Despite its large geographical area, and exposure to frequent disaster events, Australia has had relatively little exposure to multi-casualty incidents (MCI).
The largest recorded loss of life from a natural disaster occurred in 1899, when over 400 people died on Cape York, Queensland during cyclone Mahina.
In 1939, the severe heatwave that sparked the ‘Black Friday’ bushfires in Victoria caused the death of 438 lives.
And in 1974, one of the most infamous Australian disasters, cyclone Tracy, hit the city of Darwin on Christmas Eve. Although the town was completely devastated with destructive winds leaving 25,000 people homeless and many injuries, the death toll remained relatively low at 64.

Even the surge from small scale disasters can stretch the capabilities of most public hospitals. The Canberra Bushfires of 2003 resulted in our emergency department receiving 90 additional disaster related patients over a 6 hour period, an average of one presentation every 4 minutes.
Within Australia, there are strong community expectations and perceptions that its healthcare system would be able to manage an incident producing large numbers of casualties. In reality, this low exposure of the healthcare system to a large scale MCI has resulted in little data to support its level of preparedness.

It falls upon the local states and territories to prepare and test their individual response plans as well as testing their capacity to manage disasters that occur within the individual jurisdictions.
For example, all health care facilities within the Australian Capital Territory (ACT) are required to exercise their Emergency Management plans at least annually to ensure that their plan conforms to the Health Sub-Plan and other higher-level plans.
ACT Health also requires that its organisations and individuals undergo collective and individual training to ensure that they meet their respective responsibilities and duties.
Emergency Management Australia (EMA) has defined the concept of community as: a group of people with a commonality of shared experience and function.

Within the context of disaster management, the hospital itself may be seen as a complex community that has shares a common function of assisting the sick and injured during the response and recovery phases of a disaster. The ability of a community to withstand a disaster, and its consequences has been described in terms of resilience. Implicit in this description is the ‘elasticity’ or ability to return to a pre-disaster state.
When it comes to unique demands that would be placed upon the healthcare community during a large disaster, two additional properties might be explored.
Plasticity could be thought of as the ability of the hospital system to strategically adapt or stretch to underestimated or unplanned demands upon its systems and personnel.
Tensility might be thought of as the inherent strength of the healthcare community, enabling it to maintain functionality even when stretched or disrupted.

All three of these properties are dependent on appropriate attention to planning. The hospital itself must be a prepared community.

Hospital disaster plans should be regularly tested and measured for utility against some form of standardized measurement tool. Information gained from disaster exercises should be reviewed and necessary adjustments made to renew the plan. To remain effective, it is vital that any hospital disaster plan remain a living document.
It is also vital that the response ability of the hospital community is enhanced by the integration or weave of its preparedness planning into that of other key stakeholders within the government and community.
To continue this analogy, our public hospitals might currently be viewed as somewhat of a marginalized community, sitting somewhere out on a limb of the disaster management structure.

In fact, there is an increasing concern that hospitals are not adequately integrated into their communities disaster planning. Hospitals are said to be isolated in their planning activities and are possibly the weakest link in emergency response. As was noted by the Auditor General in 2006, there is a lack of provision for the regular rehearsal and testing of disaster plans in Australia.
Even though NSW Health had developed a template to assess the plan for completeness, it was found to be lacking in information response standards, minimum resource requirements, milestones or deadlines (Auditor Generals Report Performance Audit 2006).

The danger with this is that separate agencies might recede into compartmentalized planning silos. For example, the Australian Health Protection Committee (AHPC) is the highest level health disaster management group in Australia and yet it has no representation of hospital services.

Even though we should be thankful that the frequency of a disaster impacting any one hospital is currently very low, multiplying factors such as global warming, increased spread of disease and terrorist activities suggest the likelihood of future impact is increasing.
Currently, it is this very perception of low likelihood that risks engendering a continued complacency in the development of hospital disaster response planning.

Emergency Management Australia (2001) highlights the importance of disaster exercising to:

• Evaluate plans.
• Explore planning and response issues.
• Promote awareness.
• Develop and assess competence.
• Demonstrate capability.
• Evaluate risk strategies, as well as equipment, techniques and processes.
• Validate training.
• Identify performance gaps.

Education and videos:

Although not strictly a disaster exercise, the use of didactic teaching, discussions and workshops, allow participants to interact and explore many of the elements of the hospital disaster plan. Such activates enable staff to develop the competence and confidence to work effectively within the structure of the hospital disaster plan.

Tabletop:

Another option for testing the disaster plan is the table top exercise. Properly designed table top exercises can be a powerful tool, providing information on preparedness, logistical effectiveness, as well as analysing weak spots within the hospitals disaster plan.

They are cheaper, require fewer resources to run and have a smaller footprint than larger scale disaster scenarios, making them a more viable option for rural and smaller hospitals. Table top exercises also have the added ability to test a wide range of scenarios and involve multiple agencies and departments, for example infection control, critical care, and communications within the hospital system.
They also provide a forum to establish networking relationships amongst individuals from other campuses and external agencies that will be called upon during an actual disaster response.

Shortfalls in table top exercising lay in the fact that they usually only involve a small number of players, and that they must rely on accurate data of resource availability and realistic responses in order to produce any meaningful information for any of the participants.

Emergotrain:

The Emergotrain system is a highly structured disaster response simulation developed at the Centre for Teaching and Research in Disaster Medicine and Traumatology (KMC) at the University of Linköping Sweden.
The system constructs a virtual replication of the hospital environment as well as the geographical area of the disaster site on whiteboards. It then tests the disaster plan in real time utilizing a set of magnetic ‘casualties’ known as Gubers.

Each Guber has a set of clinical signs and symptoms and if an appropriate intervention is not performed within a prescribed time frame will result in its death. The system has protocols for identifying time requirements for specific clinical interventions and probable outcomes.

The strength of this system lies in its simplicity, its relative low costs and its transparency to a structured evaluation of patient outcomes and surge capacity. A wide range of scenarios may be tested and exercises can be begun at any stage of the disaster. For example by setting up and starting the exercise at ‘hour 4’ of the disaster the focus on surge impact may be shifted from the emergency department to Theatres, Intensive Care and high dependency units.

As with tabletop exercises, the Emergo Train System only utilizes a small number of players, usually small groups representing different operational areas of the hospital. Although it allows the surge capacity of the hospital to be tested with some realism, it offers limited experiential exposure to the majority of staff who would actually be involved in a real response.

Large Scale Exercises:

Hospitals may participate in larger scale exercises run by other agencies or develop their own.
These scenarios require considerable planning and resources. They may involve volunteers who play the role of casualties, family members and other people affected by the disaster. Often considerable effort will go into promoting a realistic environment by using props and moulaging traumatic injuries onto the volunteers.

By simulating the disaster scenario with such realism, hospital participants are exposed in real time to many of the challenges and constraints that invariably arise during the intense human interactions following a disaster. Interactions that are difficult to replicate in other forms of exercise.
Failure in communication is a common theme in major incidents (McCormack & Wardrope 2003) and large scale exercises can accurately test and challenge current practices.
They also permit the running of specialised scenarios such as Chemical, Biological, Radiological or pandemic responses.

The problem with these exercises is that by their very nature they may have a significant impact on the operational integrity of the hospital and in particular, its emergency department.

A recent snapshot of emergency departments throughout Australia found that most are overcrowded and struggling to maintain normal services, a situation that allows little wiggle room to conduct a significant realistic exercise. Difficulties in providing such rigorous testing of the hospital disaster plan are exacerbated by the fact that most public hospitals are run at or above capacity, unable to tolerate even the virtual surge of an exercise without impacting on actual patient care.

Resources are often stretched to the extent that even tabletop exercising or effective education sessions are difficult. Any opportunities to train healthcare workers in disaster preparedness must compete in an environment already overloaded with clinical competencies, training in the operation of new technology, mandatory educational requirements and other responsibilities.

Compounding this problem is the high turnover of staff in many departments, the increasing utilization of casual and agency nurses, and the regular rotation of doctors through ward areas which further dilutes the effectiveness of any disaster training that might occur.

It is also important to recognise that the success of a disaster exercise does not necessarily mean that the plan being tested was a success. Often more valuable information is generated when things go wrong and weaknesses are exposed.
Given the possibility that realistic exercising may publicly expose shortfalls and deficiencies in the current plan, hospital executives may show some reluctance to risk such politically sensitive events.

Despite this, running regular disaster exercises almost certainly enhances preparedness by increasing awareness of hospital disaster plans, improving organizational relationships, stimulating an experiential environment for staff to practice the special skills required in this situation, exposing weaknesses and strengths within the current response and providing a catalyst to develop focused strategies and solutions.Disaster exercises also provide an opportunity for individuals to reflect on ethical and moral issues that might arise including the effects of a disaster impacting directly on the individual or their families.

In conclusion, although there is little evidence based information on the effectiveness of any one form of disaster training over another it would seem reasonable to surmise that each of the different models of training have their own strengths and weaknesses. Any disaster response will activate a wide range of actions and responsibilities each with its unique challenges. Each agency within the organization may find a different model to best suit their requirements.

What does seem to be of universal agreement is the need for further research into the area of disaster exercising, standardization of a set of disaster related competencies and evaluation tools for medical staff, greater buy in from hospital executives and administrators and a much greater recoginition of the place of disaster exercising in the hospital agenda.