Discussion

This study found no significant difference in the quality of surge capacity preparedness between hospitals that had previously been exposed to a disaster and those that had not. The median score of surge capacity in the hospitals studied was only 65% on the WHO HPP checklist, and thus classified in the “insufficient” category. This suggests that simply experiencing a disaster does not automatically lead to improvement in surge capacity preparedness as measured by the WHO checklist.

The level and effectiveness of preparedness in Finnish hospitals bear comparison with other countries: in the Netherlands in 2002, 89% of hospitals had a disaster plan, in Switzerland in 2018 the same number was 92%, and in South Africa in 2008, it was 93%.^{Reference Stander, Wallis and Smith4,Reference Dell’Era, Hugli and Dami17,Reference van Remmen18} In 2012, the average hospital preparedness level for disaster management amongst 27 European Union member states was 54% when analyzed using a modified WHO toolkit.^{Reference Djalali, Della Corte and Foletti19} In Italy, 3 out of 15 hospitals (20%) and in Yemen, one out of 11 hospitals (9%) had an effective preparedness level with an average overall preparedness level of 56%, and 38% respectively.^{Reference ladhrai, Djalali and Della Corte5,Reference ngrassia, Mangini and Azzaretto10}

The less than adequate consideration of surge capacity in HPPs is a worldwide phenomenon.^{Reference Stander, Wallis and Smith4–Reference ngrassia, Mangini and Azzaretto10} In hospitals in Italy and Yemen, the average surge capacity level was 42% and 38% respectively, when analyzed using the WHO checklist.^{Reference ladhrai, Djalali and Della Corte5,Reference ngrassia, Mangini and Azzaretto10} In Canada, only 54% of the examined hospitals were aware of their surge capacity, while in South Africa, only 26% were aware.^{Reference Stander, Wallis and Smith4,Reference Nantais, Gabbe, Nathens and Gomez6} In a study of 53 Swedish hospitals, the surgical surge capacity could be increased 3.8-fold in respect of trauma teams, surgical theaters, and intensive care unit (ICU) beds available in 8 hours, but their daily usage levels were not analyzed.^{Reference Blimark, Örtenwall and Lönroth9} In USA, 50 - 86% of the examined hospitals had taken into consideration different parts of the surge capacity, like cancellation of elective procedures, and setting up alternate care areas.^{Reference Kaji and Lewis7,Reference Niska and Shimizu8}

There are several reasons why exposure to a disaster may fail to lead to meaningful improvements in surge capacity preparedness. First, it is unclear if all institutions had a structured debriefing process to facilitate the translation of observations into meaningful changes in the disaster plan. This echoes the common theme that lessons observed are not always lessons learned. Second, hospitals who succeed in responding to a disaster may be eager to emphasize the successes in their response, and hesitant to acknowledge the shortcomings. They may feel that no changes are needed to their disaster plans, as they were able to cope with the situation. However, the low overall scores of the surge capacity plans in Finland suggests that improvement is in fact needed. Finally, as disasters are infrequent events, disaster planning may require much more deliberate evaluation and planning to maintain institutional expertise when compared to more normal day-to-day operations.

The overall level of surge capacity preparedness in Finland was insufficient as per the WHO tool: this may be synonymous to the examples of other western countries. Surge capacity is an important marker for overall hospital preparedness, as it is limited not only by the number of beds in the emergency department (ED) and wards, but also by the resources of the ICU, operating rooms, and trauma teams.^{Reference Lennquist1,Reference Kaji, Koenig and Lewis3,Reference Hirshberg, Holcomb and Mattox20–Reference Sheikhbardsiri, Raeisi and Nekoei-Moghadam22} Surge capacity can be locally enhanced (especially in a disaster situation) by maneuvers such as cancelling elective procedures and admissions, adding extra beds, discharging inpatients, and finding alternative sites for care, particularly for less injured and ill patients.^{Reference Kelen, Kraus and McCarthy23,Reference Knouss24} In some papers, the realistic surge capacity of a hospital is thought to be 20% more than its usual capacity.^{Reference ladhrai, Djalali and Della Corte5,Reference ngrassia, Mangini and Azzaretto10} Mathematical models have been introduced to calculate the surge capacity, but they rely heavily on available beds in the ED, which studies show is not the critical part in surge capacity.^{Reference Lennquist1,Reference Hirshberg, Holcomb and Mattox20,Reference Bayram, Zuabi and Subbarao25,Reference Faccincani, Della Corte and Sesana26} The ineffective level of surge capacity in Finnish hospitals might be due to the lack of proper methods for measuring the complex surge capacity or the fact that hospitals tend to overestimate their surge capacity before a disaster or MCI occurs.^{Reference Kaji, Koenig and Lewis3,Reference Hirshberg, Holcomb and Mattox20,Reference Kaji, Koenig and Bey21} In addition, as the demands for patient care continue to grow, many of the resources previously considered as surge capacity reserves are being used on a daily basis, thus reducing the real reserve capacity during a MCI or disaster.^{Reference Lennquist1,Reference Kaji, Koenig and Lewis3,Reference Schafermeyer and Asplin27} Increased demands in health care, centralization of treatment, closure of smaller local hospitals, and nursing shortage has led to overcrowded EDs and aggravated access to primary and specialty care, leading to many hospitals working at full capacity on a daily basis.^{Reference Kaji, Koenig and Lewis3,Reference Niska and Shimizu8,Reference Schafermeyer and Asplin27–Reference Sequeira29} Until now, each of the 21 hospital districts in Finland have been authorized to create, rehearse, and implement their own medical contingency plan without uniform standards.¹³ The lack of a national strategy for disaster preparedness could be contributory, as it may be unrealistic to rely on individual hospitals alone to cope with a disaster in their area.^{Reference Kaji, Koenig and Lewis3,Reference Franco, Toner and Waldhorn30} This study suggests that more consideration and improvement should be directed towards surge capacity in the HPPs in Finland.

Several other interesting insights can be collected from the WHO evaluation checklist scores. This study found that in Finland, at least 97% (28/29) hospitals receiving surgical emergency patients had a written HPP. Overall preparedness level was 76% when analyzed using the WHO checklist, thus considered as “effective.” Finland is a small country in Northern Europe; part of the European Union with a comprehensive social security system, and public healthcare funded by taxation. After the Winter War and Continuation War (1939 – 1944), Finland developed into a politically non-violent and stable country. In 2020 it was 14^th in the Global Peace Index ranking out of 152 countries involved. Currently, Finland is not a geologically disaster-prone country, as seen in the fact that no natural disasters or MCIs have occurred in Finland during the past 25 years. It is also a safe country where only 12 anthropogenic disasters and MCIs occurred during the last 25 years. However, even a moderate number of casualties arriving at the same time to an ED may require special arrangements to be taken into consideration, and thus they can be considered as an MCI: the three incidents labeled as a disaster had 79 – 171 casualties each, thus overwhelming local hospital’s resources. Enhancing the impact of these disasters and MCIs, the hospital staff in a non-disaster-prone country might not feel adequately prepared to confront and work in a disaster.^{Reference Gowing, Walker and Elmer31} The attitude, knowledge, and skills of the hospital staff can be enhanced with training.^{Reference Hirshberg, Holcomb and Mattox20,Reference Gowing, Walker and Elmer31} A proper HPP which includes the key aspects is a crucial part of the disaster response.^{Reference Lennquist1,Reference Waeckerle2,Reference Lewis and Aghababian32} The wide coverage of HPPs in Finland may also be explained by the fact that it is mandatory by law for hospital districts to have a medical contingency plan.¹³ Finland’s military history, size of the population, and wide public health care may explain the overall effective level of HPPs throughout the country.

In the HPP, the area with the most coverage in Finland, is command and control (WHO checklist level 93%). This may reflect the highly organized Finnish Defense Forces. As in the military, a designated Incident Command System consisting of everyday key management staff with additional units or persons is also a widely accepted key feature in the HPP. The hospital incident command system is preferably a linear, hierarchical organization with specific tasks; this is crucial to manage a chaotic and unpredictable situation of a disaster or MCI.^{Reference Lennquist1,Reference Lewis and Aghababian32,Reference Born, Briggs and Ciraulo33} The least prepared aspect nationally, was the post-disaster recovery plan (WHO checklist level 50%). Despite often being understated in the hospital disaster plan, the recovery phase might last from weeks or months, and with increased patient visits in ED, and physically and emotionally tired workers, it may require additional resources, and thus should not be ignored in a plan.^{Reference Lewis and Aghababian32,Reference Born, Briggs and Ciraulo33} The scarce incidence of disasters and MCIs in Finland during the last 25 years might explain the ineffective preparedness in post-disaster recovery.

The primary aim of this study was to determine if surge capacity preparedness differs between hospitals that have previously been exposed to a disaster, and those that have not. This study suggests that exposure to a disaster does not necessarily lead to increased surge capacity when compared to other hospitals in the same country. The results suggest that disaster medicine responders may need to seek a more deliberate or structured approach in turning experience with one disaster into deliberate preparation for the next. In addition, the study suggests that as overall surge capacity preparation in Finland is low, further efforts should be implemented for improvement.

To the best of our knowledge, this is the first study to evaluate hospital disaster preparedness in Finland using an internationally standardized tool. The WHO all-hazard tool Hospital emergency response checklist contains the main key components of a HPP and has been used in previous studies.^{Reference Waeckerle2,Reference ladhrai, Djalali and Della Corte5,Reference ngrassia, Mangini and Azzaretto10,Reference Rezaei, Maracy and Yarmohammadian16,Reference Djalali, Della Corte and Foletti19} This study is also one of the most comprehensive studies exploring overall national hospital preparedness in a developed non-disaster-prone country with 97% of nation’s hospitals included in the study.