Assessing Thai Hospitals’ Evacuation Preparedness Using the Flexible Surge Capacity Concept and Its Collaborative Tool

Hospitals play a crucial role in disasters caused by natural hazards, manmade threats, and public health emergencies (DPHE), aiming to optimize the outcomes of medical management of injuries and to reduce the suffering of victims under limited access to resources (Khorram-Manesh and Burkle 2020; CRED and UNDRR 2020). Some emergencies directly affect hospitals, resulting in partial or total evacuation—for example, natural hazards such as hurricanes destroy several hospital structures in the United States annually (Mattox 2006; Griffin et al. 2019; Hines and Reid 2021); flooding in the middle of Thailand affected hospitals causing infrastructure destruction and interrupting patient care (Khorram-Manesh et al. 2014); and in the ongoing Ukrainian war, hospitals and other vital civilian service sectors are frequently attacked, resulting in the deaths and injuries of civilians living in or adjacent to the targeted areas (Al Jazeera 2022). Other events may indirectly impact a hospital—for example, a pandemic, such as the still-active Coronavirus 2019 (Covid-19) infection, which prevents unaffected hospitals from admitting new patients, and forces affected hospitals to partially or entirely evacuate unaffected patients and their routine activities. In both cases, there is also a need to isolate out-of-hospital cases and offer care at home using potential diagnostic and surveillance methods (Phattharapornjaroen et al. 2022b). All these events that necessitate partial or total evacuation require extra resources and an expansion of healthcare capacity through multiagency collaboration. The capacity expansions to multiple agencies require synchronized and tested collaboration, preferably using collaborative elements to harmonize the working process, developing from coordination (that is, resource-pooling and adapting), cooperation (that is, distribution of tasks in an agreed order), communication (that is, information sharing), to collaboration (that is, achieving the same goals) (Gajda 2004; Lozano et al. 2021).

Hospital evacuation is defined by the United Nations Office for Disaster Risk Reduction (UNDRR) as a process of “Moving people and assets temporarily to safer places before, during or after the occurrence of a hazardous event to protect them” (UNDRR 2009). The UNDRR expresses the complex chain of collaboration needed to achieve the goals over an extended period. The Pan American Health Organization (PAHO) focuses on the goal of evacuation that is to safeguard the health and lives of its occupants (Pan American Health Organization 2018). This indicates the need for protection of both patients and medical staff and indirectly creates moral and ethical issues of whom to evacuate and who has the power to decide. Other researchers, for example, Tekin et al. (2017), emphasized an attempt to empty an entire hospital or a part of it as the description of a hospital evacuation, which ultimately presents different aspects of evacuation, that is, where should the occupants of a hospital be moved to if totally evacuated.

Irrespective of definitions, evacuation inherently increases the risks for patients, staff, and other people nearby when transferred due to a variety of internal and external factors that may impact them (Tekin et al. 2017). Moreover, hospitals serve a large number of people who require special assistance, such as those with physical impairments or hearing and vision difficulties, which complicates the evacuation process (Al-Wathinani et al. 2022). Within this complex process, there is a need for critical decision making in several levels of action and care. The decision to evacuate frequently arises from safety threats or total operation disruptions with eminent impact on infrastructure (McGinty et al. 2016; Ariscain 2019). Decision making is challenging and requires the ability to command and control the necessary activities in several lines of command. Reasonable control of the situation and collaboration with other agencies necessitate appropriate communication ability and updated risk and vulnerability assessments to continuously plan and implement new measures, including what is needed to guarantee patient safety, triage, treatment, and transport to the proper medical and non-medical facilities (Wabo et al. 2012; Hicks and Glick 2015). The surge planning includes four essential elements (4S): (1) Staff comprising both medical and non-medical personnel; (2) Stuff such as medical devices and ambulances; (3) Structure or Spaces that refer to needed areas to be modified to either treatment zones or shelters; and (4) Systems that refer to practical or mutual guidelines (Bonnett et al. 2007; Hick et al. 2014). Additionally, the multiagency approach to disaster and emergency response requires a collaborative instrument to harmonize the interaction between agencies (Sammut et al. 2001; Bahrami et al. 2020; Khorram-Manesh and Burkle 2020; Phattharapornjaaroen et al. 2022a, 2022b).

One of the approaches to expanding the response capacity is through the flexible surge capacity (FSC) concept, in which the collaboration is extended further to embrace communities’ potential resources and facilities (Khorram-Manesh 2020; Phattharapornjaroen et al. 2022b). According to the FSC theoretical framework, community resources can be utilized when hospitals are the target of a hazardous event and cannot receive more patients,for example, under explosion threats, during a pandemic where the restriction policy is applied, or when the hospitals are overloaded with ordinary and disaster-related patients (Fig. 1). In such scenarios, and when other medical resources are not accessible or available, local resources, such as primary care, veterinary, and dental clinics may contribute their staff, stuff, and spaces, while hotels, schools, and sports halls may provide food, space for caring for light injured, and other appropriate needs (Glantz et al. 2020; Phattharapornjaroen et al. 2021, 2022a). A key element in organizing such a process is to create a system that governs the collaboration between these organizations and facilities (Yazdani et al. 2021; Khorram-Manesh, Dulebenets, et al. 2021). Such a system needs a collaborative tool to enhance interactions between agencies and organizations. To facilitate interactions, FSC uses the elements in Major Incident Medical Management and Support (MIMMS) education—the CSCATTT, standing for Command and control, Safety, Communication, Assessment, Triage, Treatment, and Transport—to organize the procedures to be conducted and create interaction between different agencies (Sammut et al. 2001; Hicks and Glick 2015). During an evacuation, hospitals require substantial support to transfer patients and victims, devices, and medical supplies safely and systematically. The CSCATTT can, thus, create flexibility between the most common partners in such events, that is, healthcare, rescue teams, and police forces, to achieve the goals for each element of the CSCATTT (McGinty et al. 2016; Mace and Sharma 2020; Yazdani et al. 2021).

Khorram-Manesh, Phattharapornjaroen, et al. (2021) reported the current perspectives on hospital evacuation in 15 countries using CSCATTT as a collaborative tool. They showed that most countries lacked the necessary collaborative elements and readiness for evacuation; some even lacked an evacuation plan. Despite several reports and changes in the national preparedness system, the necessary preparedness for management and response to diverse emergencies, particularly in hospital evacuations, is missing (Khorram-Manesh, Phattharapornjaroen, et al. 2021; Yazdani et al. 2021). The paucity of readiness was evident in the devastating 2004 Southeast Asian Tsunami, which caused numerous casualties and deaths (Wattanawaitunechai et al. 2005). Additionally, other incidents, such as flooding in Thailand in 2011 and the Covid-19 pandemic, have illustrated insufficiencies in several parts of the response system, including command and control, maintenance, and logistics (Khorram-Manesh et al. 2014; Dejchaisri 2019; Nittayasoot et al. 2021; Phattharapornjaroen et al. 2022b). In both events, the need for partial or total hospital evacuation in affected areas was eminent. However, there has been no evident improvement in producing guidelines or educational initiatives (Khorram-Manesh, Dulebenets, et al. 2021; Al-Wathinani et al. 2022). The FSC concept may, however, facilitate the evacuation processes and exercise initiatives to enhance the multiagency and multi-professional synchronization and collaboration needed in such an event (Phattharapornjaroen et al. 2022a).

Thailand is a disaster-prone country, where natural hazards such as flooding, manmade hazards such as protests and conflicts, and public health emergencies such as pandemics continuously increase with clear impacts on the Thai society (Peltz et al. 2006; Angthong et al. 2012; Khorram-Manesh et al. 2014; Nittayasoot et al. 2021). Thai public healthcare facilities, responsible for all citizens’ health, provide care to a geographically defined population divided into 12 regions with similar cultures, risks, and environments. The facilities have four levels of competencies and capacities: primary care, secondary care, tertiary care, and university hospital. Additionally, private hospitals’ capabilities are comparable to the public tertiary care tiers, and they are potential candidates to respond hand in hand with public and community facilities. In a previous study, community resources were used during the Covid-19 pandemic in Bangkok, and the concept of FSC could successfully be implemented (Phattharapornjaroen et al. 2022b). Although the diversity of the Thai hospital system can be a drawback (Leerapan et al. 2021), it still might be suitable for implementing the FSC concept and enhancing the community response system in other situations described by FSC, that is, during hospital evacuation. This study explored Thai hospitals’ current evacuation readiness and preparation regarding surge capacity and collaboration, using the concept of FSC and its collaborative tool. A successful assessment may be used to evaluate hospital preparedness and as a tool for future educational initiatives.

A mixed method cross-sectional study was performed employing an adapted hospital evacuation questionnaire to assess evacuation preparedness of hospitals using the FSC concept and collaborative tools.

Of the 143 hospitals, 43 hospitals from different parts of Thailand answered the survey and provided their contingency plans in attached files to confirm their responded information. The characteristics of responding hospitals are shown in Table 1. There were no statistically significant associations between the hospital’s bed capacity and elements of surge capacity and collaboration.

In this study, Thai hospitals provided credible evidence of independent incident command systems (ICS) and reported annual training. Although the study’s sample size is too small to infer the association between hospital bed capacity and surge planning and collaboration, all hospitals, regardless of bed capacity, exhibited ICS. The results contradicted a study of 1100 US hospitals in 2008 that indicated a correlation between larger bed capacity and safety cooperation and drills (Niska 2008). Nevertheless, the hospital sizes in the US study were different from our study. Of the US study examined hospitals, 60% had less than 100 beds whereas 70% of our participants had capacities of over 300 beds.

Regarding evacuation, our findings demonstrated that hospitals adopted the ICS protocols for evacuation management in some areas, including personnel surges and medicine and device stockpiling, which is consistent with previous studies (Khorram-Manesh et al. 2014; Mace and Sharma 2020). However, the planned resource utilization was limited within the healthcare system and focused on fire escape procedures. The dearth of guidelines exclusive to evacuation may be attributed to the rarity of considerable hospital hazards that necessitate evacuations, despite rising of such threats (CRED and UNDRR 2020). Additionally, the previous responses to major incidents in Thailand showed unfavorable health and socioeconomics outcomes (Wattanawaitunechai et al. 2005; Angthong et al. 2012; Khorram-Manesh et al. 2014), and the findings demonstrate a need to revisit preparedness measures, particularly evacuation plans for all causes, and the use of non-medical resources, such as community resources. Thus, it is plausible to systematically incorporate the FSC concept to establish comprehensive surge planning and a seamless multiagency collaboration (Khorram-Manesh, Phattharapornjaroen, et al. 2021; Yazdani et al. 2021).

Although the survey with an online approach was considered the most suitable method during the current pandemic due to the in-person contact limitation policy, a face-to-face interview could be a more straightforward way to achieve the highest degree of responses. The low response rate in this study may reflect the negligence of the evacuation preparedness. However, a nationally issued and supported survey may increase the response rate in future studies. Additionally, selection bias might have occurred in this study, as in all survey studies since the facilities that were more interested or prepared were more likely to participate. However, this study’s response rate met the expectation given by past research in a similar design (Aerny-Perreten et al. 2015; Ball 2019). Another significant limitation is that the data were collected when the pandemic halted most hospital routine preparation. Therefore, information about some items, such as the training, may include recall and selection bias.

Hospitals are vulnerable to internal and external hazards, which may result in an evacuation. Such evacuation needs internal and external resources to assure the safety of affected patients. This study, to the best of our knowledge, is the first study assessing hospital evacuation preparedness in Thailand and elsewhere using the theoretical and conceptual frameworks for the FSC. Focusing on surge capacity’s four vital elements and collaborative factors encompassing CSCATTT, the study’s findings indicate a gap in hospital evacuation procedures, particularly triage and logistics, and inadequacies in surge planning and multiagency collaboration, in which the FSC implementation is plausible. Although using community resources may be beneficial during a disaster, the measures for concept integration into hospital evacuation are still challenging.

Nevertheless, pragmatic research exploring planning for community engagement according to the flexible surge capacity to build a concrete hospital evacuation plan would enhance hospital readiness and its generalizations. The latter needs to be tested in simulation exercises. In conclusion, the concept of FSC and its collaborative tool seem valuable for evaluating hospital evacuation preparedness and creating educational initiatives to enhance such preparedness.