Disaster Preparedness Plans of Health Care Facilities

Disaster preparedness involves a continuous and sustainable process that encompasses activities like pre-disaster planning, training, conducting exercises, establishing early warning systems, stockpiling emergency aid materials, and informing and raising public awareness.Reference Koçak and Kaplan Serin ²⁰ Hospital plans primarily focus on managing an influx of patients resulting from emergencies occurring outside the hospital, without directly impacting its service capabilities. Internal disasters (such as power failures, fires) refer to incidents that disrupt routine services within the medical facility, regardless of their association with external or community-wide events.Reference Aghababian, Lewis and Gans ^{21 ,} Reference Puryear and Gnugnoli ²²

Disaster preparedness for health care facilities consists of 3 main stages: emergency planning, response, and salvage and recovery (Figure 1).Reference Puryear and Gnugnoli ²² Firstly, in the Emergency Planning stage, efforts focus on preventing and managing disasters domestically and internationally to minimize loss of life and financial impact. This includes planning for care, evacuation, and environmental response standards. The United Nations (UN)’s Sendai Framework, introduced in 2015, emphasizes the reduction of disaster risks and the strengthening of global resilience. ²³ Risk assessment at the emergency planning stage identifies high-priority areas and vulnerabilities, guiding mitigation efforts. ²⁴ The Hospital Safety Index, developed by WHO and PAHO (Pan-American Health Organization), is an important proactive tool that is widely used to assess the preparedness of health care facilities before disasters, anticipating and mitigating potential challenges. ²⁴ Mitigation is an investment in facilities or regions aimed at minimizing the impact of disasters as identified through risk assessments.Reference Luna ²⁵

Figure 1.

Disaster preparedness for healthcare facilities.

Key aspects of preparedness involve forming a response team with clearly defined leaders, roles, and responsibilities, as well as creating a written Emergency Response Plan that outlines strategies, procedures, and leadership roles for effective implementation in the event of a disaster. This plan should address both facility-level and regional/national planning. ^{26 , 27} The plan should be disseminated and rehearsed among stakeholders. To avoid congestion and confusion during evacuation, predetermined routes for personnel and patients should be established, and potential relocation areas, such as army reserve buildings or neighboring hospitals, should be identified in advance. Medical personnel should be tasked with triaging and classifying patients before relocation upon notification of evacuation.Reference Aghababian, Lewis and Gans ²¹

According to the United Nations High Commissioner for Refugees (UNHCR), during the first weeks of Russia’s invasion in February 2022, more than 5 million Ukrainians fled the country. ²⁸ As of May 2025, UNHCR has recorded a staggering 5.6 million refugees from Ukraine worldwide, along with an estimated 3.76 million internally displaced people within Ukraine, highlighting the dire impact of the conflict. ²⁹ This massive outflow of people will inevitably lead to a significant shortage of medical personnel. Therefore, it becomes of vital importance to train inexperienced residents and medical students, as they will be the main driving force in providing primary care services and specialists in primary medical care, to be prepared to work with migrants who may not have accessible patient records.Reference Aghababian, Lewis and Gans ²¹

Moreover, based on lessons learned from the Ukrainian war, it can be assumed that PHC is of utmost importance during times of conflict. The PHC system in Ukraine has demonstrated remarkable resilience and adaptability in the face of dual challenges posed by the COVID-19 pandemic and the war. By developing resilient and adaptable PHC systems, countries can better respond to emergencies, effectively allocate resources, and provide essential health services. ³⁰

In terms of coordinating relief efforts during times of war, the impacts can be classified into 3 primary categories: significant population displacements, disruption of health care systems, and economic deterioration. ³¹ Humanitarian organizations work diligently to address the urgent needs arising from these circumstances. The Red Cross, UN agencies, and non-governmental organizations, in collaboration with local teams, play a crucial yet often unrecognized role in delivering essential relief services, including both curative and preventive medical care, food aid, water supplies, and shelter. The Salvage and Recovery phase occurs after initial response, working to return the facility or area to normal function. This phase is essential for situations like ongoing wartime environments or prolonged epidemics that hinder recovery for extended periods.

Dependable Power Sources in Challenging Situations

In health care facilities, ensuring a stable electricity supply is crucial, particularly for the reliable functioning of laboratory devices. Additionally, drugstores requiring refrigeration to store medication should be maintained in low-temperature conditions, as well as critical medical equipment such as ventilators, ultrasound machines, and defibrillators. Additionally, access to the internet is crucial for health care professionals to access information, communicate effectively, and deliver telemedicine services. To address potential power instability, various techniques can be employed, including electric generators, multi-solar collectors and photovoltaic systems, batteries, steam systems, wind energy, biomass, and hydropower (Figure 2). Electric generators, commonly used in off-grid and health care facilities, have low upfront costs; however, they also have disadvantages, including increased fuel costs, unstable supply, noise, and emissions. Photovoltaic systems are eco-friendly, but their limitations include intermittent supply, complex installation, specialized expertise requirements, and high upfront costs. Photovoltaic systems harness solar energy, offering an environmentally friendly, standalone solution. However, limitations include an intermittent energy supply, the complexity of installation, the need for expertise in case of damage or broken parts, and high upfront costs that may overshadow its advantages. Batteries play a crucial role in electricity storage and typically require minimal maintenance.Reference Schmidt and Schmidt ^{2 ,} Reference Al-Rawi, Bicer and Al-Ghamdi ³²

Figure 2.

Dependable Power Sources in Challenging Situations.

The critical issue of power outages was vividly observed in Gaza and Ukraine, underlining the universal impact on health care systems. The Israeli siege of Gaza has caused a serious humanitarian situation, cutting off essential supplies like food, fuel, water, and medical resources. Surgeries in Gaza have had to be illuminated by flashlights, with limited or no anesthesia. More than a third of hospitals in the city became inoperable, and due to Israel’s constant bombing, health care professionals were no longer able to operate for a while. ³³ Shortages of essential fuel, vital for patient survival, were faced. Tragically, premature babies have already died at Gaza’s Al-Shifa Hospital due to the neonatal intensive care unit losing power.Reference Tin, Barten and Granholm ^{3 4 – 36} During the Russian attacks, surgeons at the Heart Institute in Kiev, Ukraine, faced a similar situation when the lights suddenly went out during a delicate heart surgery. While generators were activated to ensure that life support equipment remained operational, nurses and surgical assistants illuminated the operating table with flashlights. ³⁷ These harrowing scenarios exemplify the devastating impact of power outages on medical facilities and highlight the urgent need for constant and reliable power supplies to secure patient care in challenging conditions such as war.

In disaster response planning, effective communication is a recognized challenge for hospitals. To address potential failures, hospitals need redundancy in both internal and external communication systems. This involves using tools like 800-MHz radios, dedicated trunk lines, 2-way communication for units and essential personnel, mobile Communication-on-Wheels, and access to amateur radio operators (Figure 2). In extreme situations, resorting to runners for physical message delivery serves as a last resort.Reference Chaffee, Oster and Ciottone ³⁸

Physical Protection of Health Care Facilities in Times of War

In times of war, additional security measures must be taken for every health facility. Physical protection may include explosion protection for windows, bomb shelters in the building, and sandbags to cover windows; the use of pressure-resistant doors and windows in hospital buildings, and the use of seismic isolators, and locating the hospital in neutral territory and away from military buildings.Reference Clements, Casani, Clements and Casani ³⁹ Other key elements of a physical security plan include enabling rapid lockdown for perimeter security protection in case of emergencies; providing training and drills for hospital staff on lockdown procedures; ensuring that hospital leadership is familiar with the triggers for executing a lockdown; and having a plan for supplementing security staff in disaster scenarios (Figure 3).Reference Chaffee, Oster and Ciottone ³⁸

Figure 3.

Physical protection of healthcare facilities.

Providing shelter is a crucial factor in the initial stages of a disaster that is vital to ensure the survival, safety, and well-being of the affected population. Beyond immediate security concerns, housing also plays an important role in preserving individual dignity and facilitating the healing process. In cases where the displaced population cannot return to their original residences, temporary planned camps offer an alternative solution.Reference Pothiawala ⁴⁰ During Israel’s siege of Gaza, amidst bomb attacks on neighborhoods and refugee camps in Gaza, many Palestinian families have sought unexpected shelter in the common areas of hospitals. Seeking safety, they set up temporary homes in hospital corridors, parking lots, and courtyards—areas usually reserved for medical care and protected under international humanitarian law. ⁴¹ The challenges faced by health care facilities emphasize the importance of investing in shelters that can withstand adversity. The resilience of hospitals during unforeseen events is paramount, and implementing these types of shelters is crucial for preserving medical services and protecting patients and health care professionals. In addition to physical protection measures, the development of underground hospitals has emerged as a crucial aspect of health care resilience in conflict zones. For example, in Haifa, Israel, the Rambam Health Care Campus has converted its underground parking garage into a fully functioning, fortified hospital, demonstrating the adaptability and innovation required to ensure continued access to health care in the face of threats. This 3-story facility, spanning over 20,000 square meters, can accommodate more than 2,000 patients, providing essential medical services without disruption. ⁴²

Moreover, as observed in Ukraine and Gaza, a significant number of ambulances have been targeted during wars.Reference Jasani, Alfalasi and Cavaliere ^{8 , 14} In response, it is crucial to implement measures to enhance the resilience of ambulances and develop design and storage solutions to protect these critical health assets. Ambulances are tangible assets owned by the community and serve as critical infrastructure, providing value and support during times of crisis. By enhancing ambulance facilities, including personnel, equipment, and protocols, the resilience of emergency management can be significantly improved, ultimately saving lives and minimizing the impact of war-related emergencies.Reference Trucco, Petrenj, Kozine, Walls, Revie and Bedford ⁴³

Preparedness for Chemical, Biological, Radiological, or Nuclear Emergencies

Throughout history, chemical, biological, radiological, or nuclear (CBRN) weapons have been employed, with recent examples including warfare. ⁴⁴

White phosphorus, a chemical agent, is an extremely flammable substance that, when exposed to air, produces high-intensity flames reaching temperatures up to 1499°F. When it encounters civilians, it can cause deep burns that penetrate down to the bone. International law prohibits its use in populated areas. Reports from Ukraine allege that Russian forces have been employing phosphorus bombs in various regions of the country. ⁴⁵ Human Rights Watch accused Israel of utilizing white phosphorus munitions in its ongoing military activities in Gaza. ⁴⁶ Adequate hospital preparedness and resource availability are crucial for handling emergencies related to CBRN incidents, demanding specific skills and capabilities for an effective response.Reference Olivieri, Ingrassia and Della Corte ⁴⁷ The assessment of hospitals’ readiness for CBRN emergencies can be conducted using tools like the ThreatIdentification and Emergency Response (TIER) assessment tool or the CBRN Emergency Plan Checklist, which evaluates hospital preparedness and response performance in such scenarios.Reference Olivieri, Ingrassia and Della Corte ^{47 , 48}

Digital Health Technologies in Disaster Response

Digital health technologies (DHTs) play a crucial role in disaster response and are recognized for their potential in health care adaptation and mitigation. These technologies offer improved access to health care, reduced inefficiencies, cost reduction, and enhanced portability of patient information.Reference Lokmic-Tomkins, Bhandari and Bain ⁴⁹ The National Health Service (NHS) App, an example of digital health technologies, has been used as an e-health service in the United Kingdom.Reference KC, Tewolde and Laverty ⁵⁰ Connecting Ontario is used in Canada, allowing health care professionals to access personal health data. ⁵¹ In Australia, My Health Record is used as digital health technology. ⁵² An exemplary DHT in Türkiye, e-Nabiz, serves as a personal health record accessible through the internet and mobile devices.Reference Köksal and Akgül ⁵³ Between 2017 and 2020, systemic changes and steps toward digitalizing health care services were implemented in Ukraine. As a result of these steps, e-health is used in Ukraine.Reference Malakhov ⁵⁴ This system allows the data of patients examined in different health institutions to be transferred to a common database. To ensure the confidentiality of personal data and prevent potential data leakage, the e-health system has been developed with quality and security in mind, adhering to international standards and considering the advantages and disadvantages of other DHTs. During the COVID-19 pandemic, e-health technology enabled people to access health services without the risk of infection. In addition, a pilot project on teleconsultation was implemented in Ukraine to provide remote medical care to wounded soldiers and civilians in areas of active conflict. Within the scope of this project, doctors received video consultancy from an expert doctor. Teleconsultations and triage have been widely provided in primary care and by specialists since the onset of the pandemic. The well-established e-system of registration, e-referral, and e-prescription in the PHC has been instrumental in following the gate-keeping role of the family doctor. This system has proven immensely helpful, facilitating care for individuals who have migrated from different parts of the country, seeking refuge from the war.Reference Myronova ⁵⁵ Implementing DHT programs can greatly benefit disaster-prone countries by ensuring uninterrupted access to health care information, improving preparedness and response, and ultimately enhancing health care outcomes for affected individuals and communities.Reference Köksal and Akgül ⁵³ However, their effective use in conflict settings is often hindered by fundamental challenges such as a lack of internet connectivity, unstable electricity supply, and damaged digital infrastructure, which may limit their operational reach and sustainability.

Water Supply Plan

Ensuring access to safe water sources is crucial, as recent wars have demonstrated targeting and destruction of water supplies, regarded as a violation of international humanitarian law. In the case of the Russia-Ukraine conflict, experts believe the water supply has been cut off, and Russia has continued to target power and water infrastructure, causing shortages. ⁵⁶ The Kakhovka dam, situated in southern Ukraine, has suffered significant destruction, resulting in a massive release of water and causing concerns over extensive flooding downstream along the Dnipro river. ⁵⁷ Similarly, in the Israeli siege of Gaza, a complete siege was ordered, leading to restricted access to resources. ⁵⁸ These actions highlight the significance of safeguarding essential resources for civilian populations during conflicts. Health care facilities must create an Emergency Water Supply Plan to effectively handle and recover from complete or partial disruptions in their regular water supply, as water supply failures can significantly impact patient safety, quality of care, and facility operations. Facilities should identify alternative on-site water sources (e.g., wells, storage tanks), define critical water needs (such as for dialysis or sterilization), and establish agreements with external suppliers for emergency delivery, as recommended by the Centers for Disease Control and Prevention. ⁵⁹

Adequate Food and Material Stockpiles

The 1948 Universal Declaration of Human Rights highlights the fundamental principle that every individual has the right to a sufficient standard of living that ensures their health and well-being, as well as that of their family. This encompasses access to essential provisions such as food, clothing, housing, medical care, and necessary social services. Upholding these fundamental rights is paramount to promoting a just and equitable society, where individuals are protected and supported in their pursuit of a dignified and secure life. ⁶⁰ Despite this declaration, adequate food and material stockpiles are critical in the context of wars and disasters, as evidenced by recent conflicts in Gaza and Ukraine, which experienced challenges regarding food and health materials. In response, hospitals need to be prepared. Achieving food security during disaster response requires proactive measures in preparedness. This encompasses risk assessment, contingency planning, stockpiling necessary equipment, food, and supplies, establishment of emergency services and standby arrangements, effective communication and information management, and coordination among various involved agencies. FEMA (Food Safety: A Recipe for National Preparedness) offers general guidelines on preparedness, including stockpiling nonperishable food, water, and power. It is vital to store emergency supplies, practice proper hygiene, ensure sanitation, and follow appropriate food handling and preparation techniques to ensure the availability of safe food and water in challenging circumstances. ^{41 , 61}