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Disaster preparedness in emergency medical service agencies: A systematic review
Mehdi Beyramijam1, Mehrdad Farrokhi1, Abbas Ebadi2, Gholamreza Masoumi3, Hamid Reza Khankeh4
1 Health in Emergency and Disaster Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
2 Behavioral Sciences Research Center, Life Style Institute, Baqiyatallah University of Medical Sciences; Nursing Faculty, Baqiyatallah University of Medical Scienses, Tehran, Iran
3 Health in Emergency and Disaster Research Center, University of Social Welfare and Rehabilitation Sciences; Emergency Management Research Center, Iran University of Medical Sciences, Tehran, Iran
4 Health in Emergency and Disaster Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran; Department of Clinical Science and Education, Karolinska Institute, Stockholm, Sweden
| Date of Submission | 15-Oct-2020 |
| Date of Acceptance | 14-Dec-2020 |
| Date of Web Publication | 30-Jul-2021 |
Correspondence Address:
Prof. Hamid Reza Khankeh
Department of Clinical Science and Education, Karolinska Institute, Stockholm, Sweden
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jehp.jehp_1280_20
The Emergency Medical Services (EMSs) are in the frontline between the health-care systems and people in emergencies and disasters. With the increase in the frequency of natural or man-made disasters around the world, the need for prepared EMS services is increasing. This study aimed to evaluate the current disaster preparedness status of the EMS agencies in the literature and exploring the key preparedness elements and the strategies to improve the EMS disaster preparedness. The electronic database such as PubMed, Web of Science, Scopus, and Google Scholar was searched from 2000 to 2019. The searching keywords included: “EMS,” “Disaster,” “Preparedness,” “Emergency” “Preparedness,” “Disaster Preparedness,” “Readiness,” and the terms related to “disaster types” were used in combination with Boolean operators OR and AND. Out of 1412 articles, 7 articles were included in the review. The most important elements of the EMS disaster preparedness include the size and scope of the incident, surge capacity, planning, communication, training and education, policymaking, financial support, coordination, safety and security, early warning system, disaster response experience, and legal considerations. This systematic review showed that the EMS agencies in the world generally are inadequately prepared for an effective response to major emergencies and disasters. This study provides valuable information to EMS educators, EMS administrators to adopt and perform appropriate activities to improve the EMS disaster preparedness.
Keywords: Disaster, emergency medical services, preparedness
How to cite this article:
Beyramijam M, Farrokhi M, Ebadi A, Masoumi G, Khankeh HR. Disaster preparedness in emergency medical service agencies: A systematic review. J Edu Health Promot 2021;10:258 |
How to cite this URL:
Beyramijam M, Farrokhi M, Ebadi A, Masoumi G, Khankeh HR. Disaster preparedness in emergency medical service agencies: A systematic review. J Edu Health Promot [serial online] 2021 [cited 2023 Sep 26];10:258. Available from: https://www.jehp.net//text.asp?2021/10/1/258/322545 |
| Introduction | |  |
The EMS systems are in the frontline between the health systems and people in disasters and life-threatening situations. In many countries, EMS is a “gateway” to access specialized care and treatments.[1],[2],[3] Moreover, the WHO considers it as a critical part of an effective and efficient health-care system.[4] Disasters take place everywhere in the world and cause many injuries and death people.[5] At the time of writing this article (June 3, 2020), COVID-19 cause death of 384,617 people in the world.[6] Health is one of the main issues in disasters, and improving the health of disaster victims is a major priority for all countries and international organizations and documents such as the United Nations Office for Disaster Risk Reduction (UNDRR)[7] and Sendai Framework for Disaster Risk Riduction.[8] Hence, special consideration for the preparedness of the health systems, especially EMS systems, is essential to ensure the implementation of the UNDRR 2015–2030. EMS systems have advanced over the past 30 years, and they have a brilliant track record in leading and managing numerous disasters.[4],[9] Based on the Target Capabilities List of the Homeland Security Department, scene management, triage and treatment of casualties, management and distribution of medical supplies and equipment, and shelter are among the roles of the EMS in different emergencies and disasters.[10] With the increasing frequency of various disasters and emergencies around the world, the need for EMS services has also increased substantially, which requires extensive preparedness to improve public health response to disasters.[1] Globally, there is a consensus on the positive effects of disaster preparedness of the EMS systems, and providing the necessary education and training for improving the preparedness of the EMS will play a major role in reducing casualties and mitigating the impact of disasters.[1] Based on the International Strategy for Disaster Reduction (UNISDR 2011), preparedness is “the knowledge and capacities developed by governments, professional response and recovery organizations, communities and individuals to effectively anticipate, respond to, and recover from, the impacts of likely, imminent or current hazard events or conditions.”[7] Given the critical roles of the EMS in the management of disasters, evaluating the current status of the preparedness and exploring the main disaster preparedness elements of the EMS is necessary to improving the preparedness, and achieve effective disaster response. Therefore, this review study was conducted to evaluate the current status of EMS disaster preparedness in the literature and exploring the key preparedness dimensions and the strategies to improve the EMS disaster preparedness.
| Materials and Methods | | |
Searching strategies and databases
Search strategy
The present study was a systematic review of publications relating to disaster preparedness of EMS agencies. The study performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines[11] and the protocol for this systematic review was published previously[12]. The electronic databases were thoroughly searched to identify relevant studies. The following databases were searched: PubMed, Web of Science Core Collection, Scopus, and Google Scholar. For each database, words and expressions from a controlled vocabulary (MESH and others) and free text searching strategies were used. Only studies that have been published in English from January 1, 2005, to December 31, 2019, were considered for inclusion in this review. Furthermore, to find other potentially relevant articles, the references of the extracted articles were examined. The search was conducted using pre-determined keywords.
Selection of keywords
The keywords and their synonyms included in our search strategy were: “Emergency Medical Service,” “Emergency Prehospital Service,” “Prehospital Emergency Care,” “Ambulance agency,” “Disaster,” “Emergency,” “Mass Casualty Incident,” “Weapons of Mass Destruction,” “Chemical,” “Biological,” “Radiological,” “Nuclear,” and “Explosive Event” (CBRNE), and “Terrorist incident,” “Preparedness,” “Emergency Preparedness,” “Disaster Preparedness,” “Readiness,”. Using OR and AND, key words were combined and entered in the search box of the databases as follows: (Emergency Medical Service OR Emergency Prehospital Service OR Prehospital Emergency Care OR Ambulance agency) AND (Disaster OR Emergency OR Mass Casualty Incident OR Weapons of Mass Destruction OR CBRNE event OR Terrorist incident) AND and (Preparedness OR Emergency Preparedness OR Disaster Preparedness OR Readiness).
Eligibility criteria
Inclusion and exclusion criteria
In the present study, no restrictions were placed on the design of the selected studies. All initial and secondary studies, whose objectives were to evaluate disaster preparedness of EMS agencies, published in the English language between 2000 and 2019, were considered for review. Dissertations, book chapters, and conference papers were excluded. Furthermore, studies that were not relevant to the aims of the study or did not have abstract and full text or were not published as at the time of the study were excluded.
Selection process
After searching all the databases, the selected articles were inserted into EndNote, and duplicates were removed. After the duplicates were removed, the title and abstract of the selected articles were carefully screened by two independent reviewers for determining the potential eligibility of the studies. Disagreements were resolved by consensus. All of the articles deemed eligible were successfully downloaded and in the same way, the full-texts of the potentially relevant studies were reviewed by independent reviewers for inclusion and synthesis. Any disagreements were again resolved by consensus and reasons for excluding a specific study were documented [Figure 1].
Quality assessment
In the present study, we did not place any restrictions on the type and methodologies of the selected studies; hence, there are no specific tools for quality assessment. Therefore, to evaluate the methodological quality of the selected studies, the STROBE checklist was used tailored to the type of study. In this stage, the selected studies were assessed by two independent reviewers using an appropriate assessment tool for determining the eligibility of the articles for inclusion. Any disagreements were resolved through a consensus method, otherwise, a third reviewer was involved.
Search outcomes
The initial search yielded 1412 titles. After the removal of duplicate studies, 731 articles were considered for title screening. This number was decreased to 43 articles after title/abstract screening. The remaining articles (688) were excluded due to a lack of relevance to the aims of the study. After reading and reviewing the full text of the 43 selected articles, seven studies were considered for the present systematic review. The selection process of the studies is shown in [Figure 1].
| Results | | |
The findings of this systematic review study include specific details about: (1) research methodology of the selected studies, (2) reported preparedness status and the level of EMS agencies' disaster preparedness, (3) main elements of disaster preparedness of the EMS, and (4) and the strategies to improve preparedness.
Research methodology of the selected studies
Most of the studies included in this review were conducted in the United States[2],[13],[14],[15] and the three other studies were conducted in Iran,[3] Saudi Arabia,[16] and Finland.[17] Almost all of the studies were cross-sectional (quantitative), and questionnaires or survey checklists were used for data gathering. Only one study used the nominal group interview technique for data collection [Table 1].[2] The sample size of the various studies ranged from 13 to 1932 EMS agencies. Participants of the selected studies included personnel of providence-based, county-based, state-base, and district hospital-based EMS agencies. The majority of the studies used researcher-made tools for evaluating and measuring disaster preparedness of the EMS agencies.[2],[11],[12],[13],[14],[15],[17] One study used the modified version of the emergency medical specialists' (EMS) incident response and readiness assessment (EIRRA) tool.[16] This tool was developed by the United States National Association of State Emergency Medical Services Officials (NASEMSO) for measuring the MCI preparedness. This tool includes seven benchmarks: infrastructure, personnel, public awareness and notification, emergency care system, governance, evaluation, and mass casualty planning. There are 31 indicators in each benchmark. Another study used the “Emergency Medical Services (EMS) Checklist for Ebola preparedness” designed by the Center for Disease Control and Prevention (CDC) for data gathering.[3] The CDC questionnaire includes 54 questions classified into three themes; being prepared to detect, being prepared to protect, and being prepared to respond. Among the instruments in the various studies for data collection, only the Arabic version of the emergency medical specialists (EMS) incident response and readiness assessment (EIRRA) and the CDC “Emergency Medical Services (EMS) Checklist for Ebola preparedness” were standard tools for evaluating the EMS preparedness in emergencies and disasters. There is no valid universal standard tool specifically designed for evaluating the preparedness of EMS systems in disaster situations. A summary of the selected studies used for this review is shown in [Table 2]. | Table 1: The characteristics related to the selected studies (7 articles)
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The reported level of EMS preparedness for response to emergencies and disasters
The results of this review indicate that, overally, EMS agencies are not adequately prepared for response to disasters in the countries where the selected studies were conducted. However, a study conducted by Jadidi et al. indicated that the average preparedness score of the EMS system in Iran for response to Ebola was higher rates (63.73% ± 12.77%).[3] Alotaibi and Khan evaluated the preparedness of EMS in 13 regions of Saudi Arabia for the response to mass casualty incidents (MCI). This study showed that in general, the Saudi Arabian emergency medical systems are not adequately prepared for managing MCIs.[16] Maguire et al. explored the preparedness of EMS agencies in one US state for responding to a massive epidemic event. The authors indicated that most of the EMS agencies in this state do not have broad, formal plans for response to large-scale bioterrorism or pandemic events.[2] In another study conducted by Phelps, the preparedness of the EMS for managing victims and responding to threats from a mass-terrorism chemical weapons attack (MTCWA) was assessed. This study reported that only 6 (12%) of the EMS agencies in the region equipped their staff with personal protective equipment (PPE). The authors of this study indicated that the EMS providers were not prepared to safely respond to MTCWAs.[1] In the study of Shirm et al., 1932 state EMS agencies in the United States were randomly selected to document the preparedness of EMS agencies for the care of children in mass-casualty events. The study showed that though most (72.9%) of the EMS agencies have a written plan for responding to an MCI, only 248 (13.3%) of EMS agencies had pediatric-specific MCI plans. Furthermore, this study reported that there are considerable deficiencies in the preparedness plans of EMS agencies in the United States for the care of children in MCIs.[14] Jama and Kuisma in Finland conducted a study to survey the preparedness level of EMS systems to respond to chemical MCIs in the prehospital phase. The results of their study indicate that the EMS capacity in Finland for treating casualties in chemical MCIs, especially for cyanide gas exposure, is weak. Nevertheless, there was a good level of preparedness for managing and handling chemical accident patients with bronchodilators, supplemental oxygen, and inhaled corticosteroids.[17] And finally, Furbee et al., in the USA, evaluated 768 rural EMS organizations to determine the preparedness of rural EMS agencies for emergencies and disasters. The findings of their study indicate that many rural EMS organizations have limited resources and surge capacities, and are not adequately prepared for the response to events involving 10 or more victims. In addition, there was a low level of preparedness for response to terrorist bombing.[15] [Table 2].
Main preparedness elements of EMS agencies in disasters
After analysis of the selected studies (7 papers), 12 main elements of preparedness, and some activities (subthemes) that can positively affect the outcome of disaster response were identified. The elements include size and scope of the incident, surge capacity (staff, stuff, and infrastructures), planning, communication, training and education, policymaking, financial support, coordination, safety and security, early warning system, disaster response experience, and legal considerations [Table 3]. | Table 3: Main elements of emergency medical services disaster preparedness and their activities
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Strategies to enhance of the EMS agencies preparedness in disasters
Several strategies aimed at enhancing disaster preparedness of EMS agencies have been introduced in the literature. Alotaibi and Khan suggested the supply of sufficient skilled EMS personnel, including medical directors and paramedic graduates. Skilled EMS personnel are trained on how to respond to disasters and they participate in developing guidelines and disaster preparedness planning.[16] Infrastructure improvement, prehospital care system, public awareness/notification, effective evaluation system (evaluation of the performance of emergency responders during disasters and status of pre-hospital medical care), and the development and implementation of disaster preparedness plan were other strategies suggested by Alotaibi and Khan.[16] Close coordination between local EMS agencies and state or national EMS agencies in making EMS policies, guidelines, and procedures for response to disasters is another strategy suggested by Maguire et al.[2] Other strategies suggested by Maguire et al. include the following: providing safety and support for both responders and their families, the use of alternative modes of prehospital transportation and treatment, including expanding the role of EMS personnel to providing additional treatments and prescribing medications, the integration of local plans of EMS agencies with public health response plans, identifying and training alternate groups of people such as school teachers, artists, business professionals, and other professions without disaster-related responsibilities by the EMS system, the coordination of EMS leaders with hospital and local health officers to make alternate treatment plans and triage methods, and the development of close working relationships with health agencies, emergency management, and selected administrators within their local communities (2007).[2] Jadidi et al. indicated that improving staff motivation, stuff, educational courses, management, and IT sectors could potentially increase the level of EMS preparedness (2007),[2] Phelps have also suggested expanding the role of EMS technicians to providing additional treatments and prescribing medications (2007).[13] Supplying sufficient PPE and allocating grants to provide the necessary tools and also for staff training are other EMS preparedness strategies suggested by Phelps.[13] The focus of Shirm et al.,[14] in their study was child prehospital health care in disasters. Shirm et al., suggested the following strategies: specific written disaster plan for the care of pediatric victims, the involvement of pediatricians in community-level disaster planning and coordination with local schools and child care center officials to discuss emergency planning, the use of pediatric-specific triage protocol for the triage of pediatric victims in disasters, including local reunification plan in the local disaster plan, and including of pediatric victims in the community and regional disaster drills for acquiring pediatric-specific skills in disasters.[14] Improving decontamination preparedness and the capacity of emergency medical services for treating chemically affected patients are two important preparedness strategies suggested by Jama and Kuisma.[17] Moreover, improving the efficiency and effectiveness of day-to-day operations of the EMS, maintaining an all-hazards approach in disaster management measures, improving inter-agency communication skills and capabilities, increasing the participation of local EMS agencies in regional planning, and clarification of the local EMS roles and responsibilities in communication and interaction with other local, state and federal EMS agencies are some suggestions proposed by Furbee et al.[15]
| Discussion | | |
The main objective of this review was to evaluate the preparedness level of EMS agencies in disasters. The most significant finding of this study is that the EMS agencies in the countries that the studies have originated from there are not adequately prepared for response to the disasters. Despite the critical role of EMS in the care of disaster casualties, very few studies have been conducted on the preparedness of the EMS for the response to the disaster in different countries in the world. Most of the studies reviewed in the present systematic review were conducted in the USA.[2],[13],[14],[15] Disaster occurrence is unpredictable and hence, the need for further research to improve disaster response is recommended, especially in disaster-stricken countries and countries with high disaster risks. Most of the studies used researcher-made tools.[2],[13],[14],[15],[17] Moreover, specific hazard questionnaires for data collection, however, most of these tools did not have psychometric analysis to confirm their validity. This highlights the necessity of developing standard all-hazard approach tools that have been validated through the appropriate psychometric process and measure comprehensively all aspects and dimensions of EMS agencies' preparedness in disasters.
In the present review, we also explored the main dimensions of EMS preparedness for response to emergencies and disasters. In this regard, we identified 12 main dimensions of preparedness, including Size and scope of the incident, surge capacity, disaster planning, communication, training and education, policymaking, financial support, coordination, safety and security, early warning system, disaster response experience, and legal considerations. Some activities related to these dimensions that can positively affect the outcome of disaster response hare shown in [Table 3]. The dimensions of preparedness include various aims or final states that preparedness seeks to achieve, and the activities are solid actions that need to be taken to meet those goals.[18] One of the dimensions of preparedness identified in this study is the “Size and scope of the incident.” What is clear based on reviewed literature is that with the increase in the size and complexity of the incidents and the number of casualties, the confidence of EMS agencies in response to disasters decreases.[15],[17] Furbee et al., reported that many rural EMS organization personnel had low confidence in their preparedness for incidents involving a greater number of victims and for terrorist bombing incidents.[15] In addition, based on the findings of Jama and Kuisma, EMS agencies have low confidence in responding successfully to chemical mass-casualty situations.[17] However, EMS agencies feel confident in dealing with motor vehicle trauma.[15] This could be due to the increase in the response capacity. Depending on the size of the incident and the number of casualties, health systems face variable demands for healthcare resources.[19] Moreover, fluctuations in readiness or willingness to respond to different disasters can affect the confidence of EMS agencies. Recent evidence shows that emergency medical service providers may not always be willing to respond to CBRNE terrorism and related incidents.[20],[21] Another study reported that the willingness of EMS paramedics to respond to disasters is directly influenced by the type, duration, and visibility of the disaster.[22]
Policy-making is another preparedness dimension that was explored in this study. Using an all-hazard approach is a cost-effective approach in term of time and money[23] in disaster planning, and determination of single standards for it are two main activities that expected by EMS officials in all jurisdictions.[2],[15] This is because if policies are developed as part of a disaster preparedness plan in all jurisdictions, disaster relief will be more organized, less chaotic, and more estimated.[24] Based on the results of this study, disaster planning is among the main pillars of EMS disaster preparedness. Disaster planning plays a critical role in an effective response to disasters, and it involves a coordinated process to meet urgent needs with existing resources.[25] In addition, disaster planning is one of the most important elements in the assessment of disaster preparedness of health-care agencies such as hospitals.[26],[27] The standard operating procedures (SOPs) is an essential element in emergency and disaster management.[28] The codification and development of SOPs and protocols for EMS disaster management include the following phases: mitigation, preparedness, response, and recovery [Table 3].
An increase in demand for health-care services due to a sudden surge of casualties is one of the most important concerns of health-care systems during disasters[29] and this is the main goal of the “surge capacity” concept in disasters.[30],[31] Staff (human resources), structures (facilities and physical space), and specialized and nonspecialized equipment are the three main elements of surge capacity.[32] Therefore, strengthening the capacity of the EMS agencies in areas of human resources, structures, and facilities and equipment are the most important activities in this dimension than can positively affect the preparedness of the EMS [Table 3]. Effective communication and coordination are other elements of preparedness of the EMS identified in this review. Developing national communications networks,[2],[16] having closer intra- and extra-organizational relationships,[2] risk communication,[16] having intraorganizational communication[2] and having a closer working relationship with health institutes and elected officials within their local communities[2] are some of the activities suggested by the available literature for improving the communication of EMS systems in disasters. Palttala et al., indicated that communication in disasters is not yet properly integrated into disaster management practice and just the existence of disaster communication plans and other guidelines are not adequate, but rather they need to be developed further.[33]
Education and training of the EMS providers, considered as the heart of EMS systems,[34] are other critical elements of EMS preparedness in disasters. Providing standardized disaster training is one of the main requirements for assessing EMS disaster preparedness.[35] Evidence from previous studies shows a lack of sufficient training courses aimed at improving disaster response outcomes.[21],[35] Also, other studies have shown that adequate disaster-related education and training improve disaster preparedness perceptions.[36],[37] The assessment of training needs, planning, and implementation of continuous theoretical and practical disaster educational courses, as well as training alternate groups of peoples, were the main strategies suggested by the studies in this review. Disaster response experience, early warning system, financial support, legal considerations, and safety and security were the other elements of EMS disaster preparedness highlighted by the studies in this systematic review. About the effects of previous disaster response experience on disaster preparedness, studies conducted by Alotaibi and Al Thobaity,[38] Baack andAlfred[39] and Nilsson et al.[40] demonstrated that previous experience from major disasters increased the perceived level of disaster preparedness among healthcare providers. Providing safety and security are also among the most important issues in preparedness and the willingness of EMS providers to respond to various emergencies and disasters. Rebmann et al. reported that administering prophylaxis to EMS personnel and their family and safety were the main factors that affected the willingness of health-care workers' response to the influenza pandemic.[41]
Limitations
One of the limitations of this literature review is related to the study selection phase. In this review, only the studies published in the English language were selected, and potentially relevant studies published in other languages were not selected. Further limitation for this study is the inability to generalize the study results to all EMS agencies in the world due to lack of broad representation of most world nations about EMS disaster preparedness.
| Conclusion | | |
The most important finding of this systematic review is that the EMS agencies in the countries that the studies have originated from there are not adequately prepared for response to various emergencies and disasters. In addition, few studies have been conducted on EMS disaster preparedness in the world; therefore, more studies are needed in other countries, especially in disaster-stricken countries and in countries with high disaster risks. The findings of this review indicate that the most tools used in the selected studies is not standard, especially standard tool with a multi-hazard approach for evaluating and assessing the preparedness of EMS agencies in emergencies and disasters. Therefore, designing the tools with a standard methodological approach is required. Planning and implementing activities related to the roles of the main elements of preparedness that were identified in this review can help to improve the preparedness of EMS systems in disasters. Also, the findings of this study provide valuable information to EMS educators, EMS administrators, and researchers which can be utilized in designing standard disaster preparedness assessment tools. Disaster preparedness assessment can support EMS agencies to be adequately prepared for the response to different emergencies and disasters.
Acknowledgments
The authors would like to acknowledge the Health in Emergency and Disaster Research Center of the University of Social Welfare and Rehabilitation Sciences for their counseling and support of this study.
Financial support and sponsorship
This study has been ethically approved by the Institute of Board Review of the University of Social Welfare and Rehabilitation Sciences with the registration Number IR.USWR.REC.1396.26.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1]
[Table 1], [Table 2], [Table 3]
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