Flexible Surge Capacity in Disasters and Major Incidents Phatthranit Phattharapornjaroen Department of Surgery Institute of Clinical Sciences Sahlgrenska Academy, University of Gothenburg Gothenburg 2024 Cover illustration: The image was generated with the assistance of AI. © Phatthranit Phattharapornjaroen 2024 Phatthranit.phattharapornjaroen@gu.se ‘It always seems impossible until it’s done’ Phatthranit.pha@gmail.com - Nelson Mandela - ISBN: 978-91-8069-683-8 (PRINT) ISBN: 978-91-8069-684-5 (PDF) http://hdl.handle.net/2077/79338 Printed in Borås, Sweden 2024 AN ENMÄ NENMÄ R V R K VA KEE Printed by Stema Specialtryck AB Trycksak 3T0r4y1c k0s2a3k4 3041 0234 SS TT Cover illustration: The image was generated with the assistance of AI. © Phatthranit Phattharapornjaroen 2024 Phatthranit.phattharapornjaroen@gu.se ‘It always seems impossible until it’s done’ Phatthranit.pha@gmail.com - Nelson Mandela - ISBN: 978-91-8069-683-8 (PRINT) ISBN: 978-91-8069-684-5 (PDF) http://hdl.handle.net/2077/79338 Printed in Borås, Sweden 2024 Printed by Stema Specialtryck AB Flexible Surge Capacity in Disasters and Major Incidents Phatthranit Phattharapornjaroen Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden ABSTRACT In the face of the escalating frequency of disasters and major incidents, the imperative for surge capacity expansion becomes apparent for effective emergency response. However, existing preparedness measures often hinge on available resources and prove insufficient when confronted with disaster dynamics. The thesis aims to assess the feasibility and applicability of the "flexible surge capacity” (FSC) concept, focusing on leveraging community resources and collaboration among various entities across different disaster etiologies. The research method employed a descriptive construction of the FSC concept to establish its framework for generalization and evaluation. Subsequently, a pragmatic approach integrating both qualitative and quantitative research methods using online surveys, direct observation, and semi-structured interviews was adopted to explore the implications of the concept. The findings reveal the promising feasibility and applicability of the FSC concept in urbanized communities. Facilities of interest expressed willingness to participate, and the concept implementation demonstrated effectiveness in alleviating overcrowded hospitals during the Coronavirus 2019 pandemic and facilitating hospital evacuation through the Three-level Collaboration exercise. Additionally, educational initiatives led to significant improvements in staff engagement and system sustainability. In conclusion, FSC, aligning with the proactivity philosophy of the World Health Organization, proves instrumental in optimizing the use of community resources and fostering effective collaboration in disaster management. Keywords: surge capacity, leadership, multiagency collaboration, disaster preparedness, hospital evacuation, exercise ISBN: 978-91-8069-683-8 (PRINT) http://hdl.handle.net/2077/79338 ISBN: 978-91-8069-684-5 (PDF) Flexible Surge Capacity in Disasters and Major Incidents Phatthranit Phattharapornjaroen Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden ABSTRACT In the face of the escalating frequency of disasters and major incidents, the imperative for surge capacity expansion becomes apparent for effective emergency response. However, existing preparedness measures often hinge on available resources and prove insufficient when confronted with disaster dynamics. The thesis aims to assess the feasibility and applicability of the "flexible surge capacity” (FSC) concept, focusing on leveraging community resources and collaboration among various entities across different disaster etiologies. The research method employed a descriptive construction of the FSC concept to establish its framework for generalization and evaluation. Subsequently, a pragmatic approach integrating both qualitative and quantitative research methods using online surveys, direct observation, and semi-structured interviews was adopted to explore the implications of the concept. The findings reveal the promising feasibility and applicability of the FSC concept in urbanized communities. Facilities of interest expressed willingness to participate, and the concept implementation demonstrated effectiveness in alleviating overcrowded hospitals during the Coronavirus 2019 pandemic and facilitating hospital evacuation through the Three-level Collaboration exercise. Additionally, educational initiatives led to significant improvements in staff engagement and system sustainability. In conclusion, FSC, aligning with the proactivity philosophy of the World Health Organization, proves instrumental in optimizing the use of community resources and fostering effective collaboration in disaster management. Keywords: surge capacity, leadership, multiagency collaboration, disaster preparedness, hospital evacuation, exercise ISBN: 978-91-8069-683-8 (PRINT) http://hdl.handle.net/2077/79338 ISBN: 978-91-8069-684-5 (PDF) SAMMANFATTNING PÅ SVENSKA LIST OF PAPERS Med ökningen av antalet katastrofer och allvarliga händelser, blir behovet av This thesis is based on the following studies, referred to in the text by their snabba och effektiva insatser alltmer påtagligt. Denna avhandling syftar till att Roman numerals. pröva tillämpningen av "flexibel kapacitetsökning" (Flexible Surge Capacity=FSC) med avseende genomförbarheten vid katastrofhantering. I. Phattharapornjaroen, P. et al. Developing a conceptual framework for flexible surge capacity based on complexity Fokus i avhandlingens delstudier är samverkan mellan olika enheter och and collaborative theoretical frameworks. integrering av samhällsresurser. Public Health. 2022; 208: 46-51. Metod doi:10.1016/j.puhe.2022.04.012. Epub 2022 Jun 7. PMID: 35687955. För att tydligöra FSC-konceptet fastställdes först dess betydelse och teoretiska ramverk. Med denna utgångspunkt har det i avhandlingens II. Phattharapornjaroen, P. et al. The Feasibility of delstudier värderats hur konceptet kan operationaliseras. Ett pragmatiskt Implementing the Flexible Surge Capacity Concept in Bangkok: Willing Participants and Educational Gaps. tillvägagångssätt antgogs där såväl kvalitativa som kvantitativa forskningsmetoder har använts. Det har inkluderat onlineundersökningar, Int J Environ Res Public Health. 2021;18(15):7793. doi: direkta observationer och semistrukturerade intervjuer. 10.3390/ijerph18157793. PMID: 34360083. III. Phattharapornjaroen, P. et al. Community-based response Resultat to the COVID-19 pandemic: a case study of a home Resultaten visar lovande möjligheter att implementera FSC-konceptet i isolation center using flexible surge capacity. urbaniserade samhällen. Lämpliga faciliteter i samhället visade villighet att Public Health. 2022; 211: 29-36. doi: delta vid hanteringen av katastrofer. FSC-konceptet operationaliserades 10.1016/j.puhe.2022.06.025. Epub 2022 Jul 13. PMID: framgångsrikt vid hantering av överfulla sjukhus under pågående Coronavirus 35994836. 2019-pandemin. Under simuleringsövningar där större sjukhus evakuerades IV. Phattharapornjaroen, P. et al. Assessing Thai Hospitals’ tillämpades konceptet. Avhandlingen visar också att anpassade Evacuation Preparedness Using the Flexible Surge Capacity utbildningsinitiativ resulterar i betydande förbättringar i personalengagemang Concept and Its Collaborative Tool. och systemhållbarhet. Int J Disaster Risk Sci 14, 52–63 (2023). https://doi.org/10.1007/s13753-023-00468-z Slutsats V. Phattharapornjaroen, P. et al. The impact of the three-level Sammanfattningsvis visar sig FSC, i enighet med Världshälsoorganisationens collaboration exercise on collaboration and leadership proaktivitetsfilosofi, bidra till att optimera användningen av samhällets during scenario-based hospital evacuation exercises using resurser och främja en effektiv samverkan vid hantering av katastrofer. flexible surge capacity concept: a mixed method cross- sectional study. BMC Health Serv Res. 2023 Aug 14;23(1):862. doi: 10.1186/s12913-023-09882-x. SAMMANFATTNING PÅ SVENSKA LIST OF PAPERS Med ökningen av antalet katastrofer och allvarliga händelser, blir behovet av This thesis is based on the following studies, referred to in the text by their snabba och effektiva insatser alltmer påtagligt. Denna avhandling syftar till att Roman numerals. pröva tillämpningen av "flexibel kapacitetsökning" (Flexible Surge Capacity=FSC) med avseende genomförbarheten vid katastrofhantering. I. Phattharapornjaroen, P. et al. Developing a conceptual framework for flexible surge capacity based on complexity Fokus i avhandlingens delstudier är samverkan mellan olika enheter och and collaborative theoretical frameworks. integrering av samhällsresurser. Public Health. 2022; 208: 46-51. Metod doi:10.1016/j.puhe.2022.04.012. Epub 2022 Jun 7. PMID: 35687955. För att tydligöra FSC-konceptet fastställdes först dess betydelse och teoretiska ramverk. Med denna utgångspunkt har det i avhandlingens II. Phattharapornjaroen, P. et al. The Feasibility of delstudier värderats hur konceptet kan operationaliseras. Ett pragmatiskt Implementing the Flexible Surge Capacity Concept in Bangkok: Willing Participants and Educational Gaps. tillvägagångssätt antgogs där såväl kvalitativa som kvantitativa forskningsmetoder har använts. Det har inkluderat onlineundersökningar, Int J Environ Res Public Health. 2021;18(15):7793. doi: direkta observationer och semistrukturerade intervjuer. 10.3390/ijerph18157793. PMID: 34360083. III. Phattharapornjaroen, P. et al. Community-based response Resultat to the COVID-19 pandemic: a case study of a home Resultaten visar lovande möjligheter att implementera FSC-konceptet i isolation center using flexible surge capacity. urbaniserade samhällen. Lämpliga faciliteter i samhället visade villighet att Public Health. 2022; 211: 29-36. doi: delta vid hanteringen av katastrofer. FSC-konceptet operationaliserades 10.1016/j.puhe.2022.06.025. Epub 2022 Jul 13. PMID: framgångsrikt vid hantering av överfulla sjukhus under pågående Coronavirus 35994836. 2019-pandemin. Under simuleringsövningar där större sjukhus evakuerades IV. Phattharapornjaroen, P. et al. Assessing Thai Hospitals’ tillämpades konceptet. Avhandlingen visar också att anpassade Evacuation Preparedness Using the Flexible Surge Capacity utbildningsinitiativ resulterar i betydande förbättringar i personalengagemang Concept and Its Collaborative Tool. och systemhållbarhet. Int J Disaster Risk Sci 14, 52–63 (2023). https://doi.org/10.1007/s13753-023-00468-z Slutsats V. Phattharapornjaroen, P. et al. The impact of the three-level Sammanfattningsvis visar sig FSC, i enighet med Världshälsoorganisationens collaboration exercise on collaboration and leadership proaktivitetsfilosofi, bidra till att optimera användningen av samhällets during scenario-based hospital evacuation exercises using resurser och främja en effektiv samverkan vid hantering av katastrofer. flexible surge capacity concept: a mixed method cross- sectional study. BMC Health Serv Res. 2023 Aug 14;23(1):862. doi: 10.1186/s12913-023-09882-x. CONTENTS ETHICAL CONSIDERATIONS 46 RESULTS 48 STUDY I 48 STUDY II 49 Non-response Analysis 53 ABBREVIATIONS 1 STUDY III 54 STUDY IV 55 DEFINITIONS IN SHORT 2 Non-response Analysis 56 INTRODUCTION 6 STUDY V 57 SURGE CAPACITY FOR DISASTER RESPONSE 9 DISCUSSION 61 Enhancing Surge Capacity 10 Limitations 67 LEADERSHIP AND MULTIAGENCY COLLABORATIONS FOR DISASTER RESPONSE 10 Leadership and Collaborative Measures 10 CONCLUSION 70 Multiagency Collaboration 14 FUTURE PERSPECTIVES 71 HEALTHCARE INTERVENTION IMPLEMENTATION 16 ACKNOWLEDGMENT 72 Key Uncertainties 17 Contexts 20 REFERENCES 75 RESEARCH METHODS FOR DISASTER MANAGEMENT 23 APPENDIX 93 THE RATIONALE OF THE THESIS 24 STUDY II 93 AIMS 27 Information Sheet, Questionnaire and interview guide 93 METHODS 29 STUDY III 98 Observation and interview concepts on the CSCATTT 98 CONCEPTUAL AND THEORETICAL FRAMEWORK OF THE FLEXIBLE SURGE CAPACITY STUDY IV 99 (FSC) (STUDY I) 31 Hospital evacuation questionnaire 99 Review, Identification, and Selection of Literature 31 STUDY V 101 Integrating, Synthesizing, and Proposing the Conceptual Framework of the Flexible The self-evaluation form 101 Surge Capacity (FSC) 35 The Observational Checklist 103 FEASIBILITY STUDY OF THE FSC CONCEPT IN COMMUNITIES AND HOSPITALS (STUDY II The 3LC exercise scenarios 109 & IV) 35 Participants 36 INDEX 110 Study Tools 36 Data Collection and Processing 38 Data Analysis 40 APPLICABILITY STUDY AND IMPLEMENTATION IN DIVERSE INCIDENTS (STUDY III & V) 41 Study Design, Participants, and Data Collection 41 Study Tool 44 Data Analysis 45 CONTENTS ETHICAL CONSIDERATIONS 46 RESULTS 48 STUDY I 48 STUDY II 49 Non-response Analysis 53 ABBREVIATIONS 1 STUDY III 54 STUDY IV 55 DEFINITIONS IN SHORT 2 Non-response Analysis 56 INTRODUCTION 6 STUDY V 57 SURGE CAPACITY FOR DISASTER RESPONSE 9 DISCUSSION 61 Enhancing Surge Capacity 10 Limitations 67 LEADERSHIP AND MULTIAGENCY COLLABORATIONS FOR DISASTER RESPONSE 10 Leadership and Collaborative Measures 10 CONCLUSION 70 Multiagency Collaboration 14 FUTURE PERSPECTIVES 71 HEALTHCARE INTERVENTION IMPLEMENTATION 16 ACKNOWLEDGMENT 72 Key Uncertainties 17 Contexts 20 REFERENCES 75 RESEARCH METHODS FOR DISASTER MANAGEMENT 23 APPENDIX 93 THE RATIONALE OF THE THESIS 24 STUDY II 93 AIMS 27 Information Sheet, Questionnaire and interview guide 93 METHODS 29 STUDY III 98 Observation and interview concepts on the CSCATTT 98 CONCEPTUAL AND THEORETICAL FRAMEWORK OF THE FLEXIBLE SURGE CAPACITY STUDY IV 99 (FSC) (STUDY I) 31 Hospital evacuation questionnaire 99 Review, Identification, and Selection of Literature 31 STUDY V 101 Integrating, Synthesizing, and Proposing the Conceptual Framework of the Flexible The self-evaluation form 101 Surge Capacity (FSC) 35 The Observational Checklist 103 FEASIBILITY STUDY OF THE FSC CONCEPT IN COMMUNITIES AND HOSPITALS (STUDY II The 3LC exercise scenarios 109 & IV) 35 Participants 36 INDEX 110 Study Tools 36 Data Collection and Processing 38 Data Analysis 40 APPLICABILITY STUDY AND IMPLEMENTATION IN DIVERSE INCIDENTS (STUDY III & V) 41 Study Design, Participants, and Data Collection 41 Study Tool 44 Data Analysis 45 ABBREVIATIONS 3LC Three Level Collaboration ACFs Alternative Care Facilities COVID-19 Coronavirus 2019 CSCATTT Command and control, Safety, Communication, Assessment, Triage, Treatment, Transport CRED Center for Research on the Epidemiology of Disasters DRR Disaster Risk Reduction FSC Flexible Surge Capacity HIC Home Isolation Center ICS Incident Command MIMMS Major Incident Medical Management and Support PHCCs Public Primary Healthcare Centers SDGs Sustainable Development Goals UN The United Nations UNDRR The United Nations Office for Disaster Risk Reduction WHO The World Health Organization 1 ABBREVIATIONS 3LC Three Level Collaboration ACFs Alternative Care Facilities COVID-19 Coronavirus 2019 CSCATTT Command and control, Safety, Communication, Assessment, Triage, Treatment, Transport CRED Center for Research on the Epidemiology of Disasters DRR Disaster Risk Reduction FSC Flexible Surge Capacity HIC Home Isolation Center ICS Incident Command MIMMS Major Incident Medical Management and Support PHCCs Public Primary Healthcare Centers SDGs Sustainable Development Goals UN The United Nations UNDRR The United Nations Office for Disaster Risk Reduction WHO The World Health Organization 1 DEFINITIONS IN SHORT Mitigation The process involves reducing the adverse impacts of a hazardous event 1. Hospital evacuation The acts of relocating individuals and assets Field specific terms temporarily to secure locations before, during, or after the onset of a hazardous Disaster An abrupt and severe occurrence that event with the primary goals of induces substantial disruption to the normal safeguarding lives and assets (can take one functioning and operational dynamics of a to several days) 1. community or society, resulting in extensive human, material, economic, and Surge capacity The ability of organizations or systems to environmental setbacks. These adversities rapidly and effectively expand their surpass the affected entity’s capacity to operations, resources, and capabilities in manage and recover through its inherent response to an increased demand of needs resources 1. during crisis 4,5. Major incident An event that demands an extraordinary First/primary surge The initial and immediate response response due to its scale, complexity, or capacity capabilities that organizations, particularly potential impact on public safety. It can be in healthcare and emergency services part of, or lead to, a disaster 2. mobilize in the earliest stages of a crisis 6. Contained incident The incident is characterized by its discrete Second/secondary surge Capacities and capabilities that and focal nature, despite the potential for capacity organizations employ during the substantial scale, and necessitates a subsequent phases after the first surge are targeted local response. Examples of such addressed and a sustained demand requires events include bombing or hurricanes 3. continuous responses 6. Population-based incident The incident impacts a broad and diverse Flexible surge capacity Untapped resources inherent within the demographic within a specific geographic community possess the advantages of being area, extending beyond immediate locally accessible and adaptable to needs, localities. The incidents may include natural allowing for a dynamic scaling of capacity causes like widespread floods, or based on the incident and its associated pandemics. 3. impacts 7. 2 3 DEFINITIONS IN SHORT Mitigation The process involves reducing the adverse impacts of a hazardous event 1. Hospital evacuation The acts of relocating individuals and assets Field specific terms temporarily to secure locations before, during, or after the onset of a hazardous Disaster An abrupt and severe occurrence that event with the primary goals of induces substantial disruption to the normal safeguarding lives and assets (can take one functioning and operational dynamics of a to several days) 1. community or society, resulting in extensive human, material, economic, and Surge capacity The ability of organizations or systems to environmental setbacks. These adversities rapidly and effectively expand their surpass the affected entity’s capacity to operations, resources, and capabilities in manage and recover through its inherent response to an increased demand of needs resources 1. during crisis 4,5. Major incident An event that demands an extraordinary First/primary surge The initial and immediate response response due to its scale, complexity, or capacity capabilities that organizations, particularly potential impact on public safety. It can be in healthcare and emergency services part of, or lead to, a disaster 2. mobilize in the earliest stages of a crisis 6. Contained incident The incident is characterized by its discrete Second/secondary surge Capacities and capabilities that and focal nature, despite the potential for capacity organizations employ during the substantial scale, and necessitates a subsequent phases after the first surge are targeted local response. Examples of such addressed and a sustained demand requires events include bombing or hurricanes 3. continuous responses 6. Population-based incident The incident impacts a broad and diverse Flexible surge capacity Untapped resources inherent within the demographic within a specific geographic community possess the advantages of being area, extending beyond immediate locally accessible and adaptable to needs, localities. The incidents may include natural allowing for a dynamic scaling of capacity causes like widespread floods, or based on the incident and its associated pandemics. 3. impacts 7. 2 3 Complex intervention implemented, the complexity of delivering Collaboration The act of goal alignment, resource-pooling, (continue) and receiving individuals' behaviors, the cross-functional activity, and information range of targeted groups or organizational sharing for empowerment, and sense- levels affected by the intervention, the making among collaborative independent diversity and variability of outcomes, and organizations 8-11. degree of flexibility permitted 15,16. Coordination The act of working together in an efficient Efficacy A comprehensive examination of the and organized way by pooling resources extent to which the intervention yields the and harmonizing goals among independent intended outcomes under idealized entities 8,11. conditions 17. Cooperation The act or instance of working or acting Effectiveness A comprehensive examination of the together and cross functioning for a extent to which the intervention yields the common purpose or benefit for intended outcomes in real-world settings 17. empowerment among independent entities 8,11,12. Pragmatic paradigm An epistemology for employing optimal methodologies for investigating real-world Sustainable Development The global goals adopted by the United issues. The chosen methodologies which Goals Nations in 2015 comprise 17 calls to action are particularly evident in mixed methods and aspire to eradicate poverty, safeguard allow for the incorporation of diverse the environment, and guarantee universal sources of data and knowledge to well-being by the year 2030 13. effectively address research inquiries 18. Research specific terms Utilitarianism A consequentialist ethical theory asserting Feasibility study A study that aims to evaluate the (Utilitarian theory) that actions are morally right if they appropriateness of an intervention for maximize overall happiness or pleasure and minimize suffering 19-21further testing the adaptability and . sustainability of conceptual ideas 14. Complex intervention Interventions in health or social care services at different levels characterized by the convergence of various interacting components in real-world events including quantity and diversity of interventions 4 5 Complex intervention implemented, the complexity of delivering Collaboration The act of goal alignment, resource-pooling, (continue) and receiving individuals' behaviors, the cross-functional activity, and information range of targeted groups or organizational sharing for empowerment, and sense- levels affected by the intervention, the making among collaborative independent diversity and variability of outcomes, and organizations 8-11. degree of flexibility permitted 15,16. Coordination The act of working together in an efficient Efficacy A comprehensive examination of the and organized way by pooling resources extent to which the intervention yields the and harmonizing goals among independent intended outcomes under idealized entities 8,11. conditions 17. Cooperation The act or instance of working or acting Effectiveness A comprehensive examination of the together and cross functioning for a extent to which the intervention yields the common purpose or benefit for intended outcomes in real-world settings 17. empowerment among independent entities 8,11,12. Pragmatic paradigm An epistemology for employing optimal methodologies for investigating real-world Sustainable Development The global goals adopted by the United issues. The chosen methodologies which Goals Nations in 2015 comprise 17 calls to action are particularly evident in mixed methods and aspire to eradicate poverty, safeguard allow for the incorporation of diverse the environment, and guarantee universal sources of data and knowledge to well-being by the year 2030 13. effectively address research inquiries 18. Research specific terms Utilitarianism A consequentialist ethical theory asserting Feasibility study A study that aims to evaluate the (Utilitarian theory) that actions are morally right if they appropriateness of an intervention for maximize overall happiness or pleasure and minimize suffering 19-21further testing the adaptability and . sustainability of conceptual ideas 14. Complex intervention Interventions in health or social care services at different levels characterized by the convergence of various interacting components in real-world events including quantity and diversity of interventions 4 5 Flexible Surge Capacity in Disasters and Major Incidents Hospitals play a pivotal role in optimizing the population's health outcomes and addressing determinants of health. These determinants encompass a broader spectrum of factors, including the social and economic environment, the physical environment, and individual characteristics and INTRODUCTION behaviors 43. Despite their routine care responsibilities, hospitals face additional challenges during disasters, including sudden surges in injuries and suffering. Nevertheless, overcrowded hospitals exhibit limited availability of beds, spaces, and staff to manage a sudden onset emergency. A surge in capacity following the instructions in a preplanned contingency plan may Disasters and emergencies caused by diverse hazards have exhibited resolve this predicament. Such a plan instructs to stop admission of non- pronounced and escalating impacts on individuals and communities on a emergency cases, planned hospital activities, such as surgical interventions, global scale 22. The Center for Research on the Epidemiology of Disasters and discharging patients capable of receiving care at home, thus preparing to (CRED) has revealed a concerning trend in natural hazard impacts. receive affected and injured populations from the incident areas 44-46. Comparing the periods between 1980-1999 and 2000-2019, the number of affected individuals increased by one-third, with a nearly twofold rise in There are, however, two possible scenarios that may hinder such action. economic losses 23. Among natural events, floods, storms, and earthquakes First, when hospital functionality is compromised during infectious disease have steadily risen 24. Moreover, it has been widely discussed that climate outbreaks and unable to admit additional patients. For instance, during the change has contributed to the heightened frequency and probability of these COVID-19 pandemic, new patients could barely be accepted since the natural events 25-27. hospitals were already overwhelmed with infected patients and were a place for isolation of diagnosed cases 47,48. Second, hospitals may be threatened In addition to natural threats, man-made incidents, including industrial directly, necessitating partial or total evacuation, such as fire outbreaks or accidents or terrorist attacks 28-33, and public health emergencies like terror attacks. Fire outbreaks are more commonly associated with the pandemics contribute to this growing global concern 34,35. Recent practice of partial evacuation and rarely escalate to the point of necessitating catastrophic events, such as the Coronavirus 2019 (COVID-19) pandemic, a total evacuation. In contrast, total evacuation is more frequent in which resulted in over 6 million deaths worldwide 36, and the Turkey-Syria scenarios such as terror attacks and armed conflicts, as observed in conflicts earthquake that claimed the lives of at least fifty thousand individuals 37,38, in Syria, and the ongoing war in several locations, e.g., the Ukrainian war, further emphasize the profound impacts of disasters on humanity. and war in Gaza 49-52. Furthermore, the protracted hybrid conflict between Russia and Ukraine, which targets critical infrastructures and densely populated areas, including It is, therefore, imperative for hospitals to be prepared to address internal hospitals, places the injured at greater risk of fatalities due to limited access and external threats and effectively mitigate and respond when facing to medical treatments 39,40. Despite the increase in the frequency of emergencies, including hospital evacuation 53, which is a complex procedure catastrophic events, population growth, urbanization, and demographic aging defined by the United Nations Office for Disaster Risk Reduction (UNDRR) also contribute to the heightened disaster risks and impacts by increasing as “moving people and assets temporarily to safer places before, during, or exposures and vulnerabilities to such events 41,42. after the occurrence of a hazardous event to protect them” 54. Additionally, other experts have provided similar definitions of hospital evacuation, emphasizing the importance of ensuring individuals’ safety 55-57. 6 INTRODUCTION 7 Flexible Surge Capacity in Disasters and Major Incidents Hospitals play a pivotal role in optimizing the population's health outcomes and addressing determinants of health. These determinants encompass a broader spectrum of factors, including the social and economic environment, the physical environment, and individual characteristics and INTRODUCTION behaviors 43. Despite their routine care responsibilities, hospitals face additional challenges during disasters, including sudden surges in injuries and suffering. Nevertheless, overcrowded hospitals exhibit limited availability of beds, spaces, and staff to manage a sudden onset emergency. A surge in capacity following the instructions in a preplanned contingency plan may Disasters and emergencies caused by diverse hazards have exhibited resolve this predicament. Such a plan instructs to stop admission of non- pronounced and escalating impacts on individuals and communities on a emergency cases, planned hospital activities, such as surgical interventions, global scale 22. The Center for Research on the Epidemiology of Disasters and discharging patients capable of receiving care at home, thus preparing to (CRED) has revealed a concerning trend in natural hazard impacts. receive affected and injured populations from the incident areas 44-46. Comparing the periods between 1980-1999 and 2000-2019, the number of affected individuals increased by one-third, with a nearly twofold rise in There are, however, two possible scenarios that may hinder such action. economic losses 23. Among natural events, floods, storms, and earthquakes First, when hospital functionality is compromised during infectious disease have steadily risen 24. Moreover, it has been widely discussed that climate outbreaks and unable to admit additional patients. For instance, during the change has contributed to the heightened frequency and probability of these COVID-19 pandemic, new patients could barely be accepted since the natural events 25-27. hospitals were already overwhelmed with infected patients and were a place for isolation of diagnosed cases 47,48. Second, hospitals may be threatened In addition to natural threats, man-made incidents, including industrial directly, necessitating partial or total evacuation, such as fire outbreaks or accidents or terrorist attacks 28-33, and public health emergencies like terror attacks. Fire outbreaks are more commonly associated with the pandemics contribute to this growing global concern 34,35. Recent practice of partial evacuation and rarely escalate to the point of necessitating catastrophic events, such as the Coronavirus 2019 (COVID-19) pandemic, a total evacuation. In contrast, total evacuation is more frequent in which resulted in over 6 million deaths worldwide 36, and the Turkey-Syria scenarios such as terror attacks and armed conflicts, as observed in conflicts earthquake that claimed the lives of at least fifty thousand individuals 37,38, in Syria, and the ongoing war in several locations, e.g., the Ukrainian war, further emphasize the profound impacts of disasters on humanity. and war in Gaza 49-52. Furthermore, the protracted hybrid conflict between Russia and Ukraine, which targets critical infrastructures and densely populated areas, including It is, therefore, imperative for hospitals to be prepared to address internal hospitals, places the injured at greater risk of fatalities due to limited access and external threats and effectively mitigate and respond when facing to medical treatments 39,40. Despite the increase in the frequency of emergencies, including hospital evacuation 53, which is a complex procedure catastrophic events, population growth, urbanization, and demographic aging defined by the United Nations Office for Disaster Risk Reduction (UNDRR) also contribute to the heightened disaster risks and impacts by increasing as “moving people and assets temporarily to safer places before, during, or exposures and vulnerabilities to such events 41,42. after the occurrence of a hazardous event to protect them” 54. Additionally, other experts have provided similar definitions of hospital evacuation, emphasizing the importance of ensuring individuals’ safety 55-57. 6 INTRODUCTION 7 Flexible Surge Capacity in Disasters and Major Incidents Consequently, hospital evacuation requires extensive support from external approach leverages the expertise of diverse organizations, enabling the resources 58-60. creation of a more comprehensive disaster management plan and enhancing surge capacity for effective response and recovery from various major Given the escalating internal and external threats to hospitals, the incidents 68,69. emergence of new threats creating new disasters and public health emergencies, and the fact that each hazard presents unique challenges, a comprehensive disaster preparedness framework, researched and practically SURGE CAPACITY FOR DISASTER RESPONSE integrated is crucial to ensure a timely and effective response throughout all Surge capacity is a crucial concept in disaster and emergency management. It phases of the disaster cycle 6,61. These phases include mitigation, preparation, represents the ability and preparedness of a system or organization to response, and recovery. Such a framework also needs to consider several rapidly enhance its response capabilities when faced with sudden or vital factors, such as the severity and complexity of the incident, its duration, unforeseen events 46,70. This measure embraces the swift mobilization of available resources and existing surge, proactivity and determination in additional resources. Surge capacity comprises 4 essential elements known leadership, and the need for multiagency collaboration, which in turn, also as the 4S: Staff, Stuff, Structure, and System. Staff includes medical and non- indicates a need for given and tested collaborative elements, enhancing and medical personnel who possess skills beneficial to disaster response, which promoting partnership, striving after mutual goals. A collaborative tool may may involve on-call physicians, hospital or clinic personnel, retired nurses, also be used to measure the impact of the actions and responses made 62,63. and community volunteers. Stuff refers to the medical and non-medical In 2015, the UNDRR collaborated with stakeholders at various levels, from equipment and supplies related to disaster management. Such resources local to international, to develop the Sendai Framework for Disaster Risk include personal protective equipment, ventilators, and blood pressure Reduction 64. This global policy framework provides countries with 15-year measurement devices. Structure primarily focuses on spaces or areas period guidelines to integrate DRR considerations into strategic plans, designated as command centers or medical treatment zones. Finally, the focusing on enhancing population health and well-being outcomes in system pertains to the practical guidelines and instructions governing Staff, alignment with the Sustainable Development Goals (SDGs) outlined by the Stuff, and Space utilization. Maintaining an adequate surge capacity is World Health Organization (WHO) 65. The alignment efforts emphasize the essential for effectively and efficiently managing disasters, as it facilitates the need for integrated and synergistic actions in a proactive approach to build prompt escalation of response efforts based on the event’s severity 5,46,71,72. resilience and consequently reduce vulnerabilities to hazards 66. The In practical terms, the first surge capacity relies on the available onsite staff, framework identifies priority areas for action, including risk comprehension stuff, and spaces within the organization. These resources are typically to strengthen risk governance and investigate risk reduction methods for sufficient to respond to the immediate impacts of the disaster 73,74. practical disaster preparedness efforts. These areas pave the way for a more However, due to the dynamic nature of disasters, the events and their secure and sustainable future for communities worldwide 67. consequences inevitably expand, necessitating the activation of a second Additionally, it is imperative to establish coordinated, cooperative, and well- surge capacity 33,75,76. This second surge relies on available personnel who communicated efforts among the various agencies and stakeholders involved may be off-duty or retired and medical devices and treatment areas that are in disaster management 8,9. These efforts facilitate appropriate information currently unoccupied. While contingency plans incorporate comprehensive sharing, resource mobilization, and utilization while clearly defining the roles surge planning, the actual impact of disasters and emergencies often and responsibilities of relevant parties. This multiagency collaboration necessitates an extensive expansion that surpasses even the second surge capacity. Previous studies reported situations where the demands on 8 INTRODUCTION 9 Flexible Surge Capacity in Disasters and Major Incidents Consequently, hospital evacuation requires extensive support from external approach leverages the expertise of diverse organizations, enabling the resources 58-60. creation of a more comprehensive disaster management plan and enhancing surge capacity for effective response and recovery from various major Given the escalating internal and external threats to hospitals, the incidents 68,69. emergence of new threats creating new disasters and public health emergencies, and the fact that each hazard presents unique challenges, a comprehensive disaster preparedness framework, researched and practically SURGE CAPACITY FOR DISASTER RESPONSE integrated is crucial to ensure a timely and effective response throughout all Surge capacity is a crucial concept in disaster and emergency management. It phases of the disaster cycle 6,61. These phases include mitigation, preparation, represents the ability and preparedness of a system or organization to response, and recovery. Such a framework also needs to consider several rapidly enhance its response capabilities when faced with sudden or vital factors, such as the severity and complexity of the incident, its duration, unforeseen events 46,70. This measure embraces the swift mobilization of available resources and existing surge, proactivity and determination in additional resources. Surge capacity comprises 4 essential elements known leadership, and the need for multiagency collaboration, which in turn, also as the 4S: Staff, Stuff, Structure, and System. Staff includes medical and non- indicates a need for given and tested collaborative elements, enhancing and medical personnel who possess skills beneficial to disaster response, which promoting partnership, striving after mutual goals. A collaborative tool may may involve on-call physicians, hospital or clinic personnel, retired nurses, also be used to measure the impact of the actions and responses made 62,63. and community volunteers. Stuff refers to the medical and non-medical In 2015, the UNDRR collaborated with stakeholders at various levels, from equipment and supplies related to disaster management. Such resources local to international, to develop the Sendai Framework for Disaster Risk include personal protective equipment, ventilators, and blood pressure Reduction 64. This global policy framework provides countries with 15-year measurement devices. Structure primarily focuses on spaces or areas period guidelines to integrate DRR considerations into strategic plans, designated as command centers or medical treatment zones. Finally, the focusing on enhancing population health and well-being outcomes in system pertains to the practical guidelines and instructions governing Staff, alignment with the Sustainable Development Goals (SDGs) outlined by the Stuff, and Space utilization. Maintaining an adequate surge capacity is World Health Organization (WHO) 65. The alignment efforts emphasize the essential for effectively and efficiently managing disasters, as it facilitates the need for integrated and synergistic actions in a proactive approach to build prompt escalation of response efforts based on the event’s severity 5,46,71,72. resilience and consequently reduce vulnerabilities to hazards 66. The In practical terms, the first surge capacity relies on the available onsite staff, framework identifies priority areas for action, including risk comprehension stuff, and spaces within the organization. These resources are typically to strengthen risk governance and investigate risk reduction methods for sufficient to respond to the immediate impacts of the disaster 73,74. practical disaster preparedness efforts. These areas pave the way for a more However, due to the dynamic nature of disasters, the events and their secure and sustainable future for communities worldwide 67. consequences inevitably expand, necessitating the activation of a second Additionally, it is imperative to establish coordinated, cooperative, and well- surge capacity 33,75,76. This second surge relies on available personnel who communicated efforts among the various agencies and stakeholders involved may be off-duty or retired and medical devices and treatment areas that are in disaster management 8,9. These efforts facilitate appropriate information currently unoccupied. While contingency plans incorporate comprehensive sharing, resource mobilization, and utilization while clearly defining the roles surge planning, the actual impact of disasters and emergencies often and responsibilities of relevant parties. This multiagency collaboration necessitates an extensive expansion that surpasses even the second surge capacity. Previous studies reported situations where the demands on 8 INTRODUCTION 9 Flexible Surge Capacity in Disasters and Major Incidents emergency medical services, emergency care utilization, and hospital administration section, and logistics section 87,88. The ICS framework is capacity became overwhelming and stretched existing resources to their illustrated in Figure 1. This system is advantageous in high-risk situations limits 33,76,77. For example, during hurricanes in the United States and with numerous variables, as it ensures reliable performance 88. earthquakes in Japan, hospitals were confronted with the daunting task of evacuating patients, demanding a substantial influx of transportation resources, including transport ventilators, trained personnel, and suitable vehicles 76,78-80. In these situations, a more flexible surge capacity, using other Incident resources than the healthcare facilities might be beneficial 7,66,81,82. commander Enhancing Surge Capacity SafetyLiaison In recognition of the formidable challenges posed by such catastrophic events, initiatives have been made to explore and mobilize resources from various sectors beyond the traditional boundaries of healthcare Public Information organizations. These include the private sector, which comprises medical entities like private hospitals and clinics, non-medical private organizations, Finance/ nongovernmental organizations such as the Red Cross, and community- Operation Planning LogisticsAdminstration based facilities 81,83-86. The goal is to recruit and leverage the capacities and capabilities of these diverse entities, pooling resources to meet the Figure 1 An Incident Command System framework. Adapted from Bigley GA and Roberts 91 escalating demands of disaster situations. Such surge enhancement may shift KH. Published in 2001 . from reactivity to proactivity and emphasize the significance of the new However, comprehensive disaster management necessitates the adoption of paradigm of disaster management 7. systematic, multidimensional, interdependent decision-making and multiagency approaches 6. The vertical structure of the ICS may pose LEADERSHIP AND MULTIAGENCY constraints in these regards. Subsequent literature, therefore, has COLLABORATIONS FOR DISASTER RESPONSE introduced more horizontal structures, particularly in the context of large- scale disasters 89,90. These horizontal structures facilitate improved Leadership and Collaborative Measures collaboration among multiple agencies, including community, nongovernmental, and private sectors 61,89. These alternative structures have The Incident Command System (ICS) has been extensively employed to been recognized and incorporated into disaster response plans and training communicate and deploy temporary tasks among organizations involved in programs, such as the Major Incident Medical Management and Support disasters and emergencies 87. The system was originally developed in (MIMMS) program, which also utilizes seven key principles, often used to response to California-wide fires in the early 1970s; the ICS encompasses facilitate the implementation of horizontal multiagency collaboration 91. hierarchical functions essential for addressing such events. These functions include the incident commander, liaison officer, safety officer, public The principles comprise Command and Control, Safety, Communication, information officer, operation section, planning section, finance and Assessment, Triage, Treatment, and Transport, referred to by the acronym CSCATTT. These principles serve as fundamental pillars for effective 10 INTRODUCTION 11 Flexible Surge Capacity in Disasters and Major Incidents emergency medical services, emergency care utilization, and hospital administration section, and logistics section 87,88. The ICS framework is capacity became overwhelming and stretched existing resources to their illustrated in Figure 1. This system is advantageous in high-risk situations limits 33,76,77. For example, during hurricanes in the United States and with numerous variables, as it ensures reliable performance 88. earthquakes in Japan, hospitals were confronted with the daunting task of evacuating patients, demanding a substantial influx of transportation resources, including transport ventilators, trained personnel, and suitable vehicles 76,78-80. In these situations, a more flexible surge capacity, using other Incident resources than the healthcare facilities might be beneficial 7,66,81,82. commander Enhancing Surge Capacity SafetyLiaison In recognition of the formidable challenges posed by such catastrophic events, initiatives have been made to explore and mobilize resources from various sectors beyond the traditional boundaries of healthcare Public Information organizations. These include the private sector, which comprises medical entities like private hospitals and clinics, non-medical private organizations, Finance/ nongovernmental organizations such as the Red Cross, and community- Operation Planning LogisticsAdminstration based facilities 81,83-86. The goal is to recruit and leverage the capacities and capabilities of these diverse entities, pooling resources to meet the Figure 1 An Incident Command System framework. Adapted from Bigley GA and Roberts 91 escalating demands of disaster situations. Such surge enhancement may shift KH. Published in 2001 . from reactivity to proactivity and emphasize the significance of the new However, comprehensive disaster management necessitates the adoption of paradigm of disaster management 7. systematic, multidimensional, interdependent decision-making and multiagency approaches 6. The vertical structure of the ICS may pose LEADERSHIP AND MULTIAGENCY constraints in these regards. Subsequent literature, therefore, has COLLABORATIONS FOR DISASTER RESPONSE introduced more horizontal structures, particularly in the context of large- scale disasters 89,90. These horizontal structures facilitate improved Leadership and Collaborative Measures collaboration among multiple agencies, including community, nongovernmental, and private sectors 61,89. These alternative structures have The Incident Command System (ICS) has been extensively employed to been recognized and incorporated into disaster response plans and training communicate and deploy temporary tasks among organizations involved in programs, such as the Major Incident Medical Management and Support disasters and emergencies 87. The system was originally developed in (MIMMS) program, which also utilizes seven key principles, often used to response to California-wide fires in the early 1970s; the ICS encompasses facilitate the implementation of horizontal multiagency collaboration 91. hierarchical functions essential for addressing such events. These functions include the incident commander, liaison officer, safety officer, public The principles comprise Command and Control, Safety, Communication, information officer, operation section, planning section, finance and Assessment, Triage, Treatment, and Transport, referred to by the acronym CSCATTT. These principles serve as fundamental pillars for effective 10 INTRODUCTION 11 Flexible Surge Capacity in Disasters and Major Incidents response efforts. Moreover, they have been employed as measurements for continuous surveillance to identify and address vulnerabilities that could evaluating capabilities across various domains 92,93. jeopardize data integrity and confidentiality 105. The first 2C principles, Command and Control (C2), encompass strategic Communication (C) involves internal, external, and public communication. management and governance involving initiation and decision-making All communication has vertical and horizontal means and components to processes 92,94,95. Command-and-control principles aim to facilitate and consider, covering channels, devices, and content 106. The channel and enhance the performance of individuals directing under resource devices depend on available resources at the time 107. Flexibility is essential constraints. It is crucial to acknowledge that while most critical decision- in this regard, as the dynamic nature of disaster situations may necessitate making should ideally be premeditated as part of a hazard vulnerability adaptation to ensure effective communication. Equally significant is the assessment and contingency plans, the exigencies of actual incidents often content, which demands meticulous preparation and consideration. Key necessitate prompt and potentially challenging decision-making processes 96- elements include clearly defined communication goals, the formulation of 98. These decisions may be contingent upon those in charge’s leadership core messages, and the identification of target audiences 108. styles and personal attributes, subsequently influencing the application of Assessment (A) components in MIMMS revolve around evaluating and command-and-control principles 99. Previous research explored leadership surveilling disaster circumstances and resource availability. The inherent styles within command-and-control contexts among emergency physicians dynamism of disaster events mandates a continuous and vigilant assessment engaged in disaster scenarios and revealed a diverse spectrum of leadership process. This assessment process entails ongoing evaluation of the evolving styles, including active, passive, and consensus-based approaches. Notably, disaster circumstances, encompassing factors such as the extent of damage, despite the apparent divergence in leadership styles, the overarching potential consequences, and resource requirements. The information objectives of the responses remained consistent, primarily centered on gathered through assessment serves as foundational information for preserving lives and efficiently managing resources 94,100. strategically allocating resources (4S) to meet the escalating demands of the Safety (S) within disaster management comprises a multifaceted approach incidents. Furthermore, the assessed information is significant in determining involving assessment, surveillance, and monitoring 101. The paramount the necessity for additional response organizations and the recruitment of objective is the safety of the dedicated personnel (Self), incident scene specialized expertise. The latter necessitates educational initiatives that (Scene), and patients (Survivors), respectively, which entails continuous and synchronize the knowledge and abilities of volunteers and extra staff to rigorous safety evaluation and oversight. Significantly, in incidents involving smoothly fit in the chain of actions 109-111. chemical, biological, radiological, nuclear, and explosive (CBRNE) agents, a Triage (T) and Treatment (T) represent the medical aspects of MIMMS, specialized safety framework is required 102,103. This framework necessitates primarily focusing on the balance between maximizing survivors and make the presence of technical safety personnel, the deployment of specific the greatest good for most under austere circumstances. This utilitarian equipment tailored to the nature of the incident, the allocation of dedicated approach grounded in the ethical philosophy that seeks to achieve the spaces, and adherence to safety protocols. Moreover, in the digital era, greatest happiness for the greatest number of people has been recognized where the world is rapidly advancing towards digitalization, the significance during disaster management 20,21. Attuning to utilitarianism, the triage and of data has grown exponentially which may pose potential threats 104. Hence, treatment processes prioritize the overarching welfare of the affected data security has become one of the critical safeties in disaster preparedness population as the supreme moral objective. This ethical stance underscores components. This security involves comprehensive risk assessment and the commitment to making decisions that optimize the chances of survival and well-being for most individuals affected by a disaster. Consequently, the 12 INTRODUCTION 13 Flexible Surge Capacity in Disasters and Major Incidents response efforts. Moreover, they have been employed as measurements for continuous surveillance to identify and address vulnerabilities that could evaluating capabilities across various domains 92,93. jeopardize data integrity and confidentiality 105. The first 2C principles, Command and Control (C2), encompass strategic Communication (C) involves internal, external, and public communication. management and governance involving initiation and decision-making All communication has vertical and horizontal means and components to processes 92,94,95. Command-and-control principles aim to facilitate and consider, covering channels, devices, and content 106. The channel and enhance the performance of individuals directing under resource devices depend on available resources at the time 107. Flexibility is essential constraints. It is crucial to acknowledge that while most critical decision- in this regard, as the dynamic nature of disaster situations may necessitate making should ideally be premeditated as part of a hazard vulnerability adaptation to ensure effective communication. Equally significant is the assessment and contingency plans, the exigencies of actual incidents often content, which demands meticulous preparation and consideration. Key necessitate prompt and potentially challenging decision-making processes 96- elements include clearly defined communication goals, the formulation of 98. These decisions may be contingent upon those in charge’s leadership core messages, and the identification of target audiences 108. styles and personal attributes, subsequently influencing the application of Assessment (A) components in MIMMS revolve around evaluating and command-and-control principles 99. Previous research explored leadership surveilling disaster circumstances and resource availability. The inherent styles within command-and-control contexts among emergency physicians dynamism of disaster events mandates a continuous and vigilant assessment engaged in disaster scenarios and revealed a diverse spectrum of leadership process. This assessment process entails ongoing evaluation of the evolving styles, including active, passive, and consensus-based approaches. Notably, disaster circumstances, encompassing factors such as the extent of damage, despite the apparent divergence in leadership styles, the overarching potential consequences, and resource requirements. The information objectives of the responses remained consistent, primarily centered on gathered through assessment serves as foundational information for preserving lives and efficiently managing resources 94,100. strategically allocating resources (4S) to meet the escalating demands of the Safety (S) within disaster management comprises a multifaceted approach incidents. Furthermore, the assessed information is significant in determining involving assessment, surveillance, and monitoring 101. The paramount the necessity for additional response organizations and the recruitment of objective is the safety of the dedicated personnel (Self), incident scene specialized expertise. The latter necessitates educational initiatives that (Scene), and patients (Survivors), respectively, which entails continuous and synchronize the knowledge and abilities of volunteers and extra staff to rigorous safety evaluation and oversight. Significantly, in incidents involving smoothly fit in the chain of actions 109-111. chemical, biological, radiological, nuclear, and explosive (CBRNE) agents, a Triage (T) and Treatment (T) represent the medical aspects of MIMMS, specialized safety framework is required 102,103. This framework necessitates primarily focusing on the balance between maximizing survivors and make the presence of technical safety personnel, the deployment of specific the greatest good for most under austere circumstances. This utilitarian equipment tailored to the nature of the incident, the allocation of dedicated approach grounded in the ethical philosophy that seeks to achieve the spaces, and adherence to safety protocols. Moreover, in the digital era, greatest happiness for the greatest number of people has been recognized where the world is rapidly advancing towards digitalization, the significance during disaster management 20,21. Attuning to utilitarianism, the triage and of data has grown exponentially which may pose potential threats 104. Hence, treatment processes prioritize the overarching welfare of the affected data security has become one of the critical safeties in disaster preparedness population as the supreme moral objective. This ethical stance underscores components. This security involves comprehensive risk assessment and the commitment to making decisions that optimize the chances of survival and well-being for most individuals affected by a disaster. Consequently, the 12 INTRODUCTION 13 Flexible Surge Capacity in Disasters and Major Incidents crisis standard of care concept has been developed 112, and is widely Public organizations, such as fire and police departments and healthcare accepted to provide sound ethical and legal issues for the actions of medical organizations, have been recognized as vital early responders. Historical personnel during disasters 113,114. The crisis standard of care reconciles the incidents are downright reminders of the adverse consequences of challenging decisions that must be made in resource-limited crises. It serves inadequate collaboration among governmental agencies 123-125. Accordingly, as a critical ethical compass for healthcare providers, offering guidance on governance systems and collaborative policies have been methodically allocating resources and prioritizing care in the face of overwhelming structured and organized. Moreover, recent crises, such as the COVID-19 demand 113,114. pandemic, have provided tangible evidence of the efficacy of these refined systems and policies, building up to disaster response resilience through The final principle in the MIMMS is Transport (T), assuming a critical role in orchestrated collaboration among government officials, and rigorously disaster logistics management 115. It is designed to address the testing inter-governmental collaboration efforts worldwide 126. transportation’s details, including access, routes, and how staff, resources, and survivors are transported both to and from disaster incident sites and In addition, private actors have been duly recognized as indispensable between treatment facilities 71. Timely and safe transportation access is partners 86. The global overview on the roles of the private sector in paramount. In addition, transportation management during disasters lies in disaster risk reduction identified 5 potential avenues of private actors the need for multiagency collaboration. Effective disaster response often including 1) direct community assistance, 2) the innovation of products for necessitates various transportation options, including ground, air, and sea public applications, 3) collaborative ventures with other implementing transportation. In many cases, these transportation resources may be entities (NGOs, governments, and international bodies), 4) the available within military bases 116,117, underscoring the importance of well- establishment of private foundations, and 5) the development of structured communication, coordination, and cooperation to achieve preparedness protocols 85. The primary motivation driving private sector collaboration among various agencies. Ground transportation, often involvement is the preservation of business continuity. Over decades, public- facilitated by emergency vehicles and personnel, ensures rapid access to private collaborations have been initiated and cultivated. As a result, private affected areas and the movement of critically injured individuals to medical sectors have become integral components of disaster risk reduction, facilities 118. Air and sea transportation may be indispensable when rapid response, and recovery endeavors 83,127,128. The recent Global Assessment deployment and evacuation are necessary, especially in regions with Report on Disaster Risk Reduction (GAR) issued by the UNDRR in 2022 challenging terrain or when dealing with large-scale disasters 31,119,120. continued to accentuate the strengthening of such partnerships 69. Multiagency Collaboration Furthermore, previous incidents have highlighted the NGOs in supporting the public and society during response and recovery phases, particularly in Coherent collaboration among multiple responding organizations is low to middle-income countries 122,129. These organizations usually originate fundamental in fortifying disaster response resilience 61,90,121. Extensive from locals, possess intimate knowledge of neighborhoods, and boast research has reported the pivotal roles in bolstering disaster responses extensive experience collaborating closely with communities. They deliver played by and collaborated among public organizations, private actors, services to local communities during routine circumstances and exhibit nongovernmental organizations (NGOs), and local facilities, underscoring flexibility in redirecting their support to areas necessitating assistance during the imperative to strengthen these partnerships. The recruitment of these disasters. NGOs assume substantial responsibilities in providing surge entities is contingent upon cultural, educational, social, and environmental capacity during and following incidents. Furthermore, community factors 122. partnership as part of disaster risk reduction plans, response strategies, and 14 INTRODUCTION 15 Flexible Surge Capacity in Disasters and Major Incidents crisis standard of care concept has been developed 112, and is widely Public organizations, such as fire and police departments and healthcare accepted to provide sound ethical and legal issues for the actions of medical organizations, have been recognized as vital early responders. Historical personnel during disasters 113,114. The crisis standard of care reconciles the incidents are downright reminders of the adverse consequences of challenging decisions that must be made in resource-limited crises. It serves inadequate collaboration among governmental agencies 123-125. Accordingly, as a critical ethical compass for healthcare providers, offering guidance on governance systems and collaborative policies have been methodically allocating resources and prioritizing care in the face of overwhelming structured and organized. Moreover, recent crises, such as the COVID-19 demand 113,114. pandemic, have provided tangible evidence of the efficacy of these refined systems and policies, building up to disaster response resilience through The final principle in the MIMMS is Transport (T), assuming a critical role in orchestrated collaboration among government officials, and rigorously disaster logistics management 115. It is designed to address the testing inter-governmental collaboration efforts worldwide 126. transportation’s details, including access, routes, and how staff, resources, and survivors are transported both to and from disaster incident sites and In addition, private actors have been duly recognized as indispensable between treatment facilities 71. Timely and safe transportation access is partners 86. The global overview on the roles of the private sector in paramount. In addition, transportation management during disasters lies in disaster risk reduction identified 5 potential avenues of private actors the need for multiagency collaboration. Effective disaster response often including 1) direct community assistance, 2) the innovation of products for necessitates various transportation options, including ground, air, and sea public applications, 3) collaborative ventures with other implementing transportation. In many cases, these transportation resources may be entities (NGOs, governments, and international bodies), 4) the available within military bases 116,117, underscoring the importance of well- establishment of private foundations, and 5) the development of structured communication, coordination, and cooperation to achieve preparedness protocols 85. The primary motivation driving private sector collaboration among various agencies. Ground transportation, often involvement is the preservation of business continuity. Over decades, public- facilitated by emergency vehicles and personnel, ensures rapid access to private collaborations have been initiated and cultivated. As a result, private affected areas and the movement of critically injured individuals to medical sectors have become integral components of disaster risk reduction, facilities 118. Air and sea transportation may be indispensable when rapid response, and recovery endeavors 83,127,128. The recent Global Assessment deployment and evacuation are necessary, especially in regions with Report on Disaster Risk Reduction (GAR) issued by the UNDRR in 2022 challenging terrain or when dealing with large-scale disasters 31,119,120. continued to accentuate the strengthening of such partnerships 69. Multiagency Collaboration Furthermore, previous incidents have highlighted the NGOs in supporting the public and society during response and recovery phases, particularly in Coherent collaboration among multiple responding organizations is low to middle-income countries 122,129. These organizations usually originate fundamental in fortifying disaster response resilience 61,90,121. Extensive from locals, possess intimate knowledge of neighborhoods, and boast research has reported the pivotal roles in bolstering disaster responses extensive experience collaborating closely with communities. They deliver played by and collaborated among public organizations, private actors, services to local communities during routine circumstances and exhibit nongovernmental organizations (NGOs), and local facilities, underscoring flexibility in redirecting their support to areas necessitating assistance during the imperative to strengthen these partnerships. The recruitment of these disasters. NGOs assume substantial responsibilities in providing surge entities is contingent upon cultural, educational, social, and environmental capacity during and following incidents. Furthermore, community factors 122. partnership as part of disaster risk reduction plans, response strategies, and 14 INTRODUCTION 15 Flexible Surge Capacity in Disasters and Major Incidents recovery initiatives has consistently demonstrated efficacy in strengthening implementation and the adaptability of the surge expansion interventions interdependence and augmenting overall outcomes 130,131. However, the 17,135,136. capacities and capabilities of communities can exhibit significant disparities Given the complexity of the healthcare systems and intervention, deploying between countries, thereby necessitating the establishment of local and developed interventions within the healthcare system requires a national directives to engage these invaluable resources systematically comprehensive assessment of the system, the community’s specific 81,122,129,132. contextual factors, and early engagement of stakeholders. Prior literature Besides community partnerships, military organizations have contributed has summarized the stages of implementing interventions, i.e., developing, knowledge, skills, and supplies during disaster responses 116. Military tactical testing, evaluating, and implementing 17. As theories and strategies for techniques have been transferred and adopted by civilian healthcare community collaboration have been established and continue to undergo professionals, providing rapid treatments under austere circumstances 133. periodic review by the UNDRR, in this thesis, the development stage Furthermore, in some countries, military-built field hospitals have frequently contributes to undertaking a more pragmatic approach within the disaster extended their services to meet the demand for alternative care options. In response system. The primary objective is to develop a practical and recent times, the escalating rates of wars and acts of terrorism have accessible framework explicitly tailored for expanding surge capacity to necessitated a more structured collaboration between civilian and military harness community resources effectively. Furthermore, this pragmatic entities39,134. This evolving collaboration reflects a critical aspect of disaster framework is tested, refined, evaluated, and implemented. These stages are response strategies, leveraging the expertise and resources of both sectors undertaken across a spectrum of relevant contexts and diverse scenarios, to ensure a more robust and coordinated approach to disaster mitigation aiming to affirm the intervention’s feasibility, efficacy, and effectiveness when and recovery 116,134. integrated into the healthcare system. HEALTHCARE INTERVENTION IMPLEMENTATION Key Uncertainties The inadequacies in surge planning and multiagency collaborations highlight Challenges in Surge Expansion and Multiagency Collaboration the need for more effective measures. A recent proposition put forth by the The collaborative surge expansion involving diverse organizations with UNDRR, WHO, and CDC is the intervention of a community partnership distinct objectives and historical trajectories presents a formidable challenge concept 66,68,69,81. While this proposition outlined the expansion of the surge within disaster management. These organizations typically operate capacities to the local community, the proposed details predominantly independently, each with internal capacities and capabilities tailored to its remained in the theoretical strategies intended for generalization across specific missions. Understanding and aligning these internal processes and nations. However, the effective execution of these strategies necessitates a resources for collaborative surge planning necessitates considerable efforts deep and comprehensive community engagement. This engagement must and strategic measures 9,10. Thus, multiagency collaboration for surge consider the intricate nature of interventions encompassing cultural, expansion and disaster response efforts remains complex 68. educational, and socioeconomic aspects 69. Additionally, the healthcare system itself is a complex entity, marked by variations in its components and Previous research further identified the difficulty in adhering to the a multitude of factors, including the healthcare setting and the number of contingency plan, particularly in staff and stuff management during actual target groups or levels. These variations significantly influence the successful incidents as one of the critical challenges 48,93. Descriptive data revealed instances where staff reallocation plans were incomplete, often due to 16 INTRODUCTION 17 Flexible Surge Capacity in Disasters and Major Incidents recovery initiatives has consistently demonstrated efficacy in strengthening implementation and the adaptability of the surge expansion interventions interdependence and augmenting overall outcomes 130,131. However, the 17,135,136. capacities and capabilities of communities can exhibit significant disparities Given the complexity of the healthcare systems and intervention, deploying between countries, thereby necessitating the establishment of local and developed interventions within the healthcare system requires a national directives to engage these invaluable resources systematically comprehensive assessment of the system, the community’s specific 81,122,129,132. contextual factors, and early engagement of stakeholders. Prior literature Besides community partnerships, military organizations have contributed has summarized the stages of implementing interventions, i.e., developing, knowledge, skills, and supplies during disaster responses 116. Military tactical testing, evaluating, and implementing 17. As theories and strategies for techniques have been transferred and adopted by civilian healthcare community collaboration have been established and continue to undergo professionals, providing rapid treatments under austere circumstances 133. periodic review by the UNDRR, in this thesis, the development stage Furthermore, in some countries, military-built field hospitals have frequently contributes to undertaking a more pragmatic approach within the disaster extended their services to meet the demand for alternative care options. In response system. The primary objective is to develop a practical and recent times, the escalating rates of wars and acts of terrorism have accessible framework explicitly tailored for expanding surge capacity to necessitated a more structured collaboration between civilian and military harness community resources effectively. Furthermore, this pragmatic entities39,134. This evolving collaboration reflects a critical aspect of disaster framework is tested, refined, evaluated, and implemented. These stages are response strategies, leveraging the expertise and resources of both sectors undertaken across a spectrum of relevant contexts and diverse scenarios, to ensure a more robust and coordinated approach to disaster mitigation aiming to affirm the intervention’s feasibility, efficacy, and effectiveness when and recovery 116,134. integrated into the healthcare system. HEALTHCARE INTERVENTION IMPLEMENTATION Key Uncertainties The inadequacies in surge planning and multiagency collaborations highlight Challenges in Surge Expansion and Multiagency Collaboration the need for more effective measures. A recent proposition put forth by the The collaborative surge expansion involving diverse organizations with UNDRR, WHO, and CDC is the intervention of a community partnership distinct objectives and historical trajectories presents a formidable challenge concept 66,68,69,81. While this proposition outlined the expansion of the surge within disaster management. These organizations typically operate capacities to the local community, the proposed details predominantly independently, each with internal capacities and capabilities tailored to its remained in the theoretical strategies intended for generalization across specific missions. Understanding and aligning these internal processes and nations. However, the effective execution of these strategies necessitates a resources for collaborative surge planning necessitates considerable efforts deep and comprehensive community engagement. This engagement must and strategic measures 9,10. Thus, multiagency collaboration for surge consider the intricate nature of interventions encompassing cultural, expansion and disaster response efforts remains complex 68. educational, and socioeconomic aspects 69. Additionally, the healthcare system itself is a complex entity, marked by variations in its components and Previous research further identified the difficulty in adhering to the a multitude of factors, including the healthcare setting and the number of contingency plan, particularly in staff and stuff management during actual target groups or levels. These variations significantly influence the successful incidents as one of the critical challenges 48,93. Descriptive data revealed instances where staff reallocation plans were incomplete, often due to 16 INTRODUCTION 17 Flexible Surge Capacity in Disasters and Major Incidents ambiguities in role definitions or challenges faced by individuals instructed to phases of the disaster cycle, including mitigation, preparation, response, and leave patients behind 74. Additionally, delays in reloading supplies compared recovery 141,146. One of the most widely adopted models for developing and to the pace of incident expansion were found to be another critical evaluating training programs is Kirkpatrick’s four-level evaluation model, challenge 48. These issues highlight the importance of effective surge planning which assesses participants’ reactions, learning outcomes, behaviors, and and multiagency collaboration which demand the creation of comprehensive results. These measurements are integrated within disaster literacy models plans and execution measures. Therefore, it is essential to consider the and are incorporated into simulation exercises 147. implementation of complex interventions within healthcare services 135,137,138. Previous studies have consistently demonstrated the essential role of Such measures may include process evaluations to navigate the intricacies of simulation exercises in enhancing knowledge and skills, ultimately leading to interventions regarding surge capacity and multiagency responses during improved learning outcomes and heightened levels of engagement 148-150. crises 66,68,139,140. Moreover, repeated scenario-based training has significantly enhanced disaster management proficiency 151. Two validated exercise systems, namely Disaster Literacy and Educational Initiatives the three-level collaboration (3LC) and MAss Casualty SIMulation Çalskan and Üner have proposed a comprehensive definition of disaster (MACSIM), have been extensively employed in disaster literacy 152. The 3LC literacy, characterizing it as “the capacity of individuals to access, exercise is a tabletop exercise that focuses on functionality and enhances comprehend, evaluate, and apply disaster-related information for making organizational and structural knowledge in disaster management 100,153. informed decisions and adhering to instructions throughout their lives, with While the latter is a modular exercise based on authentic patient cards a focus on disaster mitigation, preparedness, response, recovery, and overall derived from real events and can enhance the learning in all managerial levels quality of life improvement” 141. Research has identified a deficiency in and medical aspects of individual patients (triage, treatment) 154,155.These disaster literacy, particularly in disaster preparedness, mitigation, and risk exercises allow participants to refine their decision-making and collaboration reduction, with a notable gap observed among vulnerable populations such skills across operational, tactical, and strategical levels, thus facilitating as individuals with physical and mental impairments, children, and minority effective resource allocation in response to major incidents within dynamic groups 142-145. scenarios 62,100,153,156. Moreover, the common denominator for both exercises in this thesis is the use of CSCATTT, which also creates The UNDRR has emphasized the significance of evidence-based translation collaborative factors to engage all professionals irrespective of their strategies to improve public disaster literacy. These strategies are designed professions, i.e., they enhance multiagency and interdisciplinary to facilitate greater public access to risk assessments and relevant collaboration. information, particularly in geographically specific disaster-prone areas 68. Furthermore, individual preparedness capacity, encompassing collaboration Ethical and Legal Perspectives on Disasters skills and well-informed decision-making processes among policymakers and leaders, constitutes a fundamental and indispensable aspect of disaster Disaster circumstances often compel healthcare professionals to confront literacy. This literacy plays a pivotal role in implementing disaster complex decision-making scenarios fraught with ethical dilemmas, thereby management interventions 109,144. Disaster literacy models encompass raising the specter of potential human rights violations 39. To ensure the processes that equip individuals with the knowledge and skills necessary to provision of optimal care to patients and to establish appropriate ethical and enhance their comprehension, critical analysis, and application throughout all legal boundaries for healthcare providers, it is imperative that ethical and legal guidance be integrated into disaster management plans 114,157. Research 18 INTRODUCTION 19 Flexible Surge Capacity in Disasters and Major Incidents ambiguities in role definitions or challenges faced by individuals instructed to phases of the disaster cycle, including mitigation, preparation, response, and leave patients behind 74. Additionally, delays in reloading supplies compared recovery 141,146. One of the most widely adopted models for developing and to the pace of incident expansion were found to be another critical evaluating training programs is Kirkpatrick’s four-level evaluation model, challenge 48. These issues highlight the importance of effective surge planning which assesses participants’ reactions, learning outcomes, behaviors, and and multiagency collaboration which demand the creation of comprehensive results. These measurements are integrated within disaster literacy models plans and execution measures. Therefore, it is essential to consider the and are incorporated into simulation exercises 147. implementation of complex interventions within healthcare services 135,137,138. Previous studies have consistently demonstrated the essential role of Such measures may include process evaluations to navigate the intricacies of simulation exercises in enhancing knowledge and skills, ultimately leading to interventions regarding surge capacity and multiagency responses during improved learning outcomes and heightened levels of engagement 148-150. crises 66,68,139,140. Moreover, repeated scenario-based training has significantly enhanced disaster management proficiency 151. Two validated exercise systems, namely Disaster Literacy and Educational Initiatives the three-level collaboration (3LC) and MAss Casualty SIMulation Çalskan and Üner have proposed a comprehensive definition of disaster (MACSIM), have been extensively employed in disaster literacy 152. The 3LC literacy, characterizing it as “the capacity of individuals to access, exercise is a tabletop exercise that focuses on functionality and enhances comprehend, evaluate, and apply disaster-related information for making organizational and structural knowledge in disaster management 100,153. informed decisions and adhering to instructions throughout their lives, with While the latter is a modular exercise based on authentic patient cards a focus on disaster mitigation, preparedness, response, recovery, and overall derived from real events and can enhance the learning in all managerial levels quality of life improvement” 141. Research has identified a deficiency in and medical aspects of individual patients (triage, treatment) 154,155.These disaster literacy, particularly in disaster preparedness, mitigation, and risk exercises allow participants to refine their decision-making and collaboration reduction, with a notable gap observed among vulnerable populations such skills across operational, tactical, and strategical levels, thus facilitating as individuals with physical and mental impairments, children, and minority effective resource allocation in response to major incidents within dynamic groups 142-145. scenarios 62,100,153,156. Moreover, the common denominator for both exercises in this thesis is the use of CSCATTT, which also creates The UNDRR has emphasized the significance of evidence-based translation collaborative factors to engage all professionals irrespective of their strategies to improve public disaster literacy. These strategies are designed professions, i.e., they enhance multiagency and interdisciplinary to facilitate greater public access to risk assessments and relevant collaboration. information, particularly in geographically specific disaster-prone areas 68. Furthermore, individual preparedness capacity, encompassing collaboration Ethical and Legal Perspectives on Disasters skills and well-informed decision-making processes among policymakers and leaders, constitutes a fundamental and indispensable aspect of disaster Disaster circumstances often compel healthcare professionals to confront literacy. This literacy plays a pivotal role in implementing disaster complex decision-making scenarios fraught with ethical dilemmas, thereby management interventions 109,144. Disaster literacy models encompass raising the specter of potential human rights violations 39. To ensure the processes that equip individuals with the knowledge and skills necessary to provision of optimal care to patients and to establish appropriate ethical and enhance their comprehension, critical analysis, and application throughout all legal boundaries for healthcare providers, it is imperative that ethical and legal guidance be integrated into disaster management plans 114,157. Research 18 INTRODUCTION 19 Flexible Surge Capacity in Disasters and Major Incidents into ethical quandaries during crises has underscored the significance of operates through a network of village health volunteers. These local imbuing disaster plans with moral considerations. These moral individuals serve as the initial contact points between the community and considerations entail the development of protocols for decision support the healthcare system. systems, crisis standard of care guidance, and comprehensive training Within hospital-based healthcare services, the care includes prehospital and initiatives. Such measures can potentially mitigate moral distress and hospital services, operating within a multi-tiered system designed to safeguard the essential tenets of ethical frameworks within medical care accommodate diverse healthcare needs and competencies. The foundation 158,159. of this system consists of primary care hospitals, referred to as community The crisis standard of care guidance, introduced by the American Medical hospitals, which typically possess bed capacities ranging from 10 to 120. Association 112, aligns with the ethical theory of utilitarianism. According to These community hospitals are primarily responsible for managing chronic diseases, addressing uncomplicated health issues, and providing life-saving this utilitarian theory, prioritizing the greatest happiness for the most prehospital and emergency care services. The next tier is occupied by significant number takes precedence, particularly in contexts involving secondary care facilities. This tier offers more advanced prehospital care, a patient prioritization and allocating scarce critical resources during crises broader range of medical treatment options, and the capacity to 20,21. However, the criteria for invoking the crisis standard of care remain accommodate patients requiring simple surgical procedures. The facilities undefined, and its global adoption has not yet materialized 113,160. A prior feature bed capacities ranging from 120 to 500 166,167. study delving into multinational ethical awareness and guidance and the legal aspects of disaster management and evacuation revealed a conspicuous At the summit of this healthcare pyramid lies the tertiary care level, absence in these dimensions 161. characterized by highly skilled healthcare professionals and, foremost, medical equipment. These facilities are geared towards delivering advanced Contexts prehospital, medical, and surgical interventions of a complex nature. Lastly, university hospitals constitute the apex of healthcare provision, distinguished As a developing nation, Thailand frequently faces disasters and has made by their commitment to professional excellence, knowledge advancement comparatively slower strides in infrastructure development. The through research, and the presence of teaching institutions 166,167. geographical distribution of hospitals in the country is skewed towards high- risk areas, consequently rendering them susceptible to frequent encounters During major events, the activation of healthcare services is contingent upon with natural and man-made threats 31,162,163. Notably, some of these hospitals the geographical location of the events and the availability of local resources. contend with annual flooding incidents 31,164,165. Hospitals rely on their disaster response plans to determine the appropriate course of action in response to external threats and fire evacuations. These Thai National Healthcare System plans outline the procedures for activating external resources, which may come from neighboring local facilities, regional entities, national agencies, The national healthcare system in Thailand is orchestrated by the Ministry of and even international organizations, depending on the severity and scope of Public Health, serving as the central governing body, vested with the the emergency 168,169. authority and responsibility for policy formulation and financial planning 166,167. These policies and financial allocations are subsequently channeled to Regarding health financial schemes, all Thai citizens’ healthcare financing falls the District Health Services, tasked with executing healthcare services. The into 3 schemes 166,170. These major schemes include (i) the civil servants’ district health service manages primary healthcare delivery and partly medical benefit scheme under the Finance Ministry, (ii) the social security scheme under the Labor Ministry, and (iii) the universal coverage scheme 20 INTRODUCTION 21 Flexible Surge Capacity in Disasters and Major Incidents into ethical quandaries during crises has underscored the significance of operates through a network of village health volunteers. These local imbuing disaster plans with moral considerations. These moral individuals serve as the initial contact points between the community and considerations entail the development of protocols for decision support the healthcare system. systems, crisis standard of care guidance, and comprehensive training Within hospital-based healthcare services, the care includes prehospital and initiatives. Such measures can potentially mitigate moral distress and hospital services, operating within a multi-tiered system designed to safeguard the essential tenets of ethical frameworks within medical care accommodate diverse healthcare needs and competencies. The foundation 158,159. of this system consists of primary care hospitals, referred to as community The crisis standard of care guidance, introduced by the American Medical hospitals, which typically possess bed capacities ranging from 10 to 120. Association 112, aligns with the ethical theory of utilitarianism. According to These community hospitals are primarily responsible for managing chronic diseases, addressing uncomplicated health issues, and providing life-saving this utilitarian theory, prioritizing the greatest happiness for the most prehospital and emergency care services. The next tier is occupied by significant number takes precedence, particularly in contexts involving secondary care facilities. This tier offers more advanced prehospital care, a patient prioritization and allocating scarce critical resources during crises broader range of medical treatment options, and the capacity to 20,21. However, the criteria for invoking the crisis standard of care remain accommodate patients requiring simple surgical procedures. The facilities undefined, and its global adoption has not yet materialized 113,160. A prior feature bed capacities ranging from 120 to 500 166,167. study delving into multinational ethical awareness and guidance and the legal aspects of disaster management and evacuation revealed a conspicuous At the summit of this healthcare pyramid lies the tertiary care level, absence in these dimensions 161. characterized by highly skilled healthcare professionals and, foremost, medical equipment. These facilities are geared towards delivering advanced Contexts prehospital, medical, and surgical interventions of a complex nature. Lastly, university hospitals constitute the apex of healthcare provision, distinguished As a developing nation, Thailand frequently faces disasters and has made by their commitment to professional excellence, knowledge advancement comparatively slower strides in infrastructure development. The through research, and the presence of teaching institutions 166,167. geographical distribution of hospitals in the country is skewed towards high- risk areas, consequently rendering them susceptible to frequent encounters During major events, the activation of healthcare services is contingent upon with natural and man-made threats 31,162,163. Notably, some of these hospitals the geographical location of the events and the availability of local resources. contend with annual flooding incidents 31,164,165. Hospitals rely on their disaster response plans to determine the appropriate course of action in response to external threats and fire evacuations. These Thai National Healthcare System plans outline the procedures for activating external resources, which may come from neighboring local facilities, regional entities, national agencies, The national healthcare system in Thailand is orchestrated by the Ministry of and even international organizations, depending on the severity and scope of Public Health, serving as the central governing body, vested with the the emergency 168,169. authority and responsibility for policy formulation and financial planning 166,167. These policies and financial allocations are subsequently channeled to Regarding health financial schemes, all Thai citizens’ healthcare financing falls the District Health Services, tasked with executing healthcare services. The into 3 schemes 166,170. These major schemes include (i) the civil servants’ district health service manages primary healthcare delivery and partly medical benefit scheme under the Finance Ministry, (ii) the social security scheme under the Labor Ministry, and (iii) the universal coverage scheme 20 INTRODUCTION 21 Flexible Surge Capacity in Disasters and Major Incidents under the Public Health Ministry. The universal coverage scheme serves as a subsequent recovery phases, leading to considerable challenges in managing safety net for all Thais not covered by the other schemes; they are directed injuries and relief efforts. This pivotal event catalyzed a comprehensive to hospitals according to their civil registration. This scheme extends reevaluation of Thailand’s healthcare system in the context of disaster coverage to more than 72% of the population 166,170. management, prompting significant restructuring and fostering collaborations on an international scale. 28,171. Previous Experiences and Responses to Major Incidents Subsequently, in 2011, weighty rains caused profound flooding in major The 2004 tsunami stands out as a significant natural hazard that struck the hospitals in the central part of the country, necessitating hospital evacuation. southwestern coastline of the country, triggered by a profound 9.0 Reports indicated a structured disaster response, notably using the ICS with magnitude earthquake 171. The events resulted in the tragic loss of more the CSCATTT elements 31. However, managerial deficiencies were than 5,000 lives, affecting both residents and foreigners while causing concentrated on the inappropriate multiagency collaboration and inadequacy extensive damage to infrastructure across four provinces: Phangnga, Krabi, of evacuation resources, including boats, transport ventilators, and Phuket, and Ranong. The literature revealed the precarious state of transported staff 31,84,169. prehospital and hospital management during this crisis. Prehospital facilities were inadequately established, primarily relying on volunteer personnel, RESEARCH METHODS FOR DISASTER donated equipment, and vehicles172. This reliance resulted in severe deficits MANAGEMENT in scene evacuation resources, leading to a “first-come-first-serve” approach to victim transportation 171,172. Research in the field of disasters necessitates a critical examination of inherently dynamic and uncertain situations. Various research approaches, Conversely, hospital management adhered to a standard major incident can be employed, such as epidemiologic measures, economic impact policy, albeit activated shortly before the arrival of the first patient 171. Local assessments, descriptive studies/surveillance, and analytic measures 140. hospital staff worked tirelessly to address the influx of cases and resource Given the intricate nature of disasters, research designs often require a constraints, with hospital directors assuming the role of incident mixed-methods approach, combining quantitative surveys and qualitative commanders at each facility 173. However, comprehensive safety evaluations, interviews. Within this context, a pragmatic paradigm, representing a surveillance mechanisms, situational assessments, and resource evaluations common epistemological worldview, proves particularly suitable, especially were absent. Communication breakdowns due to damaged tele- in inquiries related to leadership, decision-making, and collaboration in communications towers further exacerbated the situation 171. disaster settings 18,175,176. Additionally, in the context of research Within a mere 24-hour timeframe following the incident, national and perspectives related to complex intervention implementation, international aid poured in despite the absence of formal requests 174. considerations include efficacy, theory-based approaches, and system- Additionally, given Thailand’s robust culture of volunteering, many medical focused analyses 17. This thesis focused on exploring the implementation of a and non-medical volunteers offered their assistance, providing healthcare intervention (the Flexible Surge Capacity - FSC concept), deems uncomplicated medical care, interpretation services, aid in lifting and pragmatism as a paradigm conducive to mixed-method research. This choice transporting patients, and donations of food and disposable supplies. facilitates comprehensive data collection and analysis, addressing efficacy, However, the sheer magnitude of the disaster placed an overwhelming theory-based considerations, and systemic perspectives within the context burden on the healthcare system during both the immediate response and of healthcare intervention implementation in disaster scenarios. 177. 22 INTRODUCTION 23 Flexible Surge Capacity in Disasters and Major Incidents under the Public Health Ministry. The universal coverage scheme serves as a subsequent recovery phases, leading to considerable challenges in managing safety net for all Thais not covered by the other schemes; they are directed injuries and relief efforts. This pivotal event catalyzed a comprehensive to hospitals according to their civil registration. This scheme extends reevaluation of Thailand’s healthcare system in the context of disaster coverage to more than 72% of the population 166,170. management, prompting significant restructuring and fostering collaborations on an international scale. 28,171. Previous Experiences and Responses to Major Incidents Subsequently, in 2011, weighty rains caused profound flooding in major The 2004 tsunami stands out as a significant natural hazard that struck the hospitals in the central part of the country, necessitating hospital evacuation. southwestern coastline of the country, triggered by a profound 9.0 Reports indicated a structured disaster response, notably using the ICS with magnitude earthquake 171. The events resulted in the tragic loss of more the CSCATTT elements 31. However, managerial deficiencies were than 5,000 lives, affecting both residents and foreigners while causing concentrated on the inappropriate multiagency collaboration and inadequacy extensive damage to infrastructure across four provinces: Phangnga, Krabi, of evacuation resources, including boats, transport ventilators, and Phuket, and Ranong. The literature revealed the precarious state of transported staff 31,84,169. prehospital and hospital management during this crisis. Prehospital facilities were inadequately established, primarily relying on volunteer personnel, RESEARCH METHODS FOR DISASTER donated equipment, and vehicles172. This reliance resulted in severe deficits MANAGEMENT in scene evacuation resources, leading to a “first-come-first-serve” approach to victim transportation 171,172. Research in the field of disasters necessitates a critical examination of inherently dynamic and uncertain situations. Various research approaches, Conversely, hospital management adhered to a standard major incident can be employed, such as epidemiologic measures, economic impact policy, albeit activated shortly before the arrival of the first patient 171. Local assessments, descriptive studies/surveillance, and analytic measures 140. hospital staff worked tirelessly to address the influx of cases and resource Given the intricate nature of disasters, research designs often require a constraints, with hospital directors assuming the role of incident mixed-methods approach, combining quantitative surveys and qualitative commanders at each facility 173. However, comprehensive safety evaluations, interviews. Within this context, a pragmatic paradigm, representing a surveillance mechanisms, situational assessments, and resource evaluations common epistemological worldview, proves particularly suitable, especially were absent. Communication breakdowns due to damaged tele- in inquiries related to leadership, decision-making, and collaboration in communications towers further exacerbated the situation 171. disaster settings 18,175,176. Additionally, in the context of research Within a mere 24-hour timeframe following the incident, national and perspectives related to complex intervention implementation, international aid poured in despite the absence of formal requests 174. considerations include efficacy, theory-based approaches, and system- Additionally, given Thailand’s robust culture of volunteering, many medical focused analyses 17. This thesis focused on exploring the implementation of a and non-medical volunteers offered their assistance, providing healthcare intervention (the Flexible Surge Capacity - FSC concept), deems uncomplicated medical care, interpretation services, aid in lifting and pragmatism as a paradigm conducive to mixed-method research. This choice transporting patients, and donations of food and disposable supplies. facilitates comprehensive data collection and analysis, addressing efficacy, However, the sheer magnitude of the disaster placed an overwhelming theory-based considerations, and systemic perspectives within the context burden on the healthcare system during both the immediate response and of healthcare intervention implementation in disaster scenarios. 177. 22 INTRODUCTION 23 Flexible Surge Capacity in Disasters and Major Incidents THE RATIONALE OF THE THESIS Despite the existence of structured disaster response plans, there have been Applicability test in Feasibility diverse incidents - Applicability test in knowledge gaps in the execution of these plans and in the comprehensive test in COVID-19 Home diverse incidents - Community Isolation Center Hospital evacuation management of resources. These gaps underscore the importance of (Study II) (Study III) (Study V) continuous evaluation and refinement of disaster preparedness strategies. Such ongoing efforts are essential to ensure that the healthcare system can effectively respond to emergencies and address potential issues related to Conceptual Hospital framework Evacuation - resource allocation and plan adherence shortcomings. construction context (Study I) assessment One proactive approach to addressing these challenges involves the (Study IV) engagement of local resources, known as FSC. This becomes especially Figure 2 Data collection chart for Study I-V crucial when external resource deliveries are disrupted due to infrastructure damage, or when hospitals face the necessity of evacuation, necessitating Given the overlap between the COVID-19 pandemic and the timing of the significant mobilization of staff and transportation resources. The FSC doctoral study, Study II was the first study conducted online, facilitating concept, as introduced by Khorram-Manesh, represents an additional virtual data collection. Thus, Study II serves as an appropriate initial point of resource pool derived from the local community 29. In the related study, exploration within the thesis, examining the adoption and feasibility of the Glantz et al. conducted an implementation test of this concept in a region in FSC concept in Thailand. Sweden 30. This empirical evaluation contributes insights into the practicality The FSC concept was the core component of the innovation implemented in of FSC and the locals’ perceptions toward the concept, shedding light on its the Thai healthcare system. Figure 3 presents a logical model visualizing the potential as a valuable component of disaster preparedness strategies. implementation strategy using pragmatic research methods for disaster and This thesis builds upon the FSC concept and aims to assess its feasibility and public health emergencies through scenario-based simulations (the 3LC applicability within the healthcare system, targeting the expansion of exercise) and the expected disaster preparedness outcomes. resources to the community and fostering multiagency collaboration during crises. Figure 4 illustrates the chronological data collection and flows. The subsequent chapters of the thesis will provide a detailed description of the implementation process, offering a comprehensive understanding of the concept execution in the Thai context. 24 INTRODUCTION 25 Flexible Surge Capacity in Disasters and Major Incidents THE RATIONALE OF THE THESIS Despite the existence of structured disaster response plans, there have been Applicability test in Feasibility diverse incidents - Applicability test in knowledge gaps in the execution of these plans and in the comprehensive test in COVID-19 Home diverse incidents - Community Isolation Center Hospital evacuation management of resources. These gaps underscore the importance of (Study II) (Study III) (Study V) continuous evaluation and refinement of disaster preparedness strategies. Such ongoing efforts are essential to ensure that the healthcare system can effectively respond to emergencies and address potential issues related to Conceptual Hospital framework Evacuation - resource allocation and plan adherence shortcomings. construction context (Study I) assessment One proactive approach to addressing these challenges involves the (Study IV) engagement of local resources, known as FSC. This becomes especially Figure 2 Data collection chart for Study I-V crucial when external resource deliveries are disrupted due to infrastructure damage, or when hospitals face the necessity of evacuation, necessitating Given the overlap between the COVID-19 pandemic and the timing of the significant mobilization of staff and transportation resources. The FSC doctoral study, Study II was the first study conducted online, facilitating concept, as introduced by Khorram-Manesh, represents an additional virtual data collection. Thus, Study II serves as an appropriate initial point of resource pool derived from the local community 29. In the related study, exploration within the thesis, examining the adoption and feasibility of the Glantz et al. conducted an implementation test of this concept in a region in FSC concept in Thailand. Sweden 30. This empirical evaluation contributes insights into the practicality The FSC concept was the core component of the innovation implemented in of FSC and the locals’ perceptions toward the concept, shedding light on its the Thai healthcare system. Figure 3 presents a logical model visualizing the potential as a valuable component of disaster preparedness strategies. implementation strategy using pragmatic research methods for disaster and This thesis builds upon the FSC concept and aims to assess its feasibility and public health emergencies through scenario-based simulations (the 3LC applicability within the healthcare system, targeting the expansion of exercise) and the expected disaster preparedness outcomes. resources to the community and fostering multiagency collaboration during crises. Figure 4 illustrates the chronological data collection and flows. The subsequent chapters of the thesis will provide a detailed description of the implementation process, offering a comprehensive understanding of the concept execution in the Thai context. 24 INTRODUCTION 25 Flexible Surge Capacity in Disasters and Major Incidents AIMS This thesis examined the feasibility and applicability of a flexible concept described as “flexible surge capacity” in the management of major incidents and disasters. The studies concentrate on the essential components of a community’s surge capacity and the collaborative aspects required in various infrastructures and disaster etiologies. Conceptual framework construction (Study I) Conceptual understanding Feasibility study in Community (Study II & IV) Generalization Community Partnership Applicability study in diverse Implementation: Internal incidents (Studay III & V) validity Theory based and Systems • Efficacy perspective perspective - Intervention Refinement Figure 3 Logic model of FSC concept implementation. 3LC = Three Level Collaboration, • Internal and external validity and COVID-19 = Coronavirus 2019. • Context and Stakeholders • Collaborations Figure 4 Coherence of the studies and aims in the thesis. Specific aims: I Conceptual framework construction using a review of the literature. To develop a theoretical framework for the flexible surge capacity, inspired by existing surge capacity, complexity theory, and collaborative theoretical frameworks, and discuss its implementation and use in emergencies. II Feasibility test using a mixed-method cross-sectional study. To investigate the possibility of creating alternative care facilities, as part of Flexible Surge Capacity, to relieve hospitals in Bangkok, Thailand III Applicability test using a qualitative study. To explore the possibility of implementing the concept of flexible surge capacity to reduce the burden on hospitals by focusing on community 26 AIMS 27 Flexible Surge Capacity in Disasters and Major Incidents AIMS This thesis examined the feasibility and applicability of a flexible concept described as “flexible surge capacity” in the management of major incidents and disasters. The studies concentrate on the essential components of a community’s surge capacity and the collaborative aspects required in various infrastructures and disaster etiologies. Conceptual framework construction (Study I) Conceptual understanding Feasibility study in Community (Study II & IV) Generalization Community Partnership Applicability study in diverse Implementation: Internal incidents (Studay III & V) validity Theory based and Systems • Efficacy perspective perspective - Intervention Refinement Figure 3 Logic model of FSC concept implementation. 3LC = Three Level Collaboration, • Internal and external validity and COVID-19 = Coronavirus 2019. • Context and Stakeholders • Collaborations Figure 4 Coherence of the studies and aims in the thesis. Specific aims: I Conceptual framework construction using a review of the literature. To develop a theoretical framework for the flexible surge capacity, inspired by existing surge capacity, complexity theory, and collaborative theoretical frameworks, and discuss its implementation and use in emergencies. II Feasibility test using a mixed-method cross-sectional study. To investigate the possibility of creating alternative care facilities, as part of Flexible Surge Capacity, to relieve hospitals in Bangkok, Thailand III Applicability test using a qualitative study. To explore the possibility of implementing the concept of flexible surge capacity to reduce the burden on hospitals by focusing on community 26 AIMS 27 Flexible Surge Capacity in Disasters and Major Incidents resources to develop home isolation centers in Bangkok, Thailand, during METHODS the COVID-19 pandemic. IV Hospital evacuation context evaluation using a mixed-method cross- sectional study. Besides the pandemic, hospital evacuation is another incident necessitating the “flexible surge capacity” concept. This study aimed to investigate the extent of hospital evacuation preparedness in Thailand, using the main The thesis employed several research methodologies, including descriptive elements of the concept. reviews and mixed-method cross-sectional designs, to implement complex interventions, ‘Flexible Surge Capacity,’ in the healthcare system during V Applicability test using a mixed-method cross-sectional study. disaster response. Table 1 demonstrates the studies’ methodologies To assess the effectiveness of using the 3LC exercise in developing overview. collaboration and leadership in districts in Thailand, using the FSC concept Table 1 Methodologies of Study I-V and its collaborative tool during hospital evacuation scenarios. Study I II III IV V Designs Descriptive Mixed- Qualitative Mixed- Mixed- review method prospective method cross- method cross- cross- sectional cross- sectional sectional sectional Data Literature Online Observation, Online Observatio collection review, questionnair Semi- questionnaire, n, Record Descriptive e, Semi- structured Semi- transcript- and structured interview structured tion, Self- conceptual interview interview evaluation Participants Search Alternative Operation in Represen- Representa engine care facilities home tatives from tives from in Bangkok, isolation hospitals disaster Thailand center and (secondary responding volunteers in care, tertiary organiza- non- care, and tions in governmental university districts of organizations hospitals) Thailand 28 METHODS 29 Flexible Surge Capacity in Disasters and Major Incidents resources to develop home isolation centers in Bangkok, Thailand, during METHODS the COVID-19 pandemic. IV Hospital evacuation context evaluation using a mixed-method cross- sectional study. Besides the pandemic, hospital evacuation is another incident necessitating the “flexible surge capacity” concept. This study aimed to investigate the extent of hospital evacuation preparedness in Thailand, using the main The thesis employed several research methodologies, including descriptive elements of the concept. reviews and mixed-method cross-sectional designs, to implement complex interventions, ‘Flexible Surge Capacity,’ in the healthcare system during V Applicability test using a mixed-method cross-sectional study. disaster response. Table 1 demonstrates the studies’ methodologies To assess the effectiveness of using the 3LC exercise in developing overview. collaboration and leadership in districts in Thailand, using the FSC concept Table 1 Methodologies of Study I-V and its collaborative tool during hospital evacuation scenarios. Study I II III IV V Designs Descriptive Mixed- Qualitative Mixed- Mixed- review method prospective method cross- method cross- cross- sectional cross- sectional sectional sectional Data Literature Online Observation, Online Observatio collection review, questionnair Semi- questionnaire, n, Record Descriptive e, Semi- structured Semi- transcript- and structured interview structured tion, Self- conceptual interview interview evaluation Participants Search Alternative Operation in Represen- Representa engine care facilities home tatives from tives from in Bangkok, isolation hospitals disaster Thailand center and (secondary responding volunteers in care, tertiary organiza- non- care, and tions in governmental university districts of organizations hospitals) Thailand 28 METHODS 29 Flexible Surge Capacity in Disasters and Major Incidents Study I II III IV V CONCEPTUAL AND THEORETICAL FRAMEWORK OF THE FLEXIBLE SURGE CAPACITY (FSC) Data Descriptive Quantitative Deductive Quantitative Quantitativ (STUDY I) analysis review and content and deductive e and deductive analysis content deductive The concepts and theories concerning surge capacity and disaster content analysis content analysis analysis management were reviewed, mapped, and conceptualized to construct the flexible surge capacity (FSC) conceptual framework 178-180. Tools N/A Questionnair Observation Questionnaire Self- e according to (Adapted evaluation Review, Identification, and Selection of Literature (Adapted CSCATTT from form, from Glantz Khorram- Observatio Multidisciplinary literature on surge capacity disaster characteristics, V. et al. Manesh, A. nal healthcare facilities’ responses, and collaboration theories and concepts 2020) et al. 2021) checklist were extensively reviewed. Relevant literature was cultivated and categorized based on their logic and coherence to disasters and public Primary Conceptual Willingness Applicability Hospital The 3LC outcomes framework to of the FSC preparedness exercise health emergency management. participate in concept in status can The literature review delves into an examination of surge capacity, its the FSC the COVID- regarding improve concept and 19 pandemic surge capacity the taxonomies, and expansion. Theoretical frameworks proposed by Hick et al. facilities’ to unburden and developme and Bonnett et al. significantly contribute to comprehending surge capacity capacities hospitals collaborations nt of dynamics 3-5. The surge-generating events manifest in 2 primary forms: and collaboratio contained events (i.e., significant damage to infrastructure or massive local capabilities n and impact) and population-based (i.e., pandemic) events. The nuanced leadership in hospital conceptualization of surge capacity is achieved through its categorization evacuation into public health, facility-based, and community-based surges (Figure 5). using the Additionally, the classification into conventional, contingency, and crisis FSC capacity provides a practical demonstration for the disaster response phase concept (Figure 6)3,5,45,70,74. However, the predominantly healthcare-centric focus of Ethical N/A MURA MURA MURA MURA these models necessitates a broader perspective on surge planning, and the Approval 2020/1621 2021/786 2021/573 2021/960 efficacy of surge capacity expansion remains a challenge. Previous studies (University Ref.1299 have highlighted deficiencies in surge planning efforts, leading to the Ethical inadequacy of surge expansion endeavors 31,84,173,181,182. Review Board) Status Published Published Published Published Published 2022 2021 2022 2023 2023 30 METHODS 31 Flexible Surge Capacity in Disasters and Major Incidents Study I II III IV V CONCEPTUAL AND THEORETICAL FRAMEWORK OF THE FLEXIBLE SURGE CAPACITY (FSC) Data Descriptive Quantitative Deductive Quantitative Quantitativ (STUDY I) analysis review and content and deductive e and deductive analysis content deductive The concepts and theories concerning surge capacity and disaster content analysis content analysis analysis management were reviewed, mapped, and conceptualized to construct the flexible surge capacity (FSC) conceptual framework 178-180. Tools N/A Questionnair Observation Questionnaire Self- e according to (Adapted evaluation Review, Identification, and Selection of Literature (Adapted CSCATTT from form, from Glantz Khorram- Observatio Multidisciplinary literature on surge capacity disaster characteristics, V. et al. Manesh, A. nal healthcare facilities’ responses, and collaboration theories and concepts 2020) et al. 2021) checklist were extensively reviewed. Relevant literature was cultivated and categorized based on their logic and coherence to disasters and public Primary Conceptual Willingness Applicability Hospital The 3LC outcomes framework to of the FSC preparedness exercise health emergency management. participate in concept in status can The literature review delves into an examination of surge capacity, its the FSC the COVID- regarding improve concept and 19 pandemic surge capacity the taxonomies, and expansion. Theoretical frameworks proposed by Hick et al. facilities’ to unburden and developme and Bonnett et al. significantly contribute to comprehending surge capacity capacities hospitals collaborations nt of dynamics 3-5. The surge-generating events manifest in 2 primary forms: and collaboratio contained events (i.e., significant damage to infrastructure or massive local capabilities n and impact) and population-based (i.e., pandemic) events. The nuanced leadership in hospital conceptualization of surge capacity is achieved through its categorization evacuation into public health, facility-based, and community-based surges (Figure 5). using the Additionally, the classification into conventional, contingency, and crisis FSC capacity provides a practical demonstration for the disaster response phase concept (Figure 6)3,5,45,70,74. However, the predominantly healthcare-centric focus of Ethical N/A MURA MURA MURA MURA these models necessitates a broader perspective on surge planning, and the Approval 2020/1621 2021/786 2021/573 2021/960 efficacy of surge capacity expansion remains a challenge. Previous studies (University Ref.1299 have highlighted deficiencies in surge planning efforts, leading to the Ethical inadequacy of surge expansion endeavors 31,84,173,181,182. Review Board) Status Published Published Published Published Published 2022 2021 2022 2023 2023 30 METHODS 31 Flexible Surge Capacity in Disasters and Major Incidents Daily Operations Decreasing Morbidity and Incident demands Increasing Standard of Care Conventional Contingency CrisisIncreases in volume can be handled No significant modifications in with normal staffing and resources operations Space Usual patient care Patient care areas re-purposed Non-traditional areas used for spaces maximized (PAC U, monitored units for critical care or facility damage Disaster ICU-level care) does not permit usual critical care Staff Additional staff Staff extension (supervision Insufficient ICU trained staff called in as needed of larger number of patients, available/unable to care for Faclility-Based Surge changes in responsibilities, volume of patients, care team documentation, etc) model required & expanded scope Disaster plan Operations expanded Situation contained Supplies Cached/on-hand Conservation, adaptation and Critical supplies lacking, possible implemented within the facility within the institution supplies substitution of supplies with allocation/reallocation or lifesaving selected re-use of supplies resources when safe Standard Usual care Minimal impact on usual patient Not consistent with usual of Care care practices standards of care (Mass Critical Care) Sufficiency Community-Based Surge of Care ICU X1.2 usual capacity X 2 usual capacity (100%) X 3 usual capacity (200%) expansion (20%) Operations expand Offsite care centers and Municipal and regional goal beyond facility walls surge hospitals coordination required Resources Local Regional/State National Normal Operating Condition Extreme Extrinsic surge Figure 6 A surge capacity planning framework outlining the conventional, contingency, and crisis surge responses (PACU=post-anesthesia care unit). Assets from unaffected Victims evacuated to Avaliability will depend Adapted from Hick et al. and published in 2014 74. regions arrive unaffected areas on type of event To better prepare for and respond to disasters, it is crucial to comprehend Figure 5 The progression of surge responses after disasters. Adapted from the underlying theoretical perspectives. In this context, complexity theory Bonnett et al. Published in 20073. provides a robust framework for understanding disaster events’ dynamic and adaptive nature 183. In contrast to linear models, complexity theory acknowledges the intricate interplay of factors contributing to disaster dynamics. Embracing complexity theory in surge planning facilitates a more holistic and adaptable approach to disaster preparedness 184. Furthermore, disaster responses are contingent upon effective collaborative efforts among various stakeholders, as the impacts can extend beyond individuals to social and organizational disorders. Adopting a systematic approach encompassing multidimensional aspects and encouraging 32 METHODS 33 Flexible Surge Capacity in Disasters and Major Incidents Daily Operations Decreasing Morbidity and Incident demands Increasing Standard of Care Conventional Contingency CrisisIncreases in volume can be handled No significant modifications in with normal staffing and resources operations Space Usual patient care Patient care areas re-purposed Non-traditional areas used for spaces maximized (PAC U, monitored units for critical care or facility damage Disaster ICU-level care) does not permit usual critical care Staff Additional staff Staff extension (supervision Insufficient ICU trained staff called in as needed of larger number of patients, available/unable to care for Faclility-Based Surge changes in responsibilities, volume of patients, care team documentation, etc) model required & expanded scope Disaster plan Operations expanded Situation contained Supplies Cached/on-hand Conservation, adaptation and Critical supplies lacking, possible implemented within the facility within the institution supplies substitution of supplies with allocation/reallocation or lifesaving selected re-use of supplies resources when safe Standard Usual care Minimal impact on usual patient Not consistent with usual of Care care practices standards of care (Mass Critical Care) Sufficiency Community-Based Surge of Care ICU X1.2 usual capacity X 2 usual capacity (100%) X 3 usual capacity (200%) expansion (20%) Operations expand Offsite care centers and Municipal and regional goal beyond facility walls surge hospitals coordination required Resources Local Regional/State National Normal Operating Condition Extreme Extrinsic surge Figure 6 A surge capacity planning framework outlining the conventional, contingency, and crisis surge responses (PACU=post-anesthesia care unit). Assets from unaffected Victims evacuated to Avaliability will depend Adapted from Hick et al. and published in 2014 74. regions arrive unaffected areas on type of event To better prepare for and respond to disasters, it is crucial to comprehend Figure 5 The progression of surge responses after disasters. Adapted from the underlying theoretical perspectives. In this context, complexity theory Bonnett et al. Published in 20073. provides a robust framework for understanding disaster events’ dynamic and adaptive nature 183. In contrast to linear models, complexity theory acknowledges the intricate interplay of factors contributing to disaster dynamics. Embracing complexity theory in surge planning facilitates a more holistic and adaptable approach to disaster preparedness 184. Furthermore, disaster responses are contingent upon effective collaborative efforts among various stakeholders, as the impacts can extend beyond individuals to social and organizational disorders. Adopting a systematic approach encompassing multidimensional aspects and encouraging 32 METHODS 33 Flexible Surge Capacity in Disasters and Major Incidents collaboration among multiple agencies is necessary. Therefore, collaboration Integrating, Synthesizing, and Proposing the theories were examined to ascertain the required crucial relationships to Conceptual Framework of the Flexible Surge Capacity achieve a goal 8-10,12,185. In routine circumstances, distinct entities operate (FSC) independently, employing disparate or occasionally intersecting strategies while pursuing different or convergent objectives. However, it becomes The integration of surge capacity theoretical frameworks, complexity imperative to identify and discuss mutual interests and points of contact theory, and collaboration theory has culminated in synthesizing the FSC among these entities during disasters through effective communication. conceptual framework. The conceptual framework expands upon the Figure 7 illustrates the characteristics of collaboration. Collaboration community-based surge models previously put forth by Hick et al. and theories are essential in disaster response scenarios, where multiple entities Bonnett et al., extending its purview to encompass not only the healthcare 3,74 must work together, each with its processes and goals. One notable system but also local community resources . These community resources collaboration theory, as emphasized by Patel et al., outlines pivotal factors comprise a range of both medical and non-medical facilities. Within the that underpin successful collaborative endeavors 9. These factors from Patel medical domain, these resources include primary healthcare clinics, dental et al. align with the CSCATTT model, a framework harnessed in the clinics, veterinary clinics, and pharmacies, among others. On the non- MIMMS. The practical significance and efficacy of this CSCATTT model medical front, resources include educational institutions such as schools, render it noteworthy as both a measurement and evaluation instrument versatile venues like sports arenas, and lodging establishments like hotels. 91,186. Activating these local resources becomes imperative when all conventional facilities have been exhausted or cannot be accessed. Moreover, such activation becomes essential when the healthcare facilities are compromised, necessitating evacuation due to imminent threats. This integration of diverse resources underscores the adaptability and resilience inherent in the Flexible Surge Capacity Conceptual framework. Cooperation Cross functional FEASIBILITY STUDY OF THE FSC CONCEPT IN activities Empowerment COMMUNITIES AND HOSPITALS (STUDY II & IV) Integrating the FSC concept into the healthcare system necessitates a multifaceted approach that hinges on fostering deep community engagement. Collaboration To ensure its effective execution, we emphasize the need for comprehensive Coordination Communication Information-sharing public education and strategic actions. Central to this strategy is the conduct Resource-pooling Goal harmonization Sense-making of a feasibility study, which is instrumental in gauging the viability of the proposed interventions 14. The deployment of a feasibility study involves examining various constituent Figure 7 Collaboration characteristics9,10,185. Adapted from paper I elements contributing to the overall viability of the FSC concept. Previous reports proposed appropriate components, including acceptability, demand, implementation, practicality, adaptability, integration potential, expansion 34 METHODS 35 Flexible Surge Capacity in Disasters and Major Incidents collaboration among multiple agencies is necessary. Therefore, collaboration Integrating, Synthesizing, and Proposing the theories were examined to ascertain the required crucial relationships to Conceptual Framework of the Flexible Surge Capacity achieve a goal 8-10,12,185. In routine circumstances, distinct entities operate (FSC) independently, employing disparate or occasionally intersecting strategies while pursuing different or convergent objectives. However, it becomes The integration of surge capacity theoretical frameworks, complexity imperative to identify and discuss mutual interests and points of contact theory, and collaboration theory has culminated in synthesizing the FSC among these entities during disasters through effective communication. conceptual framework. The conceptual framework expands upon the Figure 7 illustrates the characteristics of collaboration. Collaboration community-based surge models previously put forth by Hick et al. and theories are essential in disaster response scenarios, where multiple entities Bonnett et al., extending its purview to encompass not only the healthcare 3,74 must work together, each with its processes and goals. One notable system but also local community resources . These community resources collaboration theory, as emphasized by Patel et al., outlines pivotal factors comprise a range of both medical and non-medical facilities. Within the that underpin successful collaborative endeavors 9. These factors from Patel medical domain, these resources include primary healthcare clinics, dental et al. align with the CSCATTT model, a framework harnessed in the clinics, veterinary clinics, and pharmacies, among others. On the non- MIMMS. The practical significance and efficacy of this CSCATTT model medical front, resources include educational institutions such as schools, render it noteworthy as both a measurement and evaluation instrument versatile venues like sports arenas, and lodging establishments like hotels. 91,186. Activating these local resources becomes imperative when all conventional facilities have been exhausted or cannot be accessed. Moreover, such activation becomes essential when the healthcare facilities are compromised, necessitating evacuation due to imminent threats. This integration of diverse resources underscores the adaptability and resilience inherent in the Flexible Surge Capacity Conceptual framework. Cooperation Cross functional FEASIBILITY STUDY OF THE FSC CONCEPT IN activities Empowerment COMMUNITIES AND HOSPITALS (STUDY II & IV) Integrating the FSC concept into the healthcare system necessitates a multifaceted approach that hinges on fostering deep community engagement. Collaboration To ensure its effective execution, we emphasize the need for comprehensive Coordination Communication Information-sharing public education and strategic actions. Central to this strategy is the conduct Resource-pooling Goal harmonization Sense-making of a feasibility study, which is instrumental in gauging the viability of the proposed interventions 14. The deployment of a feasibility study involves examining various constituent Figure 7 Collaboration characteristics9,10,185. Adapted from paper I elements contributing to the overall viability of the FSC concept. Previous reports proposed appropriate components, including acceptability, demand, implementation, practicality, adaptability, integration potential, expansion 34 METHODS 35 Flexible Surge Capacity in Disasters and Major Incidents possibilities, and limited-efficacy testing 14. In this thesis, studies II and IV experiences, and provide insightful perspectives. The questionnaires are evaluated the acceptability, demand, practicality, adaptation, and integration available in the Appendix. through validated questionnaires. Measuring public opinions, intentions, and perceptions is imperative to explore these facets comprehensively. Questionnaire Participants In Study II, the questionnaire underwent a comprehensive development process guided by the expertise of three individuals with extensive Study II included all available medical and non-medical facilities in the experience in instrument development and an understanding of disaster and communities in Bangkok, the capital city of Thailand. For medical facilities, emergency management 82. This panel of experts conducted a thorough face public primary healthcare centers and dental clinics were sourced from the validation, evaluating the questionnaire based on logic, relevance, Ministry of Health. Additionally, the private and veterinary clinics operating comprehension, legibility, clarity, and usability criteria. Cronbach’s alpha within the private sector were identified through online search engines. analysis for internal consistency was 0.739. The questionnaire included Non-medical establishments, namely educational institutions, were retrieved hypothetical scenarios involving major incidents with multiple injured through the Ministry of Education. Simultaneously, sports arenas and hotels individuals and queries about the facilities' capacities and capabilities in aiding were ascertained through online search engine queries. the healthcare sector's response. In Study IV, the focus shifted to healthcare facilities of varying capacities, In Study IV, the questionnaire development process diverged slightly, with stratified into secondary care facilities (ranging from 120 to 500 beds), three experts independently reviewing literature from 2002 to 2018, tertiary care institutions (with capacities exceeding 500 beds), and specifically focused on hospital evacuation 161. Subsequently, content analysis university-affiliated hospitals boasting bed capacities spanning the range of was employed to derive pertinent questions that would encapsulate the 400 to 2265. These institutions were chosen based on their capacity and complexities of hospital evacuations and their preparedness. The questions capability to provide a broad spectrum of medical interventions, a critical underwent face and content validity validation to ensure appropriateness consideration in disaster response preparedness 166,167. The Ministry of and relevancy. The questionnaire comprised a spectrum of critical elements, Health was instrumental in providing the requisite names and addresses for including surge capacity, collaborative factors, ethical and legal these 143 hospitals, which constituted the focus of our investigation. considerations, situation assessment, and the management of vulnerable groups within the context of hospital evacuations. Study Tools A translation process was executed to ensure linguistic and semantic In both study II and study IV, data collection employed validated equivalence between the English and Thai versions of both studies’ tools. questionnaires sourced from previous literature 82,161. These instruments Two native Thai speakers independently translated the tools into Thai, were designed using a Nominal Group Technique as a foundational followed by a back-translation into English. The tools were then subjected approach187 , aimed at formulating questions that encapsulate the to face validation and comparisons to the original English versions. Any involvement of the FSC concept in surge planning and collaborative factors. discrepancies were addressed through discussions between the translators, Quantitative data acquisition was facilitated through the application of a and a consensus was reached regarding the accuracy and coherence of the Likert scale. While the qualitative aspect incorporated open-ended translated versions. Furthermore, the translated tools were presented to questions, allowing respondents to articulate opinions, share personal and discussed with the original developers, further enhancing their accuracy and ensuring alignment with the intended research objectives. Once the 36 METHODS 37 Flexible Surge Capacity in Disasters and Major Incidents possibilities, and limited-efficacy testing 14. In this thesis, studies II and IV experiences, and provide insightful perspectives. The questionnaires are evaluated the acceptability, demand, practicality, adaptation, and integration available in the Appendix. through validated questionnaires. Measuring public opinions, intentions, and perceptions is imperative to explore these facets comprehensively. Questionnaire Participants In Study II, the questionnaire underwent a comprehensive development process guided by the expertise of three individuals with extensive Study II included all available medical and non-medical facilities in the experience in instrument development and an understanding of disaster and communities in Bangkok, the capital city of Thailand. For medical facilities, emergency management 82. This panel of experts conducted a thorough face public primary healthcare centers and dental clinics were sourced from the validation, evaluating the questionnaire based on logic, relevance, Ministry of Health. Additionally, the private and veterinary clinics operating comprehension, legibility, clarity, and usability criteria. Cronbach’s alpha within the private sector were identified through online search engines. analysis for internal consistency was 0.739. The questionnaire included Non-medical establishments, namely educational institutions, were retrieved hypothetical scenarios involving major incidents with multiple injured through the Ministry of Education. Simultaneously, sports arenas and hotels individuals and queries about the facilities' capacities and capabilities in aiding were ascertained through online search engine queries. the healthcare sector's response. In Study IV, the focus shifted to healthcare facilities of varying capacities, In Study IV, the questionnaire development process diverged slightly, with stratified into secondary care facilities (ranging from 120 to 500 beds), three experts independently reviewing literature from 2002 to 2018, tertiary care institutions (with capacities exceeding 500 beds), and specifically focused on hospital evacuation 161. Subsequently, content analysis university-affiliated hospitals boasting bed capacities spanning the range of was employed to derive pertinent questions that would encapsulate the 400 to 2265. These institutions were chosen based on their capacity and complexities of hospital evacuations and their preparedness. The questions capability to provide a broad spectrum of medical interventions, a critical underwent face and content validity validation to ensure appropriateness consideration in disaster response preparedness 166,167. The Ministry of and relevancy. The questionnaire comprised a spectrum of critical elements, Health was instrumental in providing the requisite names and addresses for including surge capacity, collaborative factors, ethical and legal these 143 hospitals, which constituted the focus of our investigation. considerations, situation assessment, and the management of vulnerable groups within the context of hospital evacuations. Study Tools A translation process was executed to ensure linguistic and semantic In both study II and study IV, data collection employed validated equivalence between the English and Thai versions of both studies’ tools. questionnaires sourced from previous literature 82,161. These instruments Two native Thai speakers independently translated the tools into Thai, were designed using a Nominal Group Technique as a foundational followed by a back-translation into English. The tools were then subjected approach187 , aimed at formulating questions that encapsulate the to face validation and comparisons to the original English versions. Any involvement of the FSC concept in surge planning and collaborative factors. discrepancies were addressed through discussions between the translators, Quantitative data acquisition was facilitated through the application of a and a consensus was reached regarding the accuracy and coherence of the Likert scale. While the qualitative aspect incorporated open-ended translated versions. Furthermore, the translated tools were presented to questions, allowing respondents to articulate opinions, share personal and discussed with the original developers, further enhancing their accuracy and ensuring alignment with the intended research objectives. Once the 36 METHODS 37 Flexible Surge Capacity in Disasters and Major Incidents translation process was completed, the research details, ethical approval Emphasis was placed on selecting representatives for research participation, declarations, consent, and questionnaire were transferred to an online focusing on their competencies in hospital emergency response plans and platform 188. protocols. These representatives held the authority to revise the protocols and were responsible for communicating any modifications to the Semi-structured Interviews preparedness committee. Such representatives could be the facilities' directors, heads of security or emergency departments, or individuals The semi-structured interviews were conducted as a complementary occupying equivalent roles. Subsequently, formal letters were dispatched, method of data collection 189. These interviews were structured in alignment inclusive of a hyperlink and QR code, providing access to online resources with the content and themes of the questionnaires—however, the semi- encompassing research details, ethical approval documents, consent to structured format allowed for greater discussion flexibility and depth. participation, and the questionnaire. The online form was available for Participants were encouraged to elaborate on their responses, allowing response from December 2021 to April 2022. them to diverge from the predefined questions and introduce novel ideas and insights based on their experiences and expertise. This open-ended Following the dispatch of official letters in both studies, the main investigator nature of the interviews facilitated a comprehensive understanding of the maintained a proactive engagement strategy, contacting all facilities via responses, contributing to the nuanced analysis of the data. administrative emails and telephones to reinforce the importance of their research participation 188,191. This engagement continued until the Data Collection and Processing preliminary data analysis was performed, and the qualitative data reached saturation. Saturation in this context was characterized by the emergence of In Study II, before the distribution of questionnaires, a proactive approach repetitive themes and thematic similarities within the findings, indicating that was adopted to engage with the higher authorities of governmental further data collection would not yield new insights 192. At this juncture, the establishments. The principal investigator, a PhD student, initiated direct reminder correspondence was discontinued, with approximately 3 communication to outline the prescribed procedures for collecting survey consequent reminders being issued 190. data. Subsequently, the pertinent governmental ministries orchestrated the dissemination of formal correspondence to various government-owned All data obtained from the online platform were exported into Google facilities, including public primary healthcare centers, schools, and sports Sheets and Microsoft Office Excel for initial organization and cleaning. arenas. This strategic approach to survey distribution was anticipated to Subsequently, the cleaned quantitative data were imported into Stata version enhance the responsiveness of these official entities 190. Conversely, in the 17 for comprehensive cleaning, organizing, and analysis preparation. private sector, the task of disbursing official correspondence to independent Simultaneously, the qualitative data were separately prepared for deductive entities was entrusted to Mahidol University. These letters contained a content analysis 192,193. hyperlink and QR code, enabling recipients to access a repository of research particulars, ethical approval documents, and surveys hosted on the Non-Response Strategic Approaches Google Form platform. The online form was available for response from November 2020 to January 2021. One of the challenges encountered in research methodology employing questionnaires is the issue of a response rate 194,195. A review of studies In Study IV, all official facilities enlisted from the Ministry of Health were focusing on survey methodology research has reported a general response contacted by phone to communicate research details comprehensively. rate that ranges from 22 - 68.8%. Factors influencing response rates include the survey mode, questionnaire length, content sensitivity, and language, 38 METHODS 39 Flexible Surge Capacity in Disasters and Major Incidents translation process was completed, the research details, ethical approval Emphasis was placed on selecting representatives for research participation, declarations, consent, and questionnaire were transferred to an online focusing on their competencies in hospital emergency response plans and platform 188. protocols. These representatives held the authority to revise the protocols and were responsible for communicating any modifications to the Semi-structured Interviews preparedness committee. Such representatives could be the facilities' directors, heads of security or emergency departments, or individuals The semi-structured interviews were conducted as a complementary occupying equivalent roles. Subsequently, formal letters were dispatched, method of data collection 189. These interviews were structured in alignment inclusive of a hyperlink and QR code, providing access to online resources with the content and themes of the questionnaires—however, the semi- encompassing research details, ethical approval documents, consent to structured format allowed for greater discussion flexibility and depth. participation, and the questionnaire. The online form was available for Participants were encouraged to elaborate on their responses, allowing response from December 2021 to April 2022. them to diverge from the predefined questions and introduce novel ideas and insights based on their experiences and expertise. This open-ended Following the dispatch of official letters in both studies, the main investigator nature of the interviews facilitated a comprehensive understanding of the maintained a proactive engagement strategy, contacting all facilities via responses, contributing to the nuanced analysis of the data. administrative emails and telephones to reinforce the importance of their research participation 188,191. This engagement continued until the Data Collection and Processing preliminary data analysis was performed, and the qualitative data reached saturation. Saturation in this context was characterized by the emergence of In Study II, before the distribution of questionnaires, a proactive approach repetitive themes and thematic similarities within the findings, indicating that was adopted to engage with the higher authorities of governmental further data collection would not yield new insights 192. At this juncture, the establishments. The principal investigator, a PhD student, initiated direct reminder correspondence was discontinued, with approximately 3 communication to outline the prescribed procedures for collecting survey consequent reminders being issued 190. data. Subsequently, the pertinent governmental ministries orchestrated the dissemination of formal correspondence to various government-owned All data obtained from the online platform were exported into Google facilities, including public primary healthcare centers, schools, and sports Sheets and Microsoft Office Excel for initial organization and cleaning. arenas. This strategic approach to survey distribution was anticipated to Subsequently, the cleaned quantitative data were imported into Stata version enhance the responsiveness of these official entities 190. Conversely, in the 17 for comprehensive cleaning, organizing, and analysis preparation. private sector, the task of disbursing official correspondence to independent Simultaneously, the qualitative data were separately prepared for deductive entities was entrusted to Mahidol University. These letters contained a content analysis 192,193. hyperlink and QR code, enabling recipients to access a repository of research particulars, ethical approval documents, and surveys hosted on the Non-Response Strategic Approaches Google Form platform. The online form was available for response from November 2020 to January 2021. One of the challenges encountered in research methodology employing questionnaires is the issue of a response rate 194,195. A review of studies In Study IV, all official facilities enlisted from the Ministry of Health were focusing on survey methodology research has reported a general response contacted by phone to communicate research details comprehensively. rate that ranges from 22 - 68.8%. Factors influencing response rates include the survey mode, questionnaire length, content sensitivity, and language, 38 METHODS 39 Flexible Surge Capacity in Disasters and Major Incidents rather than the ethnicities and geographical locations where the research is APPLICABILITY STUDY AND IMPLEMENTATION conducted 190,196. Studies II and IV incorporated various strategic measures, IN DIVERSE INCIDENTS (STUDY III & V) including vertical communication, advance notifications, and multiple follow- ups to augment the response rate for a predictable low success rate in The outcomes of feasibility and evaluation studies conducted in Study II and online surveys. Study IV supported the refinement of the subsequent applicability and transferability of the FSC concept in Study III and Study V. The FSC Data Analysis concept's applicability was examined in the context of two distinct incidents: firstly, its application in the management of the COVID-19 pandemic with Quantitative Analysis the aim of alleviating the strain on hospitals (Study III); and secondly, its role The quantitative data from both studies were descriptively presented in in hospital evacuation scenarios, which were assessed through the 3LC counts and proportions. In Study IV, the Chi-square or Fisher’s exact test exercise (Study V). (the Fisher’s exact test used when the expected number in each cell was Study Design, Participants, and Data Collection below 5) was employed to assess the association between hospitals’ sizes and elements in surge capacity and collaborative factors. The statistical significance level was 5% (p< .05). Study III: The Home Isolation Center for the COVID-19 Pandemic Management Qualitative Analysis A qualitative study design was employed to investigate the operational dynamics of a home isolation center (HIC) and its alignment with the The qualitative data obtained from open-ended responses and semi- collaborative factors (CSCATTT) and the incorporation of the FSC concept. structured interviews underwent a rigorous analytical process. In Study II, Data for this study were collected through direct observations and a thematic content-coding analysis was employed to examine the interviews, focusing on the operations, and performance, perceptions, and distribution of the surge capacity concept. This analysis aimed to identify experiences of volunteers within the HIC. This HIC was managed by a Thai competencies, challenges, and interests related to participation in the FSC non-governmental organization under the leadership of emergency concept. In Study IV, a deductive qualitative analysis inspired by Hsieh and physicians. Five experts in disaster and emergency management, well-versed Shannon was conducted. This analysis was grounded in the elements of in the study's methodology, independently observed and documented the surge capacity (4S) and collaboration (CSCATTT). The data were examined processes taking place within the HIC. The observation guide is available in to uncover insights into these critical dimensions and their relations to the the Appendix. FSC concept. Throughout these analyses, multiple rounds of iterative readings, coding, and thematic grouping were conducted to ensure the In addition to direct observations, participants were purposively selected for comprehensive exploration of the qualitative data. The collaborative nature semi-structured interviews based on their specific roles within the HIC and of the analysis process involved extensive discussions among the authors, in alignment with the CSCATTT framework, aiming to gather additional culminating in a consensus regarding the findings. insights and in-depth information. A total of 15 participants were chosen for these interviews, with six of them serving as team leaders within the HIC structure. The selected participants exhibited a median age of 34, with an interquartile range of 5 years. Before the commencement of the interviews, 40 METHODS 41 Flexible Surge Capacity in Disasters and Major Incidents rather than the ethnicities and geographical locations where the research is APPLICABILITY STUDY AND IMPLEMENTATION conducted 190,196. Studies II and IV incorporated various strategic measures, IN DIVERSE INCIDENTS (STUDY III & V) including vertical communication, advance notifications, and multiple follow- ups to augment the response rate for a predictable low success rate in The outcomes of feasibility and evaluation studies conducted in Study II and online surveys. Study IV supported the refinement of the subsequent applicability and transferability of the FSC concept in Study III and Study V. The FSC Data Analysis concept's applicability was examined in the context of two distinct incidents: firstly, its application in the management of the COVID-19 pandemic with Quantitative Analysis the aim of alleviating the strain on hospitals (Study III); and secondly, its role The quantitative data from both studies were descriptively presented in in hospital evacuation scenarios, which were assessed through the 3LC counts and proportions. In Study IV, the Chi-square or Fisher’s exact test exercise (Study V). (the Fisher’s exact test used when the expected number in each cell was Study Design, Participants, and Data Collection below 5) was employed to assess the association between hospitals’ sizes and elements in surge capacity and collaborative factors. The statistical significance level was 5% (p< .05). Study III: The Home Isolation Center for the COVID-19 Pandemic Management Qualitative Analysis A qualitative study design was employed to investigate the operational dynamics of a home isolation center (HIC) and its alignment with the The qualitative data obtained from open-ended responses and semi- collaborative factors (CSCATTT) and the incorporation of the FSC concept. structured interviews underwent a rigorous analytical process. In Study II, Data for this study were collected through direct observations and a thematic content-coding analysis was employed to examine the interviews, focusing on the operations, and performance, perceptions, and distribution of the surge capacity concept. This analysis aimed to identify experiences of volunteers within the HIC. This HIC was managed by a Thai competencies, challenges, and interests related to participation in the FSC non-governmental organization under the leadership of emergency concept. In Study IV, a deductive qualitative analysis inspired by Hsieh and physicians. Five experts in disaster and emergency management, well-versed Shannon was conducted. This analysis was grounded in the elements of in the study's methodology, independently observed and documented the surge capacity (4S) and collaboration (CSCATTT). The data were examined processes taking place within the HIC. The observation guide is available in to uncover insights into these critical dimensions and their relations to the the Appendix. FSC concept. Throughout these analyses, multiple rounds of iterative readings, coding, and thematic grouping were conducted to ensure the In addition to direct observations, participants were purposively selected for comprehensive exploration of the qualitative data. The collaborative nature semi-structured interviews based on their specific roles within the HIC and of the analysis process involved extensive discussions among the authors, in alignment with the CSCATTT framework, aiming to gather additional culminating in a consensus regarding the findings. insights and in-depth information. A total of 15 participants were chosen for these interviews, with six of them serving as team leaders within the HIC structure. The selected participants exhibited a median age of 34, with an interquartile range of 5 years. Before the commencement of the interviews, 40 METHODS 41 Flexible Surge Capacity in Disasters and Major Incidents comprehensive research details were communicated and discussed with the distribution between agricultural and industrial sectors. Four out of six selected participants, underscoring the voluntary nature of their districts, namely Mueang Samut Prakan, Bang Bo, Bang Phli, and Bang Sao involvement. The semi-structured interviews, each lasting approximately 60 Thong, were selected based on their suitability in terms of location, minutes, were conducted by two interviewers in a relaxed and comfortable commonality of risk for national generalization, and the feasibility of environment, ensuring no data was inadvertently overlooked. All interviews collaboration among responding organizations. were recorded and transcribed verbatim to ensure accuracy and thorough Data was collected through the 3LC exercise, a well-established method for analysis, providing the basis for the subsequent content analysis. enhancing collaboration, learning, and usefulness of disaster responses by fostering self-reflection and constructive critiques in an open and secure Study V: The Hospital Evacuation Scenarios in the 3LC Exercise environment. The exercise entailed 3 rounds of functional exercises in A mixed-method cross-sectional approach was employed. The data which participants responded to disaster scenarios, explicitly focusing on collection encompassed both quantitative and qualitative dimensions. hospital evacuation events. It also encompassed 3 rounds of seminars where Quantitative data were collected through paper-based pre- and post-3LC participants openly discussed their actions and responses. During the exercise self-evaluations and observation checklists during the exercise. exercise, participants assumed their actual roles, actively engaging in various Qualitative data were obtained from open-ended responses in the pre- and forms of collaboration within the context of disaster responses and utilizing post-self-evaluations, qualitative observation paper notes during the the FSC concept and collaborative factors (CSCATTT). exercise, and video records during seminars conducted as part of the 3LC Following the scenarios, the seminar included two open-ended questions: exercise. what participants performed during the response and what could be Participants were representatives from disaster response organizations. improved based on their experiences to enhance responses in subsequent They were selected through purposive criteria that considered their similar scenarios. The exercise was facilitated by instructors with training in knowledge of their organizations' capacity and their roles in communicating the 3LC method and over five years of experience in disaster responses or the need for future collaboration with organizational management active participation in annual hospital preparedness exercises. These committees. These organizations spanned the local healthcare sector, instructors played an active role in encouraging team collaboration, with a defense sector, municipalities, and community facilities, including religious primary focus on task execution, perspective sharing, and planning. They institutes, schools, clinics, and hotels. Participants were grouped into teams also kept an eye on any instances of overly polite, hesitant, or passive of 7-8 individuals to promote heterogeneity within the groups while engagement among participants, ensuring a productive learning environment. maintaining homogeneity. This group size was chosen to encourage active The scenarios used in the exercise, along with their dynamic components, sharing and meaningful discussion among participants. were derived from high-frequency incidents in the existing literature, a 3- The study context centered around the Chakri Naruebodindra Medical year accumulated data from internal hazard vulnerability assessments, the Institute, Faculty of Medicine Ramathibodi Hospital, and the surrounding pragmatic paradigm of disaster preparedness exercises, and the complexity districts that served as implementation areas. These areas were selected due of the healthcare system. A nominal group technique was employed to to their strategic geographic locations and proximity to Bangkok construct these scenarios, involving four representatives from the main International Airport. The districts were prone to recurrent floods and had hospital’s hazard vulnerability management committee with expertise in a substantial population of over 1.4 million residents, with an equal disaster management, each with more than five years of experience in the 42 METHODS 43 Flexible Surge Capacity in Disasters and Major Incidents comprehensive research details were communicated and discussed with the distribution between agricultural and industrial sectors. Four out of six selected participants, underscoring the voluntary nature of their districts, namely Mueang Samut Prakan, Bang Bo, Bang Phli, and Bang Sao involvement. The semi-structured interviews, each lasting approximately 60 Thong, were selected based on their suitability in terms of location, minutes, were conducted by two interviewers in a relaxed and comfortable commonality of risk for national generalization, and the feasibility of environment, ensuring no data was inadvertently overlooked. All interviews collaboration among responding organizations. were recorded and transcribed verbatim to ensure accuracy and thorough Data was collected through the 3LC exercise, a well-established method for analysis, providing the basis for the subsequent content analysis. enhancing collaboration, learning, and usefulness of disaster responses by fostering self-reflection and constructive critiques in an open and secure Study V: The Hospital Evacuation Scenarios in the 3LC Exercise environment. The exercise entailed 3 rounds of functional exercises in A mixed-method cross-sectional approach was employed. The data which participants responded to disaster scenarios, explicitly focusing on collection encompassed both quantitative and qualitative dimensions. hospital evacuation events. It also encompassed 3 rounds of seminars where Quantitative data were collected through paper-based pre- and post-3LC participants openly discussed their actions and responses. During the exercise self-evaluations and observation checklists during the exercise. exercise, participants assumed their actual roles, actively engaging in various Qualitative data were obtained from open-ended responses in the pre- and forms of collaboration within the context of disaster responses and utilizing post-self-evaluations, qualitative observation paper notes during the the FSC concept and collaborative factors (CSCATTT). exercise, and video records during seminars conducted as part of the 3LC Following the scenarios, the seminar included two open-ended questions: exercise. what participants performed during the response and what could be Participants were representatives from disaster response organizations. improved based on their experiences to enhance responses in subsequent They were selected through purposive criteria that considered their similar scenarios. The exercise was facilitated by instructors with training in knowledge of their organizations' capacity and their roles in communicating the 3LC method and over five years of experience in disaster responses or the need for future collaboration with organizational management active participation in annual hospital preparedness exercises. These committees. These organizations spanned the local healthcare sector, instructors played an active role in encouraging team collaboration, with a defense sector, municipalities, and community facilities, including religious primary focus on task execution, perspective sharing, and planning. They institutes, schools, clinics, and hotels. Participants were grouped into teams also kept an eye on any instances of overly polite, hesitant, or passive of 7-8 individuals to promote heterogeneity within the groups while engagement among participants, ensuring a productive learning environment. maintaining homogeneity. This group size was chosen to encourage active The scenarios used in the exercise, along with their dynamic components, sharing and meaningful discussion among participants. were derived from high-frequency incidents in the existing literature, a 3- The study context centered around the Chakri Naruebodindra Medical year accumulated data from internal hazard vulnerability assessments, the Institute, Faculty of Medicine Ramathibodi Hospital, and the surrounding pragmatic paradigm of disaster preparedness exercises, and the complexity districts that served as implementation areas. These areas were selected due of the healthcare system. A nominal group technique was employed to to their strategic geographic locations and proximity to Bangkok construct these scenarios, involving four representatives from the main International Airport. The districts were prone to recurrent floods and had hospital’s hazard vulnerability management committee with expertise in a substantial population of over 1.4 million residents, with an equal disaster management, each with more than five years of experience in the 42 METHODS 43 Flexible Surge Capacity in Disasters and Major Incidents field. The finalized scenarios encompassed fire, flooding, and a new emerging integrated the FSC concept manifesting through the inclusion of open-ended disease. The details of the scenarios are presented in the Appendix. questions. This section was positioned to elicit participants' perspectives regarding the application of the FSC concept during hospital evacuation Study Tool events. This approach sought to capture nuanced insights and experiential The study tools were based on collaborative factors (CSCATTT) and the feedback that could shed light on the practical utility of the FSC concept ICS with the integration of the FSC concept. All study tools are presented within the context of hospital evacuation scenarios. in the Appendix. Data Analysis Observation tools Study III: Qualitative data analysis The development of an observation tool drew upon theories and existing In accordance with the conceptual framework of the FSC and its connection literature that expounded on collaborative factors in the context of to collaborative factors, a deductive content analysis approach was emergencies and disasters 91,197-201. Subsequently, the tool underwent an employed 193,202. The first step involved a comprehensive review of evaluation and discussion by experts specializing in emergency response and observational and interview notes to gain a holistic understanding of the disaster management to achieve a consensus on its structure and content. entire dataset. Subsequently, data were scrutinized to identify meaningful The final iteration of the tool was designed into 2 parts. The first part units, which were subjected to condensation, abstraction, interpretation, involved recording participants' performances through a checklist, using a and classification into subcategories based on their similarities and yes/no format and a rubric scale. The second part included free-text differences. The final subcategories, representing the distilled insights from comment forms, which allowed the observers to offer additional qualitative the data analysis, were subjected to a comprehensive review and unanimous insights that they deemed essential for a comprehensive evaluation. approval by all Thai authors involved in the study. Ultimately, the Prior to its implementation, the observation tool was elucidated with the subcategories were sorted into overarching categories within the context of designated observers to ensure their thorough understanding and alignment the FSC and collaborative elements. with the evaluation process. This preparatory step aimed to enhance the tool's effectiveness and facilitate a consistent and rigorous assessment of Study V: Quantitative and Qualitative Data Analysis collaborative efforts. Initially, all data were transcribed from the paper-based format into electronic records, employing Microsoft Office Excel version 16.71 for initial Self-evaluation tool data processing. The data were then transferred to Stata version 17 for In Study V, a self-evaluation tool was employed as a key instrument to statistical analysis. Descriptive statistics were employed to present the data, capture the perceived levels of collaboration, learning, and usefulness including counts, proportions, medians, and interquartile ranges. The regarding collaborative factors and the FSC concept application. The tool participants' perceptions obtained from the Likert-scale responses were featured a Likert-scale format, with responses spanning from a score of 0 analyzed using the Wilcoxon-signed rank test to compare pre- and post-self- representing "unknown" to a score of 5, signifying a level of proficiency evaluation results. Furthermore, the Likert-scale data was categorized into where knowledge could be effectively conveyed. In addition, the tool three levels, specifically 'poor' (scales 0 and 1), 'fair' (scales 2 and 3), and 'good' (scales 4 and 5) for an enhanced analysis. The Chi-square test or 44 METHODS 45 Flexible Surge Capacity in Disasters and Major Incidents field. The finalized scenarios encompassed fire, flooding, and a new emerging integrated the FSC concept manifesting through the inclusion of open-ended disease. The details of the scenarios are presented in the Appendix. questions. This section was positioned to elicit participants' perspectives regarding the application of the FSC concept during hospital evacuation Study Tool events. This approach sought to capture nuanced insights and experiential The study tools were based on collaborative factors (CSCATTT) and the feedback that could shed light on the practical utility of the FSC concept ICS with the integration of the FSC concept. All study tools are presented within the context of hospital evacuation scenarios. in the Appendix. Data Analysis Observation tools Study III: Qualitative data analysis The development of an observation tool drew upon theories and existing In accordance with the conceptual framework of the FSC and its connection literature that expounded on collaborative factors in the context of to collaborative factors, a deductive content analysis approach was emergencies and disasters 91,197-201. Subsequently, the tool underwent an employed 193,202. The first step involved a comprehensive review of evaluation and discussion by experts specializing in emergency response and observational and interview notes to gain a holistic understanding of the disaster management to achieve a consensus on its structure and content. entire dataset. Subsequently, data were scrutinized to identify meaningful The final iteration of the tool was designed into 2 parts. The first part units, which were subjected to condensation, abstraction, interpretation, involved recording participants' performances through a checklist, using a and classification into subcategories based on their similarities and yes/no format and a rubric scale. The second part included free-text differences. The final subcategories, representing the distilled insights from comment forms, which allowed the observers to offer additional qualitative the data analysis, were subjected to a comprehensive review and unanimous insights that they deemed essential for a comprehensive evaluation. approval by all Thai authors involved in the study. Ultimately, the Prior to its implementation, the observation tool was elucidated with the subcategories were sorted into overarching categories within the context of designated observers to ensure their thorough understanding and alignment the FSC and collaborative elements. with the evaluation process. This preparatory step aimed to enhance the tool's effectiveness and facilitate a consistent and rigorous assessment of Study V: Quantitative and Qualitative Data Analysis collaborative efforts. Initially, all data were transcribed from the paper-based format into electronic records, employing Microsoft Office Excel version 16.71 for initial Self-evaluation tool data processing. The data were then transferred to Stata version 17 for In Study V, a self-evaluation tool was employed as a key instrument to statistical analysis. Descriptive statistics were employed to present the data, capture the perceived levels of collaboration, learning, and usefulness including counts, proportions, medians, and interquartile ranges. The regarding collaborative factors and the FSC concept application. The tool participants' perceptions obtained from the Likert-scale responses were featured a Likert-scale format, with responses spanning from a score of 0 analyzed using the Wilcoxon-signed rank test to compare pre- and post-self- representing "unknown" to a score of 5, signifying a level of proficiency evaluation results. Furthermore, the Likert-scale data was categorized into where knowledge could be effectively conveyed. In addition, the tool three levels, specifically 'poor' (scales 0 and 1), 'fair' (scales 2 and 3), and 'good' (scales 4 and 5) for an enhanced analysis. The Chi-square test or 44 METHODS 45 Flexible Surge Capacity in Disasters and Major Incidents Fischer’s exact test (if the expected number in each cell was below 5) was In addition, the research aligned with the ethical regulations and standards in employed to examine the proportion of poor, fair, and good ratings, Thailand, where the studies were conducted, and where the results were assessing the differences in collaboration levels between pre- and post- stored, analyzed, and evaluated following the research protocols and exercise. organizational procedures in place. Importantly, these ethical practices in Thailand consistently align with the ethical standards delineated in the Regarding the qualitative data, a deductive content analysis approach, World Medical Association's Declaration of Helsinki. This comprehensive influenced by the work of Graneheim and Lundman, was adopted 202. The commitment to ethical standards underscores the responsible and ethical qualitative data included participants' comments within self-evaluation forms, conduct of research, prioritizing the rights and well-being of all participants insights shared during seminars, observer notes, and transcripts from video and upholding the integrity and credibility of the studies. Before obtaining recordings. These diverse qualitative data sources were compared and participants’ informed consent, all participants were provided with a scrutinized through multiple readings to ensure a comprehensive comprehensive understanding of the research details, the secure storage of understanding of the entire dataset. Meaningful units within the data were their data, their rights regarding data access, and the freedom to withdraw identified, highlighted, and further condensed, abstracted, and coded to from the study at any time and for any reason they deemed necessary. facilitate the identification of recurrent themes. The coded data were subsequently categorized based on their commonalities and distinctions. To Ethical approval for each study was sought and granted before the ensure the rigor and relevance of the identified themes, we engaged in commencement of data collection. These approvals were obtained from the reflective analysis and undertook a comprehensive review of the existing responsible ethical oversight bodies in Thailand, ensuring that the research literature that pertained to these themes. Furthermore, the themes were was conducted in an ethically sound and responsible manner. The protocol subjected to in-depth discussions involving all authors. This collective codes and dates of approval are listed as follows: engagement served to refine, validate, and consolidate the coded data into - Study 1: The Ethics Review Act was not applicable coherent themes, offering a nuanced understanding of collaborative - Study II: MURA2020/1621, October 5, 2020 elements. - Study III: MURA2021/786, September 16, 2021 - Study IV: MURA2021/573, July 12, 2021 ETHICAL CONSIDERATIONS - Study V: MURA2021/960 Ref.1299, November 20, 2021 The thesis adhered to ethical guidelines and principles outlined by the Swedish Ethical Review Authority, particularly those of studies conducted in foreign countries. In broad terms, all studies strictly complied with the guidelines and instructions stipulated in sections 3-4 of the Swedish Ethic Review Act. These compliances mean the research does not involve sensitive or unlawful information concerning the study participants. The participation of individuals is voluntary, with stringent measures to safeguard against physical or mental harm. The research conduction also includes the absence of tests or samples necessitating laboratory analysis or registration in a biobank. 46 METHODS 47 Flexible Surge Capacity in Disasters and Major Incidents Fischer’s exact test (if the expected number in each cell was below 5) was In addition, the research aligned with the ethical regulations and standards in employed to examine the proportion of poor, fair, and good ratings, Thailand, where the studies were conducted, and where the results were assessing the differences in collaboration levels between pre- and post- stored, analyzed, and evaluated following the research protocols and exercise. organizational procedures in place. Importantly, these ethical practices in Thailand consistently align with the ethical standards delineated in the Regarding the qualitative data, a deductive content analysis approach, World Medical Association's Declaration of Helsinki. This comprehensive influenced by the work of Graneheim and Lundman, was adopted 202. The commitment to ethical standards underscores the responsible and ethical qualitative data included participants' comments within self-evaluation forms, conduct of research, prioritizing the rights and well-being of all participants insights shared during seminars, observer notes, and transcripts from video and upholding the integrity and credibility of the studies. Before obtaining recordings. These diverse qualitative data sources were compared and participants’ informed consent, all participants were provided with a scrutinized through multiple readings to ensure a comprehensive comprehensive understanding of the research details, the secure storage of understanding of the entire dataset. Meaningful units within the data were their data, their rights regarding data access, and the freedom to withdraw identified, highlighted, and further condensed, abstracted, and coded to from the study at any time and for any reason they deemed necessary. facilitate the identification of recurrent themes. The coded data were subsequently categorized based on their commonalities and distinctions. To Ethical approval for each study was sought and granted before the ensure the rigor and relevance of the identified themes, we engaged in commencement of data collection. These approvals were obtained from the reflective analysis and undertook a comprehensive review of the existing responsible ethical oversight bodies in Thailand, ensuring that the research literature that pertained to these themes. Furthermore, the themes were was conducted in an ethically sound and responsible manner. The protocol subjected to in-depth discussions involving all authors. This collective codes and dates of approval are listed as follows: engagement served to refine, validate, and consolidate the coded data into - Study 1: The Ethics Review Act was not applicable coherent themes, offering a nuanced understanding of collaborative - Study II: MURA2020/1621, October 5, 2020 elements. - Study III: MURA2021/786, September 16, 2021 - Study IV: MURA2021/573, July 12, 2021 ETHICAL CONSIDERATIONS - Study V: MURA2021/960 Ref.1299, November 20, 2021 The thesis adhered to ethical guidelines and principles outlined by the Swedish Ethical Review Authority, particularly those of studies conducted in foreign countries. In broad terms, all studies strictly complied with the guidelines and instructions stipulated in sections 3-4 of the Swedish Ethic Review Act. These compliances mean the research does not involve sensitive or unlawful information concerning the study participants. The participation of individuals is voluntary, with stringent measures to safeguard against physical or mental harm. The research conduction also includes the absence of tests or samples necessitating laboratory analysis or registration in a biobank. 46 METHODS 47 Flexible Surge Capacity in Disasters and Major Incidents RESULTS STUDY I The conceptual framework of the FSC is underpinned by the adoption of the theoretical frameworks related to surge capacity, with the integration of complexity and collaboration theories. Figure 8 demonstrates the stepwise activation of the FSC conceptual frameworks. The FSC concept is designed to be activated and become operational when hospital resources are Figure 8 The Flexible Surge Capacity Conceptual Framework. Adapted from the depleted, or external resources cannot be delivered due to infrastructure study I destruction. As a result, this concept is incorporated following the utilization It is important to note that the activation of community resources may not of all available hospital resources, illustrating a stepwise approach in its always adhere to the stepwise presumption of the framework due to the implementation. dynamic and unpredictable nature of disasters. Therefore, additional The FSC concept is a community-based resource utilization system measures, including intervention refinement, and feasibility and applicability comprising resources derived from medical and non-medical facilities within tests, are imperative to ensure the effective implementation of the concept. the local areas. The medical facilities encompass certified and authorized primary and allied healthcare centers, which include dental and veterinary STUDY II clinics, physiotherapists, and pharmacies. In contrast, non-medical resources include public and private local facilities, such as schools, sports arenas, Out of 967 facilities, 228 answered the questionnaire, with the highest hotels, and similar establishments. The successful implementation of the FSC response rate observed among the public primary healthcare centers concept hinges on deep community involvement, which necessitates the (PHCC), accounting for 50.7% of all PHCCs. To gain deeper insights and a application of measures to assess the willingness of individuals and facilities more comprehensive understanding, semi-structured interviews were to participate and the establishment of interaction points to foster conducted with individuals in authoritative positions of each facility of collaborative efforts. interest, including ten primary health care centers, six private clinics, two dental clinics, two veterinary clinics, one school director, one sports facility administrator, and one hotel owner. As a part of the data processing, 48 RESULTS 49 Flexible Surge Capacity in Disasters and Major Incidents RESULTS STUDY I The conceptual framework of the FSC is underpinned by the adoption of the theoretical frameworks related to surge capacity, with the integration of complexity and collaboration theories. Figure 8 demonstrates the stepwise activation of the FSC conceptual frameworks. The FSC concept is designed to be activated and become operational when hospital resources are Figure 8 The Flexible Surge Capacity Conceptual Framework. Adapted from the depleted, or external resources cannot be delivered due to infrastructure study I destruction. As a result, this concept is incorporated following the utilization It is important to note that the activation of community resources may not of all available hospital resources, illustrating a stepwise approach in its always adhere to the stepwise presumption of the framework due to the implementation. dynamic and unpredictable nature of disasters. Therefore, additional The FSC concept is a community-based resource utilization system measures, including intervention refinement, and feasibility and applicability comprising resources derived from medical and non-medical facilities within tests, are imperative to ensure the effective implementation of the concept. the local areas. The medical facilities encompass certified and authorized primary and allied healthcare centers, which include dental and veterinary STUDY II clinics, physiotherapists, and pharmacies. In contrast, non-medical resources include public and private local facilities, such as schools, sports arenas, Out of 967 facilities, 228 answered the questionnaire, with the highest hotels, and similar establishments. The successful implementation of the FSC response rate observed among the public primary healthcare centers concept hinges on deep community involvement, which necessitates the (PHCC), accounting for 50.7% of all PHCCs. To gain deeper insights and a application of measures to assess the willingness of individuals and facilities more comprehensive understanding, semi-structured interviews were to participate and the establishment of interaction points to foster conducted with individuals in authoritative positions of each facility of collaborative efforts. interest, including ten primary health care centers, six private clinics, two dental clinics, two veterinary clinics, one school director, one sports facility administrator, and one hotel owner. As a part of the data processing, 48 RESULTS 49 Flexible Surge Capacity in Disasters and Major Incidents smaller schools with fewer than 500 students were excluded due to their limited spaces, and the need for lifesaving and emergency care educational limited capacity. Consequently, the final number of included facilities and initiatives. Some private clinics and sports arenas expressed concerns about respondents stood at 739 and 162, respectively. the insufficient staff. Additionally, veterinary clinics expressed reservations about providing care to humans. Nevertheless, it is noteworthy that a The capacity in the PHCCs includes doctors and nurses, with some centers majority of medical and non-medical facilities expressed a genuine having pharmacists, while private clinics typically have doctors and nurse willingness to enhance their emergency care and disaster management assistants. Both types of clinics offered primary and minor emergency care capability. and perform minor procedures. Dental clinics are staffed with dentists and dental assistants and reported to be equipped with sterile supplies. Veterinary clinics, on the other hand, have veterinarians and assistants, with some having operation rooms and sterile supplies and offered helping hands. All non-medical facilities feature small treatment rooms with nurses or nurse assistants for primary care management. The proportion of responses across these facilities is illustrated in Figure 9. Hotels Sport 4% PHCCs facilities 15% 2% Private clinics 6% Dental clinics 7% Veterinary clinics 6% Schools 60% Figure 9 Response proportions The survey and interviews revealed that a significant number of facilities expressed their willingness and demonstrated the necessary capabilities to engage in the FSC. The capabilities of these facilities are presented in Figures 10-12. However, there were exceptions, as one PHCC and two private Figure 10 Medical facilities' capabilities clinics expressed that they could not help. Additionally, several challenges were highlighted in the comments from the survey and interviews, including a lack of essential medical equipment, 50 RESULTS 51 Flexible Surge Capacity in Disasters and Major Incidents smaller schools with fewer than 500 students were excluded due to their limited spaces, and the need for lifesaving and emergency care educational limited capacity. Consequently, the final number of included facilities and initiatives. Some private clinics and sports arenas expressed concerns about respondents stood at 739 and 162, respectively. the insufficient staff. Additionally, veterinary clinics expressed reservations about providing care to humans. Nevertheless, it is noteworthy that a The capacity in the PHCCs includes doctors and nurses, with some centers majority of medical and non-medical facilities expressed a genuine having pharmacists, while private clinics typically have doctors and nurse willingness to enhance their emergency care and disaster management assistants. Both types of clinics offered primary and minor emergency care capability. and perform minor procedures. Dental clinics are staffed with dentists and dental assistants and reported to be equipped with sterile supplies. Veterinary clinics, on the other hand, have veterinarians and assistants, with some having operation rooms and sterile supplies and offered helping hands. All non-medical facilities feature small treatment rooms with nurses or nurse assistants for primary care management. The proportion of responses across these facilities is illustrated in Figure 9. Hotels Sport 4% PHCCs facilities 15% 2% Private clinics 6% Dental clinics 7% Veterinary clinics 6% Schools 60% Figure 9 Response proportions The survey and interviews revealed that a significant number of facilities expressed their willingness and demonstrated the necessary capabilities to engage in the FSC. The capabilities of these facilities are presented in Figures 10-12. However, there were exceptions, as one PHCC and two private Figure 10 Medical facilities' capabilities clinics expressed that they could not help. Additionally, several challenges were highlighted in the comments from the survey and interviews, including a lack of essential medical equipment, 50 RESULTS 51 Flexible Surge Capacity in Disasters and Major Incidents Non-response Analysis With various measures to enhance response rates, the responses remained constrained, falling within the range of 13.8% to 50.7% (Table 2). The facilities enlisted in the study were re-contacted to investigate the reasons for non-response. Many facilities, particularly those in the private sector, revealed that the non-response reasons were either not receiving the initial survey or reminders or being too preoccupied to respond. Nevertheless, the total number of responding actors, which amounted to 228, represented a substantial surge in capacity expansion. Table 2 Number of responders and non-responders from facilities of interest Primary and allied healthcare facilities Non-medical facilities Facilities of interest N (%) PHCC Private Dental Veterinary Schools Sports Hotels Clinics Clinics Clinics arenas Total 69 185 116 90 437 12 58 Figure 11 Non-medical facilities' capability Overall 35 13 17 14 136 5 8 Responders (50.6) (7.0) (14.7) (15.6) (31.1) (41.7) (13.8) Before 18 13 16 14 77 1 3 reminder (26.0) (7.0) (13.8) (15.6) (17.6) (8.3) (5.2) After 17 0 1 0 59 4 5 reminder (24.6) (0.9) (13.5) (33.3) (8.6) Non- 34 172 99 76 301 7 50 responders (49.3) (93.0) (85.3) (84.4) (68.9) (58.3) (86.2) p-value <0.001 0.016 PHCC = Public primary healthcare clinics Figure 12 Capabilities of all facilities 52 RESULTS 53 Flexible Surge Capacity in Disasters and Major Incidents Non-response Analysis With various measures to enhance response rates, the responses remained constrained, falling within the range of 13.8% to 50.7% (Table 2). The facilities enlisted in the study were re-contacted to investigate the reasons for non-response. Many facilities, particularly those in the private sector, revealed that the non-response reasons were either not receiving the initial survey or reminders or being too preoccupied to respond. Nevertheless, the total number of responding actors, which amounted to 228, represented a substantial surge in capacity expansion. Table 2 Number of responders and non-responders from facilities of interest Primary and allied healthcare facilities Non-medical facilities Facilities of interest N (%) PHCC Private Dental Veterinary Schools Sports Hotels Clinics Clinics Clinics arenas Total 69 185 116 90 437 12 58 Figure 11 Non-medical facilities' capability Overall 35 13 17 14 136 5 8 Responders (50.6) (7.0) (14.7) (15.6) (31.1) (41.7) (13.8) Before 18 13 16 14 77 1 3 reminder (26.0) (7.0) (13.8) (15.6) (17.6) (8.3) (5.2) After 17 0 1 0 59 4 5 reminder (24.6) (0.9) (13.5) (33.3) (8.6) Non- 34 172 99 76 301 7 50 responders (49.3) (93.0) (85.3) (84.4) (68.9) (58.3) (86.2) p-value <0.001 0.016 PHCC = Public primary healthcare clinics Figure 12 Capabilities of all facilities 52 RESULTS 53 Flexible Surge Capacity in Disasters and Major Incidents STUDY III Furthermore, as the operation unfolded, there was a rapid escalation in the number of COVID-19 cases, eventually reaching their peak. In response, the The home isolation center (HIC) was successfully established and operated HIC lead team conducted a critical review of patient prioritization, leading in alignment with the FSC concept, the ICS, and collaborative factors. The to the reorganization of the treatment courses, patient monitoring HIC facilitated the care of 5,471 patients with 275 classified as critically ill procedures, and the delivery of essential supplies. An 8-tier triage system patients. Within this cohort, the daily influx of patients into the HIC was formulated and promptly deployed to optimize survival chances. This exhibited a dynamic range, fluctuating between 10 to 280 cases. The adjustment addressed the evolving challenges posed by the COVID-19 operational framework of the HIC consisted of three key stages that outbreak and efficiently reallocated resources, ensuring that the most critical mirrored the patient's journey within a physical hospital: registration, cases received the immediate attention they required. evaluation and treatment, and logistics. The arrangements for the HIC were participations from medical and non- STUDY IV medical staff, the integration of medical devices such as pulse oximetry and Out of the 143 hospitals initially approached, a total of 43 hospitals, each temperature monitoring, and the provision of suitable local infrastructure. varying in capacities and resources, responded to the questionnaire. In the These recruitments were achieved through individual recruitment and an context of hospital evacuation preparedness, the responding hospitals organized system to ensure robust support for the HIC. The collaboration revealed the presence of a hospital ICS. A significant majority, accounting for of all resources was systematically managed, employing the principles of the 97.6%, emphasized their capacity for autonomous responses rather than ICS and collaborative factors, specifically the CSCATTT. A detail of relying on central commands from provincial officials. Moreover, the study subcategories that emerged during the operational phase of the HIC and indicated that all elements within surge capacity exhibited various levels of sorted into the CSCATTT is demonstrated in Table 4. readiness, ensuring that these hospitals could effectively deploy them when Examples of quotations reported in Study III are as follows: necessary. However, a small number of hospitals demonstrated a relatively Responsibility clarification in command-and-control element: “The distribution of lower perception of the importance of legal and ethical considerations, as tasks is quite informal, but at the same time, we separate tasks that strictly belong well as the need for operational protocols specifically tailored for vulnerable to physicians, nurses, or social workers according to the professional and legal individuals. framework.” Volunteer nurse The findings also uncovered several noteworthy points regarding hospital Health informatics, security, and privacy in safety element: “The data access evacuation literacy and training. The triage system that was planned to be limitation was strictly implemented; only team leaders could authorize data used during evacuation was controversial around daily triages, and major access.” Non-medical volunteers incident triages. However, few hospitals were aware of reverse triage and its implementations. While the surveyed hospitals confirmed the existence of External and Internal communication in communication element: “Line annual fire evacuation training, which ranged from tabletop exercises to live application was applied to intra-organization, inter-organization and simulations, there was a notable absence of explicit mention of hospital communicate with patients, since a majority of Thai people used the evacuation training or joint training sessions with other organizations. channel.” Physician volunteer Nevertheless, there were varying degrees of collaboration among hospitals in different aspects. A high number of hospitals (88.4%) exhibited some 54 RESULTS 55 Flexible Surge Capacity in Disasters and Major Incidents STUDY III Furthermore, as the operation unfolded, there was a rapid escalation in the number of COVID-19 cases, eventually reaching their peak. In response, the The home isolation center (HIC) was successfully established and operated HIC lead team conducted a critical review of patient prioritization, leading in alignment with the FSC concept, the ICS, and collaborative factors. The to the reorganization of the treatment courses, patient monitoring HIC facilitated the care of 5,471 patients with 275 classified as critically ill procedures, and the delivery of essential supplies. An 8-tier triage system patients. Within this cohort, the daily influx of patients into the HIC was formulated and promptly deployed to optimize survival chances. This exhibited a dynamic range, fluctuating between 10 to 280 cases. The adjustment addressed the evolving challenges posed by the COVID-19 operational framework of the HIC consisted of three key stages that outbreak and efficiently reallocated resources, ensuring that the most critical mirrored the patient's journey within a physical hospital: registration, cases received the immediate attention they required. evaluation and treatment, and logistics. The arrangements for the HIC were participations from medical and non- STUDY IV medical staff, the integration of medical devices such as pulse oximetry and Out of the 143 hospitals initially approached, a total of 43 hospitals, each temperature monitoring, and the provision of suitable local infrastructure. varying in capacities and resources, responded to the questionnaire. In the These recruitments were achieved through individual recruitment and an context of hospital evacuation preparedness, the responding hospitals organized system to ensure robust support for the HIC. The collaboration revealed the presence of a hospital ICS. A significant majority, accounting for of all resources was systematically managed, employing the principles of the 97.6%, emphasized their capacity for autonomous responses rather than ICS and collaborative factors, specifically the CSCATTT. A detail of relying on central commands from provincial officials. Moreover, the study subcategories that emerged during the operational phase of the HIC and indicated that all elements within surge capacity exhibited various levels of sorted into the CSCATTT is demonstrated in Table 4. readiness, ensuring that these hospitals could effectively deploy them when Examples of quotations reported in Study III are as follows: necessary. However, a small number of hospitals demonstrated a relatively Responsibility clarification in command-and-control element: “The distribution of lower perception of the importance of legal and ethical considerations, as tasks is quite informal, but at the same time, we separate tasks that strictly belong well as the need for operational protocols specifically tailored for vulnerable to physicians, nurses, or social workers according to the professional and legal individuals. framework.” Volunteer nurse The findings also uncovered several noteworthy points regarding hospital Health informatics, security, and privacy in safety element: “The data access evacuation literacy and training. The triage system that was planned to be limitation was strictly implemented; only team leaders could authorize data used during evacuation was controversial around daily triages, and major access.” Non-medical volunteers incident triages. However, few hospitals were aware of reverse triage and its implementations. While the surveyed hospitals confirmed the existence of External and Internal communication in communication element: “Line annual fire evacuation training, which ranged from tabletop exercises to live application was applied to intra-organization, inter-organization and simulations, there was a notable absence of explicit mention of hospital communicate with patients, since a majority of Thai people used the evacuation training or joint training sessions with other organizations. channel.” Physician volunteer Nevertheless, there were varying degrees of collaboration among hospitals in different aspects. A high number of hospitals (88.4%) exhibited some 54 RESULTS 55 Flexible Surge Capacity in Disasters and Major Incidents degree of inter-hospital collaboration, primarily in the context of the patient STUDY V referral system. Similarly, fruitful collaborations were observed with municipal authorities and police/fire departments, particularly concerning A total of 50 participants were initially recruited to engage in the 3LC activities related to traffic management and fire safety. In contrast, the exercises and research, representing a diverse range of roles and survey revealed that collaborations with first responders and private organizations, including hospitals, provincial public health agencies, police organizations were relatively limited. departments, provincial administrations or city municipalities, the Department of Disaster Prevention and Mitigation, and local facilities. Of Non-response Analysis these participants, 40 remained engaged throughout the study, The comparison of characteristics of response and non-response facilities is demonstrating a significant improvement in collaboration across various represented in Table 3. There were similarities between response and non- areas and in the context of a hospital evacuation. However, the response participants. improvements were less pronounced in the treatment and transport elements. Moreover, the data concluded from self-evaluation and Table 3 Characteristics of response, reminders, and non-response facilities observations shed light on the participants' evolving perceptions regarding organizational collaboration. Participants demonstrated a heightened Total Before After Non- p- awareness of community roles within the ICS, including crucial positions Responders, reminder, Reminder,N responders, value** such as the public information officer, medical operation roles, and logistics. N (%) N (%) 1st, 2nd, 3rd* N (%) Geographical locations (N) 0.856 During the 3LC exercise, participants demonstrated an ability for multi- directional communication and coordination among multi-agency Northern (14) 5 (11.6) 1 (2.3) 0,3,1 9 (9.0) organizations. Additionally, participants from healthcare organizations Northeastern (40) 11 (25.6) 6 (14.0) 4,1,0 29 (29.0) predominantly exhibited passive or consensus-oriented leadership styles. In Eastern (14) 3 (7.0) 0 1,2,0 11 (11.0) contrast, participants from administrative officials and the police Western (4) 2 (4.7) 0 1,0,1 2 (2.0) departments took on more active leadership roles, actively guiding Middle (45) 13 (30.2) 8 (18.6) 0,4,1 32 (32.0) operational discussions and decision-making. The sub-themes that emerged Southern (26) 9 (20.9) 4 (9.3) 1,4,0 17 (17.0) within the collaborative themes during the 3LC exercise are detailed in Total N 43 (30.1) 19 (13.3) 24 (16.8) 100 (69.9) Table 4. Bed capacity (N) 0.008 Table 4 Qualitative data from direct observations (Study III and V), interviews >1000 beds (10) 3 (7.0) 1 (2.3) 0,0,2 7 (7.0) (Study III), and self-criticism (Study V) based on collaborative elements 501-1000 beds (39) 19 (44.2) 7 (16.3) 1,10,1 20 (20.0) (CSCATTT) (Adapted from Results in Study III and V) 300-500 beds (56) 9 (20.9) 5 (11.6) 2,2,0 47 (47.0) Categories/ Study III: Sub-categories Study V: Sub-themes/codes <300 beds (38) 12 (27.9) 7 (16.3) 3,2,0 26 (26.0) Themes Total N 43 (30.1) 20 (14.0) 23 (16.1) 100 (69.9) *Times of reminder;1st= 10th January 2022, 2nd= 20th February 2022, 3rd= 18thApril 2022 Command and Coordination and collaboration The ICS was used. **p-value of characteristics between responders and non-responders Control Important areas establishment 56 RESULTS 57 Flexible Surge Capacity in Disasters and Major Incidents degree of inter-hospital collaboration, primarily in the context of the patient STUDY V referral system. Similarly, fruitful collaborations were observed with municipal authorities and police/fire departments, particularly concerning A total of 50 participants were initially recruited to engage in the 3LC activities related to traffic management and fire safety. In contrast, the exercises and research, representing a diverse range of roles and survey revealed that collaborations with first responders and private organizations, including hospitals, provincial public health agencies, police organizations were relatively limited. departments, provincial administrations or city municipalities, the Department of Disaster Prevention and Mitigation, and local facilities. Of Non-response Analysis these participants, 40 remained engaged throughout the study, The comparison of characteristics of response and non-response facilities is demonstrating a significant improvement in collaboration across various represented in Table 3. There were similarities between response and non- areas and in the context of a hospital evacuation. However, the response participants. improvements were less pronounced in the treatment and transport elements. Moreover, the data concluded from self-evaluation and Table 3 Characteristics of response, reminders, and non-response facilities observations shed light on the participants' evolving perceptions regarding organizational collaboration. Participants demonstrated a heightened Total Before After Non- p- awareness of community roles within the ICS, including crucial positions Responders, reminder, Reminder,N responders, value** such as the public information officer, medical operation roles, and logistics. N (%) N (%) 1st, 2nd, 3rd* N (%) Geographical locations (N) 0.856 During the 3LC exercise, participants demonstrated an ability for multi- directional communication and coordination among multi-agency Northern (14) 5 (11.6) 1 (2.3) 0,3,1 9 (9.0) organizations. Additionally, participants from healthcare organizations Northeastern (40) 11 (25.6) 6 (14.0) 4,1,0 29 (29.0) predominantly exhibited passive or consensus-oriented leadership styles. In Eastern (14) 3 (7.0) 0 1,2,0 11 (11.0) contrast, participants from administrative officials and the police Western (4) 2 (4.7) 0 1,0,1 2 (2.0) departments took on more active leadership roles, actively guiding Middle (45) 13 (30.2) 8 (18.6) 0,4,1 32 (32.0) operational discussions and decision-making. The sub-themes that emerged Southern (26) 9 (20.9) 4 (9.3) 1,4,0 17 (17.0) within the collaborative themes during the 3LC exercise are detailed in Total N 43 (30.1) 19 (13.3) 24 (16.8) 100 (69.9) Table 4. Bed capacity (N) 0.008 Table 4 Qualitative data from direct observations (Study III and V), interviews >1000 beds (10) 3 (7.0) 1 (2.3) 0,0,2 7 (7.0) (Study III), and self-criticism (Study V) based on collaborative elements 501-1000 beds (39) 19 (44.2) 7 (16.3) 1,10,1 20 (20.0) (CSCATTT) (Adapted from Results in Study III and V) 300-500 beds (56) 9 (20.9) 5 (11.6) 2,2,0 47 (47.0) Categories/ Study III: Sub-categories Study V: Sub-themes/codes <300 beds (38) 12 (27.9) 7 (16.3) 3,2,0 26 (26.0) Themes Total N 43 (30.1) 20 (14.0) 23 (16.1) 100 (69.9) *Times of reminder;1st= 10th January 2022, 2nd= 20th February 2022, 3rd= 18thApril 2022 Command and Coordination and collaboration The ICS was used. **p-value of characteristics between responders and non-responders Control Important areas establishment 56 RESULTS 57 Flexible Surge Capacity in Disasters and Major Incidents Categories/ Study III: Sub-categories Study V: Sub-themes/codes Categories/ Study III: Sub-categories Study V: Sub-themes/codes Themes Themes Staff engagement Extension of resources to the External communication - public Public communication community communication Responsibility clarification Leaders were chosen. Assessment Patient registration – information Own resource evaluation purveying, information Leadership manifestation acquirement, and validation, Responsibilities were assigned home isolation adequacy and controlled by the whole group Patient operation – increase Surge planning health care equity and unburden Sustainability hospitals with internet Community engagement connection challenges, Safety Patient safety – Health Safety officers informatics, security, and privacy Safety management Critically ill patients care to Patient safety – Medication increase chances of survival and prescription and treatment unburden hospitals, the health reassurance care system devastation. Personnel safety – Physical safety Patient discharge procedure against the COVID-19 Triage Patient triage – optimize Patient prioritization Personnel safety – personal resources privacy Treatment Current standard treatment A treatment zone was set up Personal safety – Mental and protocols spiritual recognition Transport Equipment and consumes acquire Alternative means of Communication Intra-organizational Internal communication transportation communication - process continuity and development Delivery procedure Patient transportation External communication - Inter-organizational Timely critical patient Device transportation, teleconsultation communication transportation particularly in critical cases Challenges Supplies related process. Command and control – (NGO-Government organize a well-structured Collaboration) command post. 58 RESULTS 59 Flexible Surge Capacity in Disasters and Major Incidents Categories/ Study III: Sub-categories Study V: Sub-themes/codes Categories/ Study III: Sub-categories Study V: Sub-themes/codes Themes Themes Staff engagement Extension of resources to the External communication - public Public communication community communication Responsibility clarification Leaders were chosen. Assessment Patient registration – information Own resource evaluation purveying, information Leadership manifestation acquirement, and validation, Responsibilities were assigned home isolation adequacy and controlled by the whole group Patient operation – increase Surge planning health care equity and unburden Sustainability hospitals with internet Community engagement connection challenges, Safety Patient safety – Health Safety officers informatics, security, and privacy Safety management Critically ill patients care to Patient safety – Medication increase chances of survival and prescription and treatment unburden hospitals, the health reassurance care system devastation. Personnel safety – Physical safety Patient discharge procedure against the COVID-19 Triage Patient triage – optimize Patient prioritization Personnel safety – personal resources privacy Treatment Current standard treatment A treatment zone was set up Personal safety – Mental and protocols spiritual recognition Transport Equipment and consumes acquire Alternative means of Communication Intra-organizational Internal communication transportation communication - process continuity and development Delivery procedure Patient transportation External communication - Inter-organizational Timely critical patient Device transportation, teleconsultation communication transportation particularly in critical cases Challenges Supplies related process. Command and control – (NGO-Government organize a well-structured Collaboration) command post. 58 RESULTS 59 Flexible Surge Capacity in Disasters and Major Incidents Categories/ Study III: Sub-categories Study V: Sub-themes/codes DISCUSSION Themes Safety – develop and implement Patient care-related process. safety policy. (Teams’ and communities’ resilience) Communication – establish standard communication This thesis aims to examine the implementation of the FSC concept in major channels and common incidents and disaster management, with a focus on assessing to what extent information access points. (feasibility) and how (applicability) the concept contributes to enhancing Assessment – provide staff and resource expansion and multiagency collaboration in such scenarios. The patients’ survival supplies. introductory part of this thesis describes the dependency of a response to Transport – Develop practice the emergency’s severity and complexity, the timeframe and duration of the guidelines for stockpiling and logistics of medical devices. event, the number and availability of existing resources, such as staff, stuff, and structures, and the risks for escalation. Nevertheless, all these factors Staff – provide educational initiatives. need to be orchestrated in a way that all parts of the response puzzles find their places. Therefore, guidelines and instructions are required to glue all Structure – develop guidelines for community areas’ response units and disciplines into a state of partnership, gradually formed utilization. from coordination to cooperation, into collaboration when the aims are similar, under the assumption that these units meet the feasibility requirement, that is, the knowledge and the ability of collaboration. Within the Thai context, the feasibility and successful execution of the FSC concept were observed during population-based incidents amid the COVID-19 pandemic, alleviating hospital burdens, and in contained incidents, such as hospital evacuation scenarios. Recognition of abundant community resources has spanned decades, with various attempts, albeit largely anecdotal, to integrate these resources into the processes of disaster mitigation, preparation, response, and recovery 68,81,203-205. Despite certain established activities, such as enlisting village volunteers in COVID-19 screening and strengthening community networks during the recovery phase 129,206,207, achieving comprehensive integration has remained equivocal. An essential facilitator for effectively utilizing community resources is early engagement, wherein communities can articulate their perspectives through collaborative efforts. However, achieving comprehensive integration has proven elusive 135,208,209. This thesis represents a pioneering effort in this regard, employing the implementation 60 DISCUSSION 61 Flexible Surge Capacity in Disasters and Major Incidents Categories/ Study III: Sub-categories Study V: Sub-themes/codes DISCUSSION Themes Safety – develop and implement Patient care-related process. safety policy. (Teams’ and communities’ resilience) Communication – establish standard communication This thesis aims to examine the implementation of the FSC concept in major channels and common incidents and disaster management, with a focus on assessing to what extent information access points. (feasibility) and how (applicability) the concept contributes to enhancing Assessment – provide staff and resource expansion and multiagency collaboration in such scenarios. The patients’ survival supplies. introductory part of this thesis describes the dependency of a response to Transport – Develop practice the emergency’s severity and complexity, the timeframe and duration of the guidelines for stockpiling and logistics of medical devices. event, the number and availability of existing resources, such as staff, stuff, and structures, and the risks for escalation. Nevertheless, all these factors Staff – provide educational initiatives. need to be orchestrated in a way that all parts of the response puzzles find their places. Therefore, guidelines and instructions are required to glue all Structure – develop guidelines for community areas’ response units and disciplines into a state of partnership, gradually formed utilization. from coordination to cooperation, into collaboration when the aims are similar, under the assumption that these units meet the feasibility requirement, that is, the knowledge and the ability of collaboration. Within the Thai context, the feasibility and successful execution of the FSC concept were observed during population-based incidents amid the COVID-19 pandemic, alleviating hospital burdens, and in contained incidents, such as hospital evacuation scenarios. Recognition of abundant community resources has spanned decades, with various attempts, albeit largely anecdotal, to integrate these resources into the processes of disaster mitigation, preparation, response, and recovery 68,81,203-205. Despite certain established activities, such as enlisting village volunteers in COVID-19 screening and strengthening community networks during the recovery phase 129,206,207, achieving comprehensive integration has remained equivocal. An essential facilitator for effectively utilizing community resources is early engagement, wherein communities can articulate their perspectives through collaborative efforts. However, achieving comprehensive integration has proven elusive 135,208,209. This thesis represents a pioneering effort in this regard, employing the implementation 60 DISCUSSION 61 Flexible Surge Capacity in Disasters and Major Incidents of healthcare science and research in disaster and public health emergencies adjusted for improved functionality during responses to the COVID-19 to facilitate the implementation of the FSC concept 17,135,140. pandemic, a real event, and hospital evacuation scenarios. The findings underscored the high potential of community capacity and capability in The initial development of the FSC conceptual framework, as detailed in engaging with incidents' responses, emphasizing collaborative elements, Study I, served as the foundation for effective communication of the concept CSCATTT. to the public, ensuring its scalability and transferability. This framework was used as a tool to engage stakeholders in the early stages 17. Subsequent In Study III, multidisciplinary stakeholders actively engaged in regular evaluation of the concept's efficacy took the form of a feasibility study, discussions addressing relevant knowledge and scientific uncertainties. These incorporating an analysis of stakeholders' perspectives. These stakeholders discussions contributed to educational initiatives, enhanced decision-making, involved representatives from community facilities in Study II and various and optimized healthcare deliveries8,142,160,216,217. The scope of these levels of hospitals in Study IV. discussions extended to cover the physical, mental, and spiritual well-being of staff concerning moral considerations, alleviating moral dilemmas and Study II reported positive responses to FSC concept participation from the distress during crises, and sustaining staff participation 114,158,218. In the facilities of interest offering workforce (staff), medical supplies (stuff), and application of the FSC to the HIC, the dynamic nature of the incident areas (structure) to support the disaster responses. These findings aligned intermittently gave rise to resource and financial challenges. This with similar explorations of community engagement concepts in disaster necessitated a re-evaluation of the relevant levels of organizational management that demonstrated affirmative results 82,210-214. However, collaboration to facilitate resource expansion129. Moreover, the donation- challenges faced by community facilities in emergency care and disaster dependent economy of the HIC resulted in financial insecurities, posing management knowledge were noted. A previous comprehensive review of additional challenges to the sustainability 219. These intricacies underscore community involvement underscored the necessity of educational initiatives the importance of considering the operational dynamics of incidents and the at the community level to enhance engagement 142. economic model when implementing the FSC concept 17,135. Regarding hospital evacuation preparedness in Study IV, hospitals reported In Study V, the practical 3LC exercise offered comprehensive and integrative readiness for evacuation, focusing on incident command structures, surge approaches for organizations and communities. This exercise facilitated the preparation, and staff mobilization from the plans for mass casualty incident alignment of goals and expectations, encouraging the sharing of relevant management. Nevertheless, areas for improvement were identified, including resources and establishing a more structured management system— knowledge regarding hospital evacuation, with specific attention to reverse command, control, and communication 84. This collaborative approach aligns triage and moral considerations. These findings resonated with multinational with the UNDRR’s call for all-of-society engagement, offering a more surveys in 2020, revealing deficiencies in education, training, and ethical comprehensive perspective than previous studies focusing solely on the awareness153,161,215. Notably, practical exercises, one of the effective health system or people’s perspectives 68,136,206. However, challenges arose educational initiatives, offer significant benefits for substantial enhancement during the exercise involved the establishment of practical collaboration of multiagency collaboration 153,161,215. guidelines and educational initiatives, consistent with findings in In subsequent studies, the implementation of the FSC concept was refined implementation sciences literature 209,220. These challenges have been based on limitations and challenges identified during the feasibility studies. In recognized as prime opportunities for enhancing disaster responses 66,69. Studies III and V, the concept's applicability was further explored and Focusing on the four vital elements of surge capacity, the findings underscore the potential surge from the community to participate in 62 DISCUSSION 63 Flexible Surge Capacity in Disasters and Major Incidents of healthcare science and research in disaster and public health emergencies adjusted for improved functionality during responses to the COVID-19 to facilitate the implementation of the FSC concept 17,135,140. pandemic, a real event, and hospital evacuation scenarios. The findings underscored the high potential of community capacity and capability in The initial development of the FSC conceptual framework, as detailed in engaging with incidents' responses, emphasizing collaborative elements, Study I, served as the foundation for effective communication of the concept CSCATTT. to the public, ensuring its scalability and transferability. This framework was used as a tool to engage stakeholders in the early stages 17. Subsequent In Study III, multidisciplinary stakeholders actively engaged in regular evaluation of the concept's efficacy took the form of a feasibility study, discussions addressing relevant knowledge and scientific uncertainties. These incorporating an analysis of stakeholders' perspectives. These stakeholders discussions contributed to educational initiatives, enhanced decision-making, involved representatives from community facilities in Study II and various and optimized healthcare deliveries8,142,160,216,217. The scope of these levels of hospitals in Study IV. discussions extended to cover the physical, mental, and spiritual well-being of staff concerning moral considerations, alleviating moral dilemmas and Study II reported positive responses to FSC concept participation from the distress during crises, and sustaining staff participation 114,158,218. In the facilities of interest offering workforce (staff), medical supplies (stuff), and application of the FSC to the HIC, the dynamic nature of the incident areas (structure) to support the disaster responses. These findings aligned intermittently gave rise to resource and financial challenges. This with similar explorations of community engagement concepts in disaster necessitated a re-evaluation of the relevant levels of organizational management that demonstrated affirmative results 82,210-214. However, collaboration to facilitate resource expansion129. Moreover, the donation- challenges faced by community facilities in emergency care and disaster dependent economy of the HIC resulted in financial insecurities, posing management knowledge were noted. A previous comprehensive review of additional challenges to the sustainability 219. These intricacies underscore community involvement underscored the necessity of educational initiatives the importance of considering the operational dynamics of incidents and the at the community level to enhance engagement 142. economic model when implementing the FSC concept 17,135. Regarding hospital evacuation preparedness in Study IV, hospitals reported In Study V, the practical 3LC exercise offered comprehensive and integrative readiness for evacuation, focusing on incident command structures, surge approaches for organizations and communities. This exercise facilitated the preparation, and staff mobilization from the plans for mass casualty incident alignment of goals and expectations, encouraging the sharing of relevant management. Nevertheless, areas for improvement were identified, including resources and establishing a more structured management system— knowledge regarding hospital evacuation, with specific attention to reverse command, control, and communication 84. This collaborative approach aligns triage and moral considerations. These findings resonated with multinational with the UNDRR’s call for all-of-society engagement, offering a more surveys in 2020, revealing deficiencies in education, training, and ethical comprehensive perspective than previous studies focusing solely on the awareness153,161,215. Notably, practical exercises, one of the effective health system or people’s perspectives 68,136,206. However, challenges arose educational initiatives, offer significant benefits for substantial enhancement during the exercise involved the establishment of practical collaboration of multiagency collaboration 153,161,215. guidelines and educational initiatives, consistent with findings in In subsequent studies, the implementation of the FSC concept was refined implementation sciences literature 209,220. These challenges have been based on limitations and challenges identified during the feasibility studies. In recognized as prime opportunities for enhancing disaster responses 66,69. Studies III and V, the concept's applicability was further explored and Focusing on the four vital elements of surge capacity, the findings underscore the potential surge from the community to participate in 62 DISCUSSION 63 Flexible Surge Capacity in Disasters and Major Incidents disaster management, highlighting the concept’s role in facilitating responses, providing values among disaster management society both comprehensive surge expansion by leveraging community resources. In the academically, and practically 100,152,225. These collaborative elements have first element, staff; a significant number of staff from facilities of interest found extensive applications in research on disasters and public health (Study II) expressed their willingness to participate in the FSC concept. This emergencies, educational initiatives, and the evaluation of training exercises finding was resonant with previous studies 82,214,221. Consequently, in later and actual responses 62,100,146 150,226. The elements served as integral tools study, when recruitment was announced, these staff volunteered to partake within the program theories to facilitate the FSC concept implementation and stayed until the end of the responses (Study III). The engagement and to conduct research data analyses, ensuring scalability and transferability. strategies adhered to the systematic approaches; the collaborative elements In previous literature, the ICS and the command-and-control elements of (CSCATTT) and ICS, and educational opportunities 10,87,91,142,213. the CSCATTT suggest a systematic and structural approach that responding Furthermore, hospitals in Study IV and responding organizations in Study V individuals and organizations designate leaders to effectively manage crises revealed their total capacity and readiness for disaster responses. 87,88,227. However, the FSC concept has brought about collaborative In the second element, stuff, all study participants offered their medical and innovations in surge expansion involving entities from communities. This non-medical supplies; surprisingly, a significant amount of capacity and involvement necessitated novel measures to structure the command, capability were uncovered. However, the challenges, aligning with previous control, communication, and collaboration 44. Traditionally, responding lessons learned, shed light on a disproportionate balance between supply organizations would assign leadership based on the nature of the incidents, stockpiling, and demand in response to the expansion of the incident and its tailoring the operational tactics, and strategies of the incident based on its consequences 71,73,74,222. These insufficiencies emphasized the need for types and hazards. For instance, in cases of terrorism, the police department community resource involvement and coherent collaboration. assumes a leadership role; in fire incidents, firefighters take charge, and healthcare personnel lead the response efforts during public health In the third element, structure, most facilities exhibited some areas in their emergencies. Furthermore, the leadership styles and structures often mirror facilities to be modified to treatment zones or shelters for affected each sector's leading organizations. individuals and staff. Studies reported the expansion of the care areas to other facilities, such as treating minor medical complain at the primary Several instances where leadership is assumed by law enforcement or healthcare clinic or building a field hospital at the school sports field 79,223,224. administrative entities manifest a vertical organizational structure 228,229. In From the survey in Study II, and 3LC exercise in Study V, allied healthcare contrast, Studies III and V demonstrated the importance of consensus-driven facilities proposed their sterile room and other treatment areas, and non- and horizontal leadership, especially among healthcare staff and healthcare medical entities offered their spaces that could be rearranged for proper organizations when they assumed leadership roles 58,60,98. Moreover, these responses. Additionally, hospitals responded in Study IV reported the observations of healthcare leaders align with the findings derived from adaptation of patient care space from adjacent facilities in the local area, antecedent investigations into leadership styles during the 3LC exercise and especially when hospitals require evacuation and infrastructure is damaged. actual disaster responses 80,100,230,231. Nonetheless, the involvement of Finally, Study III utilized private building to stockpile necessary medical communities in these scenarios predominantly concentrated on operational supplies and medication waiting for distribution. and tactical levels, aimed at supporting surge expansion efforts. The emphasis is less pronounced at the strategic level where community leaders In the last element, system, the ICS and collaborative elements, the acronym might be expected to lead the disaster responses 130,232. Additionally, the CSCATTT, played a pivotal role in systematically performing disaster findings indicated that appropriate contact points for engaging community 64 DISCUSSION 65 Flexible Surge Capacity in Disasters and Major Incidents disaster management, highlighting the concept’s role in facilitating responses, providing values among disaster management society both comprehensive surge expansion by leveraging community resources. In the academically, and practically 100,152,225. These collaborative elements have first element, staff; a significant number of staff from facilities of interest found extensive applications in research on disasters and public health (Study II) expressed their willingness to participate in the FSC concept. This emergencies, educational initiatives, and the evaluation of training exercises finding was resonant with previous studies 82,214,221. Consequently, in later and actual responses 62,100,146 150,226. The elements served as integral tools study, when recruitment was announced, these staff volunteered to partake within the program theories to facilitate the FSC concept implementation and stayed until the end of the responses (Study III). The engagement and to conduct research data analyses, ensuring scalability and transferability. strategies adhered to the systematic approaches; the collaborative elements In previous literature, the ICS and the command-and-control elements of (CSCATTT) and ICS, and educational opportunities 10,87,91,142,213. the CSCATTT suggest a systematic and structural approach that responding Furthermore, hospitals in Study IV and responding organizations in Study V individuals and organizations designate leaders to effectively manage crises revealed their total capacity and readiness for disaster responses. 87,88,227. However, the FSC concept has brought about collaborative In the second element, stuff, all study participants offered their medical and innovations in surge expansion involving entities from communities. This non-medical supplies; surprisingly, a significant amount of capacity and involvement necessitated novel measures to structure the command, capability were uncovered. However, the challenges, aligning with previous control, communication, and collaboration 44. Traditionally, responding lessons learned, shed light on a disproportionate balance between supply organizations would assign leadership based on the nature of the incidents, stockpiling, and demand in response to the expansion of the incident and its tailoring the operational tactics, and strategies of the incident based on its consequences 71,73,74,222. These insufficiencies emphasized the need for types and hazards. For instance, in cases of terrorism, the police department community resource involvement and coherent collaboration. assumes a leadership role; in fire incidents, firefighters take charge, and healthcare personnel lead the response efforts during public health In the third element, structure, most facilities exhibited some areas in their emergencies. Furthermore, the leadership styles and structures often mirror facilities to be modified to treatment zones or shelters for affected each sector's leading organizations. individuals and staff. Studies reported the expansion of the care areas to other facilities, such as treating minor medical complain at the primary Several instances where leadership is assumed by law enforcement or healthcare clinic or building a field hospital at the school sports field 79,223,224. administrative entities manifest a vertical organizational structure 228,229. In From the survey in Study II, and 3LC exercise in Study V, allied healthcare contrast, Studies III and V demonstrated the importance of consensus-driven facilities proposed their sterile room and other treatment areas, and non- and horizontal leadership, especially among healthcare staff and healthcare medical entities offered their spaces that could be rearranged for proper organizations when they assumed leadership roles 58,60,98. Moreover, these responses. Additionally, hospitals responded in Study IV reported the observations of healthcare leaders align with the findings derived from adaptation of patient care space from adjacent facilities in the local area, antecedent investigations into leadership styles during the 3LC exercise and especially when hospitals require evacuation and infrastructure is damaged. actual disaster responses 80,100,230,231. Nonetheless, the involvement of Finally, Study III utilized private building to stockpile necessary medical communities in these scenarios predominantly concentrated on operational supplies and medication waiting for distribution. and tactical levels, aimed at supporting surge expansion efforts. The emphasis is less pronounced at the strategic level where community leaders In the last element, system, the ICS and collaborative elements, the acronym might be expected to lead the disaster responses 130,232. Additionally, the CSCATTT, played a pivotal role in systematically performing disaster findings indicated that appropriate contact points for engaging community 64 DISCUSSION 65 Flexible Surge Capacity in Disasters and Major Incidents resources were facilitated through municipalities and public health wherein the critical functions of the concept were preserved. However, a administration 205,206. certain degree of flexibility in the intervention was observed concerning the levels of facilities' involvement. This adaptability underscores the FSC Studies III, IV, and V also employed a deductive content analysis within the concept's capacity to accommodate diverse operational contexts and levels collaborative elements and revealed congruences in subcategories and sub- of infrastructure, contributing to its versatility and applicability in disaster themes. The prominent commonalities were identified in the command and response and preparedness. control focusing on management structures, safety including general and incident-specific safety and security procedures, communication addressing Limitations the content and mode of communications, and transportation dealing with modes, routes, and alternatives. Conversely, assessment, triage, and treatment Biases in Feasibility Study elements exhibited variations attributed to incident-specific management strategies. This thesis emphasizes the importance of these collaborative Studies II and IV gathered data through online surveys, achieving 23% and elements in augmenting disaster response efforts across contexts. 30% overall response rates, respectively. These rates increased following Nevertheless, various practical collaboration guidelines should be phone-called personal reminders. Study II’s response rate rose from 5.2-26% premediated and may be developed and achieved during training and to 7-50.6%, while Study IV improved from 13.3% to 30.1%. These figures simulation exercises. align with average response rates in online surveys, as documented in reviews and meta-analyses 233,234. Despite the advantages of online surveys, Finally, this thesis heightened participants’ awareness of their roles and such as cost-effectiveness and ease of execution, they often yield low responsibilities and emphasized their significance across different phases of response rates, particularly among professional respondents. Various the disaster cycle. In Studies II and IV, the feasibility assessments introduced strategies have been recommended to enhance response rates, including the innovation concepts of leveraging community facilities for individuals and designed execution methods, optimizing the number of survey questions, responding organizations. These studies not only outlined the potentialities choosing an appropriate mailing time, and physical or personal repetitive of community engagement and resilience during disaster response but also reminders190,194. Both Studies II and IV incorporated and optimized these delved into the reactions and perceptions of participants towards the FSC strategies to boost responses. However, Study II, conducted during the peak concept. These insights laid the groundwork for pedagogic training of the COVID-19 pandemic, experienced even lower response rates, programs, fostering a deeper understanding of the concept 147. In addition, whereas Study IV demonstrated improved response rates. The reason could the applicability studies, Studies III and V, explored participants learning be efforts to refine survey procedures and additional measures, such as pre- outcomes, behavioral patterns, and results through a pragmatic paradigm, contacting participants with phone calls followed by postal mail containing involving simulation exercises and responses to actual incident 100,152,225. The the online survey. findings of these studies not only substantiated the viability of the FSC concept but also underscored the efficacy of pragmatic research methods in Despite implementing response enhancement strategies, non-responses fostering enhanced decision-making, collaboration, and learning—ultimately constituted the majority, introducing bias into the sample and affecting contributing to increased utility in disaster response efforts 140,153. sample size and the sampling process error235. Investigation into non- response factors in both studies revealed similarities with previous studies, In summary, the implementation of the FSC concept yielded specific including excessive workload, survey misplacement, and improper mailing outcomes centered around the optimization of community resources, timing236,237. However, Study II focused on scaling up community facilities for 66 DISCUSSION 67 Flexible Surge Capacity in Disasters and Major Incidents resources were facilitated through municipalities and public health wherein the critical functions of the concept were preserved. However, a administration 205,206. certain degree of flexibility in the intervention was observed concerning the levels of facilities' involvement. This adaptability underscores the FSC Studies III, IV, and V also employed a deductive content analysis within the concept's capacity to accommodate diverse operational contexts and levels collaborative elements and revealed congruences in subcategories and sub- of infrastructure, contributing to its versatility and applicability in disaster themes. The prominent commonalities were identified in the command and response and preparedness. control focusing on management structures, safety including general and incident-specific safety and security procedures, communication addressing Limitations the content and mode of communications, and transportation dealing with modes, routes, and alternatives. Conversely, assessment, triage, and treatment Biases in Feasibility Study elements exhibited variations attributed to incident-specific management strategies. This thesis emphasizes the importance of these collaborative Studies II and IV gathered data through online surveys, achieving 23% and elements in augmenting disaster response efforts across contexts. 30% overall response rates, respectively. These rates increased following Nevertheless, various practical collaboration guidelines should be phone-called personal reminders. Study II’s response rate rose from 5.2-26% premediated and may be developed and achieved during training and to 7-50.6%, while Study IV improved from 13.3% to 30.1%. These figures simulation exercises. align with average response rates in online surveys, as documented in reviews and meta-analyses 233,234. Despite the advantages of online surveys, Finally, this thesis heightened participants’ awareness of their roles and such as cost-effectiveness and ease of execution, they often yield low responsibilities and emphasized their significance across different phases of response rates, particularly among professional respondents. Various the disaster cycle. In Studies II and IV, the feasibility assessments introduced strategies have been recommended to enhance response rates, including the innovation concepts of leveraging community facilities for individuals and designed execution methods, optimizing the number of survey questions, responding organizations. These studies not only outlined the potentialities choosing an appropriate mailing time, and physical or personal repetitive of community engagement and resilience during disaster response but also reminders190,194. Both Studies II and IV incorporated and optimized these delved into the reactions and perceptions of participants towards the FSC strategies to boost responses. However, Study II, conducted during the peak concept. These insights laid the groundwork for pedagogic training of the COVID-19 pandemic, experienced even lower response rates, programs, fostering a deeper understanding of the concept 147. In addition, whereas Study IV demonstrated improved response rates. The reason could the applicability studies, Studies III and V, explored participants learning be efforts to refine survey procedures and additional measures, such as pre- outcomes, behavioral patterns, and results through a pragmatic paradigm, contacting participants with phone calls followed by postal mail containing involving simulation exercises and responses to actual incident 100,152,225. The the online survey. findings of these studies not only substantiated the viability of the FSC concept but also underscored the efficacy of pragmatic research methods in Despite implementing response enhancement strategies, non-responses fostering enhanced decision-making, collaboration, and learning—ultimately constituted the majority, introducing bias into the sample and affecting contributing to increased utility in disaster response efforts 140,153. sample size and the sampling process error235. Investigation into non- response factors in both studies revealed similarities with previous studies, In summary, the implementation of the FSC concept yielded specific including excessive workload, survey misplacement, and improper mailing outcomes centered around the optimization of community resources, timing236,237. However, Study II focused on scaling up community facilities for 66 DISCUSSION 67 Flexible Surge Capacity in Disasters and Major Incidents disaster response, not assessing sampling effect size. Thus, any number of especially when cultural, educational, and social structural differences are responses positively impacted the feasibility of the FSC concept. present. In contrast, Study IV aimed to explore the preparedness of hospitals for evacuation with the expectation that responses represented hospitals in Thailand; thus, non-responses are subject to selection bias. The non- response analysis in study IV demonstrated indifferences in geographical distribution between responding and non-responding hospitals, suggesting the geographic representation of the results on hospital evacuation preparedness (p=0.856). However, differences in the distribution of hospital sizes between responders and non-responders prevented the generalization of results to hospital preparedness in terms of bed capacities (p=0.008). Apart from non-response bias, Study IV exhibited a degree of recall bias concerning knowledge and training. The survey was conducted after the peak of the COVID-19 outbreak, when numerous hospitals had deferred annual training due to social distancing policies. Consequently, the levels of knowledge and training reported were lower than pre-pandemic levels but reflected the current state of readiness120,200. This temporal shift in data collection highlights the importance of considering the broader context and timing when interpreting survey results, particularly in the aftermath of significant events such as a global pandemic. Limitations in Applicability Study While the applications of the FSC concept demonstrated success in diverse disaster settings, specifically during the COVID-19 pandemic (Study III) and hospital evacuation scenarios (Study V), it is crucial to note that the contextual elements of implementation in both studies shared similar characteristics. These included densely urbanized communities in a middle- income country where the commonality of volunteering is high 31,206. Consequently, caution must be exercised when attempting to generalize the FSC concept to different contexts, considering variations in program theory, stakeholder engagement, and the identification of key uncertainties, 68 DISCUSSION 69 Flexible Surge Capacity in Disasters and Major Incidents disaster response, not assessing sampling effect size. Thus, any number of especially when cultural, educational, and social structural differences are responses positively impacted the feasibility of the FSC concept. present. In contrast, Study IV aimed to explore the preparedness of hospitals for evacuation with the expectation that responses represented hospitals in Thailand; thus, non-responses are subject to selection bias. The non- response analysis in study IV demonstrated indifferences in geographical distribution between responding and non-responding hospitals, suggesting the geographic representation of the results on hospital evacuation preparedness (p=0.856). However, differences in the distribution of hospital sizes between responders and non-responders prevented the generalization of results to hospital preparedness in terms of bed capacities (p=0.008). Apart from non-response bias, Study IV exhibited a degree of recall bias concerning knowledge and training. The survey was conducted after the peak of the COVID-19 outbreak, when numerous hospitals had deferred annual training due to social distancing policies. Consequently, the levels of knowledge and training reported were lower than pre-pandemic levels but reflected the current state of readiness120,200. This temporal shift in data collection highlights the importance of considering the broader context and timing when interpreting survey results, particularly in the aftermath of significant events such as a global pandemic. Limitations in Applicability Study While the applications of the FSC concept demonstrated success in diverse disaster settings, specifically during the COVID-19 pandemic (Study III) and hospital evacuation scenarios (Study V), it is crucial to note that the contextual elements of implementation in both studies shared similar characteristics. These included densely urbanized communities in a middle- income country where the commonality of volunteering is high 31,206. Consequently, caution must be exercised when attempting to generalize the FSC concept to different contexts, considering variations in program theory, stakeholder engagement, and the identification of key uncertainties, 68 DISCUSSION 69 Flexible Surge Capacity in Disasters and Major Incidents CONCLUSION FUTURE PERSPECTIVES The FSC concept proved feasible in the community of a low-to-middle- The adoption of the FSC concept positively grew toward the integration of income country context, where an imbalance between healthcare supply and the concept into disaster preparedness at a local level. However, efforts to demand is prominent during daily operations and exacerbated during crises. enhance seamless multiagency collaboration and community engagement on Moreover, the concept demonstrated its efficacy in diverse incidents, a larger scale remain challenging. The fundamental literacy regarding disaster particularly when hospitals are vulnerable and necessitate cases’ alleviation and public health emergency management needs to be grounded and or evacuation. Although the concept was successfully integrated into incorporated widely into the routine operations of multiple responding disaster preparedness, the thesis indicated a gap in disaster literacy and organizations. Additionally, public education initiatives should be employed inadequacy of practical guidelines, surge planning and multiagency to improve public awareness and understanding of disaster preparedness collaboration. These inadequacies could be addressed through a measures and response strategies. collaborative platform, such as the 3LC exercise presented in Study V or Moreover, for a successful and sustained implementation of the FSC concept various types of simulation training reported in previous studies. This on a broader scale, it is imperative to involve higher authorities and collaborative approach identifies individual or organizational abilities and governance systems. They are crucial in providing consistent policy-driven limitations and aims to bridge the identified gaps and enhance the regulations and financial support to explore collaboration possibilities among community's preparedness and response capabilities. In summary, the thesis diverse agencies and organizations. Establishing a regulatory framework serves as a comprehensive bridge from the research of complex ensures that community engagement interventions in disaster preparedness interventions to practices in the complex health system. become an integral part of the broader public health agenda, thereby emphasizing the significance of collaborative efforts in mitigating the impact of disasters on communities and enhancing responses and recoveries of the communities. Lastly, future research should focus on implementing the FSC concept on a larger scale and explore innovative ways to incorporate it into existing disaster response efforts. This entails not only evaluating the effectiveness of the concept but also identifying barriers and facilitators to its widespread adoption. 70 FUTURE PERSPECTIVES 71 Flexible Surge Capacity in Disasters and Major Incidents CONCLUSION FUTURE PERSPECTIVES The FSC concept proved feasible in the community of a low-to-middle- The adoption of the FSC concept positively grew toward the integration of income country context, where an imbalance between healthcare supply and the concept into disaster preparedness at a local level. However, efforts to demand is prominent during daily operations and exacerbated during crises. enhance seamless multiagency collaboration and community engagement on Moreover, the concept demonstrated its efficacy in diverse incidents, a larger scale remain challenging. The fundamental literacy regarding disaster particularly when hospitals are vulnerable and necessitate cases’ alleviation and public health emergency management needs to be grounded and or evacuation. Although the concept was successfully integrated into incorporated widely into the routine operations of multiple responding disaster preparedness, the thesis indicated a gap in disaster literacy and organizations. Additionally, public education initiatives should be employed inadequacy of practical guidelines, surge planning and multiagency to improve public awareness and understanding of disaster preparedness collaboration. These inadequacies could be addressed through a measures and response strategies. collaborative platform, such as the 3LC exercise presented in Study V or Moreover, for a successful and sustained implementation of the FSC concept various types of simulation training reported in previous studies. This on a broader scale, it is imperative to involve higher authorities and collaborative approach identifies individual or organizational abilities and governance systems. They are crucial in providing consistent policy-driven limitations and aims to bridge the identified gaps and enhance the regulations and financial support to explore collaboration possibilities among community's preparedness and response capabilities. In summary, the thesis diverse agencies and organizations. Establishing a regulatory framework serves as a comprehensive bridge from the research of complex ensures that community engagement interventions in disaster preparedness interventions to practices in the complex health system. become an integral part of the broader public health agenda, thereby emphasizing the significance of collaborative efforts in mitigating the impact of disasters on communities and enhancing responses and recoveries of the communities. Lastly, future research should focus on implementing the FSC concept on a larger scale and explore innovative ways to incorporate it into existing disaster response efforts. This entails not only evaluating the effectiveness of the concept but also identifying barriers and facilitators to its widespread adoption. 70 FUTURE PERSPECTIVES 71 Flexible Surge Capacity in Disasters and Major Incidents Dhanesh Pitidhammabhorn, MD, PhD, whose collaborative efforts during the data collection enriched this thesis with diverse perspectives. My heartfelt appreciation extends to the Let’s Be Heroes foundation team, ACKNOWLEDGMENT including Lalana Kongtoranin, MD, Assistant Professor Ornlatcha Sivarak, PhD, Assistant Professor Phantakan Tansuwannarat, MD, Phanorn Chalermdamrichai, MD, Rabkwan Phattranonuthai, MD, Phimonrat Marlow, DVM, Wiyada Winyuchonjaroen, DVM, and Nathikarn Pongpasupa, MD, for their dedication to our shared projects. In the journey of this doctoral thesis, I have been blessed with I am thankful to my co-authors, Viktor Glantz, for your contributions and encouragement, guidance and support of numerous individuals, without collaborative initiative regarding the Flexible Surge Capacity concept. whom this endeavor would not have been possible. With profound gratitude, I extend my heartfelt appreciation to each and every one of them. Special recognition is extended to Ms. Anja Andersson for your efficient administrative support at the Institutionen för kliniska vetenskaper, First and foremost, I express my deepest gratitude to my esteemed main Sahlgrenska akademin vid Göteborgs universitet. supervisor, Associate Professor Amir Khorram-Manesh, MD, Ph.D., whose support, insights, dedication, and mentorship have been vital in I extend my gratitude to my colleagues at the Centre for Disaster Medicine shaping the trajectory of my doctoral work. Your mentorship has shaped at the University of Gothenburg, particularly Yohan Robinson M.D., Ph.D., not only my academic pursuits but also my personal growth. M.B.A., and the Research Alliance in Disaster and Emergency Management (RADEM), with special thanks to Associate Professor Krzysztof I express gratitude to Professor Eric Carlström, PhD, for your Goniewicz, MD, Ph.D., and Associate Professor Jarle Løwe Sørensen, exceptional guidance, scholarly expertise, and support during the years. D.B.A. for their insights and collaboration. I am immensely thankful to Assistant Professor Lina Dahlén Holmqvist I thank Mohammed Sultan, my PhD friend; my esteemed colleagues at MD, PhD, my supervisor, for your supervision and insightful feedback. the Department of Emergency Medicine, Faculty of Medicine Ramathibodi I am indebted to my all-time role model, Professor Yuwares Hospital, Mahidol University; and the members of the Gothenburg Sittichanbuncha, MD, for your dedication, exceptional guidance, and Emergency Medicine Research Group (GEMREG), Sahlgrenska University support throughout my academic and personal journey. Your continued Hospital, particularly Samah Habbouche and Carl Magnusson, for their supports have been invaluable. collegiality and collaboration. My gratitude extends to the esteemed members of Faculty Executive To Mr. Tom Kanathat Chantrsiri and Ms. Chongkonnee Chantrsiri Committee (2020-2023) at Faculty of Medicine Ramathibodi Hospital, of the Fire And Rescue Association (FARA), I extend my sincere gratitude Mahidol University for recognizing the importance of the knowledge in this for your expertise and support in Thai emergency response insights. field and supporting my academic development. To my dear friends and family in Sweden, especially Mr. Bizhan Tondkar, I am thankful to my esteemed co-authors at Chakri Naruebodindra Medical Ms. Barbro Tondkar, and Ms. Ruedeerat Khorram-Manesh, your Institute, Assistant Professor Pongsakorn Atiksawedparit, MD, PhD, and unwavering support and encouragement have been my guiding light. "Friends are family you choose," and I am blessed to have you in my life. 72 ACKNOWLEDGMENT 73 Flexible Surge Capacity in Disasters and Major Incidents Dhanesh Pitidhammabhorn, MD, PhD, whose collaborative efforts during the data collection enriched this thesis with diverse perspectives. My heartfelt appreciation extends to the Let’s Be Heroes foundation team, ACKNOWLEDGMENT including Lalana Kongtoranin, MD, Assistant Professor Ornlatcha Sivarak, PhD, Assistant Professor Phantakan Tansuwannarat, MD, Phanorn Chalermdamrichai, MD, Rabkwan Phattranonuthai, MD, Phimonrat Marlow, DVM, Wiyada Winyuchonjaroen, DVM, and Nathikarn Pongpasupa, MD, for their dedication to our shared projects. In the journey of this doctoral thesis, I have been blessed with I am thankful to my co-authors, Viktor Glantz, for your contributions and encouragement, guidance and support of numerous individuals, without collaborative initiative regarding the Flexible Surge Capacity concept. whom this endeavor would not have been possible. With profound gratitude, I extend my heartfelt appreciation to each and every one of them. Special recognition is extended to Ms. Anja Andersson for your efficient administrative support at the Institutionen för kliniska vetenskaper, First and foremost, I express my deepest gratitude to my esteemed main Sahlgrenska akademin vid Göteborgs universitet. supervisor, Associate Professor Amir Khorram-Manesh, MD, Ph.D., whose support, insights, dedication, and mentorship have been vital in I extend my gratitude to my colleagues at the Centre for Disaster Medicine shaping the trajectory of my doctoral work. Your mentorship has shaped at the University of Gothenburg, particularly Yohan Robinson M.D., Ph.D., not only my academic pursuits but also my personal growth. M.B.A., and the Research Alliance in Disaster and Emergency Management (RADEM), with special thanks to Associate Professor Krzysztof I express gratitude to Professor Eric Carlström, PhD, for your Goniewicz, MD, Ph.D., and Associate Professor Jarle Løwe Sørensen, exceptional guidance, scholarly expertise, and support during the years. D.B.A. for their insights and collaboration. I am immensely thankful to Assistant Professor Lina Dahlén Holmqvist I thank Mohammed Sultan, my PhD friend; my esteemed colleagues at MD, PhD, my supervisor, for your supervision and insightful feedback. the Department of Emergency Medicine, Faculty of Medicine Ramathibodi I am indebted to my all-time role model, Professor Yuwares Hospital, Mahidol University; and the members of the Gothenburg Sittichanbuncha, MD, for your dedication, exceptional guidance, and Emergency Medicine Research Group (GEMREG), Sahlgrenska University support throughout my academic and personal journey. Your continued Hospital, particularly Samah Habbouche and Carl Magnusson, for their supports have been invaluable. collegiality and collaboration. My gratitude extends to the esteemed members of Faculty Executive To Mr. Tom Kanathat Chantrsiri and Ms. Chongkonnee Chantrsiri Committee (2020-2023) at Faculty of Medicine Ramathibodi Hospital, of the Fire And Rescue Association (FARA), I extend my sincere gratitude Mahidol University for recognizing the importance of the knowledge in this for your expertise and support in Thai emergency response insights. field and supporting my academic development. To my dear friends and family in Sweden, especially Mr. Bizhan Tondkar, I am thankful to my esteemed co-authors at Chakri Naruebodindra Medical Ms. Barbro Tondkar, and Ms. Ruedeerat Khorram-Manesh, your Institute, Assistant Professor Pongsakorn Atiksawedparit, MD, PhD, and unwavering support and encouragement have been my guiding light. "Friends are family you choose," and I am blessed to have you in my life. 72 ACKNOWLEDGMENT 73 Flexible Surge Capacity in Disasters and Major Incidents I express my deepest and eternal appreciation to my mother, Ms. Pratana. Your dedication, boundless love, encouragement, and understanding have been my source of strength, inspiration, and success. Finally, I am grateful to my father, Mr. Thianchai, and my brothers, Mr. REFERENCES Nattapat, Mr. Sirapach, and Mr. Sirachush, for your boundless love, and encouragement. Your belief in my potential has been the driving force behind my accomplishments. To all mentioned above, you have become an integral part of my academic journey, for which I am eternally grateful. 1 United Nations Office for Disaster Risk, R. 2009 UNISDR terminology on disaster risk reduction. (The United NAtions International Strategy for Disaster Reduction (UNISDR), 2009). 2 Greaves, I. & Hunt, P. An Introduction to Major Incident Management. (Oxford University Press 2017, 2017). 3 Bonnett, C. J. et al. Surge capacity: a proposed conceptual framework. The American Journal of Emergency Medicine 25, 297-306 (2007). https://doi.org/10.1016/j.ajem.2006.08.011 4 Kaji, A., Koenig, K. L. & Bey, T. Surge Capacity for Healthcare Systems: A Conceptual Framework. Academic Emergency Medicine 13, 1157-1159 (2008). https://doi.org/10.1197/j.aem.2006.06.032 5 Hick, J. L., Koenig, K. L., Barbisch, D. & Bey, T. A. Surge capacity concepts for health care facilities: the CO-S-TR model for initial incident assessment. Disaster medicine and public health preparedness 2 Suppl 1, S51-57 (2008). https://doi.org/10.1097/DMP.0b013e31817fffe8 6 Khorram-Manesh, A., Goniewicz, K., Hertelendy, A. & Dulebenets, M. Handbook of Disaster and Emergency Management (2nd Edition, 2021). (2021). 7 Khorram-Manesh, A. Flexible surge capacity – public health, public education, and disaster management. 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Journal of Management 46, 965- 1001 (2020). https://doi.org/10.1177/0149206320901565 74 REFERENCES 75 Flexible Surge Capacity in Disasters and Major Incidents I express my deepest and eternal appreciation to my mother, Ms. Pratana. Your dedication, boundless love, encouragement, and understanding have been my source of strength, inspiration, and success. Finally, I am grateful to my father, Mr. Thianchai, and my brothers, Mr. REFERENCES Nattapat, Mr. Sirapach, and Mr. Sirachush, for your boundless love, and encouragement. Your belief in my potential has been the driving force behind my accomplishments. To all mentioned above, you have become an integral part of my academic journey, for which I am eternally grateful. 1 United Nations Office for Disaster Risk, R. 2009 UNISDR terminology on disaster risk reduction. (The United NAtions International Strategy for Disaster Reduction (UNISDR), 2009). 2 Greaves, I. & Hunt, P. An Introduction to Major Incident Management. (Oxford University Press 2017, 2017). 3 Bonnett, C. J. et al. Surge capacity: a proposed conceptual framework. The American Journal of Emergency Medicine 25, 297-306 (2007). https://doi.org/10.1016/j.ajem.2006.08.011 4 Kaji, A., Koenig, K. L. & Bey, T. Surge Capacity for Healthcare Systems: A Conceptual Framework. Academic Emergency Medicine 13, 1157-1159 (2008). https://doi.org/10.1197/j.aem.2006.06.032 5 Hick, J. L., Koenig, K. L., Barbisch, D. & Bey, T. A. Surge capacity concepts for health care facilities: the CO-S-TR model for initial incident assessment. Disaster medicine and public health preparedness 2 Suppl 1, S51-57 (2008). https://doi.org/10.1097/DMP.0b013e31817fffe8 6 Khorram-Manesh, A., Goniewicz, K., Hertelendy, A. & Dulebenets, M. Handbook of Disaster and Emergency Management (2nd Edition, 2021). (2021). 7 Khorram-Manesh, A. Flexible surge capacity – public health, public education, and disaster management. 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Sustainable Development Goals, Thailand — Disaster Management in a District Hospital | NEJM. New England Journal (2023). of Medicine 14 Bowen, D. J. et al. How We Design Feasibility Studies. American 30 Goyet, S. et al. Post-earthquake health-service support, Nepal. Journal of Preventive Medicine 36, 452-457 (2009). Bulletin of the World Health Organization 96, 286-291 (2018). https://doi.org/10.1016/j.amepre.2009.02.002 https://doi.org/10.2471/BLT.17.205666 15 Petticrew, P. C. et al. Developing and evaluating complex 31 Khorram-Manesh, A. et al. Hospital Evacuation; Learning from the interventions: the new Medical Research Council guidance. (2008). Past? Flooding of Bangkok 2011. BJMMR 4, 395-415 (2014). https://doi.org/10.1136/bmj.a1655 https://doi.org/10.9734/BJMMR/2014/5059 16 Kinmonth, N. C. C. et al. Designing and evaluating complex 32 Edwards, D. S., McMenemy, L., Stapley, S. A., Patel, H. D. L. & interventions to improve health care. (2007). Clasper, J. 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Duty to Plan: 100 Phattharapornjaroen, P., Glantz, V., Carlström, E., Holmqvist, L. & Health Care, Crisis Standards of Care, and Novel Coronavirus SARS-CoV-2. NAM Khorram-Manesh, A. Alternative Leadership in Flexible Surge Capacity—The Perspect 2020, 10.31478/202003b (2020). https://doi.org/10.31478/202003b Perceived Impact of Tabletop Simulation Exercises on Thai Emergency Physicians 114 Leider, J. P., DeBruin, D., Reynolds, N., Koch, A. & Seaberg, J. Capability to Manage a Major Incident. Sustainability 12, 6216 (2020). Ethical Guidance for Disaster Response, Specifically Around Crisis Standards of https://doi.org/10.3390/su12156216 Care: A Systematic Review. American Journal of Public Health 107, e1-e9 (2017). 101 Stucchi, R. & Faccincani, R. in HANDBOOK OF DISASTER AND https://doi.org/10.2105/AJPH.2017.303882 EMERGENCY MANAGEMENT (eds Amir Khorram-Manesh, Krzysztof Goniewicz, 115 Dobson, R. & Khorram-Manesh, A. in Handbook of Disaster and Attila J. Hertelendy, & Maxim A. 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Preparing for effective (2014). https://doi.org/10.1378/chest.14-0735 communications during disasters: lessons from a World Health Organization quality 120 Yazdani, M., Mojtahedi, M., Loosemore, M., Sanderson, D. & Dixit, improvement project. International Journal of Emergency Medicine 7, 15 (2014). V. Hospital evacuation modelling: A critical literature review on current knowledge https://doi.org/10.1186/1865-1380-7-15 and research gaps. International Journal of Disaster Risk Reduction 66, 102627 (2021). 107 Hansen, P. M., Mikkelsen, S. & Rehn, M. Communication in Sudden- https://doi.org/10.1016/j.ijdrr.2021.102627 Onset Major Incidents: Patterns and Challenges—Scoping Review. Disaster medicine 121 Janssen, M., Lee, J., Bharosa, N. & Cresswell, A. Advances in multi- and public health preparedness 17 (2023). https://doi.org/10.1017/dmp.2023.132 agency disaster management: Key elements in disaster research. Information Systems 108 Dobson, R. & Khorram-Manesh, A. in Handbook of Disaster and Frontiers 12, 1-7 (2010). https://doi.org/10.1007/s10796-009-9176-x Emergency Management (eds Amir Khorram-Manesh, Krzysztof Goniewicz, Attila J. 122 Matsuoka, Y. & Gonzales Rocha, E. The role of non-government Hertelendy, & Maxim A. Dulebenets) 77-81 (Kompendiet, 2021). stakeholders in implementing the Sendai Framework: A view from the voluntary 109 Aremyr, J. et al. Emergency Management and Preparedness Training commitments online platform. Progress in Disaster Science 9, 100142 (2021). for Youth (EMPTY): The Results of the First Swedish Pilot Study. Disaster medicine https://doi.org/10.1016/j.pdisas.2021.100142 and public health preparedness 12, 685-688 (2018). 123 Berlin, J. M. & Carlström, E. D. Why is collaboration minimised at https://doi.org/10.1017/dmp.2017.144 the accident scene? A critical study of a hidden phenomenon. Disaster Prevention and 110 Silva, F., Proença, T. & Ferreira, M. R. 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Three principles of pragmatism for hospital in the Philippines during the COVID-19 pandemic: A third world country research on organizational processes. Methodological Innovations 13, experience. Journal of Stroke and Cerebrovascular Diseases 29 (2020). 2059799120937242 (2020). https://doi.org/10.1177/2059799120937242 https://doi.org/10.1016/j.jstrokecerebrovasdis.2020.105059 140 Ryoma Kayano, V. M. M. C. E. Y. Y. C. WHO guidance on research 128 Looi, J. C. L., Allison, S., Bastiampillai, T., Pring, W. & Reay, R. methods for health emergency and disaster risk management. 1 edn, (World Health Australian private practice metropolitan telepsychiatry during the COVID-19 Organization, 2021). pandemic: analysis of Quarter-2, 2020 usage of new MBS-telehealth item psychiatrist 141 Çalşkan, C. & Üner, S. Disaster Literacy and Public Health: A services. Australas. Psychiatry 29, 183-188 (2021). Systematic Review and Integration of Definitions and Models. Disaster medicine and https://doi.org/10.1177/1039856220975294 public health preparedness 15, 518-527 (2021). https://doi.org/10.1017/dmp.2020.100 129 Sledge, D. & Thomas, H. F. From Disaster Response to Community 142 Khorram-Manesh, A., Dulebenets, M. A. & Goniewicz, K. Recovery: Nongovernmental Entities, Government, and Public Health. American Implementing Public Health Strategies—The Need for Educational Initiatives: A Journal of Public Health 109, 437-444 (2019). Systematic Review. International Journal of Environmental Research and Public Health https://doi.org/10.2105/AJPH.2018.304895 18, 5888 (2021). https://doi.org/10.3390/ijerph18115888 130 Wells, K. B. et al. Applying community engagement to disaster 143 Kamil, P. A., Utaya, S., Sumarmi & Utomo, D. H. Improving disaster planning: developing the vision and design for the Los Angeles County Community knowledge within high school students through geographic literacy. International Disaster Resilience initiative. American Journal of Public Health 103, 1172-1180 Journal of Disaster Risk Reduction 43 (2020). (2013). https://doi.org/10.2105/AJPH.2013.301407 144 Genc, F. Z., Yildiz, S., Kaya, E. & Bilgili, N. Disaster literacy levels of 131 Liu, E. Community engagement for COVID-19 infection prevention individuals aged 18–60 years and factors affecting these levels: A web-based cross- and control: A rapid review of the evidence. 6 sectional study. International Journal of Disaster Risk Reduction 76 (2022). 132 Seddiky, M. A., Giggins, H. & Gajendran, T. International principles 145 Burkle, F. M., Khorram-Manesh, A. & Goniewicz, K. COVID-19 and of disaster risk reduction informing NGOs strategies for community based DRR Beyond: The Pivotal Role of Health Literacy in Pandemic Preparedness. Prehospital mainstreaming: The Bangladesh context. International Journal of Disaster Risk Reduction and Disaster Medicine 38, 285-286 (2023). 48, 101580 (2020). https://doi.org/10.1016/j.ijdrr.2020.101580 https://doi.org/10.1017/s1049023x23005824 133 Knudson, M. M. et al. Military-Civilian Partnerships in Training, 146 Khorram-Manesh, A. et al. Education in Disaster Management and Sustaining, Recruitment, Retention, and Readiness: Proceedings from an Exploratory Emergencies: Defining a New European Course. Disaster medicine and public health First-Steps Meeting. Journal of the American College of Surgeons 227, 284-292 (2018). preparedness 9, 245-255 (2015). https://doi.org/10.1017/dmp.2015.9 https://doi.org/10.1016/j.jamcollsurg.2018.04.030 147 Alsalamah, A. & Callinan, C. The Kirkpatrick model for training 134 Commission, E. Civil-Military Cooperation in Emergencies, (2023). 148 Gundran, C. P. D. et al. Enhancing Mass Casualty Disaster 135 Harvey, G. & Kitson, A. 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