Organizational Context

Minato City (Minato-ku), 1 of 23 sub-divisions (wards) in the special administrative district of central Tokyo, is located in a core business area with many commercial facilities and office complexes. It has an area of 20.37 km ^{Reference Barnett, Knieser and Errett2} , a residential population of 259,893, and a daytime population of approximately 970,000 (as of October 1, 2020). ⁵ Like other ordinary municipalities, the 23 sub-divisions are autonomous and have their own assembly, executive branch, and elected mayor. However, their relationship with the prefectural government (the Tokyo Metropolitan Government) differs from that between other municipalities and prefectures. The Tokyo Metropolitan Government is responsible for area-wide tasks including water supply and fire services, usually undertaken by municipalities. ⁶ The Minato City Government has its own public health center, which manages and supervises health services including disaster medical care.

In Japan, municipalities mainly take charge of disaster management in their jurisdictions under the Basic Act on Disaster Management (Table 1). Guided by national and prefectural policies, municipalities develop community disaster management plans, which include disaster medical care. In Tokyo, the Metropolitan Regional Disaster Management Plan and Disaster Medical Care Guidelines stipulate the roles of health-care providers and municipal governments. All hospitals are assigned roles for disasters, and municipalities should have their own community disaster management plans to prepare shelters and first-aid stations and coordinate with hospitals. In Minato City, the Coordination Council for Disaster Medical Care—consisting of representatives from the city government, public health center, police, fire services, and health-care providers—advises on specific disaster medical care plans. ^7,8 The Council includes municipal disaster medical care coordinators, who are appointed from among physicians working in the city to support the public health center to manage disaster medical care. The Council has a Hospital Section sub-committee that focuses on collaborations and coordination between hospitals. The Minato Public Health Center serves as the headquarters for disaster medical care management and coordination. In Tokyo, area-wide issues regarding disaster medical care, which cannot be resolved within each municipality, are managed at the medical district level, consisting of several municipalities. Minato City belongs to the Central Tokyo Medical District, which has a Regional Coordination Council for Disaster.

Table 1.

Framework and organizations for disaster management in Minato City

Note: “Hospitals” are defined as medical care facilities with 20 or more beds.

The municipal disaster medical systems should function in collaboration with the nationwide disaster management system that allocates resources to disaster-affected areas (Table 2). ^{Reference Homma9,Reference Egawa, Suda and Jones-Konneh10} The municipal disaster medical care coordinators, in cooperation with the regional and metropolitan coordinators, allocate the ward’s remaining medical resources and external assistance. The disaster base hospitals designated throughout the country to lead medical care in disaster-affected areas also provide assistance to affected areas despite being situated in an unaffected area. In large-scale disasters, various assistance teams enter the affected area from unaffected areas throughout the country. For example, disaster medical assistance teams (DMATs) are dispatched from disaster base hospitals. In addition, a wider-regional air transport system is established to mitigate the excess medical demands in affected areas; critical patients are transported to disaster base hospitals outside the affected area. The Emergency Medical Information System (EMIS) is an Internet-based system that collects and shares disaster-related information nationwide; it gathers information such as the available medical resources and demands as well as DMAT activities in the affected areas to expedite the aforementioned coordination.

Table 2.

Nationwide disaster medical system

Abbreviations: DMAT, Disaster Medical Assistance Team; MHLW, Ministry of Health, Labour and Welfare; SCU, staging care unit.

Problem

The Great East Japan Earthquake that took place in March 2011, and subsequent consecutive disasters that struck Japan, triggered the enhancement of disaster management plans, including medical care. The 2012 and 2014 amendments of the Tokyo Metropolitan Regional Disaster Management Plan and subsequent Tokyo Metropolitan Disaster Medical Care Guidelines ⁷ specified the municipalities’ responsibilities and assigned roles to all hospitals depending on their capacities and characteristics. The 2012 amendment introduced “First-aid stations” that should be set up adjacent to hospitals to provide triage and first aid, in addition to medical care stations in disaster shelters. It also introduced municipality level disaster medical care coordinators. On the advice of the disaster medical care coordinators, municipalities should delegate station management to the hospitals and coordinate their functions. Materializing these specifications requires negotiation, collaboration, and agreement with stakeholders, as well as effective disaster drills.

When the city-wide drill project was proposed, Minato City was yet to effectively administer the responsibilities specified by the regional and community disaster management plans and guidelines, with many issues still to be addressed. The hospitals in the city, except for the disaster base hospitals, had no experience, plans, or exercises to manage the first-aid stations. Thus, initial requirements to substantiate the disaster management plans involved negotiations with the hospitals for setting up of the stations adjacent to or even in the hospital premises; securing resources for the station management, such as tents, equipment, and drugs; developing concrete plans for the station management; and conducting practical drills. Particularly important were triage and coordination among hospitals to transfer patients to appropriate hospitals.

In addition, mechanisms to coordinate disaster medical system had not existed in Minato City. City-wide large-scale disaster management drills had not been conducted to assess and improve the logistics of resources and coordination abilities among stakeholders; however, there had been small-scale communication exercises among disaster base hospitals and the Minato Public Health Center, or in-hospital management training in individual hospitals. The Tokyo Metropolitan government had conducted large-scale disaster management drills every year, which experts from Minato City also attended. However, such drills were just an exhibition of equipment and skills without practical exercises in each of the organizations and coordination among them. No collaboration or communication had existed between hospitals and surrounding facilities or communities that may have had medical needs and could provide disaster management support.

Solution

City-Wide Joint Disaster Medical Care Drills

In 2016, the physicians’ project team started to develop a city-wide disaster medical care drill that involved all health-care providers in the city. To facilitate participation from various types of hospitals, they limited the drill contents to essential practices, such as setting up a first-aid station and triage, and communication exercises. Their first goal was to create a city-wide joint drill that covered all health facilities and personnel in the city to establish coordination mechanisms, and to gradually raise the level of practice in the drill to develop each hospital’s abilities. To include not only hospital staff but also health-care personnel in their private practices, the project integrated local medical, dental, and pharmaceutical associations (as most private practitioners belonged to such organizations).

The first city-wide joint disaster medical care drill was held in November 2017. Subsequently, it was held every year until and including 2019, and was canceled in 2020 due to the novel coronavirus pandemic (Table 3). The drills mainly consisted of setting up first-aid stations, triage exercises, communication exercises, and operation tests of facilities and equipment in the participating hospitals. The medical, dental, and pharmaceutical associations dispatched their members to the hospitals to support the management of the stations, particularly the triage, and the hospitals issued temporary staff IDs for them to expedite their activities in the hospitals. The dispatch destinations of the medical association members changed every year so that they could observe activities in various hospitals. Pharmaceutical associations conducted drug dispensary exercises in a hospital in 2019. The number of participants increased and the drill contents progressed year by year, with all hospitals participating in 2019. In 2018, interhospital patient transfer exercises were conducted, and in 2019, a drug dispensary appeared for the first time in 1 venue, and digital radio apparatus was introduced.

Table 3.

City-wide joint disaster medical care drills in Minato City

^a The total number of participants included those from outside Minato City because this was a joint program with Tokyo Metropolis and Chuo City.

^b One of the 13 hospitals discontinued their practice.

^c The public health center distributed lights and generators.

^d Digital radio apparatus was introduced in 2019.

Outputs

Collaborations in the city-wide joint disaster medical care drills have yielded various effects. Opinions about the effects of the Coordination Council members (the authors of this study) were summarized and categorized (Supplementary Material). The indicted effects were summarized into 28 items, rated by the council members based on their importance, and categorized into 4 groups: city-wide system development, coordination mechanisms among the stakeholders, increased awareness and motivations, and development of in-hospital system and manual (Table 4). Of these effects, those that were highly rated (mean scores of 4 points or higher) were related to city-wide system development and collaboration among the stakeholders, including the agreement between the city government and the hospitals. Although not highly rated, effects that are beneficial to the expansion of collaboration to nonhealth sectors or nondisaster issues were also indicated.

Table 4.

Effects of the collaborations and joint disaster medical care drills in Minato City

Abbreviations: COVID-19, coronavirus disease 2019; EMIS, Emergency Medical Information System.

^a An information sharing and communication tool to support implementation of business continuity plans for crisis management.

The drills could identify various practical issues that need to be addressed. Some hospitals require reconsideration of venue arrangements for first-aid stations and drug dispensaries (location, layout, and access routes). In particular, hospitals with small land areas should carefully plan the location of triage and waiting zones that should accommodate a large number of people. Different considerations are required for different disaster occurrence timing (staff availability is low at night and on holidays; heat and cold weather should be considered in the venue arrangements). The need for resources has become clear (more radio apparatus, lights, helmets, and reporting forms are needed) and improvements in drill contents have been suggested (skill training, role clarification, and reallocation; procurement of human and material resources; standardization of drill contents; consideration of electric, water, or system failure; manual development; enhancing communication and collaboration among hospitals; and consideration of continuing usual tasks).

Challenges

Collaboration activities and joint drills are still in an early stage, and there are many challenges that need to be addressed (Table 5). First, the disaster drills conducted so far did not include sufficient exercises that took into account those with special needs (elderly people; those living alone, with disabilities, and receiving home medical care; dialysis patients; expectant mothers; and infants), who tend to have difficulties in accessing medical care during disasters. ^{Reference Ochi, Murray and Hodgson11} The latest drill included private physicians providing home medical care to such people, which informed the drill planning team of the locations and conditions of such people. Integrating such information into Minato City’s disaster planning would enable the development of specific evacuation and care plans for those with special needs, the number of whom is rapidly increasing in the Japanese super-aged society.

Table 5.

Future challenge

Second, sector-wide collaborations are still insufficient for a wider impact on disaster management. So far, the drills did not involve collaboration with clinics not affiliated with the Medical Association or with the Judo Therapist (Japanese traditional osteopathists/bonesetters) Association due to competing interests among the stakeholders, and did not cover facilities such as nursing homes because the main focus of the drills was the management of first-aid stations. These organizations may be integrated in future activities. Collaborations with surrounding commercial facilities, business entities, and schools should be developed given the large number of workers, customers, and students accommodated in these facilities in the daytime. During disasters, many of these people would stay in these facilities owing to difficulties in returning home or their medical needs. ^{Reference Takayanagi, Oneyama and Ishikura12} Disaster drills that involve first aid training and dispatch of medical teams to these facilities may enable them to accommodate minor cases after triage at the first-aid stations.

To address area-wide medical needs that may exceed the available resources within the city, collaborations and communications with medical facilities and personnel outside the city, including those in remote areas, should be strengthened in the management plans and drills. During a large-scale earthquake, more injured victims would come into Minato City from municipalities outside than from those within the medical district. Excess demands should be managed through area-wide patient transfer, including wider-regional air transport to remote unaffected areas, and accepting external assistance teams (e.g., DMATs). ^{Reference Homma9,Reference Egawa, Suda and Jones-Konneh10} Additionally, training that involves sharing of information through the EMIS and simulation of area-wide transfer should be included.

Third, disaster management plans and drills should be expanded to incorporate regional business continuity management. ^{Reference Baba, Watanabe and Miyata13} The current Minato City disaster medical care system still seems to be an assortment of each hospital’s individual functions with great variations, and a lack of strong referral functions in disaster situations. We completed the first goal of doing something together. Each organization should specify its roles and improve its abilities and then, they should work in coordinated ways. To this end, inter-hospital variations in ability should be minimized, role allocation should be clearly described, and headquarter functions should be strengthened. Therefore, drill contents should be converted from “independently determined and conducted” to be more coordinated and standardized.