Assessment and development of hospital emergency preparedness plan in response to COVID-19 pandemic in Alexandria University Hospitals

ABSTRACT Background The COVID-19 ongoing pandemic is one of the deadliest pandemics in history. It has put a significant strain on healthcare systems and frontline healthcare workers. This study attempted to assess and develop the emergency preparedness of hospitals affiliated to Alexandria University. Methods A quasi-Aquasi-experimental design was conducted in three phases; the pre-intervention assessment using ahospital emergency response checklist, then awareness intervention was implemented to provide information on emergency preparedness followed by post-intervention assessment after asix-month period following the first phase using the same checklist. Results The pre-intervention assessment showed that four hospitals had a good overall preparedness level (75% or more preparedness level), while the rest of the hospitals (7 hospitals) demonstrated a fair overall preparedness level (50%- <75%). All the individual domains have demonstrated a good or fair to good preparedness levels except the recovery domain, which was fair, and the command and control domain, which was poor in the majority of the studied hospitals. The intervention awareness program has led to a significant statistical change in the command and control as well as human resources domain. However, the post-intervention scores of command and control domain remained poor in the majority of the studied hospitals.


Introduction
Since December 2019, the world has been in the grip of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the disease it causes, coronavirus disease 2019 (COVID- 19), which was initially identified in Wuhan, China [1,2], and has been declared a pandemic by the World Health Organization (WHO) on March 11 2020 [3].
As of October 2021, there have been more than 243 million confirmed cases of COVID-19 including 4.94 million deaths reported worldwide to the WHO [4].
In Egypt, COVID-19 has claimed the lives of over 18.000 out of 323.000 confirmed cases among the Egyptian population [5].
These numbers have left no doubt that the pandemic is putting huge pressure on health systems around the world as seen by overcrowded hospitals and exhausted physicians and nurses struggling to save lives with limited resources [6]. This troubling situation creates a necessity for assessment of health system preparedness in order to implement changes to healthcare delivery based on the lessons learnt during the pandemic [7].
Hospital preparedness for epidemics requires the following: [7][8][9] • Adequate command and control, which require the hospitals to establish and implement a Hospital Emergency Risk Management Program as well as an emergency response plan, to ensure effective management of the risks of different emergencies including epidemics. Also, hospital staff should be fully aware of and well trained to carry out their roles in preparing for and responding to different emergencies. • The internal and external communication lines required for coordination of the overall response to an emergency should be functioning effectively. • An adequate infection prevention and control program, adequate triage and surveillance systems as well as adequate laboratory services in order to deal with the challenges of an epidemic. • The capacity to cope with the extra health demands from the epidemic as well as the ability to ensure the continuity of essential health services at the same time as coping with an epidemic through adequate surge capacity.
• Proper logistics management to ensure sufficient amounts of the needed resources. • Proper human resources management to satisfy the physical, mental, emotional, and social requirements of hospital staff and their families. • Adequate essential support services to ensure the safety of the hospital, its occupants, uninterrupted delivery of safe food and water and nutritional services, provision of laundry, cleaning services, and waste management services as well as safe effective mortuary services.
This study aims at assessment and development of the emergency preparedness in hospitals affiliated to the University of Alexandria to allow decision-makers to formulate appropriate policies and procedures, determine priorities, allocate proper resources, and implement improvements to ensure that these hospitals are adequately prepared for potential emergency situations.

Study design
The study used a quasi-experimental design involving a pre-and post-intervention assessment of hospital emergency preparedness. The study was conducted in three phases: First phase: the pre-intervention assessment using a hospital emergency response checklist; Second phase: awareness intervention was implemented to provide information on how the studied hospitals can fulfill their role in emergency preparedness; and Third phase: the post-intervention assessment was conducted after a six-month period following the first phase using the same checklist.
Checklist for Coronavirus Disease 2019 (COVID-19) of the CDC (Center for Disease Control and prevention) [11] by adding some questions from the latter to the former as follows : 5 items were added to the command  and control domain, 3 items to the infection prevention  and control domain, 3 items to the communication  domain, and the 5 items of the recovery domain.  Data obtained included: (1) Description of the studied hospitals.
(2) Data related to hospital emergency preparedness including the following domains: The score of each item ranged from 0 to 2. If the item is present and functioning, it was given a score of two. If the item is pending/inadequate/present but not functioning, it was given one. If the item is not present/not done, it was given zero.
As regard the Incident Management System, it includes the presence of a complete activated emergency response plan, the presence of a complete trained Incident Command Team, and the presence of an adequate Emergency Coordination Center (ECC). These three items are part of the items included in the command and control domain. However, these are presented separately because of their importance.

The awareness intervention strategy
• The program was one session for every hospital held one week after the first assessment. • The attendees included hospital staff consisting of Hospital director or deputy director, some physicians, some nurses including infection control nurse, safety and security officer, one or more of the Logistics staff, Finance chef, Human services director and Personnel from the laboratory and/or radiology and/or pharmacy representing ancillary services as well as a facilitator (the researcher) and two supervisors. • Each session lasted about 2 hours and took place in private halls in the studied hospitals. • The purpose of this program is to provide information on how the studied hospitals can fulfill their role in emergency preparedness, emphasizing that most of the actions required to prepare for epidemics apply or can be adapted to other emergencies, such as mass casualties due to transport crashes, geological or chemical disasters, and so on. • The intervention was a prepared curriculum based on the WHO guide for hospital preparedness for epidemics [8] delivered in the form of power point and printed material. • This curriculum included guidelines for preparedness and response activities regarding the studied domains. • Assessment of the impact of this program was intended to be after a six-month period (postintervention survey).

Data analysis
• The monthly Bed Occupancy (in Table 1) was calculated using the following formula: Bed Occupancy/month = Total number of inpatient days in a month/(Available beds x Number of days (30)) x 100 • Because the number of items in the different domains was not equal, a percent score for each domain was calculated and categorized as follows: poor (<50%), fair (50% -<75%), and good (≥75%). Then, the overall preparedness level for each hospital was calculated by summation of the raw scores of all domains and categorized in the same way as individual domains.  The One day services center was excluded from the description because it is not intended for inpatient care (it serves outpatient clinics and surgical operations with discharge on the same day). Also, it does not have its own microbiology laboratory. Table 2 illustrates the presence and functioning of different components of the Incident Management System (IMS) in the studied hospitals. The table shows that most of the studied hospitals had an Emergency Response Plan (72.73%). One fourth (25.0%) of these hospitals had an activated plan, 27.27% of the studied hospitals had Emergency Coordination Centers (ECCs). However, none of these ECCs were adequate. Table 3 shows that four hospitals had a good overall preparedness level, while the rest of the hospitals demonstrated a fair overall preparedness level at the pre-intervention assessment.

Results
The majority of studied hospitals had a poor level of command and control preparedness.
Most of the studied hospitals (seven hospitals) had a good level of communication preparedness, while the rest of the hospitals showed a fair preparedness level.
Most of the studied hospitals had fair levels of surge capacity preparedness, a good level of human resources preparedness, and a fair level of recovery preparedness.
Six of the studied hospitals had a good level of logistics preparedness, while the rest of the hospitals showed a fair preparedness level.
All the studied hospitals had a good level of infection prevention and control, triage, surveillance, continuity of essential services, and essential support services preparedness.
Four hospitals allowed operating on suspected or confirmed COVID-19 patients, and they all had a good level of infection control in operating rooms. All the studied hospitals had a good level of laboratory services preparedness except The One day services center, which did not have a laboratory of its own. Table 4 shows that three hospitals demonstrated no change in their percent scores. These hospitals were El-Shatby Alexandria University Children's Hospital, The New University Hospital, and The One day services center. On the other hand, the rest of the hospitals showed an increase in the percent scores of one or more domains as follows: • The main university hospital has shown some improvement in the percent scores of command and control, surge capacity, infection prevention and control, continuity of essential services, and recovery domains.  Table 5 shows that only two domains showed a significant difference between the pre-and postintervention percent scores, command and control as well as human resources.

Discussion
In the present study, 72.73% of the studied hospitals had Emergency Response Plans. Different findings were reported by Ingrassia et al. [12] where all the studied hospitals had adopted a disaster management plan, all of which were appropriately developed by an authorized hospital committee. As regards the Incident Command Teams, the present study showed that 54.55% of the studied hospitals had Incident Command Teams. Meanwhile, the study by Norman D et al. [13] found that 27.3% of the studied health facilities had disaster response teams.
These differences can be related to provision of training, integration of knowledge and expertise into a practical framework for coordinating emergency response, the will of the administrative bodies, and the presence of a powerful supervisory authority to regularly evaluate the degree of emergency preparedness in the different hospitals.
The overall pre-intervention percent scores of preparedness of the studied hospitals in the present study indicated that four hospitals had a good overall preparedness and the rest had a fair overall preparedness.
These findings are in agreement with the findings of Ingrassia et al. [12], while contrasting the findings of Khan et al. in Saudi Arabia [14] which reported a low preparedness level in all of the studied hospitals.
The differences in hospitals' preparedness can be explained by their degree of success in adopting standardized guidelines and implementing strategies of emergency preparedness as well as allocation of financial resources.
Data from the current study showed that the majority of the studied hospitals had poor command and control preparedness level at the pre-intervention assessment. This finding is consistent with the finding of Khan A et al. [14] where they demonstrated an unacceptable level of command and control (corresponding to poor) in the studied hospitals. These findings could be related to the presence and functioning of the Incident Management System, which is the core of the command and control domain.
Expanded surge capacity is essential to meet the extra demand for clinical care during a potential emergency. In the present study, the pre-intervention percent scores indicated a fair to good surge capacity preparedness.  These results were similar to the findings reported by Ingrassia et al. [12] and Khan A et al. [14] where they both reported moderate surge capacity preparedness.
Data from the current study indicate that the human resources domain has shown a good preparedness level in the majority of hospitals, whereas the logistics domain has demonstrated a fair to good preparedness level; meanwhile, the findings of Hojat M [15] demonstrated a moderate level of preparedness as regard both human resources and logistics.
Monitoring adherence to infection prevention and control (IPC) measures is an essential part of the response to epidemics/pandemics. The findings of the pre-intervention assessment have shown a good IPC preparedness level at all the studied hospitals. This finding is inconsistent with that reported by a study conducted in Egypt in 2018 [16] to evaluate the preparedness level of Ismailia city hospitals and primary healthcare centers, where the infection control preparedness was moderate in hospitals and low in primary healthcare centers.
This disparity is attributed mainly to the availability of personal protective equipment and the difference in provision of training and supervision to the staff.
As regard the triage domain, the present study revealed a good level of triage preparedness at all the studied hospitals. A similar finding was reported by Ingrassia et al. [12] where the majority of the studied hospitals showed a sufficient level of preparedness to perform triage. The reported findings are most probably related to providing triage space, trained medical personnel, and all necessary resources.
Concerning the surveillance domain, the present study found a good level of surveillance preparedness at all the studied hospitals. A different finding was reported by Tiruneh et al. [17] where most of the studied hospitals demonstrated poor surveillance preparedness. This difference may be related to the level of training of health personnel responsible for surveillance activities, the level of supervision over these activities as well as the adequacy of laboratory services where the current study found a good level of laboratory services in the majority of the studied hospitals, whereas Tiruneh et al. [17] reported a poor level of laboratory services preparedness.
A well-planned hospital emergency response plan should have mechanisms to provide and maintain essential hospital services and the resources needed for the continuity of these vital services.
Communication mechanisms are one of the biggest challenges facing by healthcare systems during emergencies. The findings of the present study revealed fair to good communication preparedness. This finding is inconsistent with the finding of Tiruneh A. et al. [17] where the majority of the studied hospitals had poor communication preparedness. This difference could be related to availability of different communication means and the ease of communication between the staff inside the facility and between the facility and other facilities or authorities.
The present study found that only two domains demonstrated a significant change after the intervention, command and control and human resources.
Similar findings were reported in the study by Khan A et al. [14] and Beyramijam M et al. [18] while contrasting the finding of Delshad V et al. [19] where the intervention program failed to achieve a significant change in these domains.
This difference may be related to how the studied hospitals could benefit from these programs by translating the knowledge gained into a genuine effort to develop and upgrade their preparedness regarding these domains as well as the feasibility of conducting a change, i.e., some changes need extra financial resources and/or time and/ or collaboration and agreements.

Limitations of the study
The time constraint was the main challenge faced in this study where hospital emergency preparedness would have been better if more time was available (more than 6 months) especially when considering the fact that the study was conducted at the time when the pandemic was overburdening the health system of the studied hospitals.

Conclusion and recommendation
The pre-intervention assessment has shown that the overall preparedness level of the studied hospitals was fair to good. The awareness intervention program has succeeded in inducing a significant change in command and control as well as human resources domains. However, the command and control domain was still poor in the majority of the studied hospitals.
Based on the findings of the current study, the main recommendations include establishing complete Emergency Response Plans or development of the existing plans and activation of these plans according to the time and/or geographic proximity of the situation, establishing complete well-trained Incident command teams or development of the existing teams, deploying medical supplies upon activation of the Emergency Response Plan and planning for enough stock, developing adequate recovery plans as part of the Emergency Response Plan, and considering the appropriate timing for its activation.

Disclosure statement
No potential conflict of interest was reported by the author(s).

Notes on contributors
Eman Hamdy Basiony Darwish, Master degree of public health, preventive and social medicine, Assistant lecturer of community medicine, community medicine depart. faculty of medicine, Alexandria University.