Introduction

Nowadays, disasters degrade a major portion of a country’s resources and affect human life by interfering with community functions [1-3]. Regardless of political borders, some disasters immediately claimed more than thousands of lives [4, 5]. According to the World Health Organization (WHO), disasters can occur at any time and are dangerous. However, there is a clear lack of interest among individuals and authorities, and there is inadequate motivation to prevent disasters [6-10]. Communities have made substantial progress, however, it is still impossible to completely prevent disasters [11]. In addition, disaster effects have increased in both frequency and intensity in recent years [6], which has resulted in millions of deaths and the loss of billions of dollars [12-15].

The main prerequisites in response to disasters are the responsibility and preparedness of all community components. One of the essential sectors of any disaster response is health care provider organizations. Evidence suggests that the effective organization and management of healthcare facilities in the time of a disaster have a significant impact on reducing mortality and complications [6]. Therefore, the necessity for healthcare system preparedness is undeniable [12].

Hospitals, as the initial medical service providers [6], play a more vital role in reducing complications and casualties by providing fast and efficient treatment services [16, 17]. Hospitals’ safety and preparedness are required to provide services in times of disaster. Therefore, in addition to being resistant to disasters, destruction, and disruption in function, hospitals should provide services with maximum capacity during disasters [18]. The functional preparedness of the hospitals enables them to perform their regular duties and respond to a large number of victims and injured [19, 20]. Preparedness includes a set of pre-disaster measures to ensure appropriate and effective responses to disasters [21].

Hospital preparedness is usually investigated and evaluated in three categories including structural, non-structural, and functional. Previous studies mainly evaluated structural and non-structural areas, and the functional field was overlooked [22, 23]. This is while the low level of functional preparedness of hospitals is reasonable. The first step in enhancing preparedness is to recognize the factors that affect functional preparedness. Accordingly, the present study was designed to perform a systematic evaluation of the literature and extract the factors affecting the functional preparedness of hospitals to deal with disasters.

Materials and Methods

The search strategy was developed with the assistance and supervision of a specialist. A literature search was performed using electronic databases such as PubMed Central, Web of Science, Scopus, ProQuest, SID, and Elmnet. The search was performed using a combination of medical subject heading (MeSH) terms and keywords. The keywords included “disaster, emergency, preparedness, hospital preparedness, health care facilities preparedness, hospital functional preparedness, health care facilities functional preparedness, readiness, and effective factors” (Table 1).

There was no time limit. However, a keyword search was restricted to titles and abstracts. The search strategies were adjusted to the specific features of each database. The majority of the existing relevant publications were searched in Google Scholar. To ensure maximum coverage of the literature, the list of the selected article references and gray literature were also searched. The inclusion criteria were full text should be published up to the end of 2022 in Persian and English, and focused on hospital preparedness. Abstracts of articles published at conferences, articles that were not related to hospitals, and papers focusing on hospital staff preparedness were all excluded. Two members of the study team independently screened the articles. First, two researchers reviewed the titles and eliminated the unrelated titles. Any inconsistencies were resolved by a third researcher. Following the removal of irrelevant titles, the abstracts were evaluated again by two researchers, and unrelated articles were excluded. Finally, the full text of the remaining articles was assessed. The final evaluation included the relevant articles and the influential factors on the functional preparedness of hospitals. The quality of all selected articles was assessed by two researchers using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist. At the discretion of the research team members, four relevant checklist items related to the case and cohort studies were removed from the checklist, and finally, 18 items were evaluated. The mean scores of 0 to 12, 12 to 24, and 24 to 36 were considered poor, average, and good, respectively. Two researchers performed the initial evaluation process on five articles to establish a consensus. The remaining studies were then assessed independently by each evaluator. Finally, the ambiguous cases were referred to a third person with more expertise in the research methodology. A data extraction form was manually designed in Microsoft Office Word 2019.

The information about the title, author, journal, year, country, study design, setting, participants, criteria, and influential factors were extracted. Based on these forms, data from five studies were experimentally retrieved to address the weaknesses and problems of the initial form. Finally, two researchers independently extracted the data. Using content analysis, the extracted data were manually analyzed, summarized, and reported using content analysis.

Results

Totally 3465 articles were found through database search processes (PubMed: 2123, Scopus: 358, ProQuest: 345, Web of Science: 277, Elmnet: 84, and SID: 278). Of them, 612 were eliminated due to redundancy. After an assessment of the titles and abstracts, 2680 studies were excluded. Following the full-text review, 67 articles were removed. In addition, in the quality appraisal stage, one paper was excluded. Finally, 105 articles were included in the systematic evaluation (Figure 1).

Fig. 1. PRISMA flow diagram of the search strategy and included studies.

The majority of the studies were conducted in the United States, Iran, Italy, Sweden, and Saudi Arabia. Based on the content analysis results, 83 influential factors were retrieved and classified into seven categories. Table 2 summarizes the list of identified influential factors.

Government, Coordination, Control, and Command

Coordination, control, and command were among the most often mentioned factors that affected the hospital’s preparedness. Making the appropriate provisions both inside and outside of hospitals, as well as arranging bilateral and multilateral inter-organizational memos to share available resources and facilities is considered critical and can have an impact on the level of preparedness. Improving internal relations is dependent on the presence of the unity of command principles, the establishment of a single control line and a chain of command, conflict reconciliation, defining duties and responsibilities, and developing policies for employing hospital staff.

Guidelines and Preparedness Plans

In the reviewed articles, planning was identified as one of the most critical and hospital-specific factors affecting the hospitals’ preparedness. It is possible to achieve the desired level of preparedness with comprehensive results-based planning and attention to existing and expandable capacities. Due to the multiplicity of risks and consequences, all potential risks and health issues should be incorporated into a hospital preparedness plan as realistically as possible at different national, regional, and local levels. In this category, various aspects of the planning program were addressed including the development of the Emergency Operation Plan (EOP), the existence of Standard Operating Procedures (SOP), and updating and revising hospital preparation plans, documents, and plans. Protocols and instructions, in addition to preparation programs, are required. Integrating protocols and instructions with SOP is crucial for identifying, prioritizing, and consolidating essential functions and ensuring consistency in implementing these procedures.

Regulations

Effective disaster management requires acceptance and commitment to risk reduction and safety improvement by senior managers. The existence of national, regional, and local hazard management laws, the integration of preparation plans in the curriculum of different academic disciplines, and the provision of adequate legal authority for hospital disaster managers were all considered effective in facilitating the implementation of preparedness programs.

Resource Supply

Resource supply was another important category of the most influential factors in the hospital’s functional preparedness. This category consisted of 37 influential factors classified into six subcategories, including supply of required equipment, providing the necessary supplies, providing facilities and infrastructure, anticipating and supplying human resources, supporting response operations, and emergency financing. These resources included laboratory supplies and equipment, imaging and personal protection equipment, hospital beds, medicines, food, and disinfectants, reliable systems to vital routes and their supports, space for emergency evacuation, helipad facilities, ventilation, cooling, and heating systems and their supports, backup personnel to support the main forces, Disaster Medical Assistance Team (DMAT), setting up a system for recruiting personnel, concluding emergency procurement and support contracts, and financing.

Education and Training

Personnel education and training played a significant role in the functional preparedness of hospitals. Additional factors in this category were holding general and specialized training courses for the staff, justification, functional and full-scale training, using simulators to hold exercises and training through knowledgeable individuals, using online and virtual training if necessary, teaching ethical and legal obligations, and utilizing the capabilities of the volunteers.

Information Management and Multilayer Communications Systems

The functional preparedness of hospitals depends on the preparation and provision of infrastructure related to information and communication technologies. This category emphasizes various issues, such as hospital information systems (HIS), radio communication systems, patient and injured tracking systems, responding to clients, telemedicine systems and support systems, anticipating and providing the location of reporters and media, providing GPS and GIS and smart applications facilities, and updating the primary contact numbers and staff support.

Contextual Factors

Out of 82 factors affecting the functional preparedness of hospitals in response to disasters, four factors were related to underlying factors: the socio-economic status of the community, the development of short- and long-term strategies to improve community status in various aspects, cultural considerations, and the development status of the community.

Discussion

A systematic literature review was used to identify the factors influencing hospitals’ functional preparedness through a systematic literature review. Based on the analysis of included studies, coordination, control and command, guidelines and preparedness plans, regulations, resource provision, education and training, multilayer communication and communication management systems, and contextual factors were found to be factors affecting the functional preparedness of hospitals in response to disasters. The most important factor that affected the functional preparedness of hospitals and proper disaster management was adequate coordination. Efficient management and proper organization of hospitals in emergencies played a critical role in optimal performance [24, 25]. Many studies emphasized the necessity of establishing and operating coordination systems [26] as well as the formation of a single headquarters to deal with disasters effectively.

WHO considers coordination as the primary axis of providing health services in disaster situations, and thus, proposes new approaches to enhancing coordination [27]. Manitoba also found that coordination between different institutions and organizations was essential, and attributed the accomplishment of a disaster management program to the coordination of involved organizations and their activities before, during, and after emergencies [28]. Improvement in hospital preparedness depends on hospital staff performing their tasks coordinately [29], which requires, first and foremost, the mental and psychological readiness of staff as well as stress management for those involved [30]. However, poor communication and coordination within and outside organizations lead to parallel work, rework, waste of resources, high human casualties, and physical injuries [31]. The most significant advantages of a disaster unit’s coordination, control, and command are setting goals and integrated disaster strategies, ensuring a joint plan for tactical and operational activities based on disaster objectives, and ensuring integration of activities, commitment, and optimal use of all allocated resources [32, 33]. The ability of hospitals to enter into cooperative agreements and utilize the capabilities of other organizations can also play an influential role in improving their functional preparedness [34].

An efficient preparedness strategy is to increase hospitals’ capacity for rapid response and prompt treatment of disaster-related patients [35]. In order to handle all types of disasters, it is necessary to develop EOP and its availability. Comprehensive annual planning for maneuvers and training at different levels, as well as SOP complementing these programs, are also required [36]. The development of clear and precise protocols, and instructions, ongoing program updating, and raising awareness of all executive agents at different levels with the details of programs all contribute to the successful implementation of preparedness plans [6, 37]. In contrast, the failure of preparedness programs is sometimes caused by a lack of attention to parameters such as lack of financial resources, and time constraints.

Factors related to laws and regulations provided the basis for enhancing the functional preparedness of hospitals [6]. For instance, the integration of preparedness programs in the curriculum of different academic disciplines effectively transferred sufficient knowledge and skills to the hospital staff before disasters and resulted in the institutionalization of the preparedness concepts and their potential strengthening [38-41]. However, removing legal barriers and developing appropriate mechanisms, such as granting some legal authority and mandating hospital managers to implement preparedness programs, could be a great method to enhance the hospitals’ functional preparedness.

Factors related to the provision of resources were identified as the most critical factors. Allocation of a sufficient budget [6] for anticipating, storing, and updating equipment, supplies, and medicines will improve the hospital’s response capacity and functional preparedness in the event of an unexpected surge in demand [42-46]. Several studies emphasized the importance of standard physical space concerning capacity surges [22]. They received insufficient attention from those in charge due to the high expenditures associated with them [47]. According to different references, one of the main concerns of hospital managers was the proper management of human resources as the most critical organizational assets [48, 49]. This is why, when compared to ordinary conditions, hospitals experience a scarcity of human resources in critical situations [50]. It seems that proper organization and utilization of volunteer potential were effective in resolving the aforementioned issues.

Stronger support of functional response appeared to reduce disaster fatalities [51]. An adequate and integrated organizational structure was one of the strategies for making the optimal use of available resources and achieving predetermined objectives [52]. In this field, many protective and security measures were taken within and outside of the hospital, which had a synergistic effect in conjunction with other identified influential factors [53].

Another important factor was education and training. According to WHO, lack of knowledge was one of the main reasons for the high rate of disaster injuries [54]. Planning and implementing education programs for staff, patients, and companions was one of the most cost-effective approaches to preparedness in various fields [53, 55]. The priority is obviously the education of senior hospital executives and disaster managers [56, 57]. The findings of the majority of studies indicated that if the training is accompanied by retraining and periodic preparation maneuvers, it will have a more significant impact on hospital preparedness [58-60]. Knowledge of disasters and risk perception are effective in proper disaster management [61]. The poor performance of hospital committees in convening meetings on time [62] and failure to specify job descriptions are practical instances of how disaster preparedness is being reduced [63, 64]. In this respect, it is crucial to strengthen the target group’s knowledge, skills, and awareness of educational programs [65].

The existence of information and communication systems to manage a disaster is undeniable, and one of the ways to use the available resources is to expand and develop communication systems and their methods [66]. The existence of required and essential telephone numbers in the disaster command center, which is constantly updating, is another practical factor in the expansion of communications [67, 68]. In addition to employees’ internal and external communication, the absence of a proper mechanism for employees to communicate with families is one of the significant weaknesses in the communication sector [69]. Due to the significant impact of disasters on information and communication management systems, reliable and efficient support systems can efficiently address issues with communication devices and systems and promote hospitals’ responsiveness [70, 71].

According to previous studies, there was a direct relationship between development and comprehensive disaster preparedness planning [71, 72]. The damage caused by disasters will significantly be reduced, if planners are involved in developing short- and long-term strategies, and utilizing all available resources [72]. Given that the issue of functional preparedness of hospitals includes a wide range of measures and interventions, we attempted to utilize broad and comprehensive keywords.

Investigation of numerous databases, the absence of a time limit, and a comprehensive search were the most significant strengths of the present study, which increased the validity and reliability of its findings. The main limitation was that only English and Persian papers were included in the study, and a significant number of relevant studies in other languages were excluded.

In the aftermath of disasters, one of the most fundamental necessities of individuals is health care services. Since hospitals are the first place to give health care services, they must be prepared for such circumstances. A wide range of independent factors influences hospital preparedness in many ways. Hospitals must be prepared to respond efficiently to disasters and carefully consider all the influential factors. In this study, 82 factors affecting the preparedness of hospitals were identified. The findings can assist decision-makers in hospitals respond to disasters more efficiently by establishing appropriate goals and strategies and implementing relevant measures.

Ethics Approval: This research was approved by the ethics committee of Tabriz University of Medical Sciences (ethics approval code: IR.TBZMED.REC.1398.133.)

Consent for Publication: Not applicable.

Conflict of Interest: None declared.

Funding: This study was financially supported by Tabriz University of Medical Sciences (Grant Number: 62726).

Authors’ Contributions: Study design: JB, SAA a, and HSB; Database search: BS; Papers screening: BS, JB, ND, and RR; Data extraction and analysis: BS, JB, ND, RR, and JST; Manuscript preparing and revising: All authors.

Acknowledgment: We would like to express our deep gratitude to the officials of Tabriz University of Medical Sciences for financially supporting the research.