Archives of Academic Emergency Medicine. 2019; 7 (1): e58 REV I EW ART I C L E The Preparedness of Hospital Emergency Departments for Responding to Disasters in Iran; a Systematic Review and Meta-Analysis Mosayeb Kazemzadeh1, Elham Shafiei2, Katayoun Jahangiri3, Kosar Yousefi2, Ali Sahebi3∗ 1. MSC in Health Care Management, Ilam University of Medical Sciences, Ilam, Iran. 2. Clinical Research Development Unit, Shahid Mostafa Khomeini hospital, Ilam University of Medical Sciences, Ilam, Iran. 3. Department of Health in Disasters and Emergencies, School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Received: August 2019; Accepted: September 2019; Published online: 8 October 2019 Abstract: Introduction: Hospitals are the most important infrastructures of any society. The hospital emergency depart- ment is one of the most important wards of hospitals in response to disasters. The purpose of this study was to evaluate the preparedness of hospital emergency departments in response to disasters in Iran via a system- atic review and meta-analysis. Methods: This study was a systematic review and meta-analysis. The litera- ture search was conducted in the national and international databases including SID, Magiran, Irandoc, Google scholar, Medline, Scopus, and ISI. Valid Persian and English keywords were used to extract articles related to the preparedness of hospital emergency departments in response to disasters. The STROBE checklist was used to evaluate the quality of the articles, and the I2 index was used to assess heterogeneity among the studies. Statisti- cal analyses were conducted using STATA14 software. Results: In this study, 185 articles were initially recruited. Meta-analysis was finally performed on 4 articles selected based on inclusion criteria. The analysis included a total of 51 hospitals in Iran. According to our results, the mean preparedness of hospital emergency departments in response to disasters was calculated as 54.64% (95% CI = 41.15-68.13, I2 = 0.0%; p = 0.727). Conclusion: The results of this study showed that the average level of preparedness of hospital emergency departments in Iran to respond to disasters was moderate to high. Therefore, planning and actions should be considered based on the guidelines and accreditation standards to enhance the preparedness of hospital emergency departments in response to disasters. Keywords: Disasters; disaster medicine; emergency service, hospital; meta-analysis as topic Cite this article as: Kazemzadeh M, Shafiei E, Jahangiri K, Yousefi K, Sahebi A. The Preparedness of Hospital Emergency Departments for Responding to Disasters in Iran; a Systematic Review and Meta-Analysis. Arch Acad Emerg Mede. 2019; 7(1): e58. 1. Introduction Hospitals are among the most important infrastructures of any society. The constant activity of hospitals is essential for providing health services to the injured, both in normal con- ditions and in disasters (1). In addition to inflicting individ- uals, disasters have many impacts on the functional, struc- tural and non-structural components of hospitals (2). Hospi- tal preparedness is a part of Disaster management cycle. Dis- ∗Corresponding Author: Ali Sahebi; Department of Health in Disasters and Emergencies, School of Public Health and Safety, Shahid Beheshti Uni- versity of Medical Sciences, Tehran, Iran. Tel: 00989183434703, Email: Ali.sahebi@sbmu.ac.ir aster management preparedness consists of 9 components, the most important of which is planning. Planning includes policies and programs to minimize disaster consequences. Hospitals need to remain fully operational during disasters, and the assessment of hospital readiness is essential to en- sure this issue (3). Studies have reported moderate levels of structural, non-structural and functional safety in most Ira- nian hospitals to respond to disasters. Therefore, there is a need for proper planning and actions to improve the hospital safety level (4). A study conducted on 224 hospitals in Iran in 2014 showed that the majority (54.5%) of Iran’s hospitals had high vulnerability to disasters (5). Among hospital wards, the emergency department is a key section in response to dis- asters. This is because emergency departments play a vital This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem M. Kazemzadeh et al. 2 role in providing 24-hour acute care services to outpatients, inpatients, and those in immediate need for assistance (6). The personnel of emergency departments are hospital’s first responders to disasters and therefore, need to be appropri- ately prepared (7). The emergency department is the gate- way for patients to enter the hospital. On the other hand, hospitals face a wide range of disasters and are responsible for responding to a variety of emergencies ranging from traf- fic accidents to terrorist attacks. Hence, the preparedness of emergency department should not be neglected facing such incidents (8). At the time of disasters, the efficiency of emer- gency departments to manage Mass casualty incidents (MCI) depends on the availability and adequacy of human and fi- nancial resources (9). The purpose of this study was to eval- uate the preparedness of hospital emergency departments in Iran for responding to disasters via a systematic review and meta-analysis. 2. Methods: The present study was conducted based on the guidelines of Preferred Reporting Items for Systematic Reviews and Meta- Analyses (PRISMA) (10). To prevent bias, search, selection of studies, quality evaluation and data extraction were con- ducted by two researchers, independently in each stage. An agreement on the obtained data was finally achieved through group discussions. 2.1. Search strategy The electronic search was conducted in Irandoc, SID, Ma- giran, Scopus, PubMed (MEDLINE), Embase, and Web of science databases and manual search was done in Google Scholar using valid English keywords and their Persian equiv- alents. The keywords included emergency ward, emergency unit, emergency room, hospital, response, emergency pre- paredness, emergency readiness, disaster, hospital emer- gency preparedness, and Iran. The keywords were com- bined using (AND) and (OR) operators. The search strategy in PubMed used the following terms: ((((("civil defense"[MeSH Terms] OR ("civil"[All Fields] AND "defense"[All Fields]) OR "civil defense"[All Fields] OR ("emergency"[All Fields] AND "preparedness"[All Fields]) OR "emergency prepared- ness"[All Fields]) OR (("emergencies"[MeSH Terms] OR "emergencies"[All Fields] OR "emergency"[All Fields]) AND readiness[All Fields])) AND response[All Fields]) AND ("dis- asters"[MeSH Terms] OR "disasters"[All Fields] OR "disas- ter"[All Fields])) AND ("hospitals"[MeSH Terms] OR "hospi- tals"[All Fields] OR "hospital"[All Fields]) AND ("iran"[MeSH Terms] OR "iran"[All Fields])) . The timespan of gathering studies was limited to the end of July 2019. 2.2. Inclusion criteria The inclusion criterion was descriptive cross-sectional stud- ies that reported the rate of preparedness of emergency de- partments of Iranian hospitals in response to disasters based on the checklist presented by the world health organization (WHO) (11). The WHO hospital emergency response check- list consists of 9 sections and 90 questions. The average over- all preparedness score ranged from 0 to 100. The mean scores of 0-20, 21- 40, 41-60, 61-80 and 81-100 indicated very poor, poor, moderate, good and excellent readiness, respectively (12). Studies in both English and Persian were included. 2.3. Exclusion criteria Studies evaluating the preparedness or safety of hospitals in response to disasters as well as those evaluating the pre- paredness of emergency departments using tools other than the WHO instrument were excluded. 2.4. Qualitative assessment The quality assessment of the studies was performed using the standard 22-item STROBE checklist (13). The minimum and maximum obtainable scores using this checklist were 0 and 44, respectively. Studies that acquired a minimum score of 16 were selected for meta-analysis. 2.5. Data Extraction Initially, articles with unrelated titles were removed and then the abstracts and full texts of related articles were reviewed according to the inclusion criteria. The required data was extracted from the included articles using a pre-prepared checklist. The collected data included the first author, the location of study, the year of study publication, type of the study, number of evaluated hospitals, instruments used in the study, and finally the mean level of emergency depart- ment preparedness in response to disasters. 3. Statistical analysis Since the average level of preparedness of hospital emer- gency department in response to disasters was extracted based on the number of evaluated hospitals, binomial dis- tribution was used to calculate the variance of each study. The weighted average was used to combine the prepared- ness levels in different studies. Each study was weighted in- versely corresponding to its variance. The heterogeneity in- dex of studies was calculated as 0.0%, which was in the range of low heterogeneity indices (i.e. I2 indices <25%, 25 to 75%, and >75% indicate low, medium and high heterogeneities, re- spectively) (14). Therefore, the fixed effects model was used for meta-analysis. In the present study, Egger’s test was con- ducted to evaluate the possibility of publication bias. The data were analyzed using STATA software (version 14). This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 3 Archives of Academic Emergency Medicine. 2019; 7 (1): e58 Figure 1: PRISMA flow diagram of the study. Table 1: The characteristics of the selected studies in meta-analysis First author Place Year Study type Hospitals* Instrument Quality Mean % Yousefli (12) Ghazvin 2014 CS 6 WHO Good 70.72 Hasanpoor(20) Karaj 2015 CS 13 WHO Good 44.17 Janati (21) Tabriz 2018 CS 18 WHO Good 54.26 Seyedin (22) Tehran 2018 CS 14 WHO Good 56.93 *: Number of hospitals. CS: cross-sectional, WHO: world health organization checklist. 4. Results: In the initial search, 185 related studies were identified. Of these, 181 studies were excluded due to not fulfilling the in- clusion criteria. Finally, 4 cross-sectional studies evaluat- ing 51 hospitals between 2015 and 2018 entered quality as- sessment and meta-analysis. Figure 1 shows the process of study selection. Finally, 4 studies with good quality entered the meta-analysis. All the included studies used the Hospi- tal Emergency Response checklist presented by WHO. Table 1 displays the general specifications and the data extracted from each study. According to our results, the overall pre- paredness of emergency departments of Iranian hospitals in This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem M. Kazemzadeh et al. 4 Figure 2: The forest plot of the overall and individual percentages of emergency department preparedness of Iranian hospitals for responding to disasters with 95% confidence interval. response to disasters was 54.64% (95% CI = 41.15-68.13, I2 = 0.0%, p = 0.727) (Figure 2). The highest and lowest levels of preparedness were reported in the studies of Yousefli et al. in Qazvin and Hasanpoor et al. in Karaj, respectively. The Result of Egger’s test showed that the effect of publication bias was not significant (p = 0.396). 5. Discussion: In the present review, cross-sectional studies reporting the preparedness of emergency departments in response to dis- asters in 51 Iranian hospitals were analyzed. These studies used the standard checklist developed by the WHO. Overall, the preparedness of hospital emergency departments in re- sponse to disasters was 54.64% (95% CI = 41.15-68.13, I2 = 0.0%, p = 0.727) indicating a moderate to high level of pre- paredness. In a study in 2016, Asefzadeh et al. (4) showed that overall preparedness for facing disasters was at moder- ate level in hospitals in Iran. The overall safety level of Ilam health centers in 2016 was estimated as 22.79%(15). The re- sults of a study by Jalali et al. comparing hospital disaster pre- paredness between Iran and Sweden showed that Swedish hospitals were at level "A", while Iranian hospitals attained level "B". There was no relationship between hospital readi- ness level and neither the hospital’s size or affiliation. How- ever, the level of hospital readiness was significantly related to the social and economic levels of each country. Further- more, poor hospital readiness was due to the lack of contin- gency plans and the inadequacy of resources (16). Consider- ing the vital role of hospitals in treating the injured and re- ducing mortality in disasters, hospitals should be prepared to respond to disasters regardless of the economic status of each country. The results of another study by Amiri et al. (17) showed that the hospital preparedness in response to disas- ters was at moderate level in 53 hospitals in northern Iran. In the recent report, it was highlighted that educational pro- grams, hospital resilience, drills, and exercises significantly contributed to improving hospital readiness. In a study, Al- adhrai et al. examined the readiness of Yemen hospitals be- tween 2011 and 2013 using the WHO hospital emergency response checklist and showed that no significant improve- ment was made in Yemen hospitals preparedness against dis- asters during this period. In fact, the recent report revealed poor performance of all elements that were important for hospital preparedness such as management, surge capacity, and safety. This fact highlights the importance of implement- ing strategic plans, guidelines, and procedures by health au- thorities to promote disaster preparedness (18). The results of a study in 2016 by Ingrassia et al. who evaluated the re- sponse to disaster of emergency departments at 15 hospitals in Italy showed that 12 hospitals were inadequately prepared. Based on the WHO hospital emergency response checklist, This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 5 Archives of Academic Emergency Medicine. 2019; 7 (1): e58 the average preparedness level was lower than normal in the evaluated hospitals (19). Factors affecting the prepared- ness level of emergency departments included staff, equip- ment, and systems (8). Following disasters, the emergency departments of hospitals suddenly become overcrowded due to mass casualties, so they must be prepared to respond to the situation. The results of several studies showed that the preparedness of hospitals to respond to disasters in Iran was at moderate level. Therefore, given the high incidence of dis- asters in Iran, health policymakers should plan appropriate strategies and take adequate measures to improve disaster preparedness at all management levels. 6. Limitations There were very few studies that reported the status of hospi- tal emergency response to disasters using the WHO checklist. 7. Conclusion According to the findings of the present review, the over- all preparedness level of emergency departments of Iranian hospitals in response to disasters was moderate to high. In addition, the level of hospital preparedness in response to disasters was also moderate in Iran. Therefore, given the high incidence of disasters in Iran, health policymakers should take appropriate actions and implement required plans at all management levels using guidelines and accreditation stan- dards to enhance the preparedness of hospital emergency departments in response to disasters. 8. Appendix 8.1. Acknowledgements We thank all the colleagues and researchers who contributed to the present review by publishing their results. 8.2. Authors Contributions Study design: Mosayeb Kazemzadeh and Ali Sahebi Systematic search, Study selection, and quality assessment: Elham Shafiei, Kosar yousefi Statistical analyses and interpretation of data: Ali Sahebi, Elham Shafiei Drafting of the manuscript: Katayoun Jahangiri and Mosayeb kazemzadeh The final version of the manuscript was accepted by all authors. Authors ORCIDs Mosayeb Kazemzadeh: 0000-0003-0299-5833 Elham Shafiei: 0000-0001-5689-5235 Katayoun Jahangiri: 0000-0003-2061-1418 Kosar Yousefi: 0000-0002-7501-9238 Ali Sahebi: 0000-0003-4662-8998 8.3. Funding Support None. 8.4. Conflict of Interest The authors do not have any conflict of interest to declare. References 1. Jahangiri K, Izadkhah YO, Lari A. Hospital safety index (HSI) analysis in confronting disasters: A case study from Iran. International Journal of Health System and Disaster Management. 2014;2(1):44. 2. Ghafouri RR, Hosseini SM, Pouraghaei M. Are our hos- pitals safe against disasters? An evaluation of hospital safety index in Tabriz, Iran. Journal of Analytical Research in Clinical Medicine. 2018;6(3):139-44. 3. Nekoie-Moghadam M, Kurland L, Moosazadeh M, In- grassia PL, Della Corte F, Djalali A. Tools and checklists used for the evaluation of hospital disaster preparedness: a systematic review. Disaster medicine and public health preparedness. 2016;10(5):781-8. 4. Asefzadeh S, Rajaee R, Ghamari F, Kalhor R, Gholami S. Preparedness of Iranian Hospitals Against Disasters. Biotechnology and Health Sciences. 2016;3(3):1-6. 5. Ardalan A, Kandi M, Talebian MT, Khankeh H, Masoumi G, Mohammadi R, et al. Hospitals safety from disasters in IR iran: the results from assessment of 224 hospitals. PLoS currents. 2014;6. 6. Cimellaro GP. A Model to Evaluate Disaster Resilience of an Emergency Department. Urban Resilience for Emer- gency Response and Recovery: Springer; 2016. p. 361-87. 7. Paganini M, Borrelli F, Cattani J, Ragazzoni L, Djalali A, Carenzo L, et al. Assessment of disaster preparedness among emergency departments in Italian hospitals: a cautious warning for disaster risk reduction and manage- ment capacity. Scandinavian journal of trauma, resusci- tation and emergency medicine. 2016;24(1):101. 8. Marzaleh MA, Rezaee R, Rezaianzadeh A, Rakhshan M, Hadadi G, Peyravi M. Emergency Department Prepared- ness of Hospitals for Radiation, Nuclear Accidents, and Nuclear Terrorism: A Qualitative Study in Iran. Iranian Red Crescent Medical Journal. 2019(In Press). 9. Gul M, Guneri AF. Simulation modelling of a pa- tient surge in an emergency department under disas- ter conditions. Croatian Operational Research Review. 2015;6(2):429-43. 10. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred re- porting items for systematic reviews and meta-analyses: the PRISMA statement. International journal of surgery (London, England). 2010;8(5):336-41. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem M. Kazemzadeh et al. 6 11. Bortolin M, S. Sorensen B, D. Zane R, E. Wante B, B. Rao M, Rockenschaub G. Hospital emergency response checklist An all-hazards tool for hospital administrators and emergency managers Supported by The European Commission Together for Health2010. 12. Yousefli M, Asefzadeh S, PartoviShayan Z. Evaluation of Emergency wards readiness for responding to disasters and emergencies at hospitals of Qazvin University of Medical Sciences according to World Health Organiza- tion Model 2012. 2. 2014;6(2):0-. 13. Vandenbroucke JP, von Elm E, Altman DG, GÃÿtzsche PC, Mulrow CD, Pocock SJ, et al. Strengthening the Report- ing of Observational Studies in Epidemiology (STROBE): explanation and elaboration. International journal of surgery. 2014;12(12):1500-24. 14. Yousefi K, Adibi-Larijani H, Golitaleb M, Sahebi A. Knowl- edge, Attitude and Performance Associated with Disas- ter Preparedness in Iranian Nurses: A Systematic Re- view and Meta-analysis. Advanced Journal of Emergency Medicine. 2019. 15. Jahangiri K, Rostami N, Sahebi A. Challenges of Utiliz- ing the Primary Health Safety Index Tool for Assessing the Vulnerability of Healthcare Centers to Disasters. Ad- vanced Journal of Emergency Medicine. 2019. 16. Djalali A, Castren M, Khankeh H, Gryth D, Radestad M, ÃŰhlen G, et al. Hospital Disaster Preparedness as Mea- sured by Functional Capacity: a Comparison between Iran and Sweden. Prehospital and Disaster Medicine. 2013;28(5):454-61. 17. Amiri M, Raei M, Nasrollahpour Shirvani SD, Moham- madi GR, Afkar A, Jahani-tiji M, et al. Preparedness of Af- filiated Hospitals of Universities in North of Iran to Con- front Disasters in the Year 2011. Hospital. 2013;12(1):19- 28. 18. Aladhrai SA, Djalali A, Della Corte F, Alsabri M, El-Bakri NK, Ingrassia PL. Impact of the 2011 revolution on hos- pital disaster preparedness in Yemen. Disaster medicine and public health preparedness. 2015;9(4):396-402. 19. Ingrassia PL, Mangini M, Azzaretto M, Ciaramitaro I, Costa L, Burkle JF, et al. Hospital Disaster Preparedness in Italy: a preliminary study utilizing the World Health Organization Hospital Emergency Response Evaluation Toolkit. Minerva anestesiologica. 2016;82(12):1259-66. 20. Hasanpoor E, nazari m. Hospital Emergency Response of Iran’s Hospitals against Disasters: A Case Study in Karaj. journal of hospital. 2015;4. 21. Janati A, Sadeghi-Bazargani H, Hasanpoor E, Sokhanvar M, HaghGoshyie E, Salehi A. Emergency response of Ira- nian hospitals against disasters: a practical framework for improvement. Disaster medicine and public health preparedness. 2018;12(2):166-71. 22. Seyedin SH, Hasanpoor E, Hasanzadeh E, Sheikhy- Chaman M. Assessment of Hospital Emergency Re- sponse Against Disasters Hospitals Of Iran Univer- sity of Medical Siences: 2017. Health_Based Research. 2018;4(2):159-67. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem Introduction Methods: Statistical analysis Results: Discussion: Limitations Conclusion Appendix References