Assessment of disaster preparedness among emergency departments in Italian hospitals: a cautious warning for disaster risk reduction and management capacity

Disasters are events capable of bringing a heavy burden in terms of morbidity and mortality. On the basis of published reports, since 1990, 1.6 million people worldwide have died because of disasters, making for an approximate average of 65,000 deaths per year [1]. Italy is a country prone to catastrophic events, especially earthquakes and floods. In the last 60 years, 25 major events have occurred including earthquakes, landslides and floods accounting for the majority of deaths, injured and homeless [2‐4].

During disasters that result in a patient surge, hospitals are expected to function as a safe environment for personnel and provide essential medical care to the casualties [5]. However, various studies show that hospitals overall suffer from an insufficient level of preparedness [6, 7]. 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 [6, 8, 9]. These findings, supported by an increased global awareness of disaster risk reduction and management, have led to the development of international strategies to improve disaster preparedness and resiliency. The Sendai Framework for Disaster Risk Reduction 2015 – 2030, recently adopted by 187 countries including Italy, stress, amongst the other priorities for action, the need to strengthen functional disaster risk prevention and reduction measures in critical facilities, including hospital emergency departments [10].

Preparedness is defined as actions taken to effectively anticipate, respond to, and recover from the impact of likely or current hazard events or conditions [11]. A hospital disaster plan (HDP) is 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 [12]. In Italy, since the 1990s, hospitals are required to adopt an emergency disaster plan for external disasters, known as Emergency Plan for Massive Influx of Casualties (PEMAF acronym in Italian), in order to face a sudden patient surge [13‐15].

It is crucial to hospital disaster preparedness that the PEMAF be known and understood by those professionals who will apply it. Emergency Department employees are usually the first hospital responders in the event of disasters and are the front lines of preparedness. The aim of our study was to better determine the current preparedness of Emergency Departments of Italian hospitals by assessing the level of knowledge of front line emergency physicians-on-duty regarding basic disaster planning and procedures under the governmental PEMAF.

A cross-sectional study was used in this research and conducted from September 1, 2015, to September 30, 2015. The study group consisted of the medical consultants working at Emergency Departments (EDs) of hospitals throughout Italy. The selection of participating hospitals represents a convenience sample identified from listings available at the Italian Ministry of Health website [16]: specialized hospitals (e.g. in orthopedics, pediatrics or obstetrics and gynecology), hospitals without a complete contact list or clear informations about their level were excluded. The classification of EDs was based on the required level of care according to the criteria elicited in the Italian law D.Lgs. 70/2015 that considers, among others, factors as structures’ bed number, population density and needs of critical care / specialized surgery facilities in that geographical area [17]; according to this, a first level ED has at least internal medicine, general surgery, critical care and cardiology intensive care units, instead a second level ED has also specialized surgery (e.g. neurosurgery, cardiac surgery) and specialized critical care units in addition. Anonymous pre-structured telephone interviews were conducted during day shift with medical consultants in charge in the EDs who agreed to participate in the study. The following exclusion criteria were considered: (a) private hospitals, or (b) more than three tentative calls without answer, or (c) interruption due to sudden urgencies, or (d) clear refusal to participate the study.

Out of 352 EDs included in the Ministry of Health’s list, 85 (24 %) EDs were eligible for the interview sample. According to the Italian law D.Lgs. 70/2015, 52 of the included hospitals had second level EDs, and 17 first level EDs. The distributions of identified and participating hospitals through the country are represented in Figs. 1 and 2. Of the 69 (81 %) EDs that were reached, the physicians in charge agreed to undergo the telephone interview, with 30 at the first call attempt, 26 at the second and 13 at the third. Sixteen hospitals were excluded in the study: 6 for an explicit denial of call takers and 10 after the third call attempt resulted in no answer.

Most of the respondents were female (58 %), and the mean age was of 48 years. The most represented specialty was Internal Medicine (45 %). The characteristics of interviewed physicians are presented in Table 1. Only 45 % of participants reported to know what a HDP is and almost one third knew what an action card is which contains condensed information of vital disaster plan resources including critical contact numbers and personal information. In 41 % of the cases respondents believed to know who had the authority to activate the HDP and only 38 % knew who is in charge of all intra-hospital operations.

Six different options were reported when asked who, according to the HDP, is appointed to activate the hospital plan. Both the Hospital Chief Medical Officer (HCMO) and the ED physician-on-duty were sighted in 10 out 28 cases. The command of all operations is taken by the ED Physician-on-duty in 10 hospitals, and by HCMO in another 7. The telephone was cited as the most used communication system to recall staff when the emergency status is declared (27 out of 55) and to find information about available beds (18 out of 50). Finally, nine different roles were identified to terminate the emergency status, HCMO being the most reported by responders (12 %).

The results are shown in details in Table  2 .

Figure 3 depicts the correct answers to the 10 questions (score) regarding different aspects of respondents’ demographics.

The current study evaluated the level of the knowledge-base of front line emergency physicians-on-duty regarding basic disaster planning and procedures. Adequate preparation of ED physicians has become particularly important following the problematic response seen during recent events [8, 19, 20]. It is therefore a key responsibility to verify the knowledge-base and subsequent behaviors of its frontline hospital employees since emergency services can hamper overall disaster management especially in the immediate response phase of crisis situations. Our results demonstrate the poor knowledge-base of basic hospital disaster planning concepts by EDs’ physicians-on-duty. About two thirds of those interviewed knew what a hospital disaster plan was or heard about it at least once, but only one third knew if there was a hard copy available for rapid consultation or what an action card was. The use of action/task cards, also known as standard operating procedures, has been recommended since 1972 and incorporate sufficient instructions, information and orders to guide, step by step, the members of the hospital staff [21]. Lennquist considers the task/action cards the most important component in hospital preparedness for major incidents [22]. It should be a major concern for hospital managers to find an adequate operational level method of distributing disaster policy and procedures to physicians and to make sure that physicians know and understand the important information.

Our study results are similar to previous reports that show inadequate disaster preparedness in Italian hospitals [23‐25]. A pilot study made by D’Alessandro et al. involved a limited number of Italian hospitals in 2012 and demonstrated a state of low preparedness in complex emergency management. In particular, a written questionnaire was sent to hospitals, but the authors did not test directly the on-duty emergency consultants’ knowledge of HDP in real time through telephone interviews as was performed in this study. To the best of our knowledge, this study represents the first attempt to address the preparedness of Italian hospitals through determining the level of the actual knowledge-base of front line emergency department physicians-on-duty regarding basic disaster planning and procedures, during real working conditions.

This study also found that the on duty staff has poor knowledge of the function and roles in the required disaster response when the hospital emergency plan is activated. This is consistent with audit results of physician’s knowledge of major incident policies conducted by Carr and colleagues where less than 5 % of interviewed physicians were aware of their specific roles in such an event [26]. Some of the remaining questions revealed a lack of punctual preparation concerning specific procedures of the protocol, for example, the majority of EDs physicians did not know how additional personnel are summoned or how to find information about the number of available beds in the hospital wards. This may be due to the responders comparing the hospital disaster protocol with the more commonly understood daily working protocols and procedures. Of note, the study reveals an extreme overall variability of functions, roles and procedures in hospital disaster response. More than 5 different professionals or teams were reported to have the authority to initiate the HDP and its related actions and more than 10 had authority to terminate it. Seven different options were provided when the physicians were asked about who is in charge of all hospital disaster management. It is vital that the key function authority and responsibility be clearly specified, understood and standardized. Staff turnover today is an ongoing phenomenon, frequently on a daily basis, [27‐29] and a variety of roles and procedures in exceptional situations such disasters could challenge staff response and affect overall outcome.

Finally, the study did not show any relevant difference in the level of knowledge-base among different specialties of on duty staff. The main reason of the lack of disaster medicine knowledge for health professionals might be that disaster medicine has rarely been included in Italian medical school curriculum and continuing medical education. In fact, only a small portion of the frontline emergency physicians enrolled in the study have attended courses in disaster medicine designed to enhance their competence and level of the required knowledge-base in hospital response. Of note, these responders evidenced significantly better knowledge-base suggesting a positive effect of disaster training on performance. Currently, there is an inadequate number of emergency medicine specialized physicians in Italy because this residency program has only been in existence since 2009.

The lack of education and training in disaster preparedness in the health systems at the EU level was recently denounced by Djalali et al. [6]. Promoting and enhancing the training capacity in the field of disaster medicine is one of the ‘call-to-action requirements’ requested by the international community. In forthcoming research, CRIMEDIM plans to better assess the deficiencies in major incident management and explore how to increase the level of hospital disaster preparedness at the country level.