Challenges of providing of special care services in hospitals during emergencies and disasters: a scoping review

Abstract

Background

The ability of hospitals to provide special care services for critically ill or injured patients during emergencies and disasters poses very significant challenges that necessitate the response in-place plans. the increasing frequency of such events, coupled with limited hospital resources and increasing patient volumes, underscores the urgency of addressing these issues. Specifically, this study aims to identify the challenges faced by hospitals in providing special services during disasters.

Method

This scoping review, conducted in 2024, based upon the framework developed by Arksey and O’Malley. An extensive search of Literature searching was performed using gray literature and databases including Google Scholar, PubMed, Web of Science, and Scopus. Applying the selection criteria, a total of 33 relevant studies were identified that discuss the challenges faced when providing special care services in hospitals during emergencies and disasters. Results are presented in accordance with the PRISMA checklist to ensure quality and transparency. Data was analyzed through a systematic coding process where common themes across the studies were identified.

Results

This review identified 15 distinct challenges associated with providing special care services in hospitals during emergencies and disasters: limited resources, inadequate infrastructure, lack of pre-hospital care, financial constraints, failures in the emergency response system, triage, deficiencies in management structure, planning, and preparation, communication and coordination deficits, training and protocols development, employee welfare challenges, challenges of continuity of care, increased demand, different and complex needs of patients, ethical challenges, imbalance in distribution of service resources.

Conclusions

Response in a hospital to the needs of special care during a disaster has to be responded to with more effective preparedness through comprehensive disaster preparedness plans, better communication and coordination, and training of staff and allocation of resources. In particular, standardized triage protocols and ethical frameworks will provide the foundation for the optimization of resource use in emergency responses. Better communication among departments and also with other outside organizations will improve how resources are used to better achieve good patient outcomes within emergency responses.

Introduction

Disasters and emergences pose significant threats to communities, causing extensive infrastructural damage and resulting in loss of life, disabilities, and societal disruption. The United Nations International Strategy for Disaster Reduction (UNISDR) defines disasters as events that cause widespread disruption within a community, exceeding its capacity to cope with the situation using its own resources [1–3]. In 2023, the International Database of Disasters (EM-DAT) reported approximately 399 disasters, resulting in 86,473 deaths and affected more than 93.1 million people [4].

In such critical situations, the delivery of health services becomes the major concern for the affected societies. Effective, timely, and proper care has to be provided in order to prevent unnecessary deaths and long-term complications [5, 6]. This expected increase in the number of patients during disasters means that hospitals should be fully prepared to handle the increased demand for special medical care apart from providing safe environments for the victims [7, 8].

The Special Care Unit is one of the most important units within healthcare facilities, charged with the responsibility of managing patients needing special health intervention. This unit should be well prepared to handle the number of patients that result from disaster situations, hence preventing unnecessary deaths in the affected populations. Special care services, however can be very challenging to provide during disaster periods due to sudden surges in patient numbers. Strategic planning of such care services is therefore essential [9–11]. Special care involves a multidisciplinary approach directed at the comprehensive management of patients at risk of developing acute, life-threatening illnesses. These services may be outside the walls of the hospital and include emergency departments and outdoor emergency sites. It relies on advanced technology to support the function of vital organ systems, such as respiratory and cardiovascular systems [12–14].

This will require an increase in special care capacity by hospitals with regard to bed availability, staffing, and access to special equipment, since the want thereof may otherwise lead to delays in patient care and increased morbidity and mortality rates [15, 16].

Given the increased number of natural disasters and public health emergencies, especially in the 21st century, the Hospitals have to implement plans to make sure that the medical and special care services are availed continuously. This will involve resource optimization, effective triage systems, provision for workers’ safety, and above all, training and communication in order to respond to any emergency easily [17].

Recent studies have inferred that during disasters, a massive increase in the number of patients who require special care is often associated with compromised service qualities, increased rates of mortality, and long-term health complications. The reports from COVID-19 pandemic showed corresponding challenges where special care units are often unable to maintain standards of care while under stress; this amplifies morbidity and mortality among patients [18–20]. Previous literature indicates that hospitals face a numerous of obstacles, such as inadequate intensive care beds, poor training in disaster management, and lack of comprehensive response plans all of which combine to give inadequate medical care in times of disasters [21–23]. Given the intrinsic challenges presented by such conditions, it is recommendable to have strategic planning in several levels-local, national, and international. This will ensure that we are better equipped to provide special services and critical care in times of disaster and thus be able to save more lives affected by such situations. Poor preparedness, as manifested by the lack of basic patient equipment for those affected by trauma-related conditions, greatly hinders a successful response to disasters [21, 24–26].

This study aims to identify specific challenges of providing special care services in hospitals in emergencies and disasters.

Method

In this scoping review, conducted in 2024, a comprehensive protocol was developed by the researchers to guide the literature search, selection of publications, data extraction, and descriptive analysis of the results. The framework of Arksey and O’Malley was utilized as a guide in developing the methodology [27]. To ensure the quality and transparency throughout the process, the results of this research are presented based on the PRISMA checklist [28]. (See Fig. 1). All relevant studies were identified through systematic searches across selected databases. The selection process involved screening titles and abstracts for relevance, followed by a full-text review of potentially eligible studies.

Fig. 1.

PRISMA (2020) flow chart of the selection of articles

Search strategy

To systematically address the research question, a comprehensive list of search terms was created for each relevant concept, enhancing specificity and completeness. The search strategy involves three main bibliographic databases—Scopus, PubMed, and Web of Science—known for their prominence in medical and therapeutic literature, as well as the Google Scholar search engine A complete manual search of gray literature reference lists of all eligible studies was conducted to discover additional relevant publications (Table 1).

Table 1.

Search strategy

Database	Search strategy	Date
PubMed	(“special care“[title/abstract] OR “intensive care“[title/abstract] OR “special care“[title/abstract] ) AND(“patient*“[title/abstract]OR “patient care“[title/abstract]) AND (“hospital*“[title/abstract] OR “healthcare facility*“[title/abstract]) AND (“disaster*“[title/abstract] OR “emergenc*“[title/abstract] OR “crisis“[title/abstract]) AND (“challenges“[title/abstract] OR “barriers“[title/abstract]OR “constraints“[title/abstract] OR “obstacles“[title/abstract] OR “issues“[title/abstract]OR “problems“[title/abstract] OR “difficulties“[title/abstract]). Filters applied: Humans, English.	2024, Aug9
Scopus	TITLE-ABS-KEY (“Special care " OR “intensive care " OR “special care " AND “patient care” OR “patient*” AND “hospital*” OR “health facility*” AND “disaster*” OR “emergenc*” OR “crisis” AND “challenges” OR “barriers” ) AND ( LIMIT-TO ( SUBJAREA, “MEDI” ) ) AND ( LIMIT-TO ( DOCTYPE, “ar” ) ) AND ( LIMIT-TO ( LANGUAGE, “English” ) ) AND ( LIMIT-TO ( SRCTYPE, “j” ) ) AND ( LIMIT-TO ( PUBSTAGE, “final” ) )	2024, Aug8
Web of sciences	Refine results for “Intensive care " OR “special care " OR “special care” AND “patient” “hospitals “OR “health facility” AND " disasters” OR “emergencies” OR “crisis” AND” challenges” OR “barrier” OR “constraints” OR “obstacles” (Title) AND “Intensive care " OR “special care " OR “special care” AND “patient” “hospitals “OR “health facility” AND " disasters” OR “emergenc” OR “crisis” AND” challenges” OR “barrier” OR “constraints” OR “obstacles” (Abstract) and Article (Document Types) and English (Languages) and Emergency Medicine (Research Areas)	2024, Aug9
Google Scholar	intensive care services, special care services, special care services, patient care, hospitals, disasters, emergencies, challenges, barriers	2024, Aug6

Inclusion criteria

Eligible articles must meet the following criteria:

• Explicitly mention the proposal, implementation, or evaluation of special care services provided in the context of disasters or emergencies.

• Relate specifically to the provision of special care services in hospitals during disasters and emergences.

• Full text is available and published in English.

Exclusion criteria

The following types of articles were excluded:

• Scoping or systematic review, commentary, or theoretical articles from external teams or book chapters and conference presentations.

• Letters to the editors.

• Articles with unavailable full texts or that are not published in English.

• Studies pertaining to special care services provided in contexts other than disasters and emergencies.

Eligibility assessment

The qualification and validity of the articles were evaluated to ensure the quality and accuracy of the extracted information. The authors emphasized articles published in reputable journals, credibility of the publication source, those employing accurate and valid methodologies, and the relevance of the research focus to the review question, reliable citations, and higher citation counts. Based on these criteria [33] articles were selected. Following detailed evaluation, these articles were finalized for inclusion in this scoping review.

Data extraction and synthesis of results

The extracted data included the following variables: study title, purpose, type of study, year of publication, country of study, and key findings related to the challenges of providing special care services during various disasters and emergencies. The main focus of these studies was to provide clear evidence regarding the challenges of delivering special care services to patients in hospitals during emergencies and disasters. Based on keywords and identification of reliable sources, articles were extracted. Upon final approval, all dimensions of the study- including the type of special care services, the countries providing these services, the provision of these services in hospitals during disasters, and the type of disasters, were reviewed and validated.

Results

Summary of search

The database search retrieved 3,089 records. An additional 8 references were identified through supplemental search strategies following the removal of duplicates, 2,834 titles and abstracts were screened, resulting in 61 full-text records for detailed review. Ultimately, 33 articles met the inclusion criteria for the final review. (Fig. 1)

Characteristics of the study

The included studies originated from events in 13 countries: 11 from the USA, 3 each from England, Israel, and Africa (Kenya and Tanzania), 2 each from India, Iran, Nigeria, and Japan, and 1 each from Afghanistan, Haiti, Italy, and Germany. The studies, published between 2004 and the present, encompassed a variety of research designs : descriptive (n = 3); qualitative (n = 3); cross-sectional (n = 1); review (consensus statement (n:1); retrospective cohort study (n:1); narrative review (n:1); conventional content analysis(n:1); review (descriptive) (n:1) ); retrospective review (n:3); conceptual analysis (n:1); Delphi study (n:3); modeling study (n:1); analytical and theoretical study (n:1); qualitative - descriptive study (n:1); descriptive and analytical study (n:1); descriptive and empirical study (n:1); descriptive and cross-sectional study (n:1); review article(n:2); retrospective analysis(n:1); expletory qualitative study article(n:1); special study(qualitative case study (n:1); special review (n:1) ); policy paper(n:1); commentary or position paper (n:1)(See Table 2).

Table 2.

Characteristics of the selected studies

Number	First author /year	Title	Objective	Study type	country	Key finding (challenges)
[29]	K.E. Amaefule/2019	Trauma intensive care in a terror-ravaged, resource-constrained setting: Are did we prepare for the emerging challenge?	The aims of this research were to ascertain the pattern of patients with major trauma needing intensive care within the area, and to ascertain the outcomes of patients with major trauma who were admitted to the intensive care unit.	retrospective cohort study	Nigeria	1. Limited ICU resource 2. Poor infrastructure 3. Absence of prehospital care 4. High financial strain 5. Inadequate emergency response system
[30]	Gilbert Seda/2019	Augmenting Special Care Capacity in a Disaster	The purpose of the study was to develop a comprehensive disaster plan	Review (consensus statement)	USA	1. Staff Shortages 2. Resource Allocation 3. Triage Difficulties 4. Space Limitations 5. Management Structure 6. Utilization of Non-Special Care Staff 7. Communication and Coordination
[31]	Shalendra Singh/ 2021	Challenges faced in establishing a dedicated 250-bed COVID-19 intensive care unit in a temporary structure	This article describes the challenges and lessons learned while establishing a 250 bedded ICU in a temporary structure and achieving functionality within a period of a fortnight.	narrative review	India	1. Rapid Planning and Design 2. Equipment Procurement and Familiarity 3. Personnel Deployment 4. Logistical Support 5. Training and Protocolization
[32]	Shandiz Moslehi/2021	Challenges of Providing Health Services to Cardiovascular Patients in Emergencies and Disasters in Iran: A Qualitative Study	This study was conducted to investigate the challenges of providing health services to cardiovascular patients in emergencies and disasters in Iran.	conventional content analysis study	Iran	1. Lack of training on 2. Lack of proper infrastructure 3. Inadequate patient identification programs 4. Shortage of manpower 5. Lack of training 6. Problems with sleep and rest patterns 7. Insufficient health personnel 8. Lack of planning and management 9. Fatigue of the workforce 10. Challenges in risk management.
[33]	Kenneth N Ozoilo/2013	Challenges of the management of mass casualty: lessons learned from the Jos crisis of 2001	review the challenges that we encountered in the management of the victims of the 2001 crisis.	Review(descriptive)	Nigeria	1. Communication Issues 2. Exhaustion of Supplies 3. Poor Record Keeping: 4. Staff Exhaustion
[34]	Sabine Netters/2021	Pandemic ICU triage challenge and medical ethics	Survey covid-19 ICU triage challenge and medical ethics	qualitative study	Netherlands	1. Scarcity of Resources 2. Lack of Clear Guidelines 3. Complex Decision-Making 4. Advance Care Planning 5. Communication and Trust
[35]	Gabriella Aschkenasy- Seuer/2005	Clinical review: The Israeli experience: conventional terrorism and special care	Survey of the importance of a multidisciplinary team approach in caring for these patients.	Retrospective review	Israel	1. Operational Flexibility 2. Rapid Patient Admission 3. Staff Recruitment and Management 4. Continuity of Care 5. Resource Allocation 6. Assessment of Injury Severity 7. Management of Complex Injuries
[36]	Jiro Shimada/2015	Earle stage responses of intensive care units during major disasters: from the experiences of the great East Japan earthquake	The aim of this study was the investigate the role of the ICU during disasters	Retrospective review	Japan	1. Increased Demand 2. Supply and Demand Imbalance 3. Shortage of Medical Equipment and Materials 4. Decreased Human Resources 5. Coordination of Patient Transfers in hospitals is also affected.
[37]	Joseph A/2009	Challenge of Hospital Emergency Preparedness: Analysis and Recommendations	This study aimed to explore potential reasons for inconsistent emergency preparedness across the hospital industry.	Conceptual analysis	USA	1. Inconsistent Preparedness 2. Financial Viability Issues 3. Risk Perception 4. Planning Assumptions
[38]	Sharon Einav/ 2014	Surge Capacity Logistics Care of the Specially Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement	This article focuses on the surge Logistics to deliver mass special care.	The panel developed expert opinion-based suggestions using a modified Delphi process	USA	1. Surge Capacity Issues 2. Resource Management 3. Staffing Constraints 4. Patient Flow and Distribution
[39]	David Dries/2014	Special populations Care of the Specially Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement	The suggestions in this article are important for all who are involved in large-scale disasters or pandemics with multiple Critically ill or injured patients.	The panel developed expert opinion-based suggestions using a modified Delphi process	USA	1. Limited Resources and Capacity 2. Special Populations Vulnerability 3. Planning and Coordination Issues 4. Ethical and Triage Challenges 5. Therapeutic and Logistic Considerations
[40]	James Geiling/2014	Resource-Poor Settings: Infrastructure and Capacity Building Care of the Specially Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement	Planning for mass special care (MCC) in resource-poor or constrained settings.	The panel developed expert opinion-based suggestions using a modified Delphi process	USA	1. Resource Limitations 2. Infrastructure Weaknesses 3. Capacity Building Needs 4. Logistical and Ethical Complexities
[41]	Martin I. Meltzer/2015	Estimates of the Demand for Mechanical Ventilation in the United States During an Influenza Pandemic	The aim of this study was the build a spreadsheet model to estimate the potential demand for mechanical ventilation during an influenza pandemic, considering various scenarios of clinical attack rates and severity levels.	Modeling study	USA	1. Surge Capacity 2. Staffing Shortages 3. Resource Availability 4. Geographic Distribution 5. Timely Access 6. Planning and Preparedness
[42]	Cesar palacios Gonzalez/2022	Ethical heuristics for pandemic allocation of ventilators across hospitals	The purpose of this study is to identify the principles of ventilator allocation in hospitals, critically in low- and middle-income countries	analytical and theoretical Study	United Kingdom	1. Limited Resources 2. High Patient Demand 3. Staffing Issues 4. Logistical Challenges 5. Inequitable Distribution 6. 6. Complex Patient Needs
[43]	M. Catherine Burgess/2021	Assessing immediate bed availability and barriers to discharge in a US children’s hospital	To quantify immediate bed availability in a US children’s hospital and treatment needs of hospitalized patients whose needs could be met outside a traditional hospital setting	cross-sectional study	USA	1. Inadequate Bed Capacity 2. High Occupancy Rates 3. Complex Treatment Needs 4. Barriers to Discharge. 5. Resource Limitations 6. 6. Regionalization of Care
[44]	Mike English/2023	hospital care for special illness in low-resource settings: lessons learned during the COVID-19 pandemic	this study seeks to identify and analyze systemic challenges in providing care to Critically ill patients and provides suggestions for improving these processes.	a qualitative and descriptive study	Kenya and Tanzania	1. Resource Shortages 2. Staffing Deficiencies 3. High Patient Volume 4. Poor Infrastructure 5. Communication Failures
[45]	Mehmet S. Sever/2023	Armed conflicts and kidney patients: a consensus statement from the Renal Disaster Relief Task Force of the ERA	This study examines the condition of kidney patients in special and war conditions and suggests solutions to improve the care of these patients in such conditions.	descriptive and analytical study	Africa (Kenya and Tanzania)	1. Resource Limitations 2. Staffing Shortages 3. Surge in Patient Demand. 4. Logistical Issues 5. Complex Patient Needs 6. Inequitable Resource Distribution
[46]	Sameer Jog/2020	Preparedness of Acute Care Facility and a Hospital for COVID-19 Pandemic: What We Did!	The purpose of this study is to share experiences and strategies developed by the hospital to prepare against the COVID-19 pandemic and provide guidance to other healthcare facilities in India.	descriptive and empirical study	India	1. Resource Shortages 2. Staffing Issues 3. Increased Patient Volume 4. Logistical Challenges 5. Complex Patient Needs 6. Inequitable Resource Distribution
[47]	Sakura Ishizaki/2023	Patient Admission and Mechanical Ventilator Allocation Decision-Making Processes by Frontline Medical Professionals in a Japanese ICU During the COVID-19 Pandemic: A Qualitative Study	The purpose of this study was to explore the reserving processes between the admission of afflicted patients into intensive care units and the reservation of mechanical ventilators through the COVID-19 outbreak.	qualitative study	Japan	1. Resource Limitations 2. Staffing Shortages 3. Surge in Patient Demand 4. Logistical Issues 5. Complex Patient Needs 6. Inequitable Resource Distribution
[48]	Elaine Rabin/2016	Specialist availability in emergencies: contributions of response times and the use of ad hoc coverage in New York State	This study aimed to investigate the problems of covering the emergency calls of specialists in hospitals.	descriptive and cross-sectional study	USA	1. Shortage of Specialists 2. Unreliable On-Call Coverage 3. Increased Patient Volume 4. 4. Regional Disparities
[49]	Evan Avraham Alpert/2018	CHALLENGES IN IMPLEMENTING INTERNATIONAL STANDARDS FOR THE FIELD HOSPITAL EMERGENCY UNIT IN A DISASTER ZONE: THE ISRAELI EXPERIENCE	The article aims to improve the level of medical care in crisis areas by improving international coordination and professionalism.	descriptive study	Israel	1. Logistical Challenges 2. Equipment Shortages 3. Staffing Issues 4. Patient Volume Surges 5. Ethical Dilemmas
[50]	D.J. Lockey/2004	The deployment of an intensive care facility with a military field hospital to the 2003 conflict in Iraq	The purpose of this study is to describe the performance of the ICU unit in a war environment	descriptive study	British Army field hospital during the Iraq	1. Resource Limitations 2. Staffing Shortages 3. Increased Patient Demand. 4. Logistical Issues
[51]	Ornella Spagnolello/2022	Kabul airport suicide bombing attack: Mass casualty management at the EMERGENCY NGO Hospital	The purpose of this study is to describe the performance and challenges of the health system in the face of a suicide attack that resulted in high civilian casualties.	retrospective analysis	Afghanistan	1. Limited Resources 2. High Volume of Patients. 3. Complex Injury Profiles 4. Lack of Coordinated Prehospital Services 5. Need for Rapid Triage. 6. Inadequate ICU/HDU Capacity 7. Communication Challenges 8. Ethical Considerations
[52]	James S. Lee/2019	Caring for Specially Ill Patients in Humanitarian Settings	The purpose of this article is to describe the importance of special medicine in humanitarian contexts and crises to save lives and reduce the suffering of people in acute conditions.	review article	USA	1. Access Barriers 2. Resource Limitations 3. High Patient Volumes 4. Limited Training 5. Basic Infrastructure
[53]	Mary-Elise Manuell/2011	Pandemic Influenza: Implications for the Preparation and Delivery of Special Care Services	The purpose of this article is to describe the importance of special care medicine in humanitarian contexts and crises to save lives and reduce the suffering of people in acute situations	review article	USA	1. Resource Constraints 2. High Patient Volume. 3. Inadequate Infrastructure 4. Ethical Dilemmas 5. Training Gaps
[54]	Micha Y. Shamir/2004	Multiple Casualty Terror Events: The Anesthesiologist’s Perspective	This study aims to examine personnel activities, resource utilization (including emergency unit, operating room, and intensive care unit [ICU]), and patient flow in these incidents	retrospective review	Israel	1. Resource Limitations 2. Overwhelming Patient Volume 3. Complexity of Injuries 4. Inadequate Infrastructure 5. Communication Challenges 6. Ethical Considerations 7. Training Gaps
[55]	Olipher Makwaga/2024	Opportunities and challenges in the hospital preparedness to handle motorcycle emergences in Busia County, Kenya: an exploratory qualitative study	this study examines the current status and need for improvement in motorcycle accident casualty management in Kenya.	exploratory qualitative study	Kenya	1. Understaffing 2. Inadequate Equipment 3. Insufficient Infrastructure 4. Limited Supplies 5. Financial Barriers
[56]	Amir Yitzhak/2012	Pediatric ventilation in a disaster: Clinical and ethical decision making	The main purpose of this study was to examine ethical priorities and use decision-support tools to allocate respiratory resources in a special situation	special article (qualitative case study)	Haiti	1. Resource Limitations 2. High Patient Volume 3. Complexity of Injuries 4. Inadequate Infrastructure 5. Communication Challenges 6. Ethical Considerations 7. Training Gaps
[57]	Eleanor Pett/2022	Special care transfers and COVID-19: Managing capacity challenges through special care networks	the main purpose of the study: The main goal of this study is to show the power and benefits of a network approach in intensive care	Descriptive study	English	1. Capacity Strain 2. Staffing Issues 3. Logistical Challenges 4. Training and Preparedness
[58]	Giuseppe R/2021	COViD-19 pandemic in icu. limited resources for many patients: approaches and criteria for triaging	This study aimed to enhance understanding of the ethical complexities and practical implications of triage in the context of a crisis like the COVID-19 pandemic.	special review	Italy	1. Resource Shortages 2. Ethical Dilemmas 3. Inadequate Decision-Making Frameworks
[59]	Thomas Wurmb/2020	Hospital preparedness for mass special care during SARS-CoV-2 pandemic	The study aims to enhance hospital preparedness and response to ensure effective care during extreme circumstances caused by pandemic-related surges in patient needs.	policy paper	German	1. Increased Demand 2. Staff Shortages 3. Logistical Challenges 4. Ethical Dilemmas
[60]	Hasan Abolghasem Gorgi/2017	Hospital Surge Capacity in Disasters in a Developing Country: Challenges and Strategies	The study aims to contribute to better planning and policy-making for hospital surge capacity in developing countries, ultimately enhancing their ability to respond effectively during disasters.	qualitative research study	Iran	1. Shortage of Space 2. Failure in Providing Basic Services 3. Fundamental Weaknesses in Preparedness Plans
[61]	Arnold J/2023	Lessons From COVID-19 for the Next War: Crisis Standards of Care in the Role 3 Intensive Care Unit	This study aims to prepare military medical personnel to make better triage decisions and ultimately improve the quality of special care delivered during extensive conflict situations	Commentary or position paper	USA	1. Overwhelming Patient Volume 2. Staffing Shortages 3. Logistical Issues 4. Ethical Dilemmas 5. Inadequate Preparedness Plans

Types of challenges described

Limited resources

In this scoping review, 31 out of the 33 included studies identified limited resources including human resources, equipment, systems, and physical space as a significant challenge in delivering special care services during emergencies and disasters. Special care units frequently contend with inadequate facilities and a lack of trained personnel, challenges that are critically exacerbated in disaster scenarios. For instance, during Hurricane Katrina, many hospitals struggled to reallocate staff and equipment to meet the surge of critically ill patients, leading to increased morbidity and mortality rates [29–59].

Inadequate infrastructure

Seven studies reported that inadequate infrastructure significantly hampers the provision of special care services during emergencies. Poorly designed or outdated hospital facilities can delay timely care for critically ill patients and complicate the maintenance and operation of existing medical resources. Tests conducted in regions affected by natural disasters have shown that hospitals without proper infrastructure faced substantial delays, impacting patient outcomes [29, 32, 42, 51–54].

Lack of pre-hospital care

Five studies highlighted the lack of pre-hospital emergency care as a barrier to effective management of critically ill patients requiring special care before hospital admission. For instance, in many rural areas during a disaster, the absence of trained emergency medical personnel results in delays that jeopardize patient survival [29, 33, 50, 52, 60].

Financial constraints

Four studies indicated that financial limitations hinder the provision of adequate special care services during emergencies and disasters. The financial obligations of hospitals during crises often exceed available resources. For example, many hospitals in low-resource settings reported that ongoing operational demands limited their capacity for enhanced emergency readiness, adversely affecting their ability to serve critically ill patients during disasters [29, 46, 53, 61].

Failure in emergency response systems

Two studies identified failures in emergency response systems as challenges in delivering special care services to patients in the course of emergencies and disasters. The critical point is that effective trauma care systems, including emergency and intensive care hospital management, critically ill patients’ outcomes in emergencies and disasters cannot improved Efficient emergency response systems are essential for coordinating special care [29, 33].

Triage challenges

Nine studies highlighted triage challenges as a significant issue in providing special care services during emergencies and disasters. These studies that the triage process often struggles to balance utilitarian and egalitarian ethical considerations, necessitating the prioritization of some patients over others. Poor on-site case management can lead to the deterioration of patients’ conditions before they reach healthcare facilities [30, 31, 35, 37, 39, 49–52, 60].

Deficiencies in management structure, planning, and preparation

15 studies identified deficiencies in management structure, planning, and preparedness as critical barriers to the effective delivery of special care during emergencies and disasters, which have been often cited in previous studies, extensive healthcare disaster preparedness is uncommon. Healthcare disaster preparedness is commonly seen as inadequate, with few systems having comprehensive disaster plans in place. As a result, chaos often ensues during actual disasters. Effective collaboration between providers advocating for specific populations and government entities becomes even more essential during crises. A paradigm shift is needed in how emergency disaster responses are conceptualized, emphasizing the need to provide care to as many affected individuals as possible rather than striving for comprehensive care for every individual [30–32, 34, 35, 37, 39, 42, 43, 55, 56, 58–61].

Communication and coordination deficits

11 studies indicated that inadequate communication and coordination among healthcare providers present significant barriers to delivering care during emergencies and disasters. Effective communication is crucial in healthcare settings; however, it can become tremendously challenging during disasters. Poor internal communication and a lack of efficient liaison with external entities hinder effective coordination and preparation for potential needs. Transitioning patients to other facilities becomes particularly problematic when multiple victims and hospitals are affected [30, 33, 34, 36, 42, 46, 49, 52–55].

Training and protocols development

Eight studies raised the challenges associated with training and protocol development as key issues in providing special care services during emergencies and disasters. The need for intensive training and the establishment of standardized treatment protocols is critical to maintaining care quality in disaster situations and to initiate and establish them quickly. The surge in demand for intensive care puts immense pressure on existing staff and systems, complicating the rapid training and upskilling required [30–32, 50–52, 54, 55].

Employee welfare challenges

Eight studies discussed employee welfare challenges as a critical issue in providing special care services during emergencies and disasters. Medical personnel often experience physical and mental exhaustion due to extended working hours and insufficient support, which reduces their efficiency. Furthermore, the stress of a disaster’s impact on their own safety and that of their families can exacerbate anxiety and negatively affect their performance [32, 33, 35, 36, 40, 44, 47, 48, 55].

Challenges of continuity of care

Two studies raised concerns about the challenges of maintaining continuity of care for critically injured patients during transfers between units or facilities in emergency situations. Ensuring seamless transitions presents significant barriers, including the need for safe discharge programs and ongoing monitoring for patients who can be treated in less intensive settings [35, 41].

Increase in demand

16 studies identified an increase in demand for services as a major challenge when providing special care during emergencies and disasters. A sudden influx of injured and critically ill patients requiring intensive care can strain existing resources significantly. This surge can challenge intensive care units (ICUs) to meet patient needs, creating a disparity between demand and available resources [36, 39, 40, 42–49, 54, 55, 57, 58, 60].

Different and complex needs of patients

Seven studies raised the different and complex needs of patients as a significant challenge in providing special care services to patients during emergencies and disasters. Patients often present with a combination of injuries that complicates their diagnosis and treatment. In emergency situations, the number of patients requiring special care often exceeds the capacity and resources available in healthcare facilities. Patients with complex medical conditions frequently require a wide range of special interventions that may not be manageable in disaster settings [36, 40, 41, 44, 45, 52, 53].

Ethical challenges

Nine studies identified ethical challenges arising during emergencies and disasters as a significant concern in providing special care services. Ethical dilemmas often surface regarding the allocation of limited resources. Special populations should ideally be included in general triage and resource allocation strategies; however, their unique needs can complicate decision-making. Ethical considerations regarding resource distribution and prioritization of care pose challenges, especially when resources are scarce and a high volume of patients requires immediate attention. Such complexities can lead to moral distress among healthcare providers [37, 38, 47, 49, 51–53, 56, 58].

Imbalance in the distribution of service resources

Five studies noted an imbalance in the distribution of intensive care resources during emergencies. Areas hardest hit by disasters often receive insufficient support, leading to inequitable healthcare access. Larger hospitals typically possess better resources compared to smaller facilities, exacerbating disparities in care delivery [41, 43–46].

Discussion

This scoping review synthesized findings from 33 studies, revealing 15 distinct challenges associated with the provision of special care services specifically critical and intensive care to patients in hospitals during disasters and emergencies. For clarity, the term “special care services” in this review encompasses critical and intensive care units (ICUs), and other special medical support meant for patients with serious, acute conditions that necessitate advanced medical intervention.

Among the identified challenges include “limited resources” (financial, human, and material), “inadequate infrastructure”, “failures in emergency response systems”, and “Deficiencies in management structure” such as poor planning and communication. These challenges severely compromise the ability of healthcare facilities to deliver timely and effective care. For instance, during the COVID-19 pandemic, hospitals across various income contexts, including high-income countries, faced overwhelming demands that exceeded their resource availability, illustrating that these issues are not confined to low- and middle-income countries. The inability to allocate sufficient resources, ranging from equipment to trained personnel, severely impacts the capacity to provide urgent care. For instance, studies have documented instances where ICUs overwhelmed by disaster victims had to operate beyond their designed patient capacity, thereby compromising care quality. Hospitals must develop and regularly update disaster preparedness plans that include response scenarios based on previous events. The literature underscores the importance of these plans in ensuring readiness for surges in patient volume [62–64].

Literature has identified the devastating impact of sudden surges in the number of patients on ICUs; one of these is resource allocation and triage, leading to poor triage practices and raising ethical concern about prioritization. More drastic measures by hospitals under pressure may include discharging stable patients or transferring individuals to less-special facilities. This may compromise the care for patients with complex needs requiring special monitoring and intervention. Contemporary models, such as the “Surge Capacity Model, call for medical facilities to increase their surge management capacities through flexible staffing strategies and identification of alternative health care facilities. The development of institutional policies in consonance with this model can substantially help alleviate the challenges in resource allocation during disasters. Decision-making on triage during disaster times may involve complicated ethical problems, more so under conditions with limitations of resources. Also, literature indicates that clear triage protocols based on ethical frameworks can relieve these dilemmas, but most hospitals do not have such guidelines [42, 65–69].

Poor infrastructure, as highlighted by the aforementioned studies, impairs the provision of quality healthcare, as poor transportation and communication networks could exacerbate patients’ conditions before they seek hospital care. Additionally, the lack of organized pre-hospital care systems often leads to poor initial management of critically ill patients, a factor that significantly influences increased survival rates. Investment in country-wide pre-hospital training programs and enhanced inter-agency communication would alleviate the aforementioned infrastructural challenges. The disruption of organized prehospital care can cause critical delays in important medical interventions. The evidence suggests that the lack of an organized prehospital emergency response and hospital interface may endanger the safety of injured patients, potentially contributing to higher morbidity and mortality. Robust prehospital networks can be created to improve early patient care and ease access to appropriate specialty health centers through facilitated transfer. The paramedics must train in collaboration with their emergency departments and specialty care counterparts [36, 70–72].

Effective disaster response hinges on seamless coordination between hospital units and external organizations. Studies have repeatedly shown that hospitals lacking comprehensive disaster preparedness plans struggle with managing emergencies Developing detailed and actionable disaster management protocols, alongside conducting regular simulation exercises, can enhance intra- and inter-sectoral collaboration and ensure that hospitals are equipped to respond effectively to disasters. Effective disaster response is contingent upon seamless communication between healthcare teams and external organizations. Studies indicate that breakdowns in communication can exacerbate patient outcomes during emergencies. Hospitals should implement advanced communication tools and protocols to ensure effective information exchange among all stakeholders. This can mitigate the fragmentation of care during emergencies [42, 66, 73].

The ethical implications of resource allocation during disasters are profound. Triage systems must consider distinct patient populations, especially vulnerable groups like children, and patients with complex medical conditions. Ensuring an equitable distribution of resources can reduce disparities and improve health outcomes across demographic boundaries. Implementing a clear framework for ethical decision-making in triage that complies with legal guidelines can help navigate these dilemmas head-on. The allocation of limited resources presents ethical challenges, with decision-makers needing to balance institutional capability against patient needs. The literature emphasizes the significance of incorporating ethical principles in resource allocation during emergencies [65, 74–77].

Rapid training of personnel in order to foster resilience during emergency situations is very essential. Continuous professional development programs based on emergency care situations can help in the equipage of healthcare professionals with the competencies that enable them to adapt in situations of crisis. Also, a culture of preparedness and resilience through community engagement ensures that the health systems remain responsive and adaptive. Systematic and well-structured training programs are needed to prepare healthcare professionals to act effectively in emergencies. Training programs that use simulation methods and incorporate disaster-related scenarios have shown a marked improvement in team preparedness [71, 78].

Disasters interrupt the continuum of care for patients undergoing treatment, especially those with chronic diseases. Without an organized system addressing continuous care, there will be dire consequences for their conditions during a disaster. Research Studies have shown that in disaster situations, in order to make resources available to more people who needed special care services, medical staff could discharge patients according to their medical conditions and transfer those who had a greater chance of surviving to other facilities or could discharge them from the hospital. However, patients with specified medical conditions should not be discharged from the Intensive Care Unit. Moreover, the capacity of intensive care units should be augmented using alternative sites and non-special care personnel under the supervision of trained staff [65, 79–81].

Also, the psychological and emotional toll on healthcare workers, compounded by high-stress environments during disasters, can hinder effective care delivery. Recognizing and addressing employee welfare is essential for sustaining healthcare delivery during crises [82].

Consequently, each hospital must develop comprehensive and integrated preparedness plans to respond appropriately during disasters and emergencies. Standardized triage plans should be developed and updated regularly since triage decisions are a priority in the care of patients during disasters; the plans should be designed to promote quick and effective decision-making. Improvement in the supply chain for medical equipment and pharmaceuticals through strategic stockpiling with collaboration with various suppliers must be done to ensure availability of essential resources at the time of crisis.

Hospital staff should engage in regular training that simulates real-life scenarios and potential challenges, allowing them to develop their capacities in disaster response and the delivery of emergency care. Effective coordination and cooperation among different departments within the hospital, as well as with entities outside the hospital, must be established to ensure effective response to disasters.

Spatial attention must be given to specific needs of patients, especially pediatrics and particular medical conditions, in the development of triage strategies and resource allocation. Furthermore, the development of the legal and ethical frameworks will enable the fair allocation of resources and decision-making with respect to special care in disaster scenarios with respect to patients with a poor prognosis. Engaging the community in disaster preparedness and response programs helps to ensure the equitable distribution of resources and increases access to health services.

In all, the delivery of special care services, in a disaster scenario, has a numerous of challenges that require specific strategies to improve preparedness and response capabilities. The health care system can alleviate the impacts of disasters on patient care through the institution of multidisciplinary approaches that include training curriculums, models for ethical decision-making, and effective communication practices. Also, constant research and collaboration between health care professionals, policymakers, and members of the community will be very instrumental in improving disaster preparedness and ensuring equal access to care.

Strengths and limitations

This research examines the multifaceted challenges encountered by hospitals in providing special care services, utilizing a broad spectrum of thorough investigations conducted across several nations. This variety contributes to a more nuanced comprehension of the difficulties faced within diverse healthcare environments. Moreover, the implementation of stringent protocols for literature review, data acquisition, and analysis significantly bolsters the credibility and dependability of the results.

In this way, the current research increases the awareness of systemic challenges within healthcare systems during disasters. The gained knowledge might help in improving planning and preparedness and, consequently, increase the possibility of improving hospitals’ capacity in offering services during emergencies and crises.

However, there are some limitations to this study. While the challenges have been well delineated, many of the studies reviewed are qualitative. This may reduce the potential to generalize quantitative and measurable outcomes from the findings. Some of those challenges are perhaps context-bound, related to specific geographical or economic conditions, and thus generalization of the findings to other countries might not be feasible. In addition, certain articles were excluded due to the lack of access to full texts or their publication in languages other than English, which might have resulted in a narrower perspective on the problems that are faced worldwide.

Recommendations

Considering the challenges found in this study and its limitations, it will be appropriate that future research concentrate on quantitative studies that should seek to collect statistical data and make comparative analyses with greater precision on the impact of identified challenges on quality special care services and patient outcomes in a hospital setting facing disaster scenarios. Future studies should focus on more specific challenges, especially ethical dilemmas, triage processes, and resource management, with the view of giving more practical and holistic solutions. It would also be very important to have comparative studies across countries or regions to derive best practices or successful strategies regarding the management of special care services during emergencies.

Based on the findings of this research, we hereby make the following recommendations:

• Standardized Protocols: Develop and promote standardized protocols for crisis management and patient triage during emergencies.

• Infrastructure Assessment: Detailed assessment of the existing infrastructure of the hospitals for identifying gaps and areas for improvement.

• Hospital Infrastructure Investment: Invest in hospital infrastructure and medical equipment to increase the capacity and quality of services during disasters.

• Improvement of Pre-Hospital Services: Examine ways to improve pre-hospital services and strengthen the collaboration between emergency medical services and hospitals.

• Inter organizational Collaboration: Encourage collaborative activities among health sector organizations, government agencies, and nongovernmental organizations to improve disaster and emergency response efforts.

• Strategic Preparedness and Financial Backing: Formulate and carry out a well-planned emergency preparedness program with adequate long-term financial provision to meet equipment and human resource needs during disaster.

• The training and empowering of health professionals must be a step to increase their competencies in emergency and disaster management.

• Foster active collaboration among health sector organizations, government agencies, and voluntary agencies to improve disaster and emergency response efforts.

• Novel technologies should be utilized to enhance communication during disaster periods to increase coordination between hospitals and other institutions that will help in the transfer of patients and better management of resources.

Conclusion

This study investigated the challenges associated with providing special care services to patients in hospitals during disaster and emergences. A literature review of 33 related articles recognized 15 principal challenges. Key challenges include: limited resources, inadequate infrastructure, triage challenges, and planning and management deficiencies. These results are of immense importance to policy makers and stakeholders as they offer constructive knowledge expected to improve preparedness for and response to disasters and emergencies in the hospitals. Recommended solutions to such challenges might include better disaster preparedness planning, training, and empowering of health care personnel, improvement in communication and coordination between organizations, and the development of standardized protocols. This would definitely improve the survival chances of critically injured patients in disasters and reduce the long-term complications developed from such events.

These gaps of course bring into light the compelling need for further research in this area. Such future research efforts may enable comparative studies between different regions or countries with the aim of identifying best practices and efficient strategies of providing specialty care during crises, as well as longitudinal research to determine long-term effects of disasters on health care systems and the outcomes for patients. Better Preparedness Strategies discusses how emerging technologies can enhance disaster response and patient care in hospitals; triaging and resource allocation issues during disasters; and beyond providing a framework for ethical decision-making in emergencies.

Abbreviations

PRISMA

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

ICU

Intensive Care Unit

Author contributions

All authors (MD, MM and NT) contributed to the study conception and design of the scoping review and resulting manuscript. All authors reviewed titles, and abstracts, and made decisions on full-text articles to be included in the review. All authors were involved in data abstraction. MM drafted and prepared the manuscript. All authors were involved in the revision of the draft manuscript and approved the final version of the manuscript.

Funding

This study was performed as a regular work of the Unit of Disaster and Emergencies, Iran University of Medical Sciences, and did not use additional funds. The authors have no financial involvement that could indicate potential conflicts of interest.

Data availability

All the data generated or analyzed during this scoping review have been included in this manuscript.

Declarations

Ethics approval and consent to participate

The ethical approval of this study was obtained from the Research Ethics Committees of Iran University of Medical Sciences in Tehran, Iran (IR. IUMS. REC.1403.323).

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Clinical trial number

Not applicable.