Hospital Emergency Management Planning Discussion

Based on your readings and experience, comment on the effectiveness of HVAs. Are they too subjective? How would you approach developing an HVA?

Develop an HVA for a hospital in your community. Provide details on the hospital (bed numbers, location, ect.). List the top 5 hazards. Defend your answers.

From the Schools of Public Health On Linkages STRENGTHENING HAZARD VULNERABILITY ANALYSIS: RESULTS OF RECENT RESEARCH IN MAINE Paul Campbell, MPA, ScD Steven J. Trockman, MPH Amanda R. Walker, MPPM Since the events of September 11, 2001 (9/11), healthcare institutions have been encouraged to enhance their readiness for disasters. The Joint Commission (previously the Joint Commission on Accreditation of Healthcare Organizations) has, since 2001, required member hospitals to complete an annual hazard vulnerability analysis (HVA), which is expected to provide a foundation for emergency planning efforts. A literature search revealed that little has been written and published on HVA since that requirement came into effect, and no known investigation of current HVA procedures has been completed. To begin to address this gap, researchers from the Harvard School of Public Health and the Southern Maine Regional Resource Center for Public Health Emergency Preparedness (SMRRC) interviewed staff members at eight hospitals in Maine to document current HVA processes and develop recommendations for improvement. SMRRC is one of three regional nonprofit hospital-based centers in Maine guiding health systems and public health preparedness activities. BACKGROUND AND OBJECTIVES Hospitals and other health-care organizations have always had to prepare for and respond to a wide array of routine emergency and catastrophic disaster events. Since the terrorist attacks of 9/11 and subsequent attention and funding from the U.S. Department of Health and Human Services and Department of Homeland Security, hospitals have been urged to substantially expand their response plans and overall readiness for disasters Hospital Emergency Management Planning Discussion.

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Hospitals are now expected to develop, implement, train, and exercise comprehensive all-hazards emergency management and operations plans. These planning efforts need to be inclusive of all four phases of emergency management: mitigation, preparedness, response, and recovery. Emergency management programs and their associated emergency operations plans are only as good as the assumptions upon which they are based, which is especially true at the local level where planning must take into account specific risks unique to the immediate environment. Local priorities need to be considered, in addition to those required by federal and state authorities, and detailed in the goals, objectives, and deliverables tied to all funding streams. However, local priorities based on opinion alone, and not on objective data, can provide a weak foundation for planning. Expert clinical or administrative staff opinions can result in waste, duplication, missed opportunities, siloing, and confusion over what the true priorities are in terms of threat, vulnerability, and risk.

In the 2001 edition of its Comprehensive Accreditation Manual for Hospitals, the Joint Commission significantly revised the existing standard for emergency management.1 For the first time, the Joint Commission was guiding hospital emergency preparedness efforts “into the same arena as emergency management in the community as a whole.”2 Hospitals were now expected to function as an “integrated entity within the scope of the broader community.” The 2001 standard urged that hospital response plans now must be “based on a hazard vulnerability analysis (HVA) performed by the hospital.” Although HVA was a relatively new term for hospital staff, the concept itself was not.2 The Joint Commission defined HVA as “the identification of hazards and the direct and indirect effects these hazards may have on the hospital.” The actual or anticipated hazards are analyzed in the context of the population at risk to determine the vulnerability to each specific hazard. Hospital emergency managers have long performed HVAs in their heads, as “much of the process is highly Articles for From the Schools of Public Health highlight practice- and academic-based activities at the schools. To submit an article, faculty should send a short abstract (50–100 words) via e-mail to Allison Foster, ASPH Deputy Executive Director, at [email protected]. 290  Public Health Reports / March–April 2011 / Volume 126 From the Schools of Public Health intuitive.” For example, hospitals in the Midwest do not need to plan for hurricanes, while those along the Atlantic Coast must. Even the way risk has been defined both qualitatively and quantitatively for hospitals is wide-ranging in its scope and use. As a result, “risk may be one of the most elusive concepts in health emergency management.”3 While mandating that hospitals perform HVA, the 2001 Joint Commission standard did not formalize the process for doing so. Additionally, the Joint Commission did not offer a specific tool to normalize the process in hospitals. While the American Society for Healthcare Engineering (ASHE) of the American Hospital Association offered the first standard methodology in 2001 for performing a hospital HVA,2 a wide array of other tools and methods also became available for hospitals to utilize for risk and vulnerability assessment.3 Later in 2001, Kaiser Permanente developed a modified Hazard Vulnerability and Assessment Tool for Medical Center Hazard and Vulnerability Analysis.4 This tool expanded both the guidance and scope of hazard “events” that hospitals should consider. Specifically, it expanded the risk measures to include human impact, property impact, and business impact Hospital Emergency Management Planning Discussion.

Each measure was rated separately for each event and weighted in the final vulnerability score. Likewise, the mitigation measure was expanded from the ASHE tool, which simply rated preparedness as “poor,” “fair,” or “good.” The new tool broke mitigation down into preparedness (preplanning), internal response (time, effectiveness, and resources), and external response (community/ mutual aid staff and supplies). This final measure reflected the intended outcome of the new Joint Commission standard by assessing hospitals as community organizations rather than stand-alone institutions. The following year, HCPro, Inc., a private healthcare regulation and compliance product and service provider, published its own HVA Toolkit for hospitals.5 Similar to the Kaiser tool, this toolkit is meant to facilitate the evaluation of every potential event in each of the three categories: probability, risk, and preparedness. Like the others, the kit allows the user to add events as necessary. To determine probability, users are encouraged to consider known risk, historical data, and manufacturer/vendor statistics. The Joint Commission does not provide this level of detail or guidance; rather, it is individual private publishers that offer HVA tools with this level of specificity. While helpful, these modifications make it difficult to draw comparisons among hospitals, or across jurisdictions or states. While the Joint Commission continues to refine and expand emergency management standards, it  291 has yet to provide a standardized method or tool for conducting HVAs. What none of these tools or the Joint Commission standard offers, however, is a standardized method for collecting or using HVA data at the hospital or community level. Hospitals are left on their own to determine how they will collect information on probability and severity, how they will process that information within the institution, and what to do with the results. The primary objective of this study was to investigate how institutions at the local level, in particular hospitals in Maine, currently implement HVA, in an effort to encourage future research on this topic to ultimately improve HVA efficacy. METHODS During 2005 and 2007, the SMRRC invited eight hospitals in the Southern Maine region to participate in a regional HVA process. The Southern Maine region includes acute care and mental health hospitals within York, Cumberland, Sagadahoc, and Lincoln counties, most of which are Joint Commission accredited. An electronic copy of the Medical Center HVA template and instructions were provided to each hospital’s emergency preparedness contact.

These individuals participate regularly in SMRRC activities and preparedness efforts. They represent a variety of departments from their institutions, including hospital administration, planning, safety, infection control, and facilities management. Administration of the HVA tool was customized to best meet the needs and available resources of each facility. If a facility had recently completed an HVA, its staff members were encouraged to use those data to aid in the completion of the SMRRC version. Other facilities distributed the HVA forms to individual members of their internal Environment of Care or Emergency Preparedness Committees and then convened as a group to reach consensus for the organization. The HVA tool used in this study was based on the model developed by Kaiser Permanente and modified for use by the SMRRC. During April 2008, we conducted a series of faceto-face, semi-structured, in-depth interviews with staff from each of the participating hospitals who were identified to have a key role in the HVA process at their facility. Two interviewers attended each discussion and subsequently compared notes to assure objectivity. The questions were largely drawn from a paper entitled, “Risk and Risk Assessment in Health Emergency Management.”3 Beyond the issues suggested by this paper, the interviewers discussed the HVA results Public Health Reports / March–April 2011 / Volume 126 292  From the Schools of Public Health produced in each hospital and changes in results from year to year. 6. RESULTS The lack of standardization in the HVA process from hospital to hospital became apparent as the survey progressed. Specifically, the researchers found the following: 1. The scope of risk varied a great deal across the institutions. Some hospital staff considered the scope to be limited to the institution’s campus, while others had an expanded view and considered risks to the hospital’s entire service area. 2. The planning time frame was rarely clarified and often varied from institution to institution. In some hospitals, staff believed that they were planning for one year, while in other hospitals they believed that they were planning for a longer time frame (e.g., three to five years). 3. Hospital Emergency Management Planning Discussion

The individuals facilitating the process had a large impact on the results. For example, regarding scope of risk, staff members with hospital engineering backgrounds focused on the institution, while others with public health exposure and training tended to focus on the community. An individual’s personal experience with disasters had a substantial impact on the results. Changes in HVA results from period to period tended to be those hospitals with substantial changes in the staff responsible for HVA. 4. The level of resources committed to HVA differed greatly. None of the institutions prepared a budget specifically targeting this activity. The number of hospital staff substantially involved in the deliberations varied from one person to 20 people, and the difference was not consistently related to the size of the institution. In addition, while some hospitals invited community experts (e.g., fire, emergency medical services, police, and emergency management personnel) into the process, most limited participation to their employees. Only one hospital staff member used information available at the county emergency management agency office, despite the availability of that staff and knowledge base to all participants. 5. The decision-making process was usually informal. The process of arriving at decisions was rarely made explicit. No minutes were kept in any of the institutions to record, for example, 7. 8. 9. differences of opinion regarding risk, although many of the individuals interviewed could recall differences, including animated debates. Changes in results were apparently highly associated with whether the process was framed and managed as incremental or not. In some hospitals, the results from prior years were present for discussion of the current year’s risks. In others, the issue was considered without reference to previous results. The results of the HVA process were not widely shared. Hospital staff rarely communicated results outside the institution beyond the Regional Resource Center that requested them. Within the institution, the results were nearly all communicated to established (e.g., safety) committees, but only a few hospitals channeled results to the Chief Executive Officer (CEO) and Board of Trustees for discussion. HVA results affected preparedness activities very differently from institution to institution. In one hospital, the results were only communicated to the external Regional Resource Center, and never passed on internally.

That hospital’s staff members believed that the Regional Resource Center needed the information for regional planning purposes and did not understand that the HVA was completed primarily for internal planning and accreditation purposes. In contrast, at another hospital, staff members completed an annual action plan detailing how they were going to respond to each of the risks identified. The commitment of individual hospital senior leaders, including the CEO, had a substantial impact on the HVA process, influencing both the level of resources committed and the management of results. CONCLUSIONs AND RECOMMENDATIONS We believe the efforts presented in this article are among the first exploratory investigations into this important issue. We encourage other public health professionals to pursue investigations covering more health-care institutions and employing more rigorous research methods. In addition, we offer the following recommendations: 1. The HVA process should be developed to achieve a greater degree of standardization. For example, the scope of risk and planning time frames should be clarified and applied Public Health Reports / March–April 2011 / Volume 126 From the Schools of Public Health consistently across hospitals. Guidelines should also encourage greater use of other community experts and available information. 2. The level and types of expertise required should be addressed. The HVA was added to the Joint Commission requirements because the importance of emergency planning has been enhanced. Enhanced quality of planning also requires input from diverse areas, including facility management, public health, emergency management, administration, nursing, and medical care. 3. The Joint Commission should address the issue of periodicity. Currently, hospitals are expected to complete an HVA on an annual basis. We believe that the process should be changed from annual to every other or every third year unless a serious alteration in conditions occurs (e.g., construction of a nuclear power plant nearby).

Too-frequent assessments tend to dull the process and reduce it to an insubstantial incremental procedure with little impact. 4. Each hospital should be encouraged to pursue the following steps when completing the HVA: • Research into vulnerability through public safety, emergency management agencies, and other sources of information; • Organizational meeting of individuals to be involved in the deliberative process that would clarify the decision-making process as well as its importance within and outside the institution; • Individual completion of the assessment instrument in private to encourage differing opinions; • Group discussion and consensus;  293 • Documentation of discussion, including minority opinions and overall results; • Documentation of action planning to address identified gaps; and • Wide distribution of the results both outside and within the institution, including to the most senior decision makers. This article was supported by funding awarded to the Harvard School of Public Health (HSPH) Center for Public Health Preparedness under Grant/Cooperative Agreement #3U90TP12424205 from the Centers for Disease Control and Prevention (CDC). The contents of this article are solely those of the authors and do not necessarily represent the views of CDC, the U.S. Department of Health and Human Services, or any partner organizations, nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. government. Paul Campbell is a Lecturer on Management at the HSPH and Co-Investigator at the HSPH Center for Public Health Preparedness in Boston, Massachusetts. Steven Trockman is Director and Amanda Walker is a Project Manager, both at the Southern Maine Regional Resource Center for Emergency Preparedness at Maine Medical Center in Portland, Maine. Address correspondence to: Paul Campbell, MPA, ScD, Harvard School of Public Health, 677 Huntington Ave., Bldg. I, Room 1206, Boston, MA 02115; tel. 617-432-0681; fax 617-432-4514; e-mail . REFERENCES 1. 2. 3. 4. 5. Joint Commission on Accreditation of Healthcare Organizations. Comprehensive accreditation manual for hospitals: the official handbook. Oakbrook Terrace (IL): Joint Commission Resources, Inc.; 2008. American Society for Healthcare Engineering of the American Hospital Association. Hazard vulnerability analysis [Healthcare Facilities Management Number: 055920]. Chicago: ASHE; 2001. Arnold JL. Risk and risk assessment in health emergency management. Prehosp Disaster Med 2005;20:143-54. Kaiser Permanente. Medical center hazard and vulnerability analysis. Kaiser Foundation Health Plan, Inc. [cited 2010 Jun 16]. Available from: URL: http://www.calhospitalprepare.org/sites/ epbackup.org/files/resources/Hazard%20&%20Vulnerability% 20Analysis_kaiser_model.xls HCPro, Inc. Hospital Emergency Management Planning Discussion

Hazard vulnerability analysis toolkit: assessing risk to patients and preparing for all disasters. Marblehead (MA): Opus Communications, Inc.; 2002. Public Health Reports / March–April 2011 / Volume 126 doi:10.1111/disa.12047 Health care system hazard vulnerability analysis: an assessment of all public hospitals in Abu Dhabi Saleh Fares, Meg Femino, Assaad Sayah, Debra L. Weiner, Eugene Sun Yim, Sheila Douthwright, Michael Sean Molloy, Furqan B. Irfan, Mohamed Ali Karkoukli, Robert Lipton, Jonathan L. Burstein, Mariam Al Mazrouei and Gregory Ciottone1 Hazard vulnerability analysis (HVA) is used to risk-stratify potential threats, measure the probability of those threats, and guide disaster preparedness. The primary objective of this project was to analyse the level of disaster preparedness in public hospitals in the Emirate of Abu Dhabi, utilising the HVA tool in collaboration with the Disaster Medicine Section at Harvard Medical School. The secondary objective was to review each facility’s disaster plan and make recommendations based on the HVA findings. Based on the review, this article makes eight observations, including on the need for more accurate data; better hazard assessment capabilities; enhanced decontamination capacities; and the development of hospital-specific emergency management programmes, a hospital incident command system, and a centralised, dedicated regional disaster coordination centre. With this project, HVAs were conducted successfully for the first time in health care facilities in Abu Dhabi. This study thus serves as another successful example of multidisciplinary emergency preparedness processes. Keywords: Abu Dhabi, disaster, disaster planning, emergency management, emergency preparedness, hazard vulnerability analysis, United Arab Emirates Introduction The disasters of the past decade have led health care systems worldwide to accord increasing priority to emergency management. Over the past few years in particular, disasters—both manmade and natural—have forced health care professionals to confront the vulnerabilities of their emergency preparedness systems and to begin embracing better practices to improve their ability to manage disasters.2 Despite this work, significant disparities—and deficits in coordination—exist between various hospitals in terms of the quality of emergency management, leading to a duplication of efforts and unnecessary costs. The regionalisation of health care-related emergency preparedness has been proposed as a possible way forward. This idea has been implemented locally in Massachusetts and in the Washington, DC, metropolitan area, as well as in countries such as Canada and New Zealand, with positive outcomes related to networking, coordination, standardisation and centralisation of health preparedness practices (Grieb and Clark, 2008; Koh et al., 2008; Lewis and Kouri, 2004; Stoto and Morse, 2008). Furthermore, a Disasters, 2014, 38(2): 420−433. © 2014 The Author(s). Disasters © Overseas Development Institute, 2014 Published by John Wiley & Sons Ltd, 9600 Garsington Road, Oxford, OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA Health care system hazard vulnerability analysis: an assessment of all public hospitals in Abu Dhabi regionalised structure allows for increased levels of training, standardisation and coordination of protocols and processes within the emergency management system, which, in turn, produces more efficient systems (Krimmel, 1997)Hospital Emergency Management Planning Discussion.

This model was recently adopted in Abu Dhabi, the capital of the United Arab Emirates (UAE), with the establishment of the Abu Dhabi Health Services Company (SEHA). The Emirate of Abu Dhabi occupies an area of about 67 square kilometres; in mid2012, it was home to an estimated 2.3 million inhabitants (SCAD, 2013). The emirate itself is comprised of three distinct regions: Abu Dhabi city, Al Ain (the eastern region) and Al Gharbia (the western region). SEHA is tasked with managing and developing the emirate’s public hospitals and clinics. As part of international collaborations between Abu Dhabi and international organisations, Harvard Medical School has partnered with SEHA to carry out the first hazard vulnerability analysis of health facilities in UAE, and probably in the region. Abu Dhabi commits vast amounts of capital to ensure that the medical care it provides is of the highest quality. The preparation for and response to disaster events is addressed utilising SEHA’s health care expertise and resources. Fortunately for Abu Dhabi, experience with actual disasters has been limited. In contrast, the Disaster Medicine Section in the Division of Emergency Medicine at Harvard Medical School is comprised of health care professionals who have national and international disaster response and management experience and expertise. The goal of the collaboration was to bring that expertise to the well-organised and extensive health care system in Abu Dhabi. This interaction between an academic and a non-academic institution was also intended to enhance implementing interventions and increase their effectiveness. An important first step in developing a comprehensive all-hazards approach to disaster preparedness and response, given limited resources and variable risk to different types of disasters, is risk stratification and an evaluation of preparedness needs using a hazard vulnerability analysis (HVA). An HVA is used to identify potential threats systematically; rate the probability of those threats; estimate their impact on a given organisation or region and its resources; and then calculate a relative risk for the organisation or region for such events. This information can be used to guide the development of planning, mitigation and response strategies in a health care facility or community in a way that matches risk with the utilisation of resources. In its chapter on emergency management, the Joint Commission on hospital accreditation states that hospitals conduct HVAs and update them at annual reviews (Joint Commission, 2009). Other terms that have been used to describe this process include risk assessment, risk analysis, hazard analysis, threat assessment and vulnerability assessment. In some situations, HVAs have focused on specific types of hazards. The US Veterans Health Administration, for example, developed hazard and exposure assessments for its hospitals in response to chemical terrorism (Georgopoulos et al., 2004). Meanwhile, some hospitals have focused mainly on bioterrorism (Schultz, Mothershead and Field, 2002); still others concentrate on internal disasters, defined as hazardous events that disrupt operations and that have a direct impact on the hospital’s service capabilities (Aghababian et al., 1994). 421 422 Saleh Fares et al.

Two of the most commonly used tools for conducting HVAs are the Medical Center Hazard and Vulnerability Analysis tool, developed by Kaiser Permanente (KP), and the American Society for Healthcare Engineering HVA. The KP HVA tool was utilised for this project as it is easily accessible and widely available, is being used in the Harvard health care system and many parts of the world, and provides a common basis from which to compare data and share results (Campbell, Trockman and Walker, 2011). The KP HVA tool can be used to produce a quantitative assessment that provides a score (percentage) and graphical representation of hazard-specific relative risk. This tool also allows probability, impact, preparedness, response, resources and risk for hazard categories—whether natural, technological, human or hazardous material (hazmat)—to be evaluated and prioritised. The primary objective of this project was to analyse the level of disaster preparedness in all public hospitals of Abu Dhabi by utilising the HVA tool and through collaboration with the Disaster Medicine Section at Harvard Medical School. The secondary objective was to review existing disaster plans currently in use at those facilities and make recommendations based on the HVA findings. Joint work as a hospital system—rather than a group of individual facilities—and the use of a standardised format was expected to help health care facilities identify and stratify potential hazards and vulnerabilities. This approach was also designed to help identify areas of strength and weaknesses regarding preparedness, mitigation and response; in that way, it allows for planning for all hazards based on scientific and objective data. Methods A standardised and comprehensive HVA was conducted from September to November 2008 at all 12 public hospitals in the Emirate of Abu Dhabi utilising the KP HVA tool. Figure 1 shows the wide distribution of the surveyed hospitals in and around the following regions: • Abu Dhabi city: Al Corniche Hospital, Al Mafraq Hospital, Al Rahba Hospital and Sheikh Khalifa Medical City; • Al Ain: Al Ain Hospital and Tawam Hospital; and • Al Gharbia: Al-Marfa Hospital, Al Sila Hospital, Dalma Hospital, Ghayathi Hospital, Liwa Hospital and Madinat Zayed Hospital. The completed KP HVA was used to compute a relative risk score (percentage) with reference to different hazards for each health care facility. The level of emergency preparedness of a facility against a particular hazard was determined according to the preparedness scores in the KP HVA tool. The public hospitals were divided into primary, secondary and tertiary facilities to facilitate a comparison across hospital categories. The relative risk score (percentage) was computed for all hazards for each facility, as were mean scores of preparedness against possible disasters in each hazard Health care system hazard vulnerability analysis: an assessment of all public hospitals in Abu Dhabi Figure 1. Hospital Emergency Management Planning Discussion

Locations of participating facilities in the Emirate of Abu Dhabi Source: courtesy of Khaula Alkaabi, Geography and Urban Planning Department, College of Humanities and Social Sciences, United Arab Emirates University. classification (natural, technological, human, and hazmat). The level of emergency preparedness against any hazard at a particular level of health care—primary, secondary and tertiary—was then computed as a mean score of preparedness. The ranges of mean scores were accorded the following levels of emergency preparedness: • high: 1.00–1.67; • moderate: 1.68–2.34; • low: 2.35–3.00. A panel of experts in the fields of disaster medicine and emergency management developed reports that focus on the process of the HVA as conducted by each facility; they also conducted limited reviews of facility disaster plans. General observations were collated and recommendations for improvement were generated. Results The KP HVA tool is divided into four categories of hazard: natural, human, technological, and hazmat. Of the 12 public hospitals, 8 reported technological hazards as their highest risk category; 3 identified human hazards as the highest risk; and only 1 cited hazmat hazards (including chemical, radiological and nuclear exposures). All hospitals ranked natural hazards as the lowest or second-lowest threat to their facility (see Tables 1 and 2). The natural hazards category includes temperature extremes, epidemics and earthquakes. All types of public health facilities should have been prepared against natural hazards, yet tertiary health care centres were best prepared for temperature extremes. All facilities were similarly prepared against epidemics, tornadoes and earthquakes (see Table 3). 423 424 Saleh Fares et al. Asked to identify threats posed by technological hazards, all public health care facilities cited internal fires as well as potential failures involving communications, electricity, fire alarms, generators, information systems, sewage, and water. Tertiary hospitals were better prepared for electricity, generator and water failure as compared to other hazards in this category. Secondary and primary health care centres also cited transportation failure and fuel shortage among the technological hazards that warranted preparedness. With reference to human hazards, all public hospitals of Abu Dhabi included preparedness for mass-casualty incidents (meaning trauma and medical or infectious events) and forensic admission. Emergency preparedness for mass casualty trauma Table 1. Hospital ranking of hazard risk levels Type of hazard Number of facilities ranking risk as: Highest Second highest Third highest Lowest Natural hazard 0 0 4 8 Human hazard 3 4 4 1 Technological hazard 8 3 1 0 Hazmat hazard 1 5 3 3 Source: authors. Table 2. Relative hazard risk, by hospital and hazard category Type of health care facility Tertiary hospitals Secondary and specialist hospitals Primary hospitals Source: authors. Hospital name Relative risk scores per hazard Natural Technological Human Hazmat Al Mafraq Hospital 11% 36% 29% 19% Shaikh Khalifa Medical City 20% 36% 37% 29% Tawam Hospital 4% 9% 26% 10% Al Ain Hospital 15% 36% 32% 33% Al Corniche Hospital 20% 53% 31% 39% Al Rahba Hospital 9% 11% 10% 22% Madinat Zayed Hospital 5% 22% 18% 16% Al Marfa Hospital 6% 29% 23% 4% Al Sila Hospital 6% 19% 13% 2% Dalma Hospital 17% 21% 10% 20% Ghayathi Hospital 7% 24% 18% 20% Liwa Hospital 10% 16% 17% 7% Health care system hazard vulnerability analysis: an assessment of all public hospitals in Abu Dhabi Table 3. Emergency preparedness scores per type of health care facility and hazard* Hazard type Natural Technological Human Mean preparedness score per type of health care facility Tertiary Secondary Primary Drought – 2.25 1.60 Earthquake 2.33 2.50 2.80 Epidemic 2.33 1.50 2.60 Temperature extremes 1.25 2.25 1.80 Thunderstorm, severe 2.67 2.75 – Tornado 2.33 – – Communications failure 2.33 2.50 2.40 Electrical failure 1.66 1.50 1.60 Fire alarm failure 2.00 2.25 1.40 Fire, internal 2.00 1.75 1.60 Flood, internal 2.00 – 2.40 Fuel shortage – 2.50 1.80 Generator failure 1.66 1.75 2.00 Hazmat exposure, internal 2.00 2.00 – Heating, ventilation, and air conditioning failure – – 2.00 Information systems failure 2.00 2.00 2.40 Medical gas failure 2.00 1.75 – Medical vacuum failure – 1.25 – Sewer failure 2.33 2.00 1.80 Structural damage 2.33 – – Supply shortage 2.00 2.50 – Transportation failure – 2.00 2.60 Water failure 1.66 1.50 1.60 Bomb threat X X X Civil disturbance X X X Forensic admission 2.33 1.50 2.60 Hostage situation X X X Infant abduction X X X Labour action X X X Mass casualty incident (medical or infectious) 2.33 2.00 2.80 Mass casualty incident (trauma) 1.33 2.25 2.80 Terrorism, biological X X X VIP situation X X X 425 426 Saleh Fares et al. Hazard type Hazardous materials Mean preparedness score per type of health care facility Tertiary Secondary Primary Chemical exposure, external X X X Hazmat incident with mass casualties (>5 victims) – 2.00 – Hazmat incident with limited casualties ( Hospital Emergency Management Planning Discussion