster plans were studied. A total of 32 descriptive questions were posed in the questionnaire.


6


The number of completed questionnaires returned was 251 (58.4%) of the hospitals under consideration. The questionnaire consisted of five parts: • Part 1: Descriptive information. • Part 2: Preparedness plans of hospitals. • Part 3: Preparedness plans of hospitals, emergency services, ambulances and security. • Part 4: Preparedness plans of hospital communications, pharmacies and food services. • Part 5: Preparedness plans of hospital electrical generators, chemical and radioactive accidents and morgues. The statistical analyses were performed using SPSS (Statistical Package for Social Sciences) 15.0. Frequency distributions of the characteristics of the hospital disaster plans by hospital type and capacity were created, and the chisquare test was used to compare the characteristics across the capacity categories. The necessary permission for surveying the hospitals was requested in 2008, and written permission was obtained from the General Directorate for Medical Treatment Services. FINDINGS The first part of the survey comprised descriptive data relating to the category and capacity of the hospitals, and the occupational responsibilities of the personnel who responded. Table 1: Distribution of hospital categories Hospital Categories Public hospitals University hospitals Private hospitals All hospitals

n 219 22 10 251

(%) 87.3 8.7 4.0 100.0

According to Table 1, a total of 251 institutions were included in the study: 219 public hospitals (87.3%); 22 university hospitals (8.7%); 10 private hospitals (4.0%). Table 2: Distribution of hospitals according to capacity Number of Beds 100 - 200 > 200 Total

n 128 123 251


(%) 51.0 49.0 100.0


7

Table 2 indicates the distribution of the hospitals according to their capacity. According to Table 2, 128 hospitals (51%) in the study had a capacity of 100-200 beds, and 123 hospitals had a capacity of >200 beds (49%). A large number of hospitals in Turkey have been constructed with a capacity of 100-200 beds; thus, the hospitals were grouped according to whether they had a capacity of 100-200 beds or a capacity of >200 beds. Table 3: Distribution of responding personnel according to responsibilities Duty at the Hospital Head Physician Assistant Head Physician Hospital Manager Assistant Hospital Manager Civil Defence Expert Others Total

n 17 35 44 47 74 34 251

(%) 6.8 13.9 17.5 18.7 29.5 13.5 100.0

According to Table 3, civil defence experts were the most common respondents to the survey. The term ‘others’ incorporates personnel in the quality department, data processing and control managers, medical technologists, social workers and emergency medical experts. According to Table 4, 233 of the 251 hospitals (92.8%) had a disaster plan whilst 16 (6.4%) did not. In addition, 165 hospitals (65.7%) had updated the plans within the previous 6 months but 71 (28.3%) had not. A remarkable finding from Table 4 is that an exercise was performed according to the disaster plan once a year in 154 hospitals (61.4%), whilst in 93 hospitals (37.1%), it was not. Another noteworthy finding is that 190 hospitals (75.7%) had an evacuation plan for a disaster whereas 48 (19.1%) did not. In addition, 57 hospitals (22.7%) had a helipad and 191 (76.1%) did not. When the responses were grouped by type of institution, 93.2% of the 219 public hospitals, 100% of the 10 private hospitals and 86.4% of the 22 university hospitals included in the study had written disaster plans. In addition, 68.5% of the public hospitals, 70% of the private hospitals and 36.4% of the university hospitals had updated the data in their hospital disaster plans bi-annually. One of the important findings is that 63.5% of the public hospitals, 80% of private hospitals and 31.8% of university hospitals had performed exercises once a year, as stated in the disaster plan. Another noteworthy finding is that 40% of the public hospitals and approximately 70% of university hospitals had not conducted any yearly exercises. In addition, 68.9% of the public hospitals, 100% of the private hospitals and 63.6% of the university hospitals were found to have emergency service triage plans. Another important finding is that 19.6% of the public hospitals, 100% of the private hospitals and 45.5% of the university


8


hospitals were found to have a helipad on their grounds. It is especially noteworthy that 80% of the public hospitals did not have a helipad. In addition, 28.3% of the public hospitals, 90% of the private hospitals and 22.7% of the university hospitals had emergency action plans for chemical accidents, and 19.2% of the public hospitals, 90% of the private hospitals and 18.2% of the university hospitals had emergency action plans for radioactive accidents. Table 5 displays the characteristics of the hospital disaster plans by hospital capacity. Of the institutions with a capacity of 100-200 beds, 119 (93%) had performed an exercise once a year compared with 114 (64.1%) of those with a capacity of 200 beds. Of the hospitals with a capacity of >200 beds, 58.5% had performed an exercise once a year whereas 39% had not. Of the hospitals with a capacity of 100-200 beds, 80% did not have a helipad. The rate for hospitals with a capacity of >200 beds was 72.4%. Of the hospitals with a capacity of 100-200 beds, 56.3% did not have an emergency action plan for chemical accidents. The rate for hospitals with a capacity of >200 beds was 57.7%. Similarly, 68.8% of the hospitals with a capacity of >200 beds did not have an emergency action plan for radioactive accidents, compared with 64.2% of those with a capacity of >200 beds. According to bed capacity, there are significant differences in terms of ‘Names of people and institutions to cooperate with’, ‘Meeting place at the hospital at the time of disaster’, ‘Multiple telephones in the crisis room’ and ‘Predetermined Disaster Crisis Room’. CONCLUSIONS Of the hospitals in the study, 233 hospitals (92.8%) had a written disaster plan. In relation to the type of hospitals, 204 of the 219 public hospitals (93.2%), 19 of the 22 university hospitals (86.4%) and 10 of the 10 private hospitals (100%) were found to have written disaster plans. These results show that a large number of hospitals in Turkey have written disaster plans. When the responses to the questionnaire were carefully studied, hospitals were found to have various insufficiencies in the area of practice and application during disasters. For example, 154 of 251 hospitals (61.4%) had performed an exercise once a year, whereas 93 hospitals (37.1%) had not. Another remarkable finding is that only 57 hospitals (22.7%) had a helipad and 191 (76.1%) did not. These results show that a significant number of hospitals are insufficiently prepared for possible disasters in terms of applicable disaster exercises and scenarios. Several studies have been performed with the objective to examine the preparedness for natural disasters and unusual circumstances of hospitals in Turkey and to thereby determine whether or not hospital disaster plans have been created. According to a study by the Turkish Medical Association (‘An Assessment of The Preparedness of The Treatment Institutions that have Beds



9

where Physicians Work for Unusual Cases’), the physicians who work at 74 of the treatment facilities which have beds in 81 provinces of Turkey were asked to carry out an assessment of the unusual cases from the health facilities where they work and their corresponding risks. The physicians stated that a high rate (73.3%) of the hospitals in which they worked were not ready for unusual cases. In addition, 36.5% of the physicians stated that the hospitals in which they worked had hospital disaster plans, whilst 16.7% stated that they did not know whether their institutions had a hospital disaster plan (TTB, 2009). Three different but interrelated training activities have been conducted within the framework of the Health Services Preparedness Program of the Province of Izmir, which was created in the year 2009 by the Izmir Provincial Health Directorate. One of the prominent outcomes of this project involving medical emergency management training and the training of trainers for hospital disaster planning and disaster medical training are the following answers to the question. ‘What are the administrative difficulties you have encountered in the medical services for disasters?’: 44% of the 112 health managers responded that the difficulties were owing to insufficiently trained personnel, and 16% stated that there was ambiguity of authority (İzmir Provincial Directorate of Health & Turkish Emergency Medical Association, 2009). A 2003 study of public and private hospitals in the province of Ankara by Sarp, Tengilioğlu & Bozkırlı found that 80.6% of the participants—comprising civil defence experts and hospital administrators—stated that hospital disaster plans were available in their hospitals, 54.8% of which stated that they did not have any specific disaster scenarios. The study also found that no disaster exercises were performed in 50% of the hospitals (Sarp et al., 2006). From the results of this study, it is clear that the authorities and administrators of hospitals in Turkey must review their exercises and the scenarios of possible disasters which they may encounter. An analysis of the exercises and scenarios will help them gain a vast amount of experience in more effectively supporting the local population during a possible disaster.


10


Table 4: Characteristics of hospital disaster plans Hospital Categories

Hospital Disaster Plan Characteristics

Written hospital disaster plan Briefings for staff in charge Names of people and institutions with whom to cooperate Data updating in a six-month period Meeting place at the hospital in time of disaster Predetermined disaster crisis room Multiple telephones in the crisis room Other means of communication in the crisis room A copy of the disaster plan in the crisis room Extra lighting equipment in the crisis room

Public Hospital

University Hospital

Private Hospital

All Hospitals

(n = 219)

(n = 22)

(n = 10)

(n= 251)

Yes

No

No info.

Yes

No

No info.

Yes

No

No

Yes

No

info.

No info.

n

n

n

n

n

n

n

n

n

N

N

N

(%)

(%)

(%)

(%)

(%)

(%)

(%)

(%)

(%)

(%)

(%)

(%)

204

13

2

19

3

0

10

0

0

233

16

2

(93.2)

(5.9)

(0.9)

(86.4)

(13.6)

(0.0)

(100.0)

(0.0)

(0.0)

(92.8)

(6.4)

(0.8)

188

26

5

18

(85.8)

(11.9)

(2.3)

(81.8)

4 (18.2)

0

10

0

0

216

30

5

(0.0)

(100.0)

(0.0)

(0.0)

(86.1)

(12.0)

(2.0)

165

44

10

13

8

1

9

1

0

187

53

11

(75.3)

(20.1)

(4.6)

(59.1)

(36.4)

(4.5)

(90.0)

(10.0)

(0.0)

(74.5)

(21.1)

( 4.4)

150

55

14

8

14

0

7

2

1

165

71

15

(68.5)

(25.1)

(6.4)

(36.4)

(63.6)

(0.0)

(70.0)

(20.0)

(10.0)

(65.7)

(28.3)

(6.0)

181

32

6

17

5

0

10

0

0

208

37

6

(82.6)

(14.6)

(2.7)

(77.3)

(22.7)

(0.0)

(100.0)

(0.0)

(0.0)

(82.9)

(14.7)

(2.4)

161

52

6

16

6

0

9

1

0

186

59

6

(73.5)

(23.7)

(2.7)

(72.7)

(27.3)

(0.0)

(90.0)

(10.0)

(0.0)

(74.1)

(23.5)

(2.4)

107

104

8

13

7

2

8

2

0

128

113

10

(48.9)

(47.5)

(3.7)

(59.1)

(31.8)

(9.1)

(80.0)

(20.0)

(0.0)

(51.0)

(45.0)

(4.0)

106

103

10

11

9

2

9

1

0

126

113

12

(48.4)

(47.0)

(4.6)

(50.0)

(40.9)

(9.1)

(90.0)

(10.0)

(0.0)

(50.2)

(45.0)

(4.8)

108

98

13

13

8

1

8

2

0

129

108

14

(49.3)

(44.7)

(5.9)

(59.1)

(36.4)

(4.5)

(80.0)

(20.0)

(0.0)

(51.4)

(43.0)

(5.6)

84 (38.4)

115

20

(52.5)

(9.1)

7 (31.8)

14

1

(63.6)

(4.5)

9 (90.0)


1 (10.0)

0

100

130

21

(0.0)

(39.8)

(51.8)

(8.4)


11

Table 4: Characteristics of hospital disaster plans (continued) Hospital Categories University Hospital

Private Hospital

All Hospitals

(n = 219)

(n = 22)

(n = 10)

(n= 251)

Yes


Exercise once a year

Public Hospital No

No info.

Yes

No

No info.

Yes

No

No

Yes

No

No

info.

info.

n

n

n

n

n

n

n

n

n

N

N

N

(%)

(%)

(%)

(%)

(%)

(%)

(%)

(%)

(%)

(%)

(%)

(%)

139

77

0

7

15

0

8

1

154

93

4

(63.5)

(35.2)

(0.0)

(31.8)

(68.2)

(0.0)

(80.0)

(10.0) (10.0)

1

(61.4)

(37.1)

(1.6)

Training of the staff responsible for the Disaster 75 Management (34.2)

123

21

4

17

1

7

3

86

143

22

(56.2)

(9.6)

(18.2)

(77.3)

(4.5)

(70.0)

(30.0) (0.0)

(34.3)

(57.0)

(8.8)

Hospital disaster evacuation plan

13

0

167

40

12

13

8

1

10

0

0

190

48

(76.3)

(18.3)

(5.5)

(59.1)

(36.4)

(4.5)

(100.0)

(0.0)

(0.0)

(75.7)

(19.1)

(5.2)

161

46

12

13

8

1

10

0

0

184

54

13

(73.5)

(21.0)

(5.5)

(59.1)

(36.4)

(4.5)

(100.0)

(0.0)

(0.0)

(73.3)

(21.5)

(5.2)

151

53

15

14

7

1

10

0

0

175

60

16

(68.9)

(24.2)

(6.8)

(63.6)

(31.8)

(4.5)

(100.0)

(0.0)

(0.0)

(69.7)

(23.9)

(6.4)

Description of duty of other departments in the hospital 113 in the triage plan (51.6)

89

17

10

11

1

10

0

0

133

100

18

(40.3)

(7.8)

(45.5)

(50.0)

(4.5)

(100.0)

(0.0)

(0.0)

(53.0)

(39.8)

(7.2)

Sufficient number of ambulances at the hospital

0

Exit doors for patients in the evacuation plan Emergency service triage plan

Plan for providing ambulances from other institutions Detailed city and regional plans for the ambulances A helipad on the hospital grounds

128

84

7

11

11

0

8

2

147

97

7

(58.4)

(38.4)

(3.2)

(50.0)

(50.0)

(0.0)

(80.0)

(20.0) (0.0)

(58.6)

(38.6)

(2.8)

114

90

15

12

9

1

9

0

1

135

99

17

(52.1)

(41.1)

(6.8)

(54.5)

(40.9)

(4.5)

(90.0)

(0.0)

(10.0)

(53.8)

(39.4)

(6.8)

3

58

120

41

5

15

2

6

1

69

136

46

(6.5)

(54.8)

(18.7)

(22.7)

(68.2)

(9.1)

(60.0)

(10.0) (3.0)

(27.5)

(54.2)

(18.3)

43

174

2

10

11

1

4

6

57

191

3

(19.6)

(79.5)

(0.9)

(45.5)

(50.0)

(4.5)

(40.0)

(60.0) (0.0)

(22.7)

(76.1)

(1.2)

0


12


Table 4: Characteristics of hospital disaster plans (continued) Hospital Categories

Yes


Early warning system in case of fire in the hospital Plan for communication at the time of disaster Public relations experts to contact the press at the time of disaster Stock of sufficient vital medications, with types and amounts specified in the HDP. Preliminary agreements made with organisations to provide food services

alternative

Public Hospital

University Hospital

Private Hospital

All Hospitals

(n = 219)

(n = 22)

(n = 10)

(n= 251)

No

No info.

Yes

No

No info.

Yes

No

No

Yes

No

info.

No info.

n

n

n

n

n

n

n

n

n

N

N

N

(%)

(%)

(%)

(%)

(%)

(%)

(%)

(%)

(%)

(%)

(%)

(%)

159

56

4

16

6

0

9

1

0

184

63

4

(72.6)

(25.6)

(1.8)

(72.7)

(27.3)

(0.0)

(90.0)

(10.0)

(0.0)

(73.3)

(25.1)

(1.6)

151

54

14

13

7

2

10

0

0

174

61

16

(68.9)

(24.7)

(6.4)

(59.1)

(31.8)

(9.1)

(100.0)

(0.0)

(0.0)

(69.3)

(24.3)

(6.4)

91

116

12

18

4

0

10

0

0

119

120

12

(41.6)

(53.0)

(5.5)

(81.8)

(18.2)

(0.0)

(100.0)

(0.0)

(0.0)

(47.4)

(47.8)

(4.8)

139

52

28

12

9

1

9

1

0

160

62

29

(63.5)

(23.7)

(12.8)

(54.5)

(40.9)

(4.5)

(90.0)

(10.0)

(0.0)

(63.7)

(24.7)

(11.6)

29

163

27

4

16

2

6

4

0

39

183

29

(13.3)

(74.4)

(12.3)

(18.2)

(72.7)

(9.1)

(60.0)

(40.0)

(0.0)

(15.5)

(72.9)

(11.6)

Sufficient number of extra electrical generators with sufficient capacity at the hospital

170

41

8

17

4

1

10

0

0

197

45

9

(77.6)

(18.7)

(3.7)

(77.3)

(18.2)

(4.5)

(100.0)

(0.0)

(0.0)

(78.5)

(17.9)

(3.6)

Emergency action plan for chemical accidents in the hospital

62

127

30

5

15

2

9

1

0

76

143

32

(28.3)

(58.0)

(13.7)

(22.7)

(68.2)

(9.1)

(90.0)

(10.0)

(0.0)

(30.3)

(57.0)

(12.7)

Emergency action plan for radioactive accidents in the hospital

42

151

26

4

15

3

9

1

0

55

167

29

(19.2)

(68.9)

(11.9)

(8.2)

(68.2)

(13.6)

(90.0)

(10.0)

(0.0)

(21.9)

(66.5)

(11.6)

Temporary locations to be used as morgues in case of mass deaths

74

118

27

4

16

2

9

1

0

87

135

29

(33.8)

(53.9)

(12.3)

(18.2)

(72.7)

(9.1)

(90.0)

(10.0)

(0.0)

(34.7)

(53.8)

(11.6)



13

Table 5: Characteristics of hospital disaster plans according to the number of beds Number of Beds

Hospital disaster plan characteristics

Written hospital disaster plan Briefings for staff in charge Names of people and institutions to cooperate with Data updating in periods of six months Meeting place at the hospital at the time of disaster Predetermined disaster crisis room Multiple telephones in the crisis room

Other means of communication in the crisis room A copy of the disaster plan in the crisis room Extra lightning equipment in the crisis room

100 - 200

>200

(n = 128)

(n = 123)

Yes

No

No info

Yes

No

No info

n

n

n

n

n

n (%)

(%)

(%)

(%)

(%)

(%)

119

7

2

114

9

0

(93.0)

(5.5)

(1.5)

(92.7)

(7.3)

(0.0)

113

12

3

103

18

2

(88.3)

(9.4)

(2.3)

(83.7)

(14.6)

(1.6)

104

21

3

83

32

8

(81.3)

(16.4)

(2.3)

(67.5)

(26.0)

(6.5)

81

36

11

84

35

4

(63.3)

(28.1)

(8.6)

(68.3)

(28.5)

(3.3)

105

17

6

103

20

0

(82.0)

(13.3)

(4.7)

(83.7)

(16.3)

(0.0)

85

37

6

101

22

0

(66.4)

(28.9)

(4.7)

(82.1)

(17.9)

(0.0)

53

69

6

75

44

4

(41.4)

(53.9)

(4.7)

(61.0)

(35.8)

(3.3)

57

63

8

69

50

4

(44.5)

(49.2)

(6.3)

(56.1)

(40.7)

(3.3)

61

57

10

68

51

4

(47.7)

(44.5)

(7.8)

(55.3)

(41.5)

(3.3)

46

68

14

54

62

7

(35.9)

(53.1)

(10.9)

(43.9)

(50.4)

(5.7)

x2

p

2.259

.323

1.764

.414

6.817

.033*

3.237

.198

6.165

.046*

11.095

.004*

9.616

.008*

3.874

.144

3.186

.203

.3.152

0.207


14


Table 5: Characteristics of Hospital Disaster Plans According to the Number of Beds (continued) Number of Beds


Exercise once a year Training of the staff responsible for the Disaster Management Hospital evacuation plan for disaster Exit doors for patients in the evacuation plan Emergency service triage plan Description of duty of other departments in the hospital in the triage plan Sufficient number of ambulances at the hospital Plan for providing ambulance from other institutions Detailed city and regional plans in the ambulances A helipad on the hospital grounds

100 - 200

>200

(n = 128)

(n = 123)

Yes

No

No info

Yes

No

No info

n

n

n

n

n

n

(%)

(%)

(%)

(%)

(%)

(%)

82

45

1

72

48

3

(64.1)

(35.2)

(0.8)

(58.5)

(39.0)

(2.4)

43

70

15

43

73

7

(33.6)

(54.7)

(11.7)

(35.0)

(59.3)

(5.7)

94

26

8

96

22

5

(73.4)

(20.3)

(6.3)

(78.0)

(17.9)

(4.1)

94

28

6

90

26

7

(73.4)

(21.9)

(4.7)

(73.2)

(21.1)

(5.7)

93

30

5

82

30

11

(72.7)

(23.4)

(3.9)

(66.7)

(24.4)

(8.9)

73

46

9

60

54

9

(57.0)

(35.9)

(7.0)

(48.8)

(43.9)

(7.3)

82

43

3

65

54

4

(64.1)

(33.6)

(2.3)

(52.8)

(43.9)

(3.3)

73

47

8

62

52

9

(57.0)

(36.7)

(6.3)

(50.4)

(42.3)

(7.3)

38

70

20

31

66

26

(29.7)

(54.7)

(15.6)

(25.2)

(53.7)

(21.1)

25

102

1

32

89

2

(19.5)

(79.7)

(0.8)

(26.0)

(72.4)

(1.6)


x2

p

1.647

.439

2.874

.238

.947

.623

.138

.933

2.843

.241

1.812

.404

3.258

.196

1.108

.575

1.511

.470

1.979

.372


15

Table 5: Characteristics of hospital disaster plans according to the number of beds (continued) Number of Beds


Plan for communication at time of disaster

>200

(n = 128)

(n = 123)

Yes

No

No info

Yes

No

No info

n

n

n

n

n

n

(%) Early warning system in case of fire in the hospital

100 - 200

(%)

(%)

(%)

(%)

p

.112

.946

.416

.812

12.658

.002

.035

.983

.242

.886

3.362

.186

3.507

.173

2.721

.256

.782

.676

(%)

95

31

2

89

32

2

(74.2)

(24.2)

(1.6)

(72.4)

(26.0)

(1.6)

91

29

8

83

32

8

(71.1)

(6.5)

(22.7)

(6.3)

(67.5)

(26.0)

Public relations expert to contact the Press at the time of disaster

47

75

6

72

45

6

(36.7)

(58.6)

(4.7)

(58.5)

(36.6)

(4.9)

Stock of sufficient amount of vital medicine of which kind and amount are written in HDP

82

31

15

78

31

14

(64.1)

(24.2)

(11.7)

(63.4)

(25.2)

(11.4)

Preliminary agreement made with organisations to provide food services

20

92

16

19

91

13

(15.6)

(71.9)

(12.5)

(15.4)

(74.0)

(10.6)

alternative

x2

Sufficient number of extra electrical generators at sufficient capacity at the hospital

101

25

2

96

20

7

(78.9)

(19.5)

(1.6)

(78.0)

(16.3)

(5.7)

Emergency Action Plan for chemical accidents in the hospital

35

72

21

41

71

11

(27.3)

(56.3)

(16.4)

(33.3)

(57.7)

(8.9)

Emergency Action Plan for radioactive accidents in the hospital

23

88

17

32

79

12

(18.0)

(68.8)

(13.3)

(26.0)

(64.2)

(9.8)

Temporary places to be used as morgues in case of mass deaths

44

67

17

43

68

12

(34.4)

(52.3)

(13.3)

(35.0)

(55.3)

(9.8)

*: p < .05 significant difference


16


During the past decade in Turkey, much has occurred in the area of recognising the importance of hospital preparedness for major emergencies—both mass casualty and mass effect (Bulut et al., 2005). Clearly, the vast majority of hospitals have demonstrated significant improvements in terms of their emergency preparedness and disaster heath planning during the past decade (Sarp et al., 2006). Notably, hospital readiness may be defined as the ability to effectively maintain hospital operations, sustain a medically safe environment, and adequately address the increased and potentially unusual medical needs of the affected population (Barbera et al., 2009). Importantly, however, little evidence exists to indicate that the majority of hospitals have reached this goal for their probable hazardous incidents and disasters. Although there are many on-going initiatives concerned with addressing this critical issue, a more focused approach to understanding and promoting emergency and disaster preparedness motivation amongst key hospital decision makers in Turkey is required nevertheless. During disasters, especially earthquakes, health systems are expected to play an essential role in reducing mortality and injuries, and pre-hospital and hospital care systems are important components of the health systems (including the Turkish health system). For appropriate medical responses to these disasters, local medical services must have an effective disaster management plan, adequate equipment and, most importantly, trained workers (Emami et al., 2005). Furthermore, more effective mitigation and preparedness guidelines for disasters that establish operationally competent response capabilities are needed in Turkey. All current guidelines should be re-examined with this goal in mind. Future government-funded and/or academically developed hospital emergency and disaster management guidelines should be validated as effective in establishing operational level (rather than the usual ‘awareness’ level) competency. Guidelines on how to create a useful HDP, to identify and stratify vulnerable elements, and to accomplish risk reduction in achievable increments are needed. Moreover, guidelines also need to focus on a realistic management and response process rather than the large-scale acquisition of materials, such as personal protective equipment. In addition, it is important that those guidelines which demonstrate adequate all-hazards preparedness address small, likely hazards, and provide the foundations (e.g., patient, staff and facility protection, effective hospital incident management) for the larger, less likely incidents, which are ultimately the focus of HDPs. Turkey and other developing countries may be facing a number of deficiencies in terms of hospital disaster planning and preparedness. With this in consideration, the findings of this study may help the hospital sector in Turkey, and similar developing countries, to make improvements in the field of emergency



17

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