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Evaluation of disaster preparedness for mass casualty
incidents in private hospitals in Central Saudi Arabia
Abdullah A. Bin Shalhoub, MPH, Anas A. Khan, MD, SBEM, Yaser A. Alaska, MD, SBEM.
ABSTRACT
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Objectives: To identify and describe the hospital disaster
preparedness (HDP) in major private hospitals in
Riyadh, Saudi Arabia.
Methods: is is an observational cross-sectional survey
study performed in Riyadh city, Saudi Arabia between
December 2015 and April 2016. irteen major private
hospitals in Riyadh with more than 100 beds capacity
were included in this investigation.
Results: e 13 hospitals had HDP plan and reported to
have an HDP committee. In 12 (92.3%) hospitals, the
HDP covered both internal and external disasters and
HDP was available in every department of the hospital.
ere were agreements with other hospitals to accept
patients during disasters in 9 facilities (69.2%) while
4 (30.8%) did not have such agreement. None of the
hospitals conducted any unannounced exercises in
previous year.
Conclusion: Most of the weaknesses were apparent
particularly in the education, training and monitoring
of the hospital staff to the preparedness for disaster
emergency occasion. Few hospitals had conducted an
exercise with casualties, few had drilled evacuation of
staff and patients in the last 12 months, and none had
any unannounced exercise in the last year.
Saudi Med J 2017; Vol. 38 (3): 302-306
doi: 10.15537/smj.2017.3.17483
From the Ministry of Health (Bin Shalhoub), Al-Washim District, and
the Emergency Medicine Department (Khan, Alaska), Riyadh, Kingdom
of Saudi Arabia.
Received 27th October 2016. Accepted 23rd November 2016.
Address correspondence and reprint request to: Dr. Abdullah A. Bin Shalhoub,
Ministry of Health, Al-Washim District, Riyadh, Kingdom of Saudi
Arabia. E-mail: Alshalhoubabdullah@gmail.com
OPEN ACCESS
A
mass casualty incident (MCI) is any incident in
which emergency medical services resources, such
as personnel and equipment, are overwhelmed by
the number and severity of casualties.1 During recent
decades, major emergencies, crises, terrorist attacks, and
disasters are becoming a possibility in any community
including Saudi community. ese emergency incidents
are affecting many people and causing MCIs. is can
disrupt the health sector programs and essential services
in the community.2 Many lives could be saved if the
affected communities were better prepared, with an
organized scalable response system and emergency
plans. Riyadh is not an exception and might be
vulnerable to different types of MCIs. Riyadh is the
capital of Kingdom of Saudi Arabia and also its largest
city with over 7 million populations that accounts for
more than 22% of the population of the whole country.
ere are 11 governmental hospitals with more than
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Evaluation of disaster preparedness for MCI ... Bin Shalhoub et al
100 beds capacity in Riyadh. It is considered a strategic
and economic requirement to make our hospitals and
health facilities, including the private sector, prepared
to emergency situations.3
In Saudi Arabia most hospitals in Jeddah faced
a critical situation in 2009 due to floods. is raised
many questions in the Ministry of Health (MOH) and
higher authorities about the preparedness of hospitals
not in Jeddah area only, but also in the entire Kingdom.
e role and importance of hospitals during disasters is
essential to save as many lives as possible.4 Emergency
preparedness in the hospitals is a key success factor
for any effective emergency and MCI management
practices. In fact, hospitals play a significant role in
health care infrastructure in a community.5
Recently, Saudi Arabia has become a typical region
for natural hazards (floods, storms, earthquake, Middle
East Respiratory Syndrome (MERS), landslides, and so
forth) and/or human-made hazards (fires, explosives,
structural collapse, transportation event, and so forth)
that markedly could affect a large number of people.
e MOH realized that making hospitals and health
facilities safe from disasters is an essential strategic and
economic requirement. e failure of hospitals to face
disasters and MCIs and save lives cost KSA too high as
compared to the cost of making hospitals safe and well
prepared to face MCI.6
e aim of this work was to investigate the hospital
disaster preparedness (HDP) in 13 major Riyadh
private hospitals in case of MCIs. Although there
are controversies on the difference between disasters
and MCI, the present study focused on having many
casualties as sudden casualties of trauma only in urban
healthcare system. Since there are no Saudi national
standards for disaster management, this study was
carried out as a part of MOH supervising the private
hospitals to assess the current situation. is research
was carried out as part of Master of Public Health
(MPH) requirements and sponsored by the MOH.
is study endeavored to establish a better knowledge
about the capabilities of private hospitals in Riyadh to
respond to MCIs that might occur.
Methods. e present research was an observational
cross sectional study involving major private hospitals
in Riyadh, Saudi Arabia. is study was conducted in
Riyadh from December 2015 to April 2016. irteen
private hospitals in Riyadh were included in this
investigation. According to information from MOH,
there were 15 major large private hospitals (more than
100 beds) in Riyadh. All of them were included, but 2 of
them were excluded as it was new and not all specialties
and operations were established yet, and there was a fire
accident near the place at the time of data collection.
e study was limited to hospitals with a capacity of
100 or more beds as such organizations were assumed
to be more inclusive in their technical, administrative,
and institutional structures and could have a role during
disaster of MCIs.
e inclusion criteria were: Riyadh Private Hospitals
more than 100 beds capacity, all the specialties
Hospitals (covering all medical and surgical services),
full operation, had emergency department and intensive
care unit (ICU), and with in-patient pharmacy. e
exclusion criteria were: hospitals less than 100 beds, and
restricted specialty hospitals.
Data was collected through a questionnaire with
both open ended and closed questions through an
interview with key informants in the hospital such as
the hospital administrators, emergency managers and/
or a member of the hospital emergency preparedness
and response committee. Data were recorded via taking
notes during interviews and collected through semi-
structured interviews. Personal site visits and contact
with subjects were used to approach the participants.
All of the subjects who were approached agreed to
participate in the study. e main researcher himself
conducted the interviews and he was not a worker
at any of the hospitals, and relationships between
him and participants were not established before the
interviews. All interviews were conducted in the offices
of the participants while ensuring a private and secure
environment. Interviews lasted for a minimum of 30
minutes and maximum for an hour. Data collection was
ended after interviewing the hospital key informants.
Interview questions were adopted from WHO
toolkit for assessing health-system capacity for crisis
management and hospital emergency response
checklist.7,8 Questions were mainly related to
preparedness of the hospital to MCI and the capacity of
the hospital for surge in emergency events. e tool was
modified for use reviewed by experts in the field, and
a pilot study was conducted at King Saud University
Medical City Emergency and Disaster Preparedness
Committee, Riyadh, Saudi Arabia.
Research ethics approval was obtained from the
Institutional Review Board (IRB) at the College of
Medicine, King Saud University, Saudi Arabia (Ref. No.
Disclosure. Authors have no conflict of interests, and the
work was not supported or funded by any drug company.
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16/0526/IRB on 25.01.2016). e participants were
assured that the name of the hospital, or the participants
will not be declared and cannot be traced by any
mean. ey were reminded that there are no standards
for disaster management were issued by the MOH,
and appreciated that all activities in this regards are
carried out by the hospital eager to improve and secure
their operations and meet any international quality
accreditation they chose. No negative implications of
any mean were intended to the participating hospitals.
e data was analyzed using descriptive statistics
and analyzed using Statistical Package for Social Science
Software version 22.0 (SPSS Inc, Chicago, IL, USA).
Results. e findings of the present research were
based on the information obtained during interviews
with the hospitals key informant that answered the
open-ended and closed questions in the questionnaire
and the disaster plan checklist prepared by the researcher.
Regarding the staff workers power, the total hospital
physician ranged from 51 to 406 (140.6 ± 89.4), while
the total number of nurses ranged from 167 to 950
(320 ± 210.9). e number of ambulances owned by
the 13 hospitals ranged from 2 to 4 (2.9 ± 0.7). ere
was only one hospital of the thirteen had an on-site
helipad. Two hospitals of the 13 have no blood bank
and if they needed blood they had an agreement with
another hospital to supply them; however, they did not
know how long it will take to receive the blood from
them. All of the 13 hospitals had fatalities management.
All the hospitals have internal pharmacy. Eight (61.5%)
have a stockpile of antidotes (for organophosphate and
cyanide) maintained by the pharmacy. Most of the
pharmacies (92.3%) monitored daily medication usage
on a changing baseline (Table 1).
Table 2 demonstrated that all the 13 hospitals had
HDP plan and reported to have HDP committee. In
12 (92.3%) hospitals the HDP covered both internal
and external disasters and HDP was available in every
department of the hospital. e HDP in 11 hospitals
(84.6%) was based on an “all hazards” approach. ere
were an agreements with other hospitals to accept
patients during disasters in 9 facilities (69.2 %) while
4 (30.8%) did not have such agreement. All hospitals
reported who was responsible of training and educating
of the staff about the HDP to make the hospital staff
familiarized with their roles during disasters. All hospitals
had plan indicate the need for formal training of staff
in emergency medicine. In only 2 (15.4%) hospitals the
key informants said that it had conducted workshops to
facilitate staff awareness and to make their staff receive
orientation to HDP (Table 3). All hospitals reported
to do drills for the HDP, but when asked about their
reference only 2 hospitals showed it. Moreover, none of
the hospitals conducted any unannounced exercises in
the last year. Moreover, only 2 (15.4%) of the studied
Table 3 - Training and education about HDP in the studied hospitals.
Training and education Yes
n (%)
No
n (%)
e plan indicate who is responsible of
training and educating staff 13 (100) 0
e plan show how hospital staff will
be familiarized with their roles during
disasters
13 (100) 0
e plan indicate the need for formal
training of staff in emergency medicine 13 (100) 0
e hospital conduct workshops to
facilitate staff awareness 2 (15.4) 11 (84.6)
All staff receives orientation to the HDP 2 (15.4) 11 (84.6)
Table 2 - Hospital disaster plan (HDP) in the studied hospitals.
General considerations about HDP Yes
n (%)
No
n (%)
Does the hospital have HDP plan? 13 (100) 0
Is there HDP Committee? 13 (100) 0
Does the HDP cover both internal and
external disasters?
12 (92.3) 1 (7.7)
Is the HDP available in every department of
the hospital?
12 (92.3) 1 (7.7)
Is the HDP based on an “all hazards”
approach? (Please indicate the hazards covered
by the plan)
11 (84.6) 2 (15.4)
Does the HDP have details on any agreements
with other Hospitals or healthcare centers who
will accept patients during disasters?
9 (69.2) 4 (30.8)
Table 1 - Current patient care capacity and total hospital staff in the
studied hospitals.
Current patient care capacity Range Mean SD
Average staffed beds 130 - 430 115.4 35.7
Total number of beds 182 - 620 216.5 98.0
Emergency room beds 6 - 40 15.4 8.1
Beds with negative air flow 3 - 29 10.3 6.9
Monitored beds 20 - 100 52.8 20.0
Ventilators 8 - 60 39.1 15.9
Surge capacity 0 - 120 29.1 33.0
Number of physicians 51 - 406 140.3 89.4
Number of nurses 167 - 950 320.0 210.9
Administrators 86 - 522 286.5 127.0
Other (janitor, security, and so forth) 59 - 386 145.1 91.0
Ambulance 2 - 4 2.9 0.7
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Evaluation of disaster preparedness for MCI ... Bin Shalhoub et al
hospitals had conducted exercise with casualties, and
had drilled evacuation of staff and patients in the last
12 months (Table 4).
Two (15.4%) hospitals did exercise for the HDP in
the last 3 months, 3 (23.1%) did it in the last 6 months,
2 hospitals (15.4%) did it in the last 9 months, and
6 (46.1%) did not perform any exercise to the HDP
during the last 12 months (Table 5).
Discussion. Despite that MCIs were rare in the
last decades in Riyadh, it is essential that hospitals
are prepared to disasters due to the possibility of an
emergency event causing increase in MCI. e number
of private hospitals is increasing in Riyadh and this
prompted the researcher to study disaster preparedness
at its large private hospitals. e present study used a
HDP assessment toolkit to determine the knowledge,
attitudes, and practices of the hospital managers at 13
major private hospitals in Riyadh regarding disaster and
emergency preparedness in case of MCI.
e present work showed that there was no single
hospital of the studied ones faced an actual disaster, or
MCIs since it were established, and so the emergency
disaster plan (EDP) was not experienced until now. is
study found that there was a plan for HDP in each of
the 13 hospitals included in the study; however, certain
components of the plan were deficient or missing in
some hospitals. During the interview, it was noticed
that many of the respondents did not believe that MCI’s
is expected in Riyadh and they only prepared the plan
and make sure that it would be implemented. is was
confirmed when it was noticed that exercises and drills
for the HDP were not performed in most hospitals
in the last year and may be ever. Hospitals need a
well-documented and tested plan in order to respond
effectively and efficiently to disasters. A disaster plan is
not an aim by itself and having one does not mean that
the hospital is prepared when MCI occurs.9,10
e results of the present work showed that most
of the plans in the studied hospitals were set its disaster
risk profile of the hospital and objective in relation
to motor vehicle accidents and floods and is not
adequately cover the “all hazards” process and “whole
health” approach as recommended by the WHO.11 e
HDP might need to be reconstructed and reviewed in
order to include response to internal disasters such as
fire, collapse of hospital, flooding and external disasters
such as terrorist attack, storms, earthquake, landslides,
explosives, structural collapse, transportation event
and so forth).12 According to Adini et al13 the national
healthcare systems in a country were required to prepare
an effective response model to manage emergencies due
to MCIs. Planning for disaster preparedness should be
envisioned as a process rather than a production of a
solid plan. To guarantee proper emergency preparedness
necessitates a structured methodology to put EDP. is
plan will enable an objective assessment of the level of
readiness to respond during MCIs.
Most of the studied hospitals were found to have
weaknesses in terms of training and education, and
monitoring and evaluation of EDP. ere was weakness
in the disaster preparedness in conducting no workshops
and training to assist staff awareness and to make them
receive orientation to the hospital EDP. e present
results were in agreement with the study of Bajow and
Alkhalil14 that investigated the HDP in Jeddah area.
ey reported that hospitals in Jeddah area had tools
and indicators in hospital preparedness, but with lack
of training and management during disaster.
Most of the key informants that have been interviewed
from the private hospitals in Riyadh believed that
Riyadh was less subjected to natural disasters as it had
no history of natural disasters. However, they admitted
of the possibility of man-made catastrophe, or terrorism
attack as a cause of MCIs. One of the raised worry of
the private hospitals’ administrations was the cost and
bills for management of victims from MCIs. ey
proposed that there should be a clear written agreement,
or memorandum between MOH and private hospitals
on the hospital bills for patients received during MCIs.
Such agreement will protect the patients send to private
hospitals during disasters from facing huge hospital bills
and high fees in the private sector and will also keep the
Table 4 - Exercise and drills about HDP in the studied hospitals.
Exercise and drills Yes No
Do you do drills? 13 (100) 0
Hospital has conducted an exercise with
casualties?
2 (15.4) 11 (84.6)
At least one exercise in the last year was
unannounced?
0 13 (100)
Hospital has drilled evacuation of staff
and patients in the last 12 months?
2 (15.4) 11 (84.6)
Table 5 - e date of last exercise for HDP in the studied hospitals.
e data of last exercise n (%)
3 months ago 2 (15.4)
6 months ago 3 (23.1)
9 months ago 2 (15.4)
More than one year ago 6 (46.1)
Total 13 (100)
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rights of the private hospitals to receive back what it
spent to treat patients from MCIs.6
Abosuliman et al15 reported that the disaster
preparedness in Saudi Arabia is a key success factor for
any effective disaster management practices. e authors
stressed on the top 5 areas for future attention: training
of response teams, identification and coordination
of the organizational responsibilities, community
awareness, and preparedness. eir results showed that
the disaster mitigation was found to be very important
for the representatives of public authorities. ey found
that the population acknowledged the risk of natural
and human-initiated disasters, and were generally
responsive to disaster threats, but lacked community-
based organization. ey concluded that continually
training disaster responders with best practices and
preparedness is paramount to successful disaster crisis
prevention and management.
e Saudi government represented in the MOH
is the decisive ultimate authority in the management
of health effects from emergency events such as MCIs
as part of its overall responsibilities for the safety and
security of the country. ere is a need for financial
framework for funding private hospital preparedness
and mass casualty costs. In the present financial
situation, the pay is directed only for the immediate
costs of patients; however, there is a need for a means
to pay also for the planning, education, standby supply,
and training costs of preparedness.16
e study was limited by the inadequate local
literature. Few researches in KSA have been performed
on the preparedness of the Governmental hospital and
none were found about private hospitals up to the
date of performing the study. Moreover, not all private
hospitals in Riyadh were included in the study and no
comparison with performed Governmental hospitals.
In conclusion, all of the hospitals had well prepared
documents to prove that it was prepared to face the
emergency event of MCIs. However, most of the
weaknesses were apparent particularly in the education,
training, and monitoring of the hospital staff to the
preparedness for disaster emergency occasion. Most of
the hospitals did not conduct workshops to facilitate staff
awareness on the EDP. Few hospitals included disaster
drills in their EDP or drills involving communication
and coordination with other organizations in the region
dealing with disasters. Further research is recommended
to be carried out in order to investigate the knowledge,
attitudes, and practices of the healthcare workers at
these private hospitals regarding EDP and the hospital
disaster preparedness.
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